Role of Physiotherapists and Rehabilitation Assistants in Refugee Camps
- 1 Introduction
- 2 Rehabilitation Assistants in Refugee Camps
- 2.1 Training of Rehabilitation Assistants
- 2.2 Roles of Rehabilitation Assistants
- 2.3 Advantages of Rehabilitation Assistants
- 2.4 Supervisions of Rehabilitation Assistants
- 2.5 Quotes from Rehabilitation Assistants
- 2.6 Challenges for Rehabilitation Assistants
- 3 Self-Care for those Working in Refugee Camps
- 4 Challenges Faced in Provision of Rehabilitative Services in Long Stay Camps
- 5 Conclusion
- 6 Resources
- 7 References
Grounded in article 14 of the Universal Declaration of Human Rights 1948, which recognizes the rights of persons to seek asylum from persecution in other countries, the United Nations Convention relating to the status of Refugees, adopted in1951, is the centerpiece on international refugee protection today. The 1951 Refugee convention defines a refugee as someone who “owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality, and is unable to, or owing to such fear, is unwilling to avail himself of the protection of that country”. 
The United Nations High Commission for Refugees (UNHCR) reported that at the end of 2018 there were over 29 million refugees and asylum seekers across the globe, in addition to 41.3 million internally displaced people. Kenya is now the second biggest refugee-hosting country in Africa after Ethiopia with a total of 494,921 registered refugees as of June 2020, UNHCR, Kenya hosts refugee mainly from the Great Lakes and the Horn of Africa region. While most people fleeing from conflict in South Sudan arrive in Kakuma refugee camp in northern Kenya, Most Somali refugees flee to Dadaab, which is in Northeastern Kenya.
The World Health Organization (WHO) estimates that for every one million people who live in low or middle income countries, there are less than ten qualified rehabilitation professionals, including speech, occupational and physiotherapists. There are tremendous shortages of physiotherapists and other rehabilitation therapists in refugee camp settings. To help to fill this gap, WHO designed the strategy of Community-Based Rehabilitation (CBR). There are CBR programs present in more than 90 countries, and there are many such programs operating in refugee camps. WHO describes three levels of workers in CBR settings, the grass-root level of volunteers who have several weeks of initial training and then ongoing supervision, mid-level workers who have some form of accreditation and professional level therapists. 
There are ethical issues posed by the shortage of physiotherapists, and at times, CBR workers such as rehabilitation assistants, are asked to perform tasks which may be beyond their scope of expertise. A preliminary preprint by Mitchell-Gillespie et al describes the use of telehealth in refugee camps in Jordan, where the CBR staff working on site in the camp performed telehealth sessions using Zoom, in which occupational therapists operating in the United States provided clinical support remotely during the call and were able to observe and to participate in the session in real time, viewing the session via I-Pad video. 
With the onset of COVID-19, in some refugee camps, the fully qualified physiotherapy staff members left the camps, leaving the CBR workers such as rehabilitation assistants, who are refugees who live in the camps, as the only rehabilitation workers on-site. In these situations, the use of tele-physiotherapy, where the fully qualified therapist is “present” remotely during the entire session to assist and has video link to be able to observe and participate in the session, is ideal. The authors described issues with internet connectivity being inconsistent at times, which is a potential barrier to utilization of telehealth in refugee camps, but reported that overall, in their pilot study, telehealth was well-received by both clients and staff members. 
According to UNHCR, 2014 statistics, 40% of refugees in the world live in refugee camps, while more than half of refugees live in urban or semi-urban areas. Many of the refugee camps have been around for so many years that they are basically like cities with schools, clinics, shops and other infrastructure.  While many of the world’s refugee camps had been intended to be temporary, there are so many protracted refugee situations all in the world. Many of the biggest camps in the world were begun in the 1980’s and 1990’s, so there are generations of families who have been living their entire lives in refugee camps. According to the UNHCR, 2019 report, the top hosting countries of the world are Turkey (3.6 million), Colombia, (1.8 million), Pakistan and Uganda, (both 1.4 million) and Germany, 1.1 million. More than 80% of refugees are housed in developing countries, and the average refugee lives in refugee situations for nearly 20 years. The top “source countries” producing refugees are Syria (6.6 million), Venezuela (3.7 million), Afghanistan (2.7 million), South Sudan (2.2 million), and Myanmar (1.1 million). In 2018, only 107,800 were permanently relocated to 26 hosting countries.
It is estimated by the World Health Organization and by UNHCR that ten percent of refugees have some sort of disability, and these individuals can benefit greatly from receiving physiotherapy.  In addition, research studies show that between 15 and 44 percent of refugees have undergone some form of torture, with a systemic review of forced migrants by Sigvardsdotter et al , 2016 showing an average of 27% having a torture history. While the exact prevalence of torture among refugees living in camps is not known, it is likely that this would vary by country of origin, gender and other factors. Survivors of torture can benefit greatly from physiotherapy services, as outlined in the Physiopedia article Physiotherapy for Survivors of Torture.
