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Training and deployment of lay refugee/internally displaced persons to provide basic health services in camps: a systematic review

Training and deployment of lay refugee/internally displaced persons to provide basic health... Global Health Action REVIEW ARTICLE Training and deployment of lay refugee/internally displaced persons to provide basic health services in camps: a systematic review 1 2 3 1,4 John E. Ehiri *, Jayleen K.L. Gunn , Katherine E. Center , Ying Li , 1 5 Mae Rouhani and Echezona E. Ezeanolue Division of Health Promotion Sciences/Global Health Institute, Mel & Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA; Division of Epidemiology and Biostatistics, Mel & Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA; Department of Obstetrics and Gynecology, University of Arizona, Tucson, AZ, USA; Department of Social Medicine & Health Service Management, Third Military Medical University, Chongqing, China; Department of Pediatrics, University of Nevada School of Medicine, Las Vegas, NV, USA Background: Training of lay refugees/internally displaced persons (IDPs) and deploying them to provide basic health services to other women, children, and families in camps is perceived to be associated with public health benefits. However, there is limited evidence to support this hypothesis. Objectives: To assess the effects of interventions to train and deploy lay refugees and/or IDPs for the provision of basic health service to other women, children, and families in camps. Methods: PubMed, Science and Social Science Citation Indices, PsycINFO, EMBASE, POPLINE, CINAHL, and reference lists of relevant articles were searched (from inception to June 30, 2014) with the aim of identifying studies that reported the effects of interventions that trained and deployed lay refugees and/or IDPs for the provision of basic health service to other women, children, and families in camps. Two investigators inde- pendently reviewed all titles and abstracts to identify potentially relevant articles. Discrepancieswere resolved by repeated review, discussion, and consensus. Study quality assessment was undertaken using standard protocols. Results: Ten studies (five cross-sectional, four pre-post, and one post-test only) conducted in Africa (Guinea and Tanzania), Central America (Belize), and Asia (Myanmar) were included. The studies demonstrated some positive impact on population health associated with training and deployment of trained lay refugees/ IDPs as health workers in camps. Reported effects included increased service coverage, increased knowledge about disease symptoms and prevention, increased adoption of improved treatment seeking and protective behaviors, increased uptake of services, and improved access to reproductive health information. One study, which assessed the effect of peer refugee health education on sexual and reproductive health, did not demon- strate a marked reduction in unintended pregnancies among refugee/IDP women. Conclusion: Although available evidence suggests a positive impact of training and deployment of lay refugees/ IDPs as health workers in camps, existing body of evidence is weak, and calls for a re-examination of current practices. Interventions that promote training and deployment of lay refugees/IDPs as health workers in camps should include strong evaluation components in order to facilitate assessment of effects on popu- lation health. Keywords: maternal health; reproductive health; refugees; internally displaced persons; child health Responsible Editor: Isabel Goicolea, Umea˚ University, Sweden. *Correspondence to: John E. Ehiri, Division of Health Promotion Sciences, Mel & Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA, Email: [email protected] Received: 23 January 2014; Revised: 1 September 2014; Accepted: 2 September 2014; Published: 1 October 2014 lthough the value of using local community on expatriate health workers. Often, this dependence health workers in the provision of basic health raises concerns about the long-term sustainability, cost- Aservices is widely acknowledged, many health effectiveness, and cultural appropriateness of programs and development agencies working in camps for refugees and services. The focus of this review is to summarize and and internally displaced persons (IDPs) continue to rely critically appraise evidence regarding both the capacity Global Health Action 2014.# 2014 John E. Ehiri et al. This is an Open Access article distributed under the terms of the Creative Commons CC-BY 4.0 License 1 (http://creativecommons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix,transform,and build upon the material for any purpose, even commercially, provided the original work is properly cited and states its license. Citation: Glob Health Action 2014, 7: 23902 - http://dx.doi.org/10.3402/gha.v7.23902 (page number not for citation purpose) John E. Ehiri et al. of refugee and/or internally displaced women residing and 4) chronic disruption of services. Although several in camps to provide health services to other women and international initiatives have sought to unite aid agencies children in these camps and the effectiveness of such that respond to the needs of refugees and IDPs (11), services. Anecdotal evidence suggests that with adequate attempts to empower displaced women in camps to take training, proper supervision, and support, refugee and/ control over, and improve their own health have been or internally displaced women are able to provide basic limited. With the escalation of conflicts and emergencies health services to other women, children and families in globally, gaps in access to essential health services for camps while avoiding the challenge of ensuring cultural women and children in camps continue to occur (1214). appropriateness and sustainability that are often asso- With the flight of local health workers, the burden of ciated with transient expatriate personnel. health services typically rests on just a few foreign aid A refugee is defined as someone who has fled his or workers, severely limiting service coverage (15, 16). This her country of nationality to find protection from war problem calls for a paradigm shift in efforts to address or from persecution based on race, religion, nationality, the maternal and child-health needs of refugees and IDPs membership of a specific political party and/or political in camps using available local human resources. Over the years, a number of intervention studies have been opinion (1, 2). ‘Unlike refugees, IDPs have not crossed an conducted in which refugee and/or internally displaced international border to find sanctuary, but have remained women residing in camps were provided with targeted inside their home countries. As such, IDPs are legally training in specific basic health services related to mater- under the protection of their own government, even if nal, newborn, and child-health services to other women that government was the cause of their flight’ (2, p. 1). and families in their camps, and later deployed to apply the Also included in the definition of IDPs are civilians who resultant knowledge and skills. Anecdotal evidence sug- are made homeless by natural disasters (3). At the end of gests that such training and deployment have public health 2011, the United Nations High Commission for Refugees benefits but few reviews have articulated this evidence. (UNHCR) reported that they were providing services for This review therefore, is an effort to address this gap an estimated 26.4 million people worldwide who have in knowledge. been displaced because of conflict or persecution (3). Of this number, an estimated 10.4 million were refugees and 15.6 million were IDPs (3). In addition, UNCHR Methods estimates that nearly half of the population of refugees and IDPs were females (3). Globally, sub-Saharan Africa Search strategy and selection criteria is disproportionately affected by conflicts and emergen- The following electronic databases were searched from cies that have resulted in large numbers of refugees and inception to June 30, 2014: PsycINFO, PubMed, Web of IDPs (34% of the global total) (4). Political, religious, Science, CINAHL, Sociological Abstracts, Embase, and and ethnic disputes are significant factors contributing Internet (Google and Google Scholar). The search was not to these high numbers. For example, the genocide in restricted by publication status or language. The following Rwanda resulted in 1.7 million refugees; the conflicts in search terms were first created for a search in PubMed, Liberia 750,000, and the Somalia conflict, 450,000 (5). and later adapted for the other databases: (‘Community As the world continues to experience increases in con- Health Workers’ OR ‘Health Personnel’ OR ‘Volunteers’ flicts and emergencies, health workers and international OR ‘Health Services’ OR ‘Delivery of Health Care’ OR health agencies are confronted with the challenge of volunteer OR ‘health worker’ OR ‘health auxiliary’ OR protecting the health of displaced populations. Women, ‘relief work’ OR ‘relief worker’ OR ‘health care delivery’ infants, and children are often severely affected, not by OR peer); (‘Refugees’ [Mesh] OR ‘refugee camps’ OR the direct effects of weapons, but by displacement, gender- ‘internally displaced’); #1 AND #2. We hand-searched based violence, preventable illness, malnutrition, and inad- reference lists of identified articles, and contacted bilateral equate sexual and reproductive health services (6). Women agencies and non-governmental organizations (NGOs) and children are at increased risk for poor health when whose programs may include interventions for refugees community resources and networks that serve as their and/or IDPs with a request for information on previous safety nets are disrupted. Sexual violence and abuse are and ongoing studies. Three reviewers (JE, JG, and YL) also of particular concern for women and girls (710). coordinated the literature searches. Why it is important to do this review Inclusion/exclusion criteria As available evidence shows, major health challenges that 1) Types of study: We attempted to identify studies that often confront refugee and internally displaced women, assessed the capacity of lay women who were refugees children, adolescents and families include: 1) limited or internally displaced, to provide basic health services access to health services, 2) increased predisposition to to maternal and child populations (women, children, and sexual and reproductive health risks, 3) under-nutrition, adolescents) in camps for refugees and/or IDPs and the 2 Citation: Glob Health Action 2014, 7: 23902 - http://dx.doi.org/10.3402/gha.v7.23902 (page number not for citation purpose) Training and deployment of lay refugees/IDPs outcomes of such services. We excluded repeated reports, studies, data on the number of persons in the study groups books, studies that provided general discussion about and number of persons exposed/unexposed to health out- training of non-refugee community health workers, and comes of interest were extracted from the comparison descriptive papers on refugees and IDPs in camp settings. groups. We also extracted data on sample size, ages of Studies that assessed the effectiveness of services provided individuals in the study, and data collection methods. by trained local or expatriate health workers such nurses, doctors, and other skilled medical and allied health Study quality assessment professionals. Given the ethical and logistical challenges We assessed the quality of cohort studies using the of conducting randomized controlled trials under camp NewcastleOttawa Scale (17). In addition, we assessed settings and the dearth of empirical evidence on the the representativeness of the exposed cohort in the study subject, we sought to include a wide variety of studies in setting; the selection of non-exposed cohorts; the ascer- order to capture as much available data as possible. Thus, tainment of exposure; the demonstration that outcome of we included cohort studies, cross-sectional studies, con- interest was not present at start of study; the comparability trolled pre-and-post studies, controlled post-test studies, of cohorts on the basis of design and analyses; the out- and pre-posttest studies that included an evaluation comes assessments; and the adequacy of follow-up (17). component. 2) Study population: Females aged 15 years For cross-sectional studies, we used the guidelines for and over, who were residing in camps for refuges/IDPs, critical appraisal, developed by the National Collabo- and who were involved in providing basic health services rating Center for Environmental Health (18). We also to women, children adolescents and families in camps assessed the representativeness of the study participants; settings or who had received training to provide such methods for ascertaining exposure; comparability of expo- services. 