Facilitation of Inter-professional Working in Refugee Camp

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Introduction

There is no single treatment and rehabilitation programme that could be managed only by one single professional to assist the needs of patient’s conditions in health services atmospheres.  Depending on the individual needs of the individual patient who visit the hospital or rehabilitation centres will determine the various inputs required throughout their treatment and rehabilitation e.g. Assessment by Doctors, Radiologists, Specialised Doctors, Physiotherapists (PT), Occupational Therapists (OT), Psychologists, Dieticians, and Social Workers etc. Additionally, other professionals outside of the healthcare team when we are thinking holistically as one human need to survive such as vocational training professional, education professional, etc. Therefore, as a physiotherapist, we need to be creative and open minded to work with different professional to contribute and fullfill the needs of the patients. In the certain context as refugee camps we need to work collaboratively with other professionals who are not only health professionals as the situation for them seem very complexes and many things surround them are just interfere you rehabilitation process if you are not plan and work thoroughly.

Therefore, if you may ended up with poor progression of your patients according to they have less motivation and collaboration in your rehabilitation session because there are many issues such as no food for family members, domestic violence issues which needed to be solved. Thus, working with inter-professionals will help us to see the holistic situations of patient then see how each of profession could contribute and most importantly how much resources do we have in this camps context and who should to do what.

To summarise, a person-centered approach is necessary, combining multidisciplinary skills in one common goal. The physiotherapist often plays a central role, linking medical and social stakeholders.

Understanding the Refugee Camp Management Structure

In the complexity of the Refugee’ Camp context, there are different structures that you should aware of. Although it seem that working as physiotherapist, we are very much focused on health services, but in fact it is very helpful for you to aware of the social structure in camps so you understand who you should collaborate and who you should be aware of according to community norms, which may help you to discuss and get some advice to improve your rehabilitation session for your patients. It is also important to have an understanding of who the main authorities are to advise in relation to rules and regulations in the camps and what you should or should not do in their communities. Furthermore, in refugee camp contexts you will see many humanitarians organisations who are implementing a wide range programs with various contents e.g. health, food distribution, shelter establishment, water and sanitation, education, vocational training, protection, social services, and resettlement.

The purposes of camp management is to make sure that services and protection provided are in line with national and international laws, guidelines and agreed standards. The International Guideline Standard such as SPHER standard, which is a set of guidelines that formulate the minimum humanitarian standards in four technical areas: Water Supply, Sanitation and Hygiene Promotion, Food Security and Nutrition. Another example is the Inter-Agency Network for Education in Emergencies (INEE), which is the standard for humanitarian actors to coordinate the quality educations prior to, during and after agencies. These guidelines have set the standards of its relevant issues. They also consist of the ethical points of views, and how to work with refugee community in practice since situation analyses until outcome assessment. Therefore, as a physiotherapist you can study some specific guideline that you may see that it’s relevant to your patients’ needs, then you can assist them by referral or consultation to the relevant actors or at least give information to your patient or their families to seek for further support channels in the correct way. You may need to keep in mind that in practice, what is available in your context and what do other organisations able to give service or what process to let the population to consult further in this camp.

Camp Management in Thailand Myanmar Refugees’ Camps

There is the form of committee that created by the humanitarian agencies which are working in 9 refugees camps along Thailand/ Myanmar border. It is called ‘The Committee for Coordination of Services to Displaced Persons in Thailand (CCSDPT)’ . It was formed and aimed to be a forum for the members to communicate and coordinate between them to ensure the quality of services for refugees in camps as well as being the representing of membership’s interest to the Royal Thai Government, international organizations and embassies.

The camp management is one sector of CCSDPT which function to facilitate the refugee communities experience in their camp management as an accountable, inclusive and capacitated self-governance system that adheres to humanitarian principles ensures access to justice and involves them in planning for solutions. One of their strategies is to promote the rights of persons with specific needs and under-represented groups, ensuring their equitable access to services, including justice. The mapping services mapping document is always available and facilitate to develop by agencies group so you should look for this document to assist you to work. Therefore, here you can see the link that your patients may need to access the services from camp management like other. Moreover, this is the great opportunity that the system is already open for them to access so if in practice you patient have some challenges then they are eligible to raise their voice or contact relevant actors.