Refugees have higher rates of many non-communicable diseases than non-refugees. In some refugee camps where ICRC works, more than 17% of refugees age 18 and above have the diagnosis of diabetes.  Physiotherapists working in refugee camps need to be aware that the incidence of diabetes, hypertension, cardiovascular diseases and cancer are typically quite high among the camp populations, and tailor their interventions to include education about self-care and about the role of exercise and nutrition in helping to prevent and to treat these co-morbidities. The incidence of Depression, Post-traumatic Stress Disorder, and Anxiety Disorders are higher in refugee populations than in the general population.  It is important that physiotherapists have a comfort level in providing services to clients who have Mental Health issues. Physiotherapists working with those living in refugee camps must also be familiar with “Trauma Informed Care” and how to adapt their physiotherapy programming to meet the needs of refugees who have been through traumatic experiences.  The following link highlights 10 Key Points and some images about the refugee crisis from Global Giving which may be of interest to physiotherapists.
As so many refugees live for many years in refugee camps, with little possibility of being permanently re-settled, it is crucial that the residents of refugee camps have access to quality medical care, including physiotherapy services. As mentioned in the Physiopedia articles entitled Refugee Health and Understanding the Refugee Experience refugees are at higher risk than the general population of developing many chronic illnesses, and many can benefit from physiotherapy.
According to the UNHCR Comprehensive Refugee Response Framework: From the New York Declaration to a Global Compact on Refugees, part #59, the world community has a special obligation towards meeting the needs of children, survivors of torture and other forms of trauma, helping those with special needs including those with disabilities. Physiotherapists have an obligation to help to meet the rehabilitation needs of refugees who lives in refugee camps. As per Article 26 of the Universal Declaration of Human Rights, many refugees have war-related injuries such as amputations, spinal cord injuries, head injuries and other traumatic injuries. Those with these injuries can also benefit from receiving physiotherapy services. 
An important role for physiotherapists who work in refugee camps is to provide external training to non-physiotherapists who work for other NGO’s so that they understand who to refer for physiotherapy. In addition, since many of the refugees who would benefit from physiotherapy will not be able to receive it due to shortages, it is ideal if physiotherapists can provide psychoeducation for teachers, counselors and others, about some basic concepts of exercise, pain reduction and sleep hygiene so that these other care providers are able to try to help their clients who will not be able to access physiotherapy due to the shortages.
As the refugees living in camps have many complex needs, it is important that the physiotherapists working in camps form close connections with leaders of the refugee communities and with colleagues who work in other NGO’s and learn how to make appropriate referrals for other medical services, education, counselling, livelihood and security programs, and to address many other needs. 
Another possible role of physiotherapists working in refugee camps is to help to organize opportunities for refugees of all ages and genders to participate in physical activity, such as walking, running, bicycling and football (soccer), as well as stretching. There are several studies of physical activity with refugees who have PTSD and pain, which show that the participants benefit from the activity. 
There needs to be sensitivity when arranging group sports activities to try to have ethnically mixed teams, in order to try to minimize perception of exclusion and nationalism. In addition, it is ideal to offer a variety of different sports activities so that participants have choice.  It is ideal to offer programs for men, women and for children, if possible. While in some refugee camp contexts, there are specific NGO’s which focus on physical activity, such as Right to Play, physiotherapists can have an important role in helping to develop and support physical activity programming.
Group physiotherapy sessions can be very beneficial for those living in refugee camps. Having physiotherapy in groups can be very beneficial in terms of helping to build trust, establish connections and to help to encourage and support each other. There is a great deal of research showing that group physiotherapy can be as effective as individual physiotherapy for those with musculoskeletal pain and injuries including a study which was done in Cambodia. With the shortage of trained physiotherapists working in refugee camps around the world, working with physiotherapy groups can be an efficient way to reach more patients as well.
According to the UNHCR, half of the refugees in the world are younger than the age of 18. Physiotherapists should make efforts to provide needed services to children as well as to adults, and could potentially work with other NGO’s, schools and family members to best engage children who are Refugees.
With eighty to eighty five percent of refugees being housed in developing countries, it is ideal if the physiotherapy team can provide some services to host community members as well, as there is typically a lack of resources and poverty among the host community. 
The influx of refugees and asylum seekers has had a great impact on the social, economic and health sectors of many countries. Increasing numbers of both refugees and asylum seekers has increased the pressure and demand on both primary and secondary health care services, including for physiotherapy.  There is also a shift toward providing medical care based on the results of evidence based research, which is guided by principles of effectiveness, safety, timeliness, patient-centeredness, equity and efficiency. Research also indicates that patient expectations have changed, with patients becoming active participants rather than passive receivers of care. With these trends, healthcare providers are faced with the need to make sure there are enough health and paraprofessionals who can deliver optimum and timely services to clients. 
People living in refugee camps face a range of health, social and environmental hazards that can impact on their well-being. For example, poor water and sanitation, food insecurity, lack of essential healthcare, lack of primary health caregivers and exposure to extreme temperatures. Note the photo of the physiotherapy room in Kalobeyei below and the harsh, dusty and hot climate. Now, with the COVID-19 pandemic reaching many refugee camps, and a lack of soap, water and masks in some camps, there is fear of transmission of the virus and of lack of enough places for people to isolate if they are COVID positive.
