Role of Rehabilitation Professionals in Camps for Displaced Persons

Original Editor - Laura Gueron and Stanley Malonza from The Center for Victims of Torture as part of the PREP Content Development Project

Top Contributors - Naomi O'Reilly, Jess Bell, Kim Jackson, Ewa Jaraczewska and Wanda van Niekerk  

Introduction[edit | edit source]

The United Nations High Commission for Refugees (UNHCR) reported that at the end of 2021 there were 89.3 million people who were forced to flee their homes due to conflicts, violence, fear of persecution and human rights violations including 27.1 million refugees and 4.6 million asylum seekers across the globe, in addition to 53.2 million internally displaced people, with Turkey currently the host of the largest number of displaced persons globally, hosting more than 3.8 million.[1]

Camps for displaced persons are temporary facilities built to provide immediate protection and assistance to people who have been forced to flee their homes due to war, persecution or violence. While camps are not established to provide permanent solutions, they offer a safe haven for displaced persons and meet their most basic needs such as food, water, shelter, medical treatment and other basic services during emergencies.

In situations of long-term displacement, the services provided in camps are expanded to include educational and livelihood opportunities as well as materials to build more permanent homes to help people rebuild their lives. These services are also offered to host communities.

There are camps for displaced persons all over the world. Many of these camps were built quickly to serve the immediate needs of those forced to flee, but have grown to host hundreds of thousands of displaced people. Some of the world's largest camps for displaced persons are: Kutupalong-Balukhali Expansion Site (Bangladesh), Bidi Bidi Refugee Camp (Uganda), Dadaab and Kakuma Refugee Camps (Kenya), Azraq and Zaatari Refugee Camps (Jordan), Nyarugusu, Nduta, and Mtendeli Refugee Camps (Tanzania) and Kebribeyah; Aw-barre and Sheder Refugee Camps (Ethiopia).

Data on Camps for Displaced Persons[edit | edit source]

According to UNHCR, 6 million displaced persons in the world live in camps, which is 22% of the worlds overall displaced person population, while more than half of displaced persons live in urban or semi-urban areas. Many of the camps for displaced persons have been around for so many years that they are basically like cities with schools, clinics, shops and other infrastructure. [2] While many of the world’s camps for displaced persons had been intended to be temporary, there are so many protracted displacement situations in the world, that many of these camps have been in existence for much longer than planned. 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 lived their entire lives in camps for displaced persons. According to the UNHCR, 2021 Global Report, the top hosting countries of the world are Turkey (3.6 million), Colombia, (1.8 million), Pakistan and Uganda, (both 1.5 million) and Germany, 1.3 million. More than 80% of displaced persons are hosted in low and middle income countries, and the average displaced person lives in settlement situations for nearly 20 years. The top “source countries” where displaced persons originate from are Syria (6.8 million), Venezuela (4.6 million), Afghanistan (2.7 million), South Sudan (2.4 million), and Myanmar (1.2 million).[2] Numbers of displaced persons from Ukraine have also grown exponentially since the outbreak of conflict in March 2022, which are not included in the UNHCR Global Report 2021 but current data suggests more than 5 million people been forced to leave the country and seek protection in other countries, and a further 7 million internally displaced. [3]

It is estimated by the World Health Organization and by UNHCR that ten percent of displaced persons have some sort of disability, and these individuals can benefit greatly from receiving rehabilitation services. [4] In addition, research studies show that between 15 and 44 percent of displaced persons have undergone some form of torture, with a systemic review of forced migrants by Sigvardsdotter et al [5] showing an average of 27% having a torture history. While the exact prevalence of torture among displaced persons 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 rehabilitation services, such as those outlined in the physiopedia article Physiotherapy for Survivors of Torture.

Displaced persons have higher rates of many non-communicable diseases. In some camps for displaced persons where ICRC works, more than 17% of displaced persons age 18 and above have a diagnosis of diabetes. [6] Rehabilitation professionals working in camps for displaced persons 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 displaced person populations than in the general population. [7][8] It is important that rehabilitation professionals have a comfort level in providing services to individuals who have mental health conditions. Rehabilitation professionals working with those living in camps must also be familiar with “Trauma Informed Care” and how to adapt their programming to meet the needs of displaced persons who have been through traumatic experiences. [9][10][11]

As so many displaced persons live for many years in camps, with little possibility of being permanently resettled, it is crucial that the residents of camps for displaced persons have access to quality medical care, including rehabilitation services, as they are at higher risk than the general population of developing many chronic illnesses, which can benefit from rehabilitation services. 