The structure of CCSDPT There are different sectors that CCSDPT members divided to work as per their specialized or responsive approaches to the needs of the refugees’ communities.

Figure1. CCSDPT coordination structure

According to figure 1, you may see the overall services for the refugees in camps which you can see in the details further in the handbook or the guideline of this structure in term of which organization implementing what activities and providing what services so that you can either contact them or advice your patient to seek for further assistants. Rehabilitation project is under health sub-committee according to this structure and disabilities Inclusion project is cross cutting project so there are involve in all other sectors.

This coordination structure is similar in other refugee’s camps setting all around the world so you can explore further in other context in the references resources of this page.

Roles of Physiotherapy in Health and Rehabilitation in Camps Setting

As physiotherapy have various roles in health services system since promotion, prevention, treatment, and rehabilitation. Therefore, you should analyse the needs of the camp context that you are going to work, the local and available resources and your organization capacity to contribute to fill the gaps. If following each part of health system we can see the role of PT in camps setting as:

Health Promotion

  • The give education of physical activities to improve the strength, cardiovascular could be possible, although several times these activities seem not priority of the refugees as they tend to focus on their basic needs such as food, safety and security of family members according to the context.
  • Recreation activities such as relaxation exercises could be possible to give advices for refugees but to apply based on cultural acceptance is need to be determined.

Prevention

  • Health education
  • Awareness rising for particular health conditions such as nutrition programs.

Early Identification Activities

As we all know that early detection of all health issues is best for further treatment to see good outcomes and prognosis.  Some activities that have been conduct in camp context such as.

  • Early childhood development program -> detection of any sign of impairments in early childhood age and referral to proper services. You can find some resource in the references.
  • FAST, facial droop, arm drop, speech disturbance and time, the way to identify the signs of stroke.
  • Early detection for all impairment of people in the community

Treatment and Rehabilitation

This domain is the clinical part that you really need to work closely with inter-professional team and identify the needs with the team based when and what you should intervene the treatment or rehabilitation process. The international classification of health and disabilities framework (ICF) is effective tools for us to work together with inter-professional team though tout all cycle of rehabilitation since assessment until follow up.

You can consider give your Physiotherapy technique services in various stage for example:

Early Stage

  • Positioning
  • Passive Mobilisation
  • Gentle Active Exercise
  • Breathing Exercise
  • Early TransferS with or without assistant
  • Development Stimulation for children at simple level, based on their condition
  • Bed Mobility Training
  • Consider providing assistive devices

Recovery Stage

Techniques of early stage with more advance techniques

  • Active resisted exercises or strengthening programs
  • Independent Transfers
  • Development Stimulation (for children) at more dynamic and advance levels
  • Independent Mobility
  • Self-Stretching
  • Consider providing assistive devices

Prepare for Discharge Stage

  • Take time for patients or their care givers to learn to do thing by themselves and the therapists step back to be the coacher rather the direct services provider
  • Cross check all understanding and handling technique of patients and care givers are correct and safety
  • Prepare all education tools, such as poster, handbook, and card for patient to follow at home
  • Discussing with all relevant care givers and stakeholder according to the patients future plan e.g. continue education, willing to attend vocational training, etc.
  • If possible, visit the patient’s home and environment to identify potential obstacles that request specific adaptations.

For more information of PT techniques and intervention you can explore from “Clinical Manual: Rehabilitation in Sudden Onset Disaster”

Example of PT in emergency setting by MSF: Physiotherapy in Emergency Settings

https://www.youtube.com/watch?v=s_La3I_TS14

Challenging of making people understand and aware your value

As physical therapy services are needed a lot of collaboration and commit of the patients to collaborate to improve their health conditions. As we know rehabilitation is long time process for patient to see their improvement which some condition might take months or years to see the big progression. Moreover, physical therapy is not well known therapeutic in many countries so to start all physical therapy services or rehabilitation we really need to explain demonstration, advocate and make understand to people in target locations. This lack of understanding is not only from the population, but also from the doctors or nurses in the front line. Therefore, we would like to be prepare of develop strategies to make all relevant people aware what we can contribute and support and what are benefits of our interventions to the population health’s.