Chronic Pain and Sleep Issues among Refugees
There are multiple studies showing that refugees have higher rates of pain that the general population.  Few of the studies were done exclusively in refugee camps settings, so it is difficult to know how pervasive pain issues are in refugees. The Center for Victims of Torture conducted large representative surveys in its programs in Kenya, Ethiopia and Uganda, of more than 500 respondents each. In a representative survey of host and refugee community members conducted by CVT in Kalobeyei refugee settlement just outside of Kakuma refugee camp in 2018, 35% of refugee and 32% of host community respondents indicated that they had chronic pain.  In the same survey, 51% of refugees and 44% of host community members indicated that they were having trouble falling asleep. 
In a similar survey by the Center for Victims of Torture staff members in two refugee camps in Ethiopia in 2017, 44% of the respondents reported having difficulty sleeping, and 28% at Adi Harush and 31% at Mai Ani refugee camps reported having chronic pain. 
It is crucial that physiotherapists who are working with refugees, both in and outside of refugee camps, focus carefully on providing pain education and other pain relieving treatment and psychoeducation.  The following Physiopedia Page on Evidence-based Management of Pain in Refugees is an excellent resource for this topic area.
Sleep difficulties are common among refugees, as noted in the surveys above. Refugee camps are typically noisy and crowded and many family members can be crammed into one small room to sleep, without having comfortable bedding or electricity to be able to heat or to cool the room. These factors, as well as security issues, can make sleep very difficult. Still, it is essential for physiotherapists who are working in refugee camps to work with their clients in improving positioning and comfort, learning breathing, relaxation and grounding techniques and other ways to improve sleep hygiene as well. 
Gender Based Violence
Issues with incontinence and sexual functioning, which physiotherapists can address commonly occur as a result of gender based violence. While there are several Physiopedia Pages (Physiotherapy for survivors of GBV and physiotherapy for refugees who are members of the LGTBI community) which focus on these issues in detail, it is important to know that many refugees have issues with constipation, incontinence and with painful sexual functioning, as mentioned in a quote by RA, Amani. The Center for Victims of Torture physiotherapy group sessions are divided by gender. The physiotherapists bring up issues with pelvic floor concerns in all groups to normalize them. They do not separate out those who are known survivors of gender based violence from those who are not, but instead, do psychoeducation with all male refugees about ways to decrease erectile dysfunction, and with all refugees about ways to decrease urinary incontinence and urgency, bowel incontinence and constipation, as well as painful sexual functioning. Our experience has been that clients are usually very receptive to learning how to improve these issues, through doing pelvic floor strengthening and relaxation exercises, improving intake of foods and beverages, learning physiological quieting techniques when feeling urgency, and doing relaxation exercises and modifying positioning when engaging in sexual activities. There are some excellent review and other articles about efficacy of these activities in both group and individual physiotherapy sessions. 
Rehabilitation Assistants in Refugee Camps
In both long term and short term camps, rehabilitation assistants (RAs) provide support of health professionals in many clinical and non-clinical tasks. Being able to work alongside RAs relieves the work of allied professionals who are then able to focus on more complex tasks in order to best meet the needs of the clients. About 80% of Community Based Rehabilitation organizations employ assistants, who provide, on average, 36% of the direct care provision to clients. There are over 300 job titles used to describe support workers/assistants.  For this article, the term “Rehabilitation Assistants’ (RA’s) is used to describe the incentive refugee workers who work alongside professionally qualified physiotherapists.There has been a growing trend to tap into the available human resources within the community based rehabilitation programs and to build refugee capacity for long term program sustenance. A male RA, who was one of the two first RA’s with the Centre for Victims of Torture Kakuma, stated:
“My goals and dreams is to be someone who can change the world - To assist, to help many people having problems in their bodies and those who have been tortured, went through war, acts of violence and other conflicts. When I took time to think back to what is happening and to how people are suffering in my country, and that there is no assistance, it is clear that my future is to apply all of my experience, skills, and pieces of knowledge to my country, or to a different country. So many people are having problems including pain, and this is often caused by how they do things in a wrong way, including how they sit, how they sleep, and how they walk. Many of them are having difficulties with sleep, trouble controlling their bladder or bowel and many are having sexual problems. I have learned techniques and ways to help those who are having bad conditions in their bodies. Wherever I will be going I should be applying all of my experience, skills, and knowledge to assist people who need assistance in the community’’. Quote by an RA in Kalobeyei camp-Kakuma Kenya (Amani).However, it is also important to ensure that RA’s have appropriate training and supervision, and are not asked to do activities which are beyond their capacity, and/or outside of the regulation concerning physiotherapy in the country where the refugee camp is located.
Training of Rehabilitation Assistants
Every organization differs in its approach which is dictated by its mandate; however each has a training programme which is developed to ensure that the RAs learn the necessary basic physiotherapy-related principles and techniques. In Kenya, RAs training has not yet been accredited by the regulating bodies and a standardized curriculum is now being developed. If the rehabilitation assistant role does become accredited in Kenya, it will make it easier for RAs to join tertiary colleges with the knowledge and skills acquired.