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. Rehabilitation professionals have an obligation to help to meet the rehabilitation needs of those who lives in camps for displaced persons. As per Article 26 of the Universal Declaration of Human Rights, many displaced persons have war-related injuries such as amputations, spinal cord injuries, head injuries and other traumatic injuries, which have significant need for quality access to rehabilitation services. [12]

An important role for rehabilitation professionals who work in camps for displaced persons is to provide training to for community based rehabilitation workers who work for other NGO’s so that they understand who to identify for further support from rehabilitation. In addition, since many displaced persons who would benefit from rehabilitation services will not be able to receive it due to shortages, it is also ideal if rehabilitation professionals can provide psycho-education and psychological first aid for teachers, counsellors 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 those who are unable to access rehabilitation services due to the shortages.

As many displaced persons living in camps have complex needs, it is important that the rehabilitation professionals working in camps form close connections with leaders of the communities they work in 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. [9][11]

Another possible role of rehabilitation professionals working in camps is to help to organize opportunities for displaced persons 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 displaced persons who have PTSD and pain, which show that the participants benefit from the activity. [13][14]

There needs to be sensitivity when arranging group physical 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 physical activities so that participants have choice. [14] It is ideal to offer programs for men, women and for children, if possible. While in some camps for displaced person, there are specific NGO’s who focus on physical activity, such as Right to Play, rehabilitation professionals can still play an important role in helping to develop and support physical activity programming. 

Group rehabilitation sessions can be very beneficial for those living in camps for displaced persons, as 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.[15][16] With the shortage of trained rehabilitation professionals working in camps for displaced persons around the world, working with groups can be an efficient way to reach more patients as well. 

According to the UNHCR, half of the displaced persons in the world are younger than the age of 18. Rehabilitation professionals 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 have been displaced. 

With eighty to eighty five percent of displaced persons being housed in developing countries, it is ideal if the rehabilitation team can provide services to host community members as well, as there is typically a lack of resources and poverty among the host community. [2]

The influx of displaced persons has had a great impact on the social, economic and health sectors of many countries. Increasing numbers of displaced persons has increased the pressure and demand on both primary and secondary health care services, across all rehabilitation professionals. [17][18][19][20] 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 rehabilitation professionals who can deliver optimum and timely services to clients. [21][22]  

People living in camps for displaced persons 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.

Chronic Pain and Sleep Issues[edit | edit source]

There are multiple studies showing that displaced persons have higher rates of pain than the general population. [22][23][24] Few of the studies were done exclusively in camps settings, so it is difficult to know how pervasive pain issues are in displaced persons. 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 displaced person community members conducted by CVT in Kalobeyei Settlement just outside of Kakuma Camp in 2018, 35% of displaced persons and 32% of host community respondents indicated that they had chronic pain. [25] In the same survey, 51% of displaced persons and 44% of host community members indicated that they were having trouble falling asleep. [25]

In a similar survey by the Center for Victims of Torture staff members in two camps in Ethiopia in 2017, 44% of the respondents reported having difficulty sleeping, and 28% at Adi Harush and 31% at Mai Ani Camps reported having chronic pain. [26]

And finally, in a CVT representative survey in 2020 of displaced persons in Bidi Bidi settlement in Uganda, 56% of displaced persons reported difficulty sleeping and 51% reported having issues with chronic pain. [27] 

It is crucial that rehabilitation professionals who are working with displaced persons, both in and outside of camps, focus carefully on providing pain education and other pain relieving treatment and psychoeducation. [10][16][22][23][24][28] The following physiopedia pages on Evidence Based Assessment of Pain in Displaced Persons and Evidence-based Management of Pain in Displaced Persons are an excellent resource for this topic area. 