3) Outcome measures: a) Changes in health- sure groups (including unexposed) in terms of age, sex, related knowledge, attitudes, and practices of refugee or socioeconomic status, non-response bias, health outcomes, internally displaced lay women as a result of training determination, and validation of outcomes; internal val- aimed at equipping them to provide basic health services idity; and assessment and addressing of confounding to women, children, adolescents and families in camps; factors. Two reviewers (JE and JG) assessed study quality b) changes in health outcomes of women, children, ado- and reached a consensus for each included study. lescents and families in camps as a result of services provided by trained lay women who were refugees or Data analysis internally displaced (e.g. changed sexual risk behaviors; We did not conduct statistical meta-analysis given that fewer unintended pregnancies; increased immunization very few studies qualified for inclusion in the review. More uptake/coverage; increased uptake of ante-natal and post- importantly, there was marked heterogeneity in the design natal care and nutrition services; reduced maternal and/ and methodology of the included studies, and most did not or child under-nutrition; increased uptake and use of provide appropriate statistical data to permit meta-analysis insecticide-treated bed nets; less frequent malaria cases or tests of heterogeneity. Thus, we conducted a systematic among women, children, and adolescents; and fewer diar- review by summarizing, comparing, and contrasting the rhea episodes). Two reviewers (JE and JG) applied the extracted data. The following section presents the results of inclusion and exclusion criteria to the identified studies. the systematic review of the 10 eligible studies. Study selection Results Two reviewers (JE and KC) independently screened the titles and abstracts of identified studies to assess their Description of included studies eligibility for inclusion in the review. Where uncertainties As shown in Figure 1, we included 10 eligible studies regarding eligibility of studies occurred, all reviewers par- ticipated in the decision about inclusion. (12, 1827) (five cross-sectional, four pre-post, and one post-test only) conducted in Africa (Guinea and Tanzania) (12, 1822), Central America (Belize) (23), and Asia Data extraction (Myanmar) (2427). These studies were summarized in a Data from eligible studies were independently abstracted systematic review (see Table 1). None of the bilateral by two reviewers (JE and JG). Differences were resolved agencies and NGOs contacted provided information on by consensus among all reviewers. Studies were strati- evaluated studies of interventions that involved the use fied by design (cohort, cross-sectional studies, and case of refugees and/or IDPs in providing maternal and child studies). For cohort studies, the number of subjects in health services in camps. Overall, the literature sources did the cohort and the number of incident cases of health outcomes of interest in the exposed and non-exposed not yield studies that qualified for inclusion in the review. refugee and internally displaced women, children, ado- A detailed discussion of the characteristics of each of the lescents, and families were extracted. For cross-sectional included studies is presented below. Citation: Glob Health Action 2014, 7: 23902 - http://dx.doi.org/10.3402/gha.v7.23902 3 (page number not for citation purpose) John E. Ehiri et al. Initial Articles (n=7043): � Pubmed/Medline (n=2968) � PsychINFO (n=1015) � CINAHL (n=1186) � Web of Science (n=605) � Sociological Abstracts (n=236) � Embase (n=1033) Duplicate articles (Excluded n=1133) Unique articles included (n=5910) Titles and abstracts screened (Excluded n=5401) Abstracts accepted (n=509) Full articles screened (Excluded n=500): � 5 repeated reports � 489 discussed training of Articles accepted (n=9) non-refugees; descriptive about refugee camps; Articles identified in references focused on training of of accepted articles (n=1) non-refugee community health workers; or Total articles included in systematic review (n=10): descriptive about refugee � Cross-sectional studies (n=5) camps. � Pre-post test (n=4) � 6 books � Post-test-only (n=1) Fig. 1. Literature search outputs. Chen et al. [Guinea] (12). This study-conducted by the 6 months to 5 years. Refugee health workers were trained Reproductive Health Group (RHG) across the Forest to provide health education using local beliefs, terminol- Region of Guinea-used refugee nurses and midwives, and ogy, and disease concepts via one-to-one discussions, trained lay refugee women as facilitators who provided informal group meetings, and disseminated informational sexual and reproductive health education to reproductive- materials. Eight refugee villages were selected; four were aged Liberian and Sierra Leonean refugees living in 48 assigned to an intervention and four to a control arm. camps. Through a multistage stratified cluster sampling, A post-intervention survey of 223 households from the 445 men and 444 women were surveyed to assess whether intervention villages and 177 households from control receiving sexual and reproductive health information villages revealed a significant difference in positive treat- from lay health workers, trained nurses/midwives, or ment-seeking behaviors in parents of children who had friends was associated with better knowledge of sexually been exposed to malaria education materials provided by transmitted infections (STIs) and better health seeking a lay health worker. behaviors related to sexual and reproductive health. Over- Howard et al. [Guinea] (19). The objective of this study all, participants reported a high prevalence of STIs in was to assess the effects of peer-refugee health educa- the last 12 months (30% women; 24% men). A marked tion on maternal health knowledge, attitudes, behaviors, gap in sexual health knowledge was also reported, as and maternal health outcomes. Using a refugee self-help only 25% correctly named key symptoms of STIs. Respon- model, refugee women mobilized other women who had dents who cited either the refugee nurses/midwives and expertise as nurses, and midwives, as well as other local lay lay health facilitators as their information source of refugee women, as health educators to provide education, sexual and reproductive health information demonstrated make referrals, and distribute contraceptives to women greater knowledge of STIs. Refugee nurses/midwives or in refugee communities. Local refugees were recruited lay health facilitators were more frequently cited than and trained to interview same-sex respondents. A cross- other sources as the suppliers of sexual and reproductive sectional survey on sexual and reproductive health atti- health information by men who correctly named key tudes related to family planning was administered to STI symptoms and by men and women who correctly 889 participants (445 men; 444 women). Contraceptive identified effective STI protection methods. use was shown to be markedly higher in areas served by Cropley [Belize] (23). This study used a controlled refugee health workers than in the refugees’ under-served post-test community-based study to assess the effects countries of origin or host countries (17% vs. 3.9% and of health education intervention provided by lay refugee 4.1%, respectively). health workers on child malaria treatment-seeking prac- Howard et al. [Guinea] (20). This was a cross-sectional tices among rural refugee mothers of children aged survey that assessed the effects of peer-refugee-led health 4 Citation: Glob Health Action 2014, 7: 23902 - http://dx.doi.org/10.3402/gha.v7.23902 (page number not for citation purpose) Training and deployment of lay refugees/IDPs Citation: Glob Health Action 2014, 7: 23902 - http://dx.doi.org/10.3402/gha.v7.23902 5 (page number not for citation purpose) Table 1. Characteristics and critical appraisal of included studies Author (year) Country Study design Objectives Study population Intervention and follow-up Outcomes measured Key study results Quality assessment Chen et al. Guinea Cross- A) To assess Reproductive-age RHG recruited refugee Sexual health needs, Respondents citing The analysis did not (2008) (12) sectional sexual health Liberian and Sierra nurses and midwives to knowledge and practices RHG facilitators as separate impact of needs, knowledge Leonean men (445) provide reproductive and among refugees, e.g. their information interventions delivered and practices and women (444) sexual health services for prevalence of reported STI source were more by refugee nurses and among refugees; from an estimated refugees in the Forest symptoms, knowledge likely to respond midwives from those B) to assess the population of Region of Guinea, and about symptoms and correctly about delivered by trained potential impact of 250,000 refugees trained refugee women as prevention of STIs, STIs; RHG refugee women who their work, in living in 48 camps lay health workers. treatment seeking and facilitators were served as lay health terms of increased across the Forest protective behavior more frequently workers; cross-sectional STI knowledge Region of Guinea. adopted by those cited than non- studies measure and more experiencing STI healthcare exposure and health appropriate STI- symptoms, and the information sources outcomes related behavior in potential impact of RHG’s in men who simultaneously. Thus, it clients. work in terms of increased correctly named the is difficult to determine STI knowledge and more key STI symptoms, the direction of the appropriate STI-related and in men and observed associations; behaviors. women who the study did not correctly identified measure the relationship effective STI between degree of protection exposure to RHG methods. interventions and health outcomes. Study findings were based on self-reports with high potential for social desirability. Cropley Belize Post-test To assess the Mothers of children In four of the eight villages, Changes in knowledge, Health education High potential for social (2004) (23) only effect of health aged 6 months to 5 refugee health workers attitudes, and child fever interventions  desirability; used a post- education years who resided were trained to provide and malaria treatment- interpersonal test only design, with intervention on in eight rural health education using seeking behaviors. communication in high potential for child malaria refugee local beliefs, terminology particular  inadequate treatment-seeking communities. and disease concepts appeared to have a comparability of practices among through one-to-one positive effect on intervention and control rural refugee discussions, informal fever and malaria communities at baseline. mothers. group meetings and beliefs, and on There was potential for material dissemination. positive treatment- contamination of the seeking behaviors. control communities. John E. Ehiri et al. 6 Citation: Glob Health Action 2014, 7: 23902 - http://dx.doi.org/10.3402/gha.v7.23902 (page number not for citation purpose) Table 1 (Continued ) Author (year) Country Study design Objectives Study population Intervention and follow-up Outcomes measured Key study results Quality assessment Howard Guinea Cross- To assess the Reproductive-age RHG recruited refugee Effect of peer refugee RHG facilitators The analysis did not et al. sectional effect of peer Liberian and Sierra nurses and midwives and health education and were the primary separate impact of (2008) (19) refugee health Leonean men (445) trained refugee women as reproductive service source of interventions delivered education on and women (444) lay health workers to delivery on access to reproductive health by refugee nurses and maternal health from an estimated provide sexual and reproductive health information for all midwives from those knowledge, population of reproductive and sexual information, approval of respondents. delivered by trained attitudes and 250,000 refugees health education. family planning services, Contraceptive use refugee women who behaviors and living in 48 camps use of contraceptive, in the camps served as lay health maternal health across the Forest perceived service quality, served by RHG was workers; cross-sectional outcomes. Region of Guinea. service, risk of unintended much higher than studies measure pregnancy. typical for either exposure and health refugees’ country of outcomes origin or the host simultaneously. Thus, it country, but the risk is difficult to determine of unwanted the direction of the pregnancy observed associations; remained the study did not considerable. measure the relationship between degree of exposure to RHG interventions and health outcomes. Study findings were based on self-reports with high potential for social desirability. Howard Guinea Cross- To assess 444 reproductive- RHG recruited refugee Effect of peer refugee led Most respondents The analysis did not et al. sectional maternal health age Liberian and nurses and midwives and health education on said pregnant separate impact of (2011) (20) outcomes in Sierra Leonean trained refugee women as knowledge of danger signs women should interventions delivered relation to women in 48 lay health workers to of complications during attend antenatal by refugee nurses and refugee-led health camps across the provide sexual and pregnancy, knowledge of care and knew the midwives from those education, formal Forest Region of reproductive and sexual the importance of skilled importance of delivered by trained education, age Guinea. health education. attendant at birth, use of tetanus refugee women who and parity. family planning, sexual vaccination. Most served as lay health health services, and use of recognized workers; cross-sectional ante-natal care services. maternal danger studies measure signs and exposure and health Training and deployment of lay refugees/IDPs Citation: Glob Health Action 2014, 7: 23902 - http://dx.doi.org/10.3402/gha.v7.23902 7 (page number not for citation purpose) Table 1 (Continued ) Author (year) Country Study design Objectives Study population Intervention and follow-up Outcomes measured Key study results Quality assessment . recommended outcomes facility attendance simultaneously. Thus, it for these. Higher is difficult to determine odds of facility the direction of the delivery were found observed associations; for those exposed the study did not to RHG health measure the relationship education. No between degree of significant exposure to RHG differences were interventions and health found in knowledge outcomes. Study or attitudes. findings were based on self-reports with high potential for social desirability. Lee et al. Myanmar Pre- and To assess the Internally displaced Staff from the local health Internally displaced The intervention Although the study (2009) (26) post-test impact of training Myanmar villagers. department