Depending on the NGO whom they work for, the RAs undergo rigorous training for the first 3 to 12 months after recruitment, which is complimented by ongoing on-the-job training from senior RAs and physiotherapists. During this period there are assigned non -clinical duties such as welcoming and receiving clients, preparation of treatment arears, inventory taking etc. Delegation of duties depends on the physiotherapists experience and the training background of the RA and the amount of time that the two have interacted. 
Roles of Rehabilitation Assistants
The roles vary from organization to organization and from one country to another. It is crucial that the NGO and the physiotherapy team who is supervising the RA’s ensure that they do not work beyond their level of training and beyond what is allowed with the physiotherapy organization of the country in whom they work. Common job responsibilities of RAs include but are not limited to:
- Working with patients towards individual rehabilitation goals, as prescribed by physiotherapist.
- Supporting and supervising patients in activities of daily living.
- Promoting patient rights and identity
- Helping physiotherapists to monitor clients’ progress
- Providing feedback to the PTs on patients progress and services provision
- Assisting clinicians in identification, provision, fitting and safe use of equipment for patients and caregivers
- Educating patients on how to exercise properly by giving clear instructions on posture, frequency, benefits of exercises, etc.
- Participating in community outreach activities to create awareness of physiotherapy
- Ensuring that the cleanliness and safety of the therapeutic equipment in the department is maintained.
- Helping to maintain records of work undertaken with patients (3).
Advantages of Rehabilitation Assistants
Useful in Inter-Professional Linkages
In refugee camp settings the clients present with diverse needs including shelter and protection, collection and distribution of firewood, soap, and sanitary pads; eligibility tests, healthcare, and attending school, and work. Often, there are mandatory activities, such as fingerprinting by UNHCR staff, which needs to be done for the refugees to be able to access food rations and tokens. These competing demands can prevent clients from attending physiotherapy activities. The RAs are often able to link up with the other interagency staff and together with clients set or reschedule appointments so that the clients can receive several services on the same day, thus helping them to improve their attendance in physiotherapy.
RAs are perceived as a focal point for care delivery and serve as conduits for clients.
Provide Faster, More Accessible CareMost of the RAs are also refugees who live within the same refugee camps as the clients, which enables then to interact with clients and to provide timely care that is also culturally sensitive. The RAs are also able to follow up with the clients at their homes to provide further support on home exercises programs and to help with simple modifications and recommendations to address clients’ needs, in consultation with the qualified physiotherapy staff. Care is taken to consult with national physiotherapists and not to go beyond the scope of RA services.
“The RAs are living in the refugee camp together with the clients. Our clients came from different countries and cultures and you may find that RAs are from the same country and even the same culture. For the RAs it will be easy to know some of client’s behaviors and problems. RAs respect the confidentiality of clients and you may find that within the week we can meet on the way in the community and maybe the clients may be having some problems and the RAs can direct the clients. Many of the clients know where some of RAs are living and some of the RAs known where some of the clients are living. You may find that there are some of the exercises that we did in the sessions and maybe the clients didn't understand it well so the clients may have time to ask some questions and RAs may have time to explain to the clients and tell them how they should be doing it. That is an advantage of the RAs and clients living in the same camp”. Quote by an RA in Kalobeyei camp-Kakuma Kenya (Amani).
Provide Protocol Based Care
Many organizations have developed health care protocols, identifying how common conditions should be managed, which has helped to enhance patient care. There are also protocols and recommendations to make sure that physiotherapists are assessing for Red Flag Issues, which would necessitate referrals to other medical professionals.
Provide Rehabilitation and Intermediate Care - Joining Up Health and Social Care
The RAs are able to accompany the clients who need extra services apart from Physiotherapy e.g. shelter and protection, livelihood support, and medical appointments to help to advocate for clients. As some of the clients are unable to access physiotherapy centers due to living too far from centers to walk and not being able to afford the fare for a motorbike (often the only form of transportation in refugee camps), the RAs are sometimes able to provide home based exercise program under the direction of the physiotherapist.
Mobilisation and Community SensitisationThe RAs play an integral role in community sensitization. The typically have a good understanding of cultural differences and of communication barriers and often speak many languages. Together with the professional physiotherapists, they are able to package the community sensitization messages to meet the needs of various target groups. Most of the POCs (persons of concern - another name for refugees living in camps), especially newer arrivals, also need to be informed about health care facilities available within the camp. They are also able to identify POCs with healthcare needs within the community and to help to refer them appropriately.
“Some clients do fear looking for assistance. Therefore, we go after them (approach them) in the community’’. Quote by an RA in Kalobeyei Camp - Kakuma Kenya (Jeremy).
Supervisions of Rehabilitation Assistants
The RAs have varying degrees of supervision needs and the frequency and amount of supervision depends on their employer, setting, nature of the work and the skills of the particular RA. RAs working in NGOs dealing with torture and trauma work require close supervision. In most of the organizations the RAs are mentored and supported by a qualified staff member. They receive both individual and group supervision.