Which levels should you priorities to involve in improving situation of people in refugees camps?

As mentioned in the roles of physical therapy in health and rehabilitation in camps setting section, you can assess the community situation together with local health committees and stakeholders in targets are and see how and where should develop the interventions or project to fill the gap. To discussion with all stakeholders, you will be able to explore and understand the holistic needs of the patients and how one project may impact to others.

Facilitation of inter-professional working in the community setting

There are different approaches and level that the community’s providers and the agencies will agree who will lead or facilitate the health services in this setting. The obvious example that we can focus on this is the case management team leader. This is the role of the focal person to facilitate the discussion among that relevant team who involve contributing support this person (case). Most of the time if it is in the community’s hospital the focal person is nurse and many times in the community level such as community based rehabilitationprojects, the social worker is case manager. In addition, physiotherapist is one member of inter-professional team so you may also be the focal person too. In either your roles as member of the team or the main facilitator of the team, you need to be prepare and proactive to provide information about your assessment and what contribution you should give to this person and the team. Think holistically and prepare yourself before the team updates session start so that all of patient, care givers and your concerns can be asked and put in place to find solution for next step. The effective communication techniques are needed in this role so you can practice and learn more in the topic of ‘effective communication techniques’ webpage of physiopedia.

Keep in mind that as rehabilitation profession, you have a great and long time with patient during rehabilitation session so you tend to gain relationship with patient and care giver more than other inter-professional team members. Therefore, it is good if you can gather and catalyze important information to discuss with the team for the best beneficial rehabilitation outcomes for the patients.

ICT tool for you to facilitate the inter-professional working in the community setting

The information and Communication Tools (ICT) play a very important role in refugees camp context as the rehabilitation services are need a lot of application to ensure the patients and care giver are less dependent to health center. The reasons are that the limited resources of rehabilitation centers, over case load, long distance for patient to come to the center and care giver are not able to assist to them to come to center too often too. Therefore to develop simple tools for rehabilitation homework or home exercise is crucial to support them. This is also is a good tool for other professionals to see what you have advice the patient to take care of themselves so the inter-professional members can either remind them for you or avoid any duplication plan which may make them confuse.

In addition, the way to use the tools to make sure patient and care giver understand correctly is very important. Giving demonstration and ask them you demonstrate back to you as two way communication is one of effective way of home exercise education. Besides, pictures are more effective tools that the text as it is visible clear demonstration. Adding some text is suggested, but too much text is less interesting and many refugees are not able to read and write. Follow up process and monitoring the outcomes

Follow Up Process and Monitoring the Outcomes

The follow up process and monitoring the rehabilitation outcomes is important process which is to see the progression of the patient, quality or your services and feedback tools to your stakeholders about patient situation. It is one challenge of working in the refugee context regarding to people movement and situation changes. However, it is always possible for the inter-professional team to find the simple way to measure the outcomes of you treatment and rehabilitation. To modify the standard tools such as Functional Independence Outcomes (FIM), Barthel index and other toolsare encouraged all PT in refugees’ context to put your effort to work with inter-professional team to select the most suitable tools to apply in each context. Besides, to monitor to holistic approaches and long term rehabilitation such as community based rehabilitation approaches you may apply more tools to evaluate the person’s quality of life as well as community support level. All of this could be discuss with the communities and stakeholder to find out the proper tools or questionnaire. The good example of international tool such as Disability Measurement and Monitoring of the Washington Group Disability Questions, which available in short and long questionnaire to apply to your work context to assess the situation of people with impairments in the communities that you have involved.

Resources

References

  1. Elena Taber. Visiting A Syrian Refugee Camp. Available from: http://www.youtube.com/watch?v=SSDK2Dyqi9E[last accessed 30/07/2020]
  2. Human Rights Watch. Greece: Refugees with Disabilities Overlooked, Underserved. Available from: http://www.youtube.com/watch?v=O7fF0eFHn7o[last accessed 30/07/2020]