trained villagers performed demonstrated that demonstrated the ability study and deploying internally displaced malaria diagnosis, internally displaced of trained displaced internally villagers who lived in the treatment, vector control villagers were able villages to contribute to displaced villagers malaria program’s target and malaria education in to deliver essential significant expansion of on expansion of communities and were conflict areas. malaria control malaria treatment and malaria control familiar with other village interventions in prevention services, interventions members. These village areas of active evidence of quality or among IDPs. health workers were conflict in eastern outcomes of services trained in malaria Burma. Program provided by the trained diagnosis and treatment, expanded from villagers was not and vector control and 3,000 internally provided. education. displaced villagers to 40,000 in 5 years. Minden Thai- Pre- and To train refugee Scattered refugee Young camp members Qualitative outcomes Trained refugees Weak design. A more (1997) (27) Myanmar post-test community health camps in remote (with formal education related to complications were able to complete evaluation of Border study workers and areas along the from grade 4 to grade 10) surrounding pregnancy diagnose and treat the quality and health traditional birth Thai-Myanmar were trained to diagnose were discussed. common illnesses outcomes associated attendants to border. and treat common using drugs, with services provided provide basic illnesses. A small subset of injections and by the trained refugee reproductive the group received 618 intravenous health workers is needed John E. Ehiri et al. 8 Citation: Glob Health Action 2014, 7: 23902 - http://dx.doi.org/10.3402/gha.v7.23902 (page number not for citation purpose) Table 1 (Continued ) Author (year) Country Study design Objectives Study population Intervention and follow-up Outcomes measured Key study results Quality assessment health services, month medical training. infusions according to strengthen evidence and to diagnose Female community health to Medecins Sans of health effects of their and treat common workers were also Frontieres services. illnesses using selected to receive special guidelines. They drugs. training in maternal health prevented and to become midwives. problems, Traditional birth attendants recognized illness were also trained. early and provided treatment before complications escalated to emergencies. They were able to foresee an emergency and to stabilize the mother and/or baby while they found transportation to a hospital. Mullany Myanmar Pre- and To examine the Internally displaced In target communities, Survey to assess effect of Use of modern Weak design. A more et al. post-test feasibility of a Myanmar women local health workers and the intervention on access methods of birth complete evaluation of (2010) (24) study network of of reproductive traditional birth attendants to antenatal and postnatal control increased the quality and health community-based age. were trained in basic care, presence of skilled and births attended outcomes associated providers for emergency obstetric care, attendant at birth, and use by those trained to with services provided delivery of blood transfusion, of family planning services. deliver elements of by the trained refugee maternal health antenatal care and family emergency care health workers is needed interventions. planning. increased almost to strengthen evidence 10-fold. of health effects of their services. Rijken Thai- Pre- and To assess intra- 349 pregnant A 3-month course of Intra- and inter-observer Measurements Weak design. A more et al. Myanmar post-test observer and women and local practical and theoretical agreement of fetal made by local complete evaluation (2009) (25) Border study inter-observer Myanmar health training in obstetric biometry measured by health workers of the quality and agreement of fetal workers. ultrasound imaging based trained displaced health during obstetric health outcomes biometry by locally on World Health workers and those of the ultrasound imaging associated with services trained Organization guidelines expatriate doctor. showed high provided by the trained refugee Training and deployment of lay refugees/IDPs Citation: Glob Health Action 2014, 7: 23902 - http://dx.doi.org/10.3402/gha.v7.23902 9 (page number not for citation purpose) Table 1 (Continued ) Author (year) Country Study design Objectives Study population Intervention and follow-up Outcomes measured Key study results Quality assessment refugee health and British Medical levels of agreement health workers is needed workers in a Ultrasound Society with those of the to strengthen evidence refugee camp. recommendations. doctor. of health effects of their services. Tanaka Tanzania Cross- To assess the 576 refugees, 48 Refugee health workers Personal profiles of Refugee health The refugees were not et al. sectional impact of refugee refugee health identified health needs, refugee health workers, workers formally trained, but (2004) (22) participation in workers, 17 red made health decisions and health status, social experienced instead, used their own camp health cross volunteers, assumed the responsibility support, and knowledge of increased self- initiatives. Being a services provision. Congolese refugee to meet these needs in refugee health workers. confidence and cross-sectional study, community order to strengthen the promoted health it was not possible to members, refugee refugee community and to education. establish causal health workers, improve their health. Refugees who did relationships between and Tanzanian Red not know a refugee the number of refugee Cross staff. health worker HIT members known by had less positive refugees and health health seeking outcomes. behaviors than those who knew a refugee health worker. Woodward Guinea Cross- To assess whether 889 reproductive- RHG recruited refugee Effect of peer-refugee Refugee-led health The analysis did not et al. sectional exposure to peer age men and nurses and midwives to education on HIV education was separate impact of (2011) (21) refugee health women in 23 provide reproductive and knowledge, attitudes, and most strongly interventions delivered education was camps in the sexual health services, and safe-sex practices. associated with by refugee nurses and associated with Forest Region of trained refugee women as reported HIV- midwives from those improved HIV Guinea. lay health workers. avoidant behavior delivered by trained knowledge, change. Refugee refugee women who attitudes, or women were more served as lay health practices among likely to report HIV workers; cross-sectional refugees. risk and less likely studies measure to report making exposure and health behavioral outcomes changes. Of those simultaneously. Thus, it exposed to is difficult to determine refugee-led the direction of the observed. John E. Ehiri et al. education related to the danger signs of complications during pregnancy, knowledge of the importance of skilled attendants at birth, the use of family planning and sexual health services, and the use of ante-natal care services among 444 reproductive-age Liberian and Sierra Leonean women in 48 camps across the Forest Region of Guinea. Participants were considered ‘exposed’ to this education if they had previously participated in a peer-refugee faci- litated drama group or received information on family planning by a peer-refugee health worker. Although no difference was found in maternal knowledge or attitudes, those exposed to peer refugee-led activities had higher odds of delivery in a health facility than those who were unexposed (OR 2.13, 95% CI 1.213.75). Lee et al. [Myanmar] (26). This study used a pre- and post- test design to assess the impact of training and deploying internally displaced villagers to conduct malaria control interventions among IDPs. Staff from the local health department trained internally displaced villagers who lived in the malaria program’s target communities and were familiar with other village members. These village health workers were trained in malaria diagnosis, treatment, and vector control. Specifically, they were trained to perform a comprehensive set of malaria interventions, including promoting of the use of long-lasting malaria nets, detect- ing of early signs and symptoms of malaria, and providing treatment in an active civil conflict area. The intervention demonstrated that internally displaced villagers were able to deliver essential malaria control interventions in areas of active conflict in eastern Burma. Program coverage was expanded from 3,000 to 40,000 internally displaced villagers in 5 years. Minden [Thai-Myanmar Border] (27). This study used a pre- and post-test design to assess the impact of using trained refugee community health workers and traditional birth attendants to provide basic reproductive health ser- vices and to diagnose and treat common illnesses among refugees in camps. Qualitative assessment revealed that the trained refugee health workers were able to diag- nose and treat common illnesses using drugs, injections, and intravenous infusions according to Medecins Sans Frontieres’ guidelines (28). The trained health workers were able to prevent problems, recognize illness early, and provide treatment before complications escalated to emergencies. They were also able to foresee potential emer- gencies and were able to stabilize the mothers and/or babies while seeking transportation to a hospital. Mullany et al. [Myanmar] (24). This study used a pre- and post-intervention design to assess the feasibility of a net- work of community-based providers to deliver maternal health interventions in the complex emergency setting of eastern Burma. In target communities, lay health workers and traditional birth attendants were trained in basic emergency obstetric care, blood transfusion, antenatal care, and family planning. A post-intervention survey was 10 Citation: Glob Health Action 2014, 7: 23902 - http://dx.doi.org/10.3402/gha.v7.23902 (page number not for citation purpose) Table 1 (Continued ) Author (year) Country Study design Objectives Study population Intervention and follow-up Outcomes measured Key study results Quality assessment education, women associations; the study had greater odds did not measure the than men of relationship between reporting HIV- degree of exposure to avoidant changes. RHG interventions and health outcomes. Study findings were based on self-reports with high potential for social desirability. Training and deployment of lay refugees/IDPs conducted to assess the effects of the intervention on and compared with HIV outcomes using logistic regres- accessing ante- and post-natal care, skilled attendants at sion odds ratios. The results of these analyses showed births, and family planning services. Results showed that, that exposure to peer refugee health education was asso- following intervention, use of insecticide-treated mosqui- ciated with awareness of HIV/AIDS and reduced mis- to nets increased, as did use of modern contraceptives. conceptions about the disease. Overall, participants Births attended by those trained to deliver elements of who were exposed to peer refugee education had more emergency care increased about 10-fold. than twice the odds of reporting having made HIV- Rijken et al. [Thai-Myanmar Border] (25). This study avoidant behavioral changes than those who were un- used a pre- and post-test design to assess the effects of a exposed (72% versus 58%; adjusted OR 2.49, 95% CI 3-month practical and theoretical training for lay refugee 1.524.08) (21). health workers aimed at equipping them with skills in conducting obstetric ultrasound imaging based on World Critical appraisal of data on impact of use of Health Organization guidelines and British Medical Ultra- lay refugee health workers sound Society recommendations. Post-test assessments As shown in Table 1, all of the included studies dem- measured intra-observer and inter-observer agreement onstrated some positive impact on population health of fetal biometry in 349 pregnant women measured outcomes as a result of training and deployment of lay by trained displaced health workers compared to those refugee/IDP health workers in camps. The reported effects conducted by an expatriate physician. Measurements by included improvements in knowledge, attitudes, and refugee health workers showed high levels of agreement practices related to various sexual, reproductive and other with those of the physician, demonstrating that locally maternal and child health issues. Specific examples in- trained health workers from refugee camps could ade- cluded increased knowledge about the symptoms and quately conduct obstetric ultrasound imaging. prevention of STIs, improved treatment-seeking and Tanaka et al. [Tanzania] (22). This was a cross-sectional protective behavior adopted by those experiencing STI study in the Lugufu refugee camp in Tanzania, which symptoms, and uptake of family planning services. Other hosted refugees from Burundi, Rwanda, and the Demo- reported changes included improvements in child fever cratic Republic of Congo (DRC). At the time of the study, and malaria treatment-seeking behaviors, and improved Lugufu Camp was hosting an estimated 50,400 Congolese access to reproductive health information. One study, refugees, with an average of 1,000 people arriving each which assessed the effect of peer refugee health education month as a result of the continuing conflict in the DRC on maternal health knowledge, attitudes, behaviors and (22). The camp had a health information team (HIT) maternal health outcomes (19), did not demonstrate comprised of Congolese refugees (one HIT member/1,000 marked reduction in unintended pregnancies among population) who provided health services under the super- refugee women. For the purpose of this review, study vision