The World Health Organization estimates that there are fewer than ten rehabilitation professionals (physiotherapists, occupational and speech therapists) per one million residents in low and middle income countries, so it is clear that there are not enough physiotherapists to meet the needs of all who would benefit from receiving physiotherapy. Community Based Rehabilitation workers help to fill important gaps in services. 
Quotes from Rehabilitation AssistantsIt is important for physiotherapists to read first person accounts of refugees so that they can try to better understand the experiences of refugees. Following are several quotes from rehabilitation assistants from the Center for Victims of Torture, who are refugees living in Kalobeyei refugee settlement and who are often former clients themselves.
“I was a little bit anxious about the work because CVT clients are torture survivors and I am also a survivor. CVT had the solution - They gave us supervision every week and also gave us training on how to care for our self during and after work so that we are not affected by the client histories”. Quote from a female RA in Kalobeyei Camp - Kakuma Kenya (Chukulisa)
“Respect is very important while working with others since it helps to maintain good contact and peace at work. I do empathize with my clients since I am aware of the suffering that my clients go through. There is a great impact in the community from clients who have attended physiotherapy sessions; they feel better and the pain and injuries that they’ve had for a long time get to be managed. They acquire strategies to manage their symptoms and become productive people in the community”. Quote from an RA in Kalobeyei Camp - Kakuma Kenya (Jeremy).
“The physiotherapist should know that many of refugees have been tortured, and that some of them have money, some went to school, some had been working with the government and for other NGO’s. To assist them, the physiotherapist should know how they have been living and understand the causes of the problems or pain that they are having. If the physiotherapists could research to know what is happening in different countries and different culture in Africa it can be easy to assist the clients”. Quote from an RA in Kalobeyei Camp - Kakuma Kenya (Amani).
Challenges for Rehabilitation Assistants
It is essential that rehabilitation assistants are supported to continue to develop their skills and not be put in situations where they are asked to work beyond the scope of their practice. “They need to be appropriately supported to develop contextually relevant skills, knowledge and competence, and in some cases be a jack of all trades”.  Another issue for rehabilitation assistants is that it can be difficult to establish and to maintain boundaries, as they live in the same refugee camps as their clients. The advantage which the RA, Amani, brought up, of clients knowing where RAs live and at times going to their houses for advice and physiotherapy-related consultation, can be challenging as well. During the COVID-19 pandemic, this can be even more problematic. It is difficult to both maintain physical distance and safe practices but still be accessible to the clients, and to convey a caring presence, but still to have a separation between their work and their home lives. Physiotherapists working in refugee camps typically live in a compound with other NGO workers and have a more natural work/life balance and separation than do the RAs who are in the refugee camps at all times.
Self-Care for those Working in Refugee Camps
It is important that physiotherapists who are working and living in refugee camps pay close attention to their needs for self-care. Often, these are unaccompanied positions, so physiotherapists are far away from their family and friends. The work can be very grueling and they are exposed to a great deal of human suffering and unmet needs of their clients.
There are many blogs, podcasts, free online courses, Facebook groups and other resources for physiotherapists and others working in humanitarian settings, which may be helpful.
One example is the “Awake at Night” Podcasts, produced by UNHCR, which has episodes about humanitarian workers, including the joys and difficulties of their work, and what they do to find meaning and comfort. 
There is a global Facebook Group for physiotherapists who are working with refugees and survivors of torture, with over 200 physiotherapists from more than 30 countries. For information about joining the group, please send Facebook Message or Facebook friend request to Laura Pizer Gueron, physiotherapist. Physios share resources in a confidential forum in this group.
The website, ProQOL.org, (Professional Quality of Life) is dedicated to helping humanitarian workers, including physiotherapists, assess their current status and to find resources for improving their self -care. There is a measure there, which physiotherapists can fill out in about 10 minutes and self-score, which will provide validated and reliable scores in the three areas of:
- Compassion Fatigue versus Compassion Satisfaction
- Secondary Traumatic Stress/Vicarious Traumatization versus Vicarious Transformation.
Here is the link to the English Language Version, (42) and the ProQOL has official translations available in 26 Languages. (43)
Some NGO’s have their staff fill out the ProQOL Measure quarterly using the Pocket Card, or at other appropriate intervals, so that they can get a sense of their baseline scores in all three scales, and have an early warning if they are starting to have difficulties in one or more areas, so that they can get support as needed.
Disaster Ready has more than 1,000 free resources for humanitarian workers, including many online courses and you can create a free account. (45) While Disaster Ready is not designed specifically for physiotherapists, many of the courses at the site, about self-care, security, management, communication, program planning, etc. would be of help to physiotherapists who are working in camp or urban refugee settings.
The Headington Institute also has many free, online resources for humanitarian workers, including training about self-care and other topics which are designed to help the helpers to be happier, healthier, and as effective as possible. (46)
“50 Shades of Aid” is another Facebook group which is geared towards humanitarian workers, including physiotherapists, where members share ideas and support. To join this private group, send a message to the organizers. (47)
Challenges Faced in Provision of Rehabilitative Services in Long Stay Camps
In some refugee camps, such as Kakuma in northwestern Kenya, there are more than 30 languages spoken by refugees living in the camps. It can be difficult for NGO’s to hire and train interpreters in all of the needed languages so that physiotherapists can adequately communicate with their clients. It is ideal to hire RAs who speak many different languages as well, so that they can interpret during sessions co-led with the physiotherapists as well.