Sleep difficulties are common among displaced persons, as noted in the surveys above. Camps for displaced persons 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 rehabilitation professionals who are working in 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. [28][29][30]

Gender Based Violence[edit | edit source]

Issues with incontinence and sexual functioning, which some rehabilitation professionals can address, commonly occur as a result of gender based violence. While there are several Physiopedia Pages (Considerations for Working with Survivors of Sexual Violence and Considerations for Working with LGBTQIA+ Displaced Persons), which focus on these issues in detail, it is important to know that many displaced persons 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 displaced about ways to decrease erectile dysfunction, and with all displaced persons 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. [31][32][33][34][35][36] 

Shortage of Rehabilitation Professionals[edit | edit source]

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 displaced persons camp settings. To help to fill this gap, WHO designed the strategy of Community-Based Rehabilitation (CBR), with CBR programs present in more than 90 countries, with many such programs operating in camps for displaced persons. 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. [37]

There are ethical issues posed by the shortage of rehabilitation professionals, 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 [38] describes the use of telehealth in displaced persons camps in Jordan, where 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 iPad video. [38]

With the onset of COVID-19, in some camps for displaced persons, the qualified rehabilitation professionals left the camps, leaving CBR workers such as rehabilitation assistants, who are often displaced persons who live in the camps, as the only rehabilitation workers on-site. In these situations, the use of tele-health, where the 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 camps for displaced persons, but reported that overall, in their pilot study, telehealth was well-received by both clients and staff members. [38]

Rehabilitation Assistants in Camps for Displaced Persons[edit | edit source]

In both long term and short term camps, rehabilitation assistants provide support to rehabilitation professionals in many clinical and non-clinical tasks. Being able to work alongside rehabilitation assistants relieves the work of rehabilitation 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 rehabilitation assistants, who provide, on average, 36% of the direct care provision. There are over 300 job titles used to describe support workers or assistants. [19][21][39] For this article, the term “Rehabilitation Assistants’ is used to describe those who work alongside professionally qualified rehabilitation professionals. 

There has been a growing trend to tap into the available human resources within community based rehabilitation programs and to build displaced persons capacity for long term program sustenance.  A male rehabilitation assistant, who was one of the two first rehabilitation assistant’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 a rehabilitation assistants in Kalobeyei camp-Kakuma Kenya (Amani).

However, it is also important to ensure that rehabilitation assistants have appropriate training and supervision, and are not asked to do activities which are beyond their capacity, and/or outside of the regulation concerning specific rehabilitation professionals within the country where the camp is located. 

Training of Rehabilitation Assistants[edit | edit source]

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 rehabilitation assistants learn the necessary basic rehabilitation principles and techniques. In Kenya, rehabilitation assistants 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 rehabilitation assistants to join tertiary colleges with the knowledge and skills acquired.  

Depending on the NGO whom they work for, the rehabilitation assistants undergo rigorous training for the first 3 to 12 months after recruitment, which is complimented by ongoing on-the-job training from senior rehabilitation assistants and rehabilitation professionals such as physiotherapists, occupational therapists etc. During this period there are assigned non-clinical duties such as welcoming and receiving clients, preparation of treatment areas, inventory taking etc. Delegation of duties depends on the rehabilitation professionals experience and the training background of the rehabilitation assistants and the amount of time that the two have interacted. [37] 

Roles of Rehabilitation Assistants [edit | edit source]

The roles vary from organization to organization and from one country to another. It is crucial that the NGO and the rehabilitation 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 specific rehabilitation organization of the country where they work.  Common job responsibilities of RAs who are working as physiotherapists include but are not limited to:

  • Working with patients towards individual rehabilitation goals, as prescribed by rehabilitation professionals.
  • Supporting and supervising patients in activities of daily living.
  • Promoting patient rights and identity
  • Helping rehabilitation professionals to monitor clients’ progress
  • Providing feedback to the rehabilitation professionals 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 rehabilitation.
  • Ensuring that the cleanliness and safety of the therapeutic equipment in the department is maintained. 
  • Helping to maintain records of work undertaken with patients. [38] 

Advantages of Rehabilitation Assistants [edit | edit source]

Useful in Inter-Professional Linkages[edit | edit source]

In camp settings patients 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 rehabilitation assistants 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.   

Rehabilitation assistants are perceived as a focal point for care delivery and serve as conduits for clients.

Provide Faster, More Accessible Care[edit | edit source]

Most of the rehabilitation assistants are also themselves a displaced person who live within the same camps as the patients, which enables them to interact with patients and to provide timely care that is also culturally sensitive. The rehabilitation assistants are also able to follow up with the patients 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 rehabilitation staff. Care is taken to consult with national rehabilitation professionals and not to go beyond the scope of rehabilitation assistants services. 