of health staff of the Tanzanian Red Cross Society quality assessment revealed that all included studies were (TRCS) (22). The majority of the sampled community of poor quality. For example, in five of the included members and TRCS health staff affirmed the positive studies (12, 1821), the analysis did not separate impact contribution of HIT to refugee health (89.2 and 100%, of interventions delivered by refugee nurses and mid- respectively). Seventy-nine percent of the sampled ref- wives from those delivered by trained refugee women who ugee community members reported that they learned served as lay health workers. Cropley (23) used a post- about illness prevention from the HIT. Also, HIT was test only design. The lack of comparability of interven- the education method most highly rated by the refugee tion and control communities at baseline raises concerns community, both for learning how to prevent illnesses about internal validity (29), i.e. the approximate truth of (56.3%) and for learning how to treat mild diarrhea inferences regarding causal relationships. Although the (50.0%). The role played by the HIT as a liaison between study by Lee et al. (26) demonstrated the ability of trained the refugee community and health services was recognized displaced villages to contribute to significant expansion by 85.2% of the refugees surveyed; refugee community of malaria treatment and prevention services, it did not members who did not know a HIT member demonstrated assess the quality or outcomes of services provided by less positive health seeking behaviors than those who the trained lay refugee villagers. Minden (27), Mullany knew one or more HIT members (22). et al. (24), and Rijken et al. (25) used the before-and-after Woodward et al. [Guinea] (21). This was a cross-sectional design in assessing the effectiveness of trained lay refugee study designed to assess the association between exposure community health workers and traditional birth atten- to refugee peer education and improved HIV knowledge, dants in providing basic reproductive health services, attitudes, or practice outcomes among refugees in Guinea. and in diagnosing and treating common illnesses. Be- Data were collected from 889 reproductive-age men and fore-and-after design is relatively cheap to implement and women in 23 camps in the Forest Region of Guinea, and useful in addressing potential ethical concerns that may exposure to peer refugee led education was analyzed be associated with randomized studies or prospective Citation: Glob Health Action 2014, 7: 23902 - http://dx.doi.org/10.3402/gha.v7.23902 11 (page number not for citation purpose) John E. Ehiri et al. cohort designs. However, the lack of a comparison group and promotora approaches that have been shown to limits the degree to which observed health outcomes can be beneficial in helping to meet the healthcare needs of be attributed to services provided by lay refugee workers. women and children in resource-poor settings globally Outcome measures assessed by all studies (12, 1827) were (36), lay refugees and IDPs who reside in camps could based on self-reports, which are known to be subject to the potentially help ease reliance on foreign health pro- effects of social desirability (30). More importantly, none fessionals, improve access and coverage, and empower of the studies assessed the relationship between the degree women to enhance their health and the health of their of exposure to interventions provided by lay refugee children and families. Whereas anecdotal evidence sug- workers and health outcomes. gests that training and deployment of lay refugees and IDPs have public health benefits, no reviews have sought to assess and critically appraise the evidence base of this Discussion intervention to facilitate policy recommendations. There- Globally, a shortage of human resources for the health fore, in order to address this gap in knowledge, we con- sector is widely acknowledged as a key barrier against ducted a systematic review and critical appraisal of the provision of essential health services (31). The burden available data. of health workforce shortage is more acute in low- An exhaustive search of the literature yielded only 10 income countries, especially those experiencing conflicts studies that attempted to assess the role of lay refugees and emergencies, when the few available health workers and IDPs in reproductive health service provision in are forced to flee, health infrastructures are destroyed, and camps. All of the included studies reported some posi- resources for the health sector are diverted to other uses. tive impact association with training and deployment Available evidence shows that community health workers of lay refugee/IDP health workers in camps. The reported have the potential to be part of the solution to the human effects ranged from improvements in knowledge, atti- resource crisis that is affecting many countries (32, 33), tudes, and health seeking behavior; an increased efficacy and scaling up training and deployment of community to treat mild diarrhea; a capacity to conduct obstetric health workers is one of the strategies identified in ultrasound imaging; an ability to diagnose and treat the Kampala Declaration and the Agenda for Global minor conditions (including malaria and STIs); to an Action (34). A systematic review conducted by the Global increased uptake of family planning services. While these Health Workforce Alliance and the United States Agency findings are important, the current body of evidence is for International Development (USAID) to elucidate the weak, and there remains a paucity of high quality effectiveness of community health workers concluded evaluation studies of the impact of using trained lay that adequate training, integration, and supervision of refugees and IDPs to provide health services to camp community health workers has the potential to contri- dwellers. bute to an equitable and cost-effective scale-up of service coverage, while leading to tangible improvements in health outcomes (28). Limitations In light of evidence regarding the effectiveness of lay As noted earlier, this review included studies that used a workers in population health improvement, there is a wide variety of designs (cross-sectional, post-test only, and need to re-evaluate how camps for refugees and IDPs are pre- and post-test) that have significant inherent limita- organized and the way services are provided for women tions, especially regarding internal validity. For example, and children who reside in camps. With a five-fold cross-sectional studies measure exposure and health out- increase in emergencies caused by natural disasters and/ comes simultaneously. Thus, it is difficult to determine or conflicts over the past decade, it has become increas- the direction of the observed associations. Post-test only ingly difficult for international relief agencies to keep pace studies lack baseline comparability of intervention and (35). Camps are resource-limited settings. As such, avail- control communities; before-and-after studies lack appro- able resources and services become quickly depleted with priate comparison groups. Although many international time. There is a need to train and effectively deploy lay health agencies are involved in emergency response ac- refugees and IDPs in order to sustain access to health tivities globally, none was able to provide information basic health services. Lay-refugee and internally displaced on evaluated studies of interventions that involved the women who reside in camps have life experiences that use of refugees and/or IDPs to provide maternal and are similar to those of other women in the camps. They child health services in camps. This raises concerns about also have valuable health-related cultural knowledge that the value placed on evidence-based practice in interna- expatriates may not have (17, 31). Thus, there is the per- tional emergency response activities. However, it should ception that, if trained and adequately supported, they be understood that camps are resource-limited settings. can be well-positioned to provide culturally appropriate Under emergency situations, where the primary health support that is better targeted to the needs of women and objective is to ensure safety and access to basic services for children in the camps. Similar to the village health-worker refugees and IDPs, it may be difficult to commit limited 12 Citation: Glob Health Action 2014, 7: 23902 - http://dx.doi.org/10.3402/gha.v7.23902 (page number not for citation purpose) Training and deployment of lay refugees/IDPs 2. United Nations High Commissioner for Refugees (2013). resources to planning and implementing rigorous evaluation Internally displaced people: on the run in their own land. studies. It may also be difficult to employ such rigorous Geneva: Switzerland. evaluation designs as the randomized controlled trial 3. United Nations Commission for Refugees (2012). Displace- (RCT) due to ethical reasons. Thus, notwithstanding these ment: the new 21st century challenge. UNHCR Global Trend challenges, it is important to note that time, money, and 2012. Geneva: Switzerland. 4. Spiegel PB, Bennedsen AR, Claass J, Bruns L, Patterson N, efforts expended on activities of questionable impact have Yiweza D, et al. Prevalence of HIV infection in conflict-affected opportunity costs. To the extent that is reasonably prac- and displaced people in seven sub-Saharan African countries: a ticable, interventions that train and deploy lay refugees systematic review. Lancet 2007; 369: 218795. and IDPs as healthcare workers should be rigorously 5. Kalipeni E, Oppong J. The refugee crisis in Africa and impli- evaluated in order justify resource. cations for health and disease: a political ecology approach. Soc Sci Med 1998; 46: 163753. 6. Southall D. Armed conflict women and girls who are pregnant, Implications for research and practice infants and children: a neglected public health challenge, What To further elucidate the strength of the association be- can health professionals do? Early Hum Dev 2011; 87: 73542. tween training and deployment of lay refugee/IDP health 7. Ouyang H. Syrian refugees and sexual violence. Lancet 2013; 381: 216566. workers and the quality of basic health services in camps, 8. Moszynski P. Darfuri refugees in Chad have no escape from there is a need for high quality follow-up studies con- sexual violence. BMJ 2009; 30; 339: b3998. ducted in different geographical regions of the world 9. Bastick M, Grimm K, Kunz R. Sexual violence in armed and among individuals of diverse racial/ethnic cultural conflict. Geneva: Center for the Democratic Control of Armed backgrounds. Currently, available evidence reflects an Forces; 2007. 10. Ward J, Marsh M. Sexual violence against women and girls in urgent need for adopting a more evidence-based prac- war and its aftermath: realities, responses, and required resources. tice approach. While it is true that the most important A Briefing Paper Prepared for Symposium on Sexual Violence objective when organizing such training interventions as in Conflict and Beyond, Brussels, Belgium, 2123 June 2006. described above, is to promote population health, efforts 11. The SPHERE Project. The Sphere Handbook: humanitarian should also be made where possible to strengthen the charter and minimum standards in humanitarian response. Geneva: Switzerland; 2012 mechanisms for collecting the best evidence to advocate 12. Chen MI, von Roenne A, Souare Y, von Roenne F, Ekirapa A, for more training programs and to facilitate the replica- Howard N, et al. Reproductive health for refugees by refugees in tion of best practices in other settings. Studies that assess Guinea II: sexually transmitted infections. Conflict Health 2008; the quality of services provided by lay refugee/IDP health 2: 14. workers in camps are needed, as are studies that demon- 13. Chynoweth SK. The need for priority reproductive health services for displaced Iraqi women and girls. Reprod Health strate the effects of such hard outcome measures as Matters 2008; 16: 93102. reduced morbidity and mortality or positive measures 14. United National High Commissioner for Refugees [UNHCR]. of health and wellness, rather than simply changes in Ensuring access to health care operational guidance on refugee knowledge and attitudes. protection and solutions in urban areas. Geneva, Switzerland: United National High Commission for Refugees [UNHCR], Division of Programme Support and Management, Public Conclusion Health and HIV Section. 2011. Available from: http://www. While available evidence suggests a positive impact of refworld.org/pdfid/4e27d8622.pdf Apr 10, 2011 - refugees to training and deployment of lay refugee/IDP health work- access qu [cited 23 September 2014]. ers to provide basic maternal health services in camps, the 15. Loewenberg S. Libyan exodus creates refugee and health worker body of evidence is weak and calls for a re-examination crisis. Lancet 2011; 377: 98283. 16. Soliman HH, Gillespie DF. A test of stress theory: relief workers of current practices. It is important that every interven- in refugee camps. Disasters 2011; 35: 789800. tion includes a strong evaluation component to better 17. Wells G, Shea B, O’Connell D, V Welch, M Losos, Tugwell P. elucidate the extent to which changes in outcomes can The NewcastleOttawa Scale (NOS) for assessing the quality be attributed to interventions provided by lay refugee/IDP of nonrandomized studies in meta-analyses. Proceedings of the health workers in camps. 