Cultural-Spiritual Beliefs, Illness Perception and Expressions of Pain
Physiotherapists working in refugee camps will often work with clients from many different countries, cultures and religious backgrounds. Each client may have very different perceptions of illness, idioms of pain and it is crucial for the physiotherapists to understand these beliefs as much as possible, so that they can offer relevant instruction and use appropriate metaphors when working to address issues with pain and other issues. Many NGO’s cultivate strong connections with community leaders from various refugee groups, so that they can continue to learn and to optimize their physiotherapy care.
“When the clients visit our center for physiotherapy, we lead them in some exercises as instructed and prescribed by the physiotherapist. As a refugee also, I can connect well with the clients because I understand the culture and terms to use when giving instructions and health education.” Quote by an RA in Kalobeyei camp-Kakuma Kenya. (Jeremy)
Access and Awareness of Physiotherapy Services
Many refugee camps have many NGO’s providing many different types of services. Physiotherapists are often in short supply, as mentioned previously. It can be difficult for often overstretched physiotherapy team members to sensitize community members enough and to make themselves visible enough to other NGO’s so that the staff for other NGO’s will refer their clients for physiotherapy services. Doing external trainings about topics of interest for staff members of other agencies, such as self -care, sleep, pain reduction, proper body mechanics and similar topics, physiotherapists can increase their visibility in the refugee camp.
Physiotherapists working in refugee camps often find their work to be extremely rewarding. They need to be well-rounded clinicians who can learn to work closely with other disciplines, such as nurses, counselors and teachers, in order to best meet the needs of their clients. In many refugee camps, they will be recruiting, training, supervising and learning from rehabilitation assistants, who are members of refugee communities who live in the refugee camps. Ideally, the relationship between rehabilitation assistants and physiotherapists should be very reciprocal and respectful, where both learn from each other.
ResourcesBlogs written by Physiotherapists and Rehabilitation Assistants working in a Refugee Camp in Kenya (Kalobeyei Refugee Settlement next to Kakuma Refugee Camp)
Following are some accounts written by Kenyan physiotherapists and an RA working in Kakuma. Reading blogs, written by the staff members working on the ground in refugee camps, can be very powerful and may provide a more “human face” to the work of physiotherapists in refugee camps. The blogs address benefits of physiotherapy, difficulties of providing therapy in a refugee camp, finding meaning and preventing burn out and secondary traumatization and how life and work has changed due to the COVID-19 pandemic.
- We Say This is Not the End Physiotherapist, Winnie Chao, August 27, 2020
- Life is a Gift Physiotherapist Supervisor, Stanley Malonza August 11, 2020
- Overcoming Fear and Finding a Future Rehabilitation Assistant, Randa Anthony, July 16, 2020
- Physiotherapy Supports Healing - Even During the Pandemic Physiotherapy Trainer, Joseph Wesonga, June 17, 2020
- Finding Furaha (Happiness) at CVT Kakuma Physiotherapist Justine Chepngetich, May 16, 2019
- The Mind-Body Connection at CVT Kakuma Physiotherapist Trainer, Joseph Wesonga, August 8, 2018
Blogs about Working with Traumatised Refugees in Refugee Camps from Counselling, Logistics or General Perspectives
- From Bare Ground To a Successful Program Field Coordinator, Samuel Orangi, March 10, 2020, about logistics of starting program in 2018
- “Modified Shipping Containers: Temporary Housing for Long-Lasting Healing” Country Director, Pablo Traspas, January 16, 2018, about the process of getting ready to start program in Kakuma
- Dignity in Mental Health—Marking World Mental Health Day about refugee camps in Ethiopia commemorating World Mental Health Day with bike races and other activities, March 10, 2016
- The Lives of Women in Dadaab about the lives of refugee girls and women in Dadaab refugee camp (at the time of blog the biggest camp in the world), March 7, 2016
- Welcoming Newcomers to CVT’s Work in Dadaab about new refugees from Somalia coming to Dadaab Refugee Camp, February 25, 2016
- The Harsh Reality of Life in a Refugee Camp Psychotherapist trainer working in Dadaab, September 23, 2014
- United Nations General Assembly, Convention Relating to the Status of Refugees, 28 July 1951, United Nations Treaty Series, 189:p 137. Available from: https://www.refworld.org/docid/3be01694.html [Accessed 16 September 2020]
- United Nations High Commissioner for Refugees (UNHCR): Global Trends. Forced Displacement in 2015. Available from: http://www.unhcr.org/statistics [Accessed 23 July 2020]
- The World Health Organization. The Need to Scale Up Rehabilitation. Rehabilitation 2030: A Call for Action. 2018.