The rehabilitation assistants are living in the camp together with the clients. Our clients came from different countries and cultures and you may find that rehabilitation assistants are from the same country and even the same culture. For the rehabilitation assistants it will be easy to know some of client’s behaviours and problems. Rehabilitation assistants 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 rehabilitation assistants can direct the clients. Many of the clients know where some of rehabilitation assistants are living and some of the rehabilitation assistants 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 rehabilitation assistants may have time to explain to the clients and tell them how they should be doing it. That is an advantage of the rehabilitation assistant and clients living in the same camp”. Quote by a rehabilitation assistant in Kalobeyei camp-Kakuma Kenya (Amani).

Provide Protocol Based Care [edit | edit source]

Many organisations 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 rehabilitation professionals are assessing for Red Flags, which would necessitate onward referrals to other medical professionals. 

Provide Rehabilitation and Intermediate Care - Joining Up Health and Social Care[edit | edit source]

The rehabilitation assistants are able to accompany the clients who need extra services apart from rehabilitation 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 rehabilitation centres as a result of living too far to walk and not being able to afford the fare for a motorbike (often the only form of transportation in camps), the rehabilitation assistants are sometimes able to provide home based exercise program under the direction of the rehabilitation professional. 

Mobilisation and Community Sensitisation[edit | edit source]

The rehabilitation assistants play an integral role in community sensitisation. The typically have a good understanding of cultural differences and of communication barriers and often speak many languages. Together with rehabilitation professionals, they are able to package the community sensitisation messages to meet the needs of various target groups. Most of the persons of concern, another Term used for persons living within camps, especially newer arrivals, also need to be informed about health care facilities available within the camp. They are also able to identify persons of concern with healthcare needs within the community and to help to refer them appropriately to services they may need.  

“Some clients do fear looking for assistance. Therefore, we go after them (approach them) in the community’’.  Quote by a rehabilitation assistant in Kalobeyei Camp - Kakuma Kenya (Jeremy).

Supervision of Rehabilitation Assistants[edit | edit source]

The rehabilitation assistants 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 rehabilitation assistants. Rehabilitation assistants working in NGOs dealing with torture and trauma work require close supervision. In most of the organisations the rehabilitation assistants 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 etc.) per one million residents in low and middle income countries, so it is clear that there are not enough rehabilitation to meet the needs of all who would benefit from receiving rehabilitation services. Community Based Rehabilitation workers and rehabilitation assistants help to fill important gaps in services. [37] 

Quotes from Rehabilitation Assistants[edit | edit source]

It is important for rehabilitation professionals to read first person accounts of displaced persons so that they can try to better understand the experiences of displaced persons. Following are several quotes from rehabilitation assistants from the Center for Victims of Torture, who themselves are displaced persons living in Kalobeyei 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 rehabilitation assistant 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 a rehabilitation assistant 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 a rehabilitation assistant in Kalobeyei Camp - Kakuma Kenya (Amani).

Challenges for Rehabilitation Assistants[edit | edit source]

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”. [19] Another issue for rehabilitation assistants is that it can be difficult to establish and to maintain boundaries, as they live in the same camps as their clients. The advantage which the rehabilitation assistant, Amani, brought up, of clients knowing where rehabilitation assistants live and at times going to their houses for advice and rehabilitation-related consultation, can be challenging as well. During the COVID-19 pandemic, this was 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. Rehabilitation professionals working in camps typically live in a compound with other NGO workers and have a more natural work-life balance and separation than do many of the rehabilitation assistants who are in the camps at all times. 

Self-Care for those Working in Camps[edit | edit source]

It is important that physiotherapists who are working and living in camps pay close attention to their needs for self-care. Often, these are unaccompanied positions, so rehabilitation professionals are far away from their family and friends. The work can be very challenging 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 rehabilitation professionals 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. [40]

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. Physiotherapists share resources in a confidential forum in this group. 