3rd symposium on systematic reviews: beyond the basics; Jul 35; St Catherine’s College. Centre for Statistics in Medicine, Oxford, UK, 2000. Conflict of interest and funding 18. National Collaborating Centre for Environment Health (2011). A primer for evaluating the quality of studies on environmental The authors have not received any funding or benefits from health critical appraisal of cross-sectional studies. Available industry or elsewhere to conduct this study. from: http://www.ncceh.ca/sites/default/files/Critical_Appraisal_ Cross-Sectional_Studies_Aug_2011.pdf [cited 16 September 2014]. References 19. Howard N, Kollie S, Souare Y, von Roenne A, Blankhart D, 1. United Nations High Commission for Refugees (1951). Con- Newey C, et al. Reproductive health services for refugees by vention and protocol relating to the status of refugees. Geneva: refugees in Guinea I: family planning. Conflict Health 2008; 2: Switzerland. 12. doi: 10.1186/1752-1505-2-12. Citation: Glob Health Action 2014, 7: 23902 - http://dx.doi.org/10.3402/gha.v7.23902 13 (page number not for citation purpose) John E. Ehiri et al. 20. Howard N, Woodward A, Souare Y, Kollie S, Blankhart D, 28. Medecins sans Frontieres. Clinical guidelines: diagnosis and von Roenne A, et al. Reproductive health for refugees by treatment manual for curative programs in hospitals and dis- refugees in Guinea III: maternal health. Conflict Health 2011; pensaries. 2013 Edition. Available from: http://refbooks.msf.org/ 5: 5. doi: 10.1186/1752-1505-5-5. msf_docs/en/clinical_guide/cg_en.pdf [cited 16 September 2014]. 21. Woodward A, Howard N, Souara Y, Kollie S, von Roenne 29. Trochim WMK. Social research methods: knowledge base. A, Borchert M. Reproductive health for refugees by refugees Internal validity. 2008. Available from: http://www.socialre in Guinea IV: peer education and HIV knowledge, attitudes, searchmethods.net/kb/intval.php [cited 16 September 2014]. and reported practices. Conflict Health 2011; 5: 10. doi: 10. 30. Van de Mortel TF. Faking it: social desirability response bias in 1186/1752-1505-5-10. self-report research. Aust J Adv Nurs 2008; 25: 4048. 22. Tanaka Y, Kunii O, Okumura J, Wakai S. Refugee participa- 31. O’Brien P, Gostin LO. Health worker shortages and tion in health relief services during the post-emergency phase global justice. New York: Milbank Memorial Fund. Available in Tanzania. Public Health 2004; 118: 5061. doi: 10.1016/ from: http://www.milbank.org/uploads/documents/HealthWorker S0033-3506(03)00137-9. Shortagesfinal.pdf [cited 16 September 2014]. 23. Cropley L. The effect of health education interventions on child 32. World Health Organization (2010). Global experience of com- malaria treatment-seeking practices among mothers in rural munity health workers for delivery of health related millennium refugee villages in Belize, Central America. Health Promoti Int development goals: a systematic review, country case studies, 2004; 19: 44552. doi: 10.1093/heapro/dah406. and recommendations for integration into National Health 24. Mullany LC, Lee TJ, Yone L, Lee CI, Teela K, Paw P, et al. Systems. Geneva: World Health Organization/Global Health Impact of community-based maternal health workers on cover- Workforce Alliance. age of essential maternal health interventions among internally 33. World Health Organization (2010). Increasing access to health displaced communities in eastern Burma: the MOM Project. workers in remote and rural areas through improved reten- PLoS Med 2010; 7: e1000317. tion: global policy recommendations. Geneva: World Health 25. Rijken MJ, Lee SL, Boel ME, Papageorghiou AT, Visser GH, Organization. Dwell SL, et al. Obstetric ultrasound scanning by local health 34. World Health Organization (2008). Health workers for all and workers in a refugee camp on the ThaiBurmese border. Ultra- all for health worker: The Kampala Declaration and Agenda sound Obstet Gynecol 2009; 34: 395403. doi: 10.1002/uog. for Global Action. Geneva: World Health Organization. Global Health Workforce Alliance. 26. Lee CI, Smith LS, Shwe Oo EK, Scharschmidt BC, Whicard E, 35. Majewski B, Navangul KA, Heigh I. A peek into the future of Kler T, et al. Internally displaced human resources for health: humanitarian logistics: forewarned is forearmed. Supply Chain villager health worker partnerships to scale-up a malaria control programme in active conflict areas of eastern Burma. Glob Forum  Int 2010; 11(3): 419. Public Health 2009; 4: 22941. doi: 10.1080/17441690802676360. 36. Lucio RL, Zuniga GC, Seol YH, Garza N, Mier N, Trevino L. 27. Minden M. Midwives for refugees. World Health 1997; 50: Incorporating what promotoras learn: becoming role models to 189. effect positive change. J Community Health 2012; 37: 102631. 14 Citation: Glob Health Action 2014, 7: 23902 - http://dx.doi.org/10.3402/gha.v7.23902 (page number not for citation purpose) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Global Health Action Taylor & Francis

Training and deployment of lay refugee/internally displaced persons to provide basic health services in camps: a systematic review

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Global Health Action REVIEW ARTICLE Training and deployment of lay refugee/internally displaced persons to provide basic health services in camps: a systematic review 1 2 3 1,4 John E. Ehiri *, Jayleen K.L. Gunn , Katherine E. Center , Ying Li , 1 5 Mae Rouhani and Echezona E. Ezeanolue Division of Health Promotion Sciences/Global Health Institute, Mel & Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA; Division of Epidemiology and Biostatistics, Mel & Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA; Department of Obstetrics and Gynecology, University of Arizona, Tucson, AZ, USA; Department of Social Medicine & Health Service Management, Third Military Medical University, Chongqing, China; Department of Pediatrics, University of Nevada School of Medicine, Las Vegas, NV, USA Background: Training of lay refugees/internally displaced persons (IDPs) and deploying them to provide basic health services to other women, children, and families in camps is perceived to be associated with public health benefits. However, there is limited evidence to support this hypothesis. Objectives: To assess the effects of interventions to train and deploy lay refugees and/or IDPs for the provision of basic health service to other women, children, and families in camps. Methods: PubMed, Science and Social Science Citation Indices, PsycINFO, EMBASE, POPLINE, CINAHL, and reference lists of relevant articles were searched (from inception to June 30, 2014) with the aim of identifying studies that reported the effects of interventions that trained and deployed lay refugees and/or IDPs for the provision of basic health service to other women, children, and families in camps. Two investigators inde- pendently reviewed all titles and abstracts to identify potentially relevant articles. Discrepancieswere resolved by repeated review, discussion, and consensus. Study quality assessment was undertaken using standard protocols. Results: Ten studies (five cross-sectional, four pre-post, and one post-test only) conducted in Africa (Guinea and Tanzania), Central America (Belize), and Asia (Myanmar) were included. The studies demonstrated some positive impact on population health associated with training and deployment of trained lay refugees/ IDPs as health workers in camps. Reported effects included increased service coverage, increased knowledge about disease symptoms and prevention, increased adoption of improved treatment seeking and protective behaviors, increased uptake of services, and improved access to reproductive health information. One study, which assessed the effect of peer refugee health education on sexual and reproductive health, did not demon- strate a marked reduction in unintended pregnancies among refugee/IDP women. Conclusion: Although available evidence suggests a positive impact of training and deployment of lay refugees/ IDPs as health workers in camps, existing body of evidence is weak, and calls for a re-examination of current practices. Interventions that promote training and deployment of lay refugees/IDPs as health workers in camps should include strong evaluation components in order to facilitate assessment of effects on popu- lation health. Keywords: maternal health; reproductive health; refugees; internally displaced persons; child health Responsible Editor: Isabel Goicolea, Umea˚ University, Sweden. *Correspondence to: John E. Ehiri, Division of Health Promotion Sciences, Mel & Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA, Email: [email protected] Received: 23 January 2014; Revised: 1 September 2014; Accepted: 2 September 2014; Published: 1 October 2014 lthough the value of using local community on expatriate health workers. Often, this dependence health workers in the provision of basic health raises concerns about the long-term sustainability, cost- Aservices is widely acknowledged, many health effectiveness, and cultural appropriateness of programs and development agencies working in camps for refugees and services. The focus of this review is to summarize and and internally displaced persons (IDPs) continue to rely critically appraise evidence regarding both the capacity Global Health Action 2014.# 2014 John E. Ehiri et al. This is an Open Access article distributed under the terms of the Creative Commons CC-BY 4.0 License 1 (http://creativecommons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix,transform,and build upon the material for any purpose, even commercially, provided the original work is properly cited and states its license. Citation: Glob Health Action 2014, 7: 23902 - http://dx.doi.org/10.3402/gha.v7.23902 (page number not for citation purpose) John E. Ehiri et al. of refugee and/or internally displaced women residing and 4) chronic disruption of services. Although several in camps to provide health services to other women and international initiatives have sought to unite aid agencies children in these camps and the effectiveness of such that respond to the needs of refugees and IDPs (11), services. Anecdotal evidence suggests that with adequate attempts to empower displaced women in camps to take training, proper supervision, and support, refugee and/ control over, and improve their own health have been or internally displaced women are able to provide basic limited. With the escalation of conflicts and emergencies health services to other women, children and families in globally, gaps in access to essential health services for camps while avoiding the challenge of ensuring cultural women and children in camps continue to occur (1214). appropriateness and sustainability that are often asso- With the flight of local health workers, the burden of ciated with transient expatriate personnel. health services typically rests on just a few foreign aid A refugee is defined as someone who has fled his or workers, severely limiting service coverage (15, 16). This her country of nationality to find protection from war problem calls for a paradigm shift in efforts to address or from persecution based on race, religion, nationality, the maternal and child-health needs of refugees and IDPs membership of a specific political party and/or political in camps using available local human resources. Over the years, a number of intervention studies have been opinion (1, 2). ‘Unlike refugees, IDPs have not crossed an conducted in which refugee and/or internally displaced international border to find sanctuary, but have remained women residing in camps were provided with targeted inside their home countries. As such, IDPs are legally training in specific basic health services related to mater- under the protection of their own government, even if nal, newborn, and child-health services to other women that government was the cause of their flight’ (2, p. 1). and families in their camps, and later deployed to apply the Also included in the definition of IDPs are civilians who resultant knowledge and skills. Anecdotal evidence sug- are made homeless by natural disasters (3). At the end of gests that such training and deployment have public health 2011, the United Nations High Commission for Refugees benefits but few reviews have articulated this evidence. (UNHCR) reported that they were providing services for This review therefore, is an effort to address this gap an estimated 26.4 million people worldwide who have in knowledge. been displaced because of conflict or persecution (3). Of this number, an estimated 10.4 million were refugees and 15.6 million were IDPs (3). In addition, UNCHR Methods estimates that nearly half of the population of refugees and IDPs were females (3). Globally, sub-Saharan Africa Search strategy and selection criteria is disproportionately affected by conflicts and emergen- The following electronic databases were searched from cies that have resulted in large numbers of refugees and inception to June 30, 2014: PsycINFO, PubMed, Web of IDPs (34% of the global total) (4). Political, religious, Science, CINAHL, Sociological Abstracts, Embase, and and ethnic disputes are significant factors contributing Internet (Google and Google Scholar). The search was not to these high numbers. For example, the genocide in restricted by publication status or language. The following Rwanda resulted in 1.7 million refugees; the conflicts in search terms were first created for a search in PubMed, Liberia 750,000, and the Somalia conflict, 450,000 (5). and later adapted for the other databases: (‘Community As the world continues to experience increases in con- Health Workers’ OR ‘Health Personnel’ OR ‘Volunteers’ flicts and emergencies, health workers and international OR ‘Health Services’ OR ‘Delivery of Health Care’ OR health agencies are confronted with the challenge of volunteer OR ‘health worker’ OR ‘health auxiliary’ OR protecting the health of displaced populations. Women, ‘relief work’ OR ‘relief worker’ OR ‘health care delivery’ infants, and children are often severely affected, not by OR peer); (‘Refugees’ [Mesh] OR ‘refugee camps’ OR the direct effects of weapons, but by displacement, gender- ‘internally displaced’); #1 AND #2. We hand-searched based violence, preventable illness, malnutrition, and inad- reference lists of identified articles, and contacted