- Mitchell-Gillespie B, Hashim H, Griffin M, AlHeresh R. Sustainable support solutions for Community-Based Rehabilitation Workers in refugee camps: Piloting telehealth acceptability and implementation. 2020. Research Square-preliminary report. Available from: https://doi.org/10.21203/rs.3.rs-34117/v1;1-21 [Accessed 25 September 2020]
- UNHCR-Statistics at a Glance. 18 June 2020. Available from: https://www.unhcr.org/en-ie/figures-at-a-glance.html [Accessed 25 September 2020]
- World Health Organisation Regional Office for Europe. Health Evidence Network Synthesis Report 44 - Public health aspects of migrant health: a review of the evidence on health status for refugees and asylum seekers in the European Region. 2015. Available from:http://www.euro.who.int/__data/assets/pdf_file/0004/289246/WHO-HEN-Report-A5-2-Refugees_FINAL.pdf[Accessed 25 September 2020]
- Sigvardsdotter E, Vaez M, Rydholm Hedman AM, Saboonchi F. Prevalence of torture and other war-related traumatic events in forced migrants: A systematic review. Torture 2016;26(2):41-73.
- Aebischer Perone SA, Martinez E, du Moriter S, Rossi Ro, Pahud M, Urbaniak V, et al. Non-communicable diseases in humanitarian settings: Ten essential questions. Conf Health 2017; 11(17), 1-11. doi.org.10.1186/s13031-017-0119-8
- World Health Organization. Report on the Health of Refugees and Migrants in the WHO European Region. Geneva. World Health Organization, 2018; Available from: http://www.euro.who.int/data/assets/ [Accessed 25 September 2020]
- Bradby H, Humphris R, Newall D, Phillimore J. Public health aspects of migrant health: A review of the evidence on health status for refugees and asylum seekers in the European region. Health Evidence Network Synthesis Report, 2015; 44. Copenhagen: WHO Regional Office For Europe.
- Stammel S, Knaevelsud C. Schock K, Walther LCS, Wenk-Ansohm MP, Bottche M. Multidisciplinary treatment for traumatized refugees in a naturalistic setting: Symptom courses and predictors. Eur J Psychotraum 2017;8(2). Available from:https://doi.10.1080/20008198.2017.1377552 [Accessed 25 September 2020]
- Dibaj II, Halvorsen JO< Kennair LEO, Stenmak HI. An evaluation of combined narrative exposure therapy and physiotherapy for comorbid PTSD and chronic pain in torture survivors. Torture 2017;27(1:13-27)
- McGowan E, Beamish N, Stokes E, Lowe R. Core competencies for physiotherapists working with refugees: A scoping review. Physiotherapy 2020;108:10-21. Available from: https://doi.org/10.1016/j.physio.2019.01.002 [Accessed 25 September 2020]
- UNHCR. Global Compact on Refugees. 2 October 2018. Available from: https://www.unhcr.org/gcr/GCR.English.pdf [Accessed 25 September 2020]
- Nilsson H, Saboonchi F, Gustavsson C, Malm A, Gottvall M. Trauma-afflicted refugees’ experiences of participating in physical activity and exercise treatment: A qualitative study based on focus group discussions. Eur J Psychotraumatol 2019;10(1):1699327. Available from:https://www.doi.org:10.1080/200008198.2019.1699327 [Accessed 25 September 2020]
- Knappe F, Colledge F, Gerber M. Challenges associated with the implementation of an exercise and sport intervention program in a Greek refugee camp: A report of professional practice. Int J Env Res Pub Health. 2019; 16(4926):1-19. Available from: https://www.doi:10.3390/jerph16244926 [Accessed 25 September 2020]
- O’Keefie M, Hayes A, McCreesh K, Purtill H, O’Sullivan, K. Are group-based and individual physiotherapy exercise programmes equally effective for musculoskeletal conditions? A systematic review and meta-analysis. Brit J Sports Med 2017;51(2):126-132. Available from: https://doi.org/10.1136/bjsports-2015-045410 [Accessed 25 September 2020]
- Harlacher U, Polatin P, Taing S, Phana P, Sok P, Sotherra C. Education as a treatment for chronic pain in survivors of trauma in Cambodia: Results of a randomized controlled outcome trial. Int J Conf Violence 2019;13:1-26. Available from: https://doi.org/10.4119/UNI9/ijcv.655 [Accessed 25 September 2020]
- Crosby SS. Primary care management of non-English-speaking refugees who have experienced trauma: A clinical review. JAMA 2013; 310(5): 519-528. Available from: https://doi.org/10.1001/jama2013.8788 [Accessed 25 September 2020]
- 21. McMurray J, Breward K, Breward M, Alder R, Arya N. Integrated primary care improves access to healthcare for newly arrived refugees in Canada. J Imm Min Health 2014; 16(4):576-585. Available from: https://doi.org/10.1007/s10903-013-9954-x [Accessed 25 September 2020]
- Rolfe G, Jackson N, Gardner L, Jasper M, Gale A. Developing the role of the generic healthcare support worker: Phase 1 of an action research study. Int J Nurs Stud 1999;36:323–334
- Cheng IH, Vasi S, Wahidi S, Russel lG. Rites of passage: improving refugee access to general practice services. Aust Fam Phys, 2015; 44:503–507.
