Improving Diabetes Control for Syrian Refugees in Jordan: a Longitudinal Cohort Study Comparing the Effects of Cash Transfers and Health Education Interventions

Background: Cash transfers are an increasingly common intervention in the Syrian refugee response to meet basic needs, though there is little known of their potential secondary impact on health outcomes in humanitarian settings.

Methods: A quasi-experimental prospective cohort study was implemented from October 2018 through January 2020 to assess the effectiveness of multi-purpose cash (MPC), community health volunteer (CHV)-led education, combined with conditional cash transfers (CCT) with respect to health measures among Syrian refugees with type II diabetes in Jordan.

Results: CHV + CCT participants had the highest expenditures at endline and were the only group with statistically significant increases in payments for outpatient diabetes care (25.3%, P < 0.001) and monthly medication costs (13.6%, P < 0.001). Conversely, monthly spending on diabetes medication decreased significantly in the CHV only group (- 18.7%, P = 0.001) yet increased in the MPC and CHV + CCT groups. Expenditures on glucose monitoring increased in all groups but significantly more in the CHV + CCT group (39.2%, P < 0.001). The proportion of participants reporting regular diabetes care visits increased significantly only in the CHV + CCT group (15.1%, P = 0.002). Specialist visits also increased among CHV + CCT participants (16.8%, P = 0.001), but decreased in CHV only participants (- 27.8%, P < 0.001). Decreases in cost-motivated provider selection (- 22.8%, P < 0.001) and not receiving all needed care because of cost (- 26.2%, P < 0.001) were significant only in the CHV + CCT group. A small significant decrease in BMI was observed in the CHV + CCT group (- 1.0, P = 0.005). Decreases in HbA1C were significant in all groups with magnitudes ranging from - 0.2 to - 0.7%. The proportion of CHV + CCT participants with normal blood pressure increased significantly from baseline to endline by 11.3% (P = 0.007).

Conclusions: Combined conditional cash and health education were effective in improving expenditures, health service utilization, medication adherence, blood pressure, and diabetes control. The lower cost health education intervention was similarly effective in improving diabetes control, whereas unconditional cash transfers alone were least effective. Study findings suggest that conditional cash or combined cash and health education are promising strategies to support diabetes control among refugees and that where the purpose of MPC is to improve health outcomes, this alone is insufficient to achieve improvements in the health of refugees with diabetes.