bilateral equate sexual and reproductive health services (6). Women agencies and non-governmental organizations (NGOs) and children are at increased risk for poor health when whose programs may include interventions for refugees community resources and networks that serve as their and/or IDPs with a request for information on previous safety nets are disrupted. Sexual violence and abuse are and ongoing studies. Three reviewers (JE, JG, and YL) also of particular concern for women and girls (710). coordinated the literature searches. Why it is important to do this review Inclusion/exclusion criteria As available evidence shows, major health challenges that 1) Types of study: We attempted to identify studies that often confront refugee and internally displaced women, assessed the capacity of lay women who were refugees children, adolescents and families include: 1) limited or internally displaced, to provide basic health services access to health services, 2) increased predisposition to to maternal and child populations (women, children, and sexual and reproductive health risks, 3) under-nutrition, adolescents) in camps for refugees and/or IDPs and the 2 Citation: Glob Health Action 2014, 7: 23902 - http://dx.doi.org/10.3402/gha.v7.23902 (page number not for citation purpose) Training and deployment of lay refugees/IDPs outcomes of such services. We excluded repeated reports, studies, data on the number of persons in the study groups books, studies that provided general discussion about and number of persons exposed/unexposed to health out- training of non-refugee community health workers, and comes of interest were extracted from the comparison descriptive papers on refugees and IDPs in camp settings. groups. We also extracted data on sample size, ages of Studies that assessed the effectiveness of services provided individuals in the study, and data collection methods. by trained local or expatriate health workers such nurses, doctors, and other skilled medical and allied health Study quality assessment professionals. Given the ethical and logistical challenges We assessed the quality of cohort studies using the of conducting randomized controlled trials under camp NewcastleOttawa Scale (17). In addition, we assessed settings and the dearth of empirical evidence on the the representativeness of the exposed cohort in the study subject, we sought to include a wide variety of studies in setting; the selection of non-exposed cohorts; the ascer- order to capture as much available data as possible. Thus, tainment of exposure; the demonstration that outcome of we included cohort studies, cross-sectional studies, con- interest was not present at start of study; the comparability trolled pre-and-post studies, controlled post-test studies, of cohorts on the basis of design and analyses; the out- and pre-posttest studies that included an evaluation comes assessments; and the adequacy of follow-up (17). component. 2) Study population: Females aged 15 years For cross-sectional studies, we used the guidelines for and over, who were residing in camps for refuges/IDPs, critical appraisal, developed by the National Collabo- and who were involved in providing basic health services rating Center for Environmental Health (18). We also to women, children adolescents and families in camps assessed the representativeness of the study participants; settings or who had received training to provide such methods for ascertaining exposure; comparability of expo- services. 3) Outcome measures: a) Changes in health- sure groups (including unexposed) in terms of age, sex, related knowledge, attitudes, and practices of refugee or socioeconomic status, non-response bias, health outcomes, internally displaced lay women as a result of training determination, and validation of outcomes; internal val- aimed at equipping them to provide basic health services idity; and assessment and addressing of confounding to women, children, adolescents and families in camps; factors. Two reviewers (JE and JG) assessed study quality b) changes in health outcomes of women, children, ado- and reached a consensus for each included study. lescents and families in camps as a result of services provided by trained lay women who were refugees or Data analysis internally displaced (e.g. changed sexual risk behaviors; We did not conduct statistical meta-analysis given that fewer unintended pregnancies; increased immunization very few studies qualified for inclusion in the review. More uptake/coverage; increased uptake of ante-natal and post- importantly, there was marked heterogeneity in the design natal care and nutrition services; reduced maternal and/ and methodology of the included studies, and most did not or child under-nutrition; increased uptake and use of provide appropriate statistical data to permit meta-analysis insecticide-treated bed nets; less frequent malaria cases or tests of heterogeneity. Thus, we conducted a systematic among women, children, and adolescents; and fewer diar- review by summarizing, comparing, and contrasting the rhea episodes). Two reviewers (JE and JG) applied the extracted data. The following section presents the results of inclusion and exclusion criteria to the identified studies. the systematic review of the 10 eligible studies. Study selection Results Two reviewers (JE and KC) independently screened the titles and abstracts of identified studies to assess their Description of included studies eligibility for inclusion in the review. Where uncertainties As shown in Figure 1, we included 10 eligible studies regarding eligibility of studies occurred, all reviewers par- ticipated in the decision about inclusion. (12, 1827) (five cross-sectional, four pre-post, and one post-test only) conducted in Africa (Guinea and Tanzania) (12, 1822), Central America (Belize) (23), and Asia Data extraction (Myanmar) (2427). These studies were summarized in a Data from eligible studies were independently abstracted systematic review (see Table 1). None of the bilateral by two reviewers (JE and JG). Differences were resolved agencies and NGOs contacted provided information on by consensus among all reviewers. Studies were strati- evaluated studies of interventions that involved the use fied by design (cohort, cross-sectional studies, and case of refugees and/or IDPs in providing maternal and child studies). For cohort studies, the number of subjects in health services in camps. Overall, the literature sources did the cohort and the number of incident cases of health outcomes of interest in the exposed and non-exposed not yield studies that qualified for inclusion in the review. refugee and internally displaced women, children, ado- A detailed discussion of the characteristics of each of the lescents, and families were extracted. For cross-sectional included studies is presented below. Citation: Glob Health Action 2014, 7: 23902 - http://dx.doi.org/10.3402/gha.v7.23902 3 (page number not for citation purpose) John E. Ehiri et al. Initial Articles (n=7043): � Pubmed/Medline (n=2968) � PsychINFO (n=1015) � CINAHL (n=1186) � Web of Science (n=605) � Sociological Abstracts (n=236) � Embase (n=1033) Duplicate articles (Excluded n=1133) Unique articles included (n=5910) Titles and abstracts screened (Excluded n=5401) Abstracts accepted (n=509) Full articles screened (Excluded n=500): � 5 repeated reports � 489 discussed training of Articles accepted (n=9) non-refugees; descriptive about refugee camps; Articles identified in references focused on training of of accepted articles (n=1) non-refugee community health workers; or Total articles included in systematic review (n=10): descriptive about refugee � Cross-sectional studies (n=5) camps. � Pre-post test (n=4) � 6 books � Post-test-only (n=1) Fig. 1. Literature search outputs. Chen et al. [Guinea] (12). This study-conducted by the 6 months to 5 years. Refugee health workers were trained Reproductive Health Group (RHG) across the Forest to provide health education using local beliefs, terminol- Region of Guinea-used refugee nurses and midwives, and ogy, and disease concepts via one-to-one discussions, trained lay refugee women as facilitators who provided informal group meetings, and disseminated informational sexual and reproductive health education to reproductive- materials. Eight refugee villages were selected; four were aged Liberian and Sierra Leonean refugees living in 48 assigned to an intervention and four to a control arm. camps. Through a multistage stratified cluster sampling, A post-intervention survey of 223 households from the 445 men and 444 women were surveyed to assess whether intervention villages and 177 households from control receiving sexual and reproductive health information villages revealed a significant difference in positive treat- from lay health workers, trained nurses/midwives, or ment-seeking behaviors in parents of children who had friends was associated with better knowledge of sexually been exposed to malaria education materials provided by transmitted infections (STIs) and better health seeking a lay health worker. behaviors related to sexual and reproductive health. Over- Howard et al. [Guinea] (19). The objective of this study all, participants reported a high prevalence of STIs in was to assess the effects of peer-refugee health educa- the last 12 months (30% women; 24% men). A marked tion on maternal health knowledge, attitudes, behaviors, gap in sexual health knowledge was also reported, as and maternal health outcomes. Using a refugee self-help only 25% correctly named key symptoms of STIs. Respon- model, refugee women mobilized other women who had dents who cited either the refugee nurses/midwives and expertise as nurses, and midwives, as well as other local lay lay health facilitators as their information source of refugee women, as health educators to provide education, sexual and reproductive health information demonstrated make referrals, and distribute contraceptives to women greater knowledge of STIs. Refugee nurses/midwives or in refugee communities. Local refugees were recruited lay health facilitators were more frequently cited than and trained to interview same-sex respondents. A cross- other sources as the suppliers of sexual and reproductive sectional survey on sexual and reproductive health atti- health information by men who correctly named key tudes related to family planning was administered to STI symptoms and by men and women who correctly 889 participants (445 men; 444 women). Contraceptive identified effective STI protection methods. use was shown to be markedly higher in areas served by Cropley [Belize] (23). This study used a controlled refugee health workers than in the refugees’ under-served post-test community-based study to assess the effects countries of origin or host countries (17% vs. 3.9% and of health education intervention provided by lay refugee 4.1%, respectively). health workers on child malaria treatment-seeking prac- Howard et al. [Guinea] (20). This was a cross-sectional tices among rural refugee mothers of children aged survey that assessed the effects of peer-refugee-led health 4 Citation: Glob Health Action 2014, 7: 23902 - http://dx.doi.org/10.3402/gha.v7.23902 (page number not for citation purpose) Training and deployment of lay refugees/IDPs Citation: Glob Health Action 2014, 7: 23902 - http://dx.doi.org/10.3402/gha.v7.23902 5 (page number not for citation purpose) Table 1. Characteristics and critical appraisal of included studies Author (year) Country Study design Objectives Study population Intervention and follow-up Outcomes measured Key study results Quality assessment Chen et al. Guinea Cross- A) To assess Reproductive-age RHG recruited refugee Sexual health needs, Respondents citing The analysis did not (2008) (12) sectional sexual health Liberian and Sierra nurses and midwives to knowledge and practices RHG facilitators as separate impact of needs, knowledge Leonean men (445) provide reproductive and among refugees, e.g. their information interventions delivered and practices and women (444) sexual health services for prevalence of reported STI source were more by refugee nurses and among refugees; from an estimated refugees in the Forest symptoms, knowledge likely to respond midwives from those B) to assess the population of Region of Guinea, and about symptoms and correctly about delivered by trained potential impact of 250,000 refugees trained refugee women as prevention of STIs, STIs; RHG refugee women who their work, in living in 48 camps lay health workers. treatment seeking and facilitators were served as lay health terms of increased across the Forest protective behavior more frequently workers; cross-sectional STI knowledge Region of Guinea. adopted by those cited than non- studies measure and more experiencing STI healthcare exposure and health appropriate STI- symptoms, and the information sources outcomes related behavior in potential impact of RHG’s in men who simultaneously. Thus, it clients. work in terms of increased correctly named the is difficult to determine STI knowledge and more key STI symptoms, the direction of the appropriate STI-related and in men and observed associations; behaviors. women who the study did not correctly identified measure the relationship effective STI between degree of protection exposure to RHG methods. interventions and health outcomes. Study findings were based on self-reports with high potential for social desirability. Cropley Belize Post-test To assess the Mothers of children In four of the eight villages, Changes in knowledge, Health education High potential for social (2004) (23) only effect of health aged 6 months to 5 refugee health workers attitudes, and child fever interventions  desirability; used a post- education years who resided were trained to provide and malaria treatment- interpersonal test only design, with intervention on in eight rural health education using seeking behaviors. communication in high potential for