- Saks M, Allsop J. Social policy, professional regulation and health support work in the United Kingdom. Soc Pol Soc 2007; 6:165–177.
- Amris K, Jones L, Williams A. Pain from torture: Assessment and management. Pain Rep 2019;4(6):e794. Available from:https://doi.org.10.1097/PR9.0000000000000794 [Accessed 25 September 2020]
- Nordin I, Perrin S. Pain and posttraumatic stress disorder in refugees who survived torture: The role of pain catastrophizing and trauma-related beliefs. Eur J Pain 2019;23:1497-1506. Available from: https://doi.10.1002/ejp.1415 [Accessed 25 September 2020]
- Tsur N, Defrin R, Shahar G, Solomon Z. Dysfunctional pain perception and modulation among torture survivors: The role of pain personification. J Aff Dis 2020;46(4):15(265:10-17. Available from: https://www.hhri-gbv-manual.org or https://doi.10.1016.j.jad.2020.01.031 [Accessed 25 September 2020]
- Golden S. Assessing mental health in Kalobeyei: A representative survey of refugees and host communities. St. Paul, MN. The Center for Victims of Torture 2018;1-40.
- Golden S. Assessing refugee mental health in Ethiopia: A representative survey of Aid Harush and Mai Ani Camps. St. Paul, MN. The Center for Victims of Trauma 2017. Available from: https://www.cvt.org/sites/default/files/attachments/u93/downloads/Assessing_Refugee_Mental_Health_in_Ethiopia_letter_v1.pdf [Accessed 25 September 2020]
- Elshafie R. Assessing mental health in Bidi Bidi, Uganda: A representative survey of South Sudanese refugees in Zone 5. St. Paul, MN. The Center for Victims of Torture 2020. Available from:https://www.cvt.org/sites/default/files/attachments/u93/downloads/cvtbidi_bidi_2019_mhpss_survey_report.pdf [Accessed 25 September 2020]
- Nielsen H. Interventions for physiotherapists working with torture survivors, with special focus on chronic pain, PTSD, sleep issues. Dignity Publication Series on Torture and Organized Violence—Praxis Paper 2014.
- Sandahl H, Jennum P, Baandrup L, Pschmann IS, Carlsson J. Treatment of sleep disturbances in trauma-affected refugees: Study protocol for a randomised controlled trial. Trials 2017:18(520). Available from:https://doi.org/10.1186/s13063-017-2260-5 [Accessed 25 September 2020]
- Siengsukon CF, Al-dughmi M, Stevens S. Sleep health promotion: Practical information for physical therapists. Phys Ther 2017;97(8):826-836. Available from: https://doi.org/10.1093/ptj/pzx057 [Accessed 25 September 2020]
- Albert H. Psychosomatic group treatment helps women with chronic pelvic pain. J Psych Ob Gyn 1999;20(4):216-225. Available from: https://doi.org.10.3109/01673829909075598 [ACcessed 25 September 2020]
- Dermain S, Smith JF, Hiller L, Dziedzic K. Comparison of group and individual physiotherapy for female urinary incontinence in primary care: A pilot study. Physiotherapy 2001;87(5):235-242. Available from: https://doi.org/10.1016/S0031-9406(05)60784-5 [Accessed 25 September 2020]
- Dorey G, Speakmen M, Feneley FCL, Swinkels A, Dunn. Pelvic floor exercises for erectile dysfunction. Brit J Ur Int 2005;96(4):595-597. Available from: https://doi.org/10.1111/j.1464-410x.2005.05690.x [Accessed 25 September 2020]
- Myers C, Smith M. Pelvic floor muscle training training improves erectile dysfunction and premature ejaculation: A systemic review. Physiotherapy 2019;105(2);235-243. Available from:https://doi.org/10.1016/j.physio.2019.01.002 [Accessed 25 September 2020]
- Rosenberg TY. Pelvic floor involvement in male and female sexual dysfunction and the role of pelvic foor rehabilitation in treatment: A literature review. Uro Phys Priv Prac 2007. Available from: https://doi:10.1111/j.1743-6109.2006.00339 [Accessed 25 September 2020]
- Ussing A, Dahn, II, Due U, Sorensen M, Petrsen J, Bandholm T. Efficacy of supervised pelvic floor muscle training and biofeedback vs. attention-conrol treatment with fecal incontinence. Clin Gast Hep 2019;17:2253-2261.
- Moran, AM, Nancarrow, SA, Wiseman L, Maher,K, Boyce RA, Borthwick AM, Murphy K. Assisting role redesign: A qualitative evaluation of the implementation of a podiatry assistant role to a community health setting ultilising a traineeship approach. J of Foot and Ankle Res 2012;5(30). Available from: https://doi.org/10.1186/1757-1146-5-30 [Accessed 25 September 2020[
- UNHCR. AWAKE AT NIGHT - A Podcast with Melissa Fleming. Available from: https://www.unhcr.org/awakeatnight/ [Accessed 25 September 2020]