Background: Humanitarian actors and host-countries in the Middle East and North Africa region are challenged with meeting the health needs of Syrian refugees and adjusting the response to contemporary humanitarian conditions-urban-based refugees, stressed host-country health systems and high NCD prevalence. Although several studies have explored NCD prevalence, utilization of services and barriers to access, these analyses took place prior to dramatic shifts in Jordanian health policy and did not account for nuances in health seeking and utilization behaviors or operational barriers. Accordingly, we aimed to understand the depth and nuances of Syrian refugees' experiences accessing NCD services in urban and semi-urban settings in Jordan. Methods: A qualitative study was conducted to explore the healthcare experiences of Syrian refugees in Jordan. The study team conducted 68 in-depth interviews with Syrian refugees in urban and semi-urban locations in central and northern Jordan. Results: The findings indicated four themes key to understanding the healthcare experience: (1) emotional distress is a central concern and is frequently highlighted as the trigger for a non-communicable disease or its exacerbation; (2) service provision across all sectors-government, NGO, private-is complex, inadequate, expensive and fragmented, making engagement with the health sector physically and financially burdensome; (3) given financial constraints, participants make harmful decisions that further damage their health in order to reduce financial burdens, and (4) host-community members actively exhibit solidarity with their refugee neighbors and specifically do so during emergency health episodes. The findings from this study can be used to inform program design for forcibly displaced persons with NCDs and identify points of entry for effective interventions. Conclusions: Opportunities exist for humanitarian and host-country actors to provide more comprehensive NCD services and to improve the relevance and the quality of care provided to Syrian refugees in Jordan. Global and national funding will need to align with front-line realities and foster better coordination of services between host-country health systems, private actors and non-governmental organizations. © 2019 The Author(s).

Semi-urban Health systems Urban Humanitarian response Hypertension Development Refugees Jordan Non-communicable disease Middle east and North Africa Asthma diabetes Syria

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