The website, ProQOL.org, (Professional Quality of Life) is dedicated to helping humanitarian workers, including rehabilitation professionals, assess their current status and to find resources for improving their self -care. There is a measure there, which rehabilitation professionals can fill out in about 10 minutes and self-score, which will provide validated and reliable scores in the three areas of:

  1. Burnout
  2. Compassion Fatigue versus Compassion Satisfaction  
  3. 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 rehabilitation professionals 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 rehabilitation professionals, where members share ideas and support. To join this private group, send a message to the organizers. (47)

Challenges in Provision of Rehabilitation Services in Long Stay Camps[edit | edit source]

Language[edit | edit source]

In some camps, such as Kakuma in northwestern Kenya, there are more than 30 languages spoken by those living in the camps. It can be difficult for NGO’s to hire and train interpreters in all of the needed languages so that rehabilitation professionals can adequately communicate with their clients. It is ideal to hire rehabilitation assistants who speak many different languages as well, so that they can interpret during sessions co-led with the rehabilitation professional as well. 

Cultural-Spiritual Beliefs, Illness Perception and Expressions of Pain[edit | edit source]

Rehabilitation professionals working in 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 rehabilitation professionals 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 displaced persons groups, so that they can continue to learn and to optimize their 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 a rehabilitation assistant in Kalobeyei camp-Kakuma Kenya. (Jeremy)

Access and Awareness of Rehabilitation Services[edit | edit source]

Many camps have many NGO’s providing many different types of services. Rehabilitation professionals are often in short supply, as mentioned previously. It can be difficult for often overstretched rehabilitation 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 rehabilitation 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, rehabilitation professionals can increase their visibility in the camp.

Conclusion[edit | edit source]

Rehabilitation professionals working in camps for displaced persons often find their work to be extremely rewarding. They need to be well-rounded clinicians who can learn to work closely with other disciplines, both within and outside of healthcare such as counsellors and teachers, in order to best meet the needs of their clients. In many camps, they will be recruiting, training, supervising and learning from rehabilitation assistants, who are members of displaced communities themselves who live in the camps. Ideally, the relationship between rehabilitation assistants and rehabilitation professionals should be very reciprocal and respectful, where both learn from each other.

Resources[edit | edit source]

Blogs written by Physiotherapists and Rehabilitation Assistants working in a Camp for Displaced Persons 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.


Blogs about Working with Traumatised Refugees in Camps for Displaced Persons from Counselling, Logistics or General Perspectives 

References[edit | edit source]

  1. United Nations High Commissioner for Refugees (UNHCR): Global Trends. Forced Displacement in 2021. Available from: https://www.unhcr.org/globaltrends[Accessed 23 June 2022]
  2. 2.0 2.1 2.2 UNHCR. Figures at a Glance. Available from: https://www.unhcr.org/en-ie/figures-at-a-glance.html [Accessed 24 June 2022]
  3. UNHCR. Ukraine Refugee Situation Portal. Available from: https://data.unhcr.org/en/situations/ukraine#_ga=2.174995874.1898281340.1656069316-885200820.1645807158(Accessed 24 June 202).
  4. 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]
  5. 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.
  6. 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
  7. 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]
  8. 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.
  9. 9.0 9.1 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]
  10. 10.0 10.1 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)
  11. 11.0 11.1 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]
  12. UNHCR. Global Compact on Refugees. 2 October 2018. Available from: https://www.unhcr.org/gcr/GCR.English.pdf [Accessed 25 September 2020]
  13. 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]
  14. 14.0 14.1 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]
  15. 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]
  16. 16.0 16.1 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]
  17. 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]
  18. 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]
  19. 19.0 19.1 19.2 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
  20. 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.
  21. 21.0 21.1 Saks M, Allsop J. Social policy, professional regulation and health support work in the United Kingdom. Soc Pol Soc 2007; 6:165–177.
  22. 22.0 22.1 22.2 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]
  23. 23.0 23.1 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]
  24. 24.0 24.1 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]
  25. 25.0 25.1 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.
  26. 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]
  27. 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]
  28. 28.0 28.1 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. 
  29. 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]
  30. 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]
  31. 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]
  32. 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]
  33. 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]
  34. 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]
  35. 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]
  36. 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.
  37. 37.0 37.1 37.2 The World Health Organization. The Need to Scale Up Rehabilitation. Rehabilitation 2030: A Call for Action. 2018.
  38. 38.0 38.1 38.2 38.3 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]
  39. 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[
  40. UNHCR. AWAKE AT NIGHT - A Podcast with Melissa Fleming. Available from: https://www.unhcr.org/awakeatnight/ [Accessed 25 September 2020]