child malaria refugee local beliefs, terminology particular  inadequate treatment-seeking communities. and disease concepts appeared to have a comparability of practices among through one-to-one positive effect on intervention and control rural refugee discussions, informal fever and malaria communities at baseline. mothers. group meetings and beliefs, and on There was potential for material dissemination. positive treatment- contamination of the seeking behaviors. control communities. John E. Ehiri et al. 6 Citation: Glob Health Action 2014, 7: 23902 - http://dx.doi.org/10.3402/gha.v7.23902 (page number not for citation purpose) Table 1 (Continued ) Author (year) Country Study design Objectives Study population Intervention and follow-up Outcomes measured Key study results Quality assessment Howard Guinea Cross- To assess the Reproductive-age RHG recruited refugee Effect of peer refugee RHG facilitators The analysis did not et al. sectional effect of peer Liberian and Sierra nurses and midwives and health education and were the primary separate impact of (2008) (19) refugee health Leonean men (445) trained refugee women as reproductive service source of interventions delivered education on and women (444) lay health workers to delivery on access to reproductive health by refugee nurses and maternal health from an estimated provide sexual and reproductive health information for all midwives from those knowledge, population of reproductive and sexual information, approval of respondents. delivered by trained attitudes and 250,000 refugees health education. family planning services, Contraceptive use refugee women who behaviors and living in 48 camps use of contraceptive, in the camps served as lay health maternal health across the Forest perceived service quality, served by RHG was workers; cross-sectional outcomes. Region of Guinea. service, risk of unintended much higher than studies measure pregnancy. typical for either exposure and health refugees’ country of outcomes origin or the host simultaneously. Thus, it country, but the risk is difficult to determine of unwanted the direction of the pregnancy observed associations; remained the study did not considerable. measure the relationship between degree of exposure to RHG interventions and health outcomes. Study findings were based on self-reports with high potential for social desirability. Howard Guinea Cross- To assess 444 reproductive- RHG recruited refugee Effect of peer refugee led Most respondents The analysis did not et al. sectional maternal health age Liberian and nurses and midwives and health education on said pregnant separate impact of (2011) (20) outcomes in Sierra Leonean trained refugee women as knowledge of danger signs women should interventions delivered relation to women in 48 lay health workers to of complications during attend antenatal by refugee nurses and refugee-led health camps across the provide sexual and pregnancy, knowledge of care and knew the midwives from those education, formal Forest Region of reproductive and sexual the importance of skilled importance of delivered by trained education, age Guinea. health education. attendant at birth, use of tetanus refugee women who and parity. family planning, sexual vaccination. Most served as lay health health services, and use of recognized workers; cross-sectional ante-natal care services. maternal danger studies measure signs and exposure and health Training and deployment of lay refugees/IDPs Citation: Glob Health Action 2014, 7: 23902 - http://dx.doi.org/10.3402/gha.v7.23902 7 (page number not for citation purpose) Table 1 (Continued ) Author (year) Country Study design Objectives Study population Intervention and follow-up Outcomes measured Key study results Quality assessment . recommended outcomes facility attendance simultaneously. Thus, it for these. Higher is difficult to determine odds of facility the direction of the delivery were found observed associations; for those exposed the study did not to RHG health measure the relationship education. No between degree of significant exposure to RHG differences were interventions and health found in knowledge outcomes. Study or attitudes. findings were based on self-reports with high potential for social desirability. Lee et al. Myanmar Pre- and To assess the Internally displaced Staff from the local health Internally displaced The intervention Although the study (2009) (26) post-test impact of training Myanmar villagers. department trained villagers performed demonstrated that demonstrated the ability study and deploying internally displaced malaria diagnosis, internally displaced of trained displaced internally villagers who lived in the treatment, vector control villagers were able villages to contribute to displaced villagers malaria program’s target and malaria education in to deliver essential significant expansion of on expansion of communities and were conflict areas. malaria control malaria treatment and malaria control familiar with other village interventions in prevention services, interventions members. These village areas of active evidence of quality or among IDPs. health workers were conflict in eastern outcomes of services trained in malaria Burma. Program provided by the trained diagnosis and treatment, expanded from villagers was not and vector control and 3,000 internally provided. education. displaced villagers to 40,000 in 5 years. Minden Thai- Pre- and To train refugee Scattered refugee Young camp members Qualitative outcomes Trained refugees Weak design. A more (1997) (27) Myanmar post-test community health camps in remote (with formal education related to complications were able to complete evaluation of Border study workers and areas along the from grade 4 to grade 10) surrounding pregnancy diagnose and treat the quality and health traditional birth Thai-Myanmar were trained to diagnose were discussed. common illnesses outcomes associated attendants to border. and treat common using drugs, with services provided provide basic illnesses. A small subset of injections and by the trained refugee reproductive the group received 618 intravenous health workers is needed John E. Ehiri et al. 8 Citation: Glob Health Action 2014, 7: 23902 - http://dx.doi.org/10.3402/gha.v7.23902 (page number not for citation purpose) Table 1 (Continued ) Author (year) Country Study design Objectives Study population Intervention and follow-up Outcomes measured Key study results Quality assessment health services, month medical training. infusions according to strengthen evidence and to diagnose Female community health to Medecins Sans of health effects of their and treat common workers were also Frontieres services. illnesses using selected to receive special guidelines. They drugs. training in maternal health prevented and to become midwives. problems, Traditional birth attendants recognized illness were also trained. early and provided treatment before complications escalated to emergencies. They were able to foresee an emergency and to stabilize the mother and/or baby while they found transportation to a hospital. Mullany Myanmar Pre- and To examine the Internally displaced In target communities, Survey to assess effect of Use of modern Weak design. A more et al. post-test feasibility of a Myanmar women local health workers and the intervention on access methods of birth complete evaluation of (2010) (24) study network of of reproductive traditional birth attendants to antenatal and postnatal control increased the quality and health community-based age. were trained in basic care, presence of skilled and births attended outcomes associated providers for emergency obstetric care, attendant at birth, and use by those trained to with services provided delivery of blood transfusion, of family planning services. deliver elements of by the trained refugee maternal health antenatal care and family emergency care health workers is needed interventions. planning. increased almost to strengthen evidence 10-fold. of health effects of their services. Rijken Thai- Pre- and To assess intra- 349 pregnant A 3-month course of Intra- and inter-observer Measurements Weak design. A more et al. Myanmar post-test observer and women and local practical and theoretical agreement of fetal made by local complete evaluation (2009) (25) Border study inter-observer Myanmar health training in obstetric biometry measured by health workers of the quality and agreement of fetal workers. ultrasound imaging based trained displaced health during obstetric health outcomes biometry by locally on World Health workers and those of the ultrasound imaging associated with services trained Organization guidelines expatriate doctor. showed high provided by the trained refugee Training and deployment of lay refugees/IDPs Citation: Glob Health Action 2014, 7: 23902 - http://dx.doi.org/10.3402/gha.v7.23902 9 (page number not for citation purpose) Table 1 (Continued ) Author (year) Country Study design Objectives Study population Intervention and follow-up Outcomes measured Key study results Quality assessment refugee health and British Medical levels of agreement health workers is needed workers in a Ultrasound Society with those of the to strengthen evidence refugee camp. recommendations. doctor. of health effects of their services. Tanaka Tanzania Cross- To assess the 576 refugees, 48 Refugee health workers Personal profiles of Refugee health The refugees were not et al. sectional impact of refugee refugee health identified health needs, refugee health workers, workers formally trained, but (2004) (22) participation in workers, 17 red made health decisions and health status, social experienced instead, used their own camp health cross volunteers, assumed the responsibility support, and knowledge of increased self- initiatives. Being a services provision. Congolese refugee to meet these needs in refugee health workers. confidence and cross-sectional study, community order to strengthen the promoted health it was not possible to members, refugee refugee community and to education. establish causal health workers, improve their health. Refugees who did relationships between and Tanzanian Red not know a refugee the number of refugee Cross staff. health worker HIT members known by had less positive refugees and health health seeking outcomes. behaviors than those who knew a refugee health worker. Woodward Guinea Cross- To assess whether 889 reproductive- RHG recruited refugee Effect of peer-refugee Refugee-led health The analysis did not et al. sectional exposure to peer age men and nurses and midwives to education on HIV education was separate impact of (2011) (21) refugee health women in 23 provide reproductive and knowledge, attitudes, and most strongly interventions delivered education was camps in the sexual health services, and safe-sex practices. associated with by refugee nurses and associated with Forest Region of trained refugee women as reported HIV- midwives from those improved HIV Guinea. lay health workers. avoidant behavior delivered by trained knowledge, change. Refugee refugee women who attitudes, or women were more served as lay health practices among likely to report HIV workers; cross-sectional refugees. risk and less likely studies measure to report making exposure and health behavioral outcomes changes. Of those simultaneously. Thus, it exposed to is difficult to determine refugee-led the direction of the observed. John E. Ehiri et al. education related to the danger signs of complications during pregnancy, knowledge of the importance of skilled attendants at birth, the use of family planning and sexual health services, and the use of ante-natal care services among 444 reproductive-age Liberian and Sierra Leonean women in 48 camps across the Forest Region of Guinea. Participants were considered ‘exposed’ to this education if they had previously participated in a peer-refugee faci- litated drama group or received information on family planning by a peer-refugee health worker. Although no difference was found in maternal knowledge or attitudes, those exposed to peer refugee-led activities had higher odds of delivery in a health facility than those who were unexposed (OR 2.13, 95% CI 1.213.75). Lee et al. [Myanmar] (26). This study used a pre- and post- test design to assess the impact of training and deploying internally displaced villagers to conduct malaria control interventions among IDPs. Staff from the local health department trained internally displaced villagers who lived in the malaria program’s target communities and were familiar with other village members. These village health workers were trained in malaria diagnosis, treatment, and vector control. Specifically, they were trained to perform a comprehensive set of malaria interventions, including promoting of the use of long-lasting malaria nets, detect- ing of early signs and symptoms of malaria, and providing treatment in an active civil conflict area. The intervention demonstrated that internally displaced villagers were able to deliver essential malaria control interventions in areas of active conflict in eastern Burma. Program coverage was expanded from 3,000 to 40,000 internally displaced villagers in 5 years. Minden [Thai-Myanmar Border] (27). This study used a pre- and post-test design to assess the impact of using trained refugee community health workers and traditional birth attendants to provide basic reproductive health ser- vices and to diagnose and treat common illnesses among refugees in camps. Qualitative assessment revealed that the trained refugee health workers were able to diag- nose and treat common illnesses using drugs, injections, and intravenous infusions according to Medecins Sans Frontieres’ guidelines (28). The trained health workers were able to prevent problems, recognize illness early, and provide treatment before complications escalated to emergencies. They were also able to foresee potential emer- gencies and were able to stabilize the mothers and/or babies while seeking transportation to a hospital. Mullany et al. [Myanmar] (24). This study used a pre- and post-intervention design to assess the feasibility of a net- work of community-based providers to deliver maternal health interventions in the complex emergency setting of eastern Burma. In target communities, lay health workers and traditional birth attendants were trained in basic emergency obstetric care, blood transfusion, antenatal care, and family planning. A post-intervention survey was 10 Citation: Glob Health Action 2014, 7: 23902 - http://dx.doi.org/10.3402/gha.v7.23902 (page number not for citation purpose) Table 1 (Continued ) Author (year) Country Study design Objectives Study population Intervention and follow-up Outcomes measured Key study results Quality assessment education, women associations; the study had greater odds did not measure the than men of relationship between reporting HIV- degree of exposure to avoidant changes. RHG interventions and health outcomes. Study findings were based on self-reports with high potential for social desirability. Training and deployment of lay refugees/IDPs conducted to assess the effects of the intervention on and compared with HIV outcomes using logistic regres- accessing ante- and post-natal care, skilled attendants at sion odds ratios. The results of these analyses showed births, and family planning services. Results showed that, that exposure to peer refugee health education was asso- following intervention, use of insecticide-treated mosqui- ciated with awareness of HIV/AIDS and reduced mis- to nets increased, as did use of modern contraceptives. conceptions about the disease. Overall, participants Births attended by those trained to deliver elements of who were exposed to peer refugee education had more emergency care increased about 10-fold. than twice the odds of reporting having made HIV- Rijken et al. [Thai-Myanmar Border] (25). This study avoidant behavioral changes than those who were un- used a pre- and post-test design to assess the effects of a exposed (72% versus 58%; adjusted OR 2.49, 95% CI 3-month practical and theoretical training for lay refugee 1.524.08) (21). health workers aimed at equipping them with skills in conducting obstetric ultrasound imaging based on World Critical appraisal of data on impact of use of Health Organization guidelines and British Medical Ultra- lay refugee health workers sound Society recommendations. Post-test assessments As shown in Table 1, all of the included studies dem- measured intra-observer and inter-observer agreement onstrated some positive impact on population health of fetal biometry in 349 pregnant women measured outcomes as a result of training and deployment of lay by trained displaced health workers compared to those refugee/IDP health workers in camps. The reported effects conducted by an expatriate physician. Measurements by included improvements in knowledge, attitudes, and refugee health workers showed high levels of agreement practices related to various sexual, reproductive and other with those of the physician, demonstrating that locally maternal and child health issues. Specific examples in- trained health workers from refugee camps could ade- cluded increased knowledge about the symptoms and quately conduct obstetric ultrasound imaging. prevention of STIs, improved treatment-seeking and Tanaka et al. [Tanzania] (22). This was a cross-sectional protective behavior adopted by those experiencing STI study in the Lugufu refugee camp in Tanzania, which symptoms, and uptake of family planning services. Other hosted refugees from Burundi, Rwanda, and the Demo- reported changes included improvements in child fever cratic Republic of Congo (DRC). At the time of the study, and malaria treatment-seeking behaviors, and improved Lugufu Camp was hosting an estimated 50,400 Congolese access to reproductive health information. One study, refugees, with an average of 1,000 people arriving each which assessed the effect of peer refugee health education month as a result of the continuing conflict in the DRC on maternal health knowledge, attitudes, behaviors and (22). The camp had a health information team (HIT) maternal health outcomes (19), did not demonstrate comprised of Congolese refugees (one HIT member/1,000 marked reduction in unintended pregnancies among population) who provided health services under the super- refugee women. For the purpose of this review, study vision of health staff of the Tanzanian Red Cross Society quality assessment revealed that all included studies were (TRCS) (22). The majority of the sampled community of poor quality. For example, in five of the included members and TRCS health staff affirmed the positive studies (12, 1821), the analysis did not separate impact contribution of HIT to refugee health (89.2 and 100%, of interventions delivered by refugee nurses and mid- respectively). Seventy-nine percent of the sampled ref- wives from those delivered by trained refugee women who ugee community members reported that they learned served as lay health workers. Cropley (23) used a post- about illness prevention from the HIT. Also, HIT was test only design. The lack of comparability of interven- the education method most highly rated by the refugee tion and control communities at baseline raises concerns community, both for learning how to prevent illnesses about internal validity (29), i.e. the approximate truth of (56.3%) and for learning how to treat mild diarrhea inferences regarding causal relationships. Although the (50.0%). The role played by the HIT as a liaison between study by Lee et al. (26) demonstrated the ability of trained the refugee community and health services was recognized displaced villages to contribute to significant expansion by 85.2% of the refugees surveyed; refugee community of malaria treatment and prevention services, it did not members who did not know a HIT member demonstrated assess the quality or outcomes of services provided by less positive health seeking behaviors than those who the trained lay refugee villagers. Minden (27), Mullany knew one or more HIT members (22). et al. (24), and Rijken et al. (25) used the before-and-after Woodward et al. [Guinea] (21). This was a cross-sectional design in assessing the effectiveness of trained lay refugee study designed to assess the association between exposure community health workers and traditional birth atten- to refugee peer education and improved HIV knowledge, dants in providing basic reproductive health services, attitudes, or practice outcomes among refugees in Guinea. and in diagnosing and treating common illnesses. Be- Data were collected from 889 reproductive-age men and fore-and-after design is relatively cheap to implement and women in 23 camps in the Forest Region of Guinea, and useful in addressing potential ethical concerns that may exposure to peer refugee led education was analyzed be associated with randomized studies or prospective Citation: Glob Health Action 2014, 7: 23902 - http://dx.doi.org/10.3402/gha.v7.23902 11 (page number not for citation purpose) John E. Ehiri et al. cohort designs. However, the lack of a comparison group and promotora approaches that have been shown to limits the degree to which observed health outcomes can be beneficial in helping to meet the healthcare needs of be attributed to services provided by lay refugee workers. women and children in resource-poor settings globally Outcome measures assessed by all studies (12, 1827) were (36), lay refugees and IDPs who reside in camps could based on self-reports, which are known to be subject to the potentially help ease reliance on foreign health pro- effects of social desirability (30). More importantly, none fessionals, improve access and coverage, and empower of the studies assessed the relationship between the degree women to enhance their health and the health of their of exposure to interventions provided by lay refugee children and families. Whereas anecdotal evidence sug- workers and health outcomes. gests that training and deployment of lay refugees and IDPs have public health benefits, no reviews have sought to assess and critically appraise the evidence base of this Discussion intervention to facilitate policy recommendations. There- Globally, a shortage of human resources for the health fore, in order to address this gap in knowledge, we con- sector is widely acknowledged as a key barrier against ducted a systematic review and critical appraisal of the provision of essential health services (31). The burden available data. of health workforce shortage is more acute in low- An exhaustive search of the literature yielded only 10 income countries, especially those experiencing conflicts studies that attempted to assess the role of lay refugees and emergencies, when the few available health workers and IDPs in reproductive health service provision in are forced to flee, health infrastructures are destroyed, and camps. All of the included studies reported some posi- resources for the health sector are diverted to other uses. tive impact association with training and deployment Available evidence shows that community health workers of lay refugee/IDP health workers in camps. The reported have the potential to be part of the solution to the human effects ranged from improvements in knowledge, atti- resource crisis that is affecting many countries (32, 33), tudes, and health seeking behavior; an increased efficacy and scaling up training and deployment of community to treat mild diarrhea; a capacity to conduct obstetric health workers is one of the strategies identified in ultrasound imaging; an ability to diagnose and treat the Kampala Declaration and the Agenda for Global minor conditions (including malaria and STIs); to an Action (34). A systematic review conducted by the Global increased uptake of family planning services. While these Health Workforce Alliance and the United States Agency findings are important, the current body of evidence is for International Development (USAID) to elucidate the weak, and there remains a paucity of high quality effectiveness of community health workers concluded evaluation studies of the impact of using trained lay that adequate training, integration, and supervision of refugees and IDPs to provide health services to camp community health workers has the potential to contri- dwellers. bute to an equitable and cost-effective scale-up of service coverage, while leading to tangible improvements in health outcomes (28). Limitations In light of evidence regarding the effectiveness of lay As noted earlier, this review included studies that used a workers in population health improvement, there is a wide variety of designs (cross-sectional, post-test only, and need to re-evaluate how camps for refugees and IDPs are pre- and post-test) that have significant inherent limita- organized and the way services are provided for women tions, especially regarding internal validity. For example, and children who reside in camps. With a five-fold cross-sectional studies measure exposure and health out- increase in emergencies caused by natural disasters and/ comes simultaneously. Thus, it is difficult to determine or conflicts over the past decade, it has become increas- the direction of the observed associations. Post-test only ingly difficult for international relief agencies to keep pace studies lack baseline comparability of intervention and (35). Camps are resource-limited settings. As such, avail- control communities; before-and-after studies lack appro- able resources and services become quickly depleted with priate comparison groups. Although many international time. There is a need to train and effectively deploy lay health agencies are involved in emergency response ac- refugees and IDPs in order to sustain access to health tivities globally, none was able to provide information basic health services. Lay-refugee and internally displaced on evaluated studies of interventions that involved the women who reside in camps have life experiences that use of refugees and/or IDPs to provide maternal and are similar to those of other women in the camps. They child health services in camps. This raises concerns about also have valuable health-related cultural knowledge that the value placed on evidence-based practice in interna- expatriates may not have (17, 31). Thus, there is the per- tional emergency response activities. However, it should ception that, if trained and adequately supported, they be understood that camps are resource-limited settings. can be well-positioned to provide culturally appropriate Under emergency situations, where the primary health support that is better targeted to the needs of women and objective is to ensure safety and access to basic services for children in the camps. Similar to the village health-worker refugees and IDPs, it may be difficult to commit limited 12 Citation: Glob Health Action 2014, 7: 23902 - http://dx.doi.org/10.3402/gha.v7.23902 (page number not for citation purpose) Training and deployment of lay refugees/IDPs 2. United Nations High Commissioner for Refugees (2013). resources to planning and implementing rigorous evaluation Internally displaced people: on the run in their own land. studies. It may also be difficult to employ such rigorous Geneva: Switzerland. evaluation designs as the randomized controlled trial 3. 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World Health 1997; 50: Incorporating what promotoras learn: becoming role models to 189. effect positive change. J Community Health 2012; 37: 102631. 14 Citation: Glob Health Action 2014, 7: 23902 - http://dx.doi.org/10.3402/gha.v7.23902 (page number not for citation purpose)

Journal

Global Health Action – Taylor & Francis

Published: Dec 1, 2014

Keywords: maternal health; reproductive health; refugees; internally displaced persons; child health

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