By: D Atallah, S Kramer, L Al Bast, B Stanley, D Scales, N Jawabreh, S Alazzah, M Abu Srour, H Abedrabbu, H Louis, R Abu Srour, S Alazzah, M Al Mashakhah, M Darwish, A Ewise, M Rumi, and B Wispelwey
Program Context
Aida and al-Azza refugee camps were founded in Palestine in 1950 and currently have an estimated population of 7,500 and a population density of roughly 220,000 people per square mile. Aida and Al-Azza are adjacent to the separation wall and a military barracks in Bethlehem in the Occupied Palestinian Territory. A recent report described the Aida camp as the most heavily teargassed population in the world.1 Lajee Center, a community-based cultural center located in Aida, and 1for3, a Boston-based NGO that empowers underserved Palestinian communities, established the Health for Palestine (H4P) initiative to address the social and political determinants of health in both camps. H4P is a community health worker (CHW) program that focuses on non-communicable diseases and psychological trauma related to the historical and ongoing colonial violence that so profoundly mark trajectories of Palestinian refugee wellness. The program’s goal is to generate a people-centered grassroots health movement that will coordinate with existing health delivery partners, which can be integrated into a comprehensive health system. Starting in 2018, the initiative presently supports six CHWs and 80 clients. This case study describes the H4P CHW initiative and shares results of a recent qualitative research study that will help refine the program and contribute to its expansion in this complex environment in which individual health is heavily influenced by geopolitics.
Program Context
Aida and al-Azza refugee camps were founded in the occupied Palestinian territory in 1950 and currently have an estimated population of 7,500 and a population density of roughly 220,000 people per square mile. Aida and Al-Azza are adjacent to the separation and annexation wall and a military barracks in Bethlehem. A recent report described the Aida camp as the most heavily teargassed population in the world.1 Lajee Center, a community-based cultural center located in Aida, and 1for3, a Boston-based NGO that empowers underserved Palestinian communities, established the Health for Palestine (H4P) initiative to address the social and political determinants of health in both camps. H4P is a community health worker (CHW) program that focuses on non-communicable diseases and psychological trauma related to the historical and ongoing colonial violence that so profoundly mark trajectories of Palestinian refugee wellness. The program’s goal is to generate a people-centered grassroots health movement that will coordinate with existing health delivery partners, which can be integrated into a comprehensive health system. Started in 2018, the initiative presently supports six CHWs and 80 clients. This case study describes the H4P CHW initiative and shares results of a recent qualitative research study that will help refine the program and contribute to its expansion in this complex environment in which individual health is heavily influenced by geopolitics.
Program Design
To develop an effective program that is community derived and driven, H4P conducted focus group interviews with refugees in 2017. Barriers to health were identified, including poverty, transportation difficulties, high rates of incarceration, military incursions and tear gas exposure, psychological trauma, medication costs, and distrust of the health system. Generated by community knowledge and priorities, H4P’s model centers social accompaniment, a care approach that focuses on sharing patient experiences and working collaboratively to find solutions for better health. CHWs accompany patients to other providers and social services, provide vital sign and glucose monitoring in the home, and bear witness to the downstream effects of settler colonialism and day-to-day political violence on individual health. They also provide medication supervision, supply provisions based on need, psychological first aid, and tools and resources for organizing patients to enforce their own health rights. H4P also incorporates community organizing and activism into its model of care because a narrow focus on health — a downstream effect of geopolitics — risks reducing the responsibility of the occupying power.
H4P is also designed to mitigate the detrimental effects of care fragmentation – disrupted patient-clinician relationships, poor information flow, and misaligned incentives between various providers leading to increased out-of-pocket costs – by helping patients access the UN system, the Ministry of Health, and private networks of care. Since care fragmentation is associated with worse health outcomes,2 a strategy for its mitigation is essential in Palestinian communities for whom over half of mortality is due to non-communicable diseases like hypertension, diabetes, heart disease, and strokes.
The six CHWs employed by H4P care for more than 80 clients in the two refugee camps through weekly or semiweekly visits. Already under discussion is the potential for scaling the model to other Palestinian camps, positioning refugees to take the vanguard in a new era for Palestinian health. Trauma-informed care and empowering health promotion approaches are paramount for achieving multifaceted health outcomes in settings marked by structural violence and enormous social inequalities.
CHWs require training and knowledge to deliver care under conditions of continuous trauma and debilitating inequalities related to settler colonialism. To address the structural, social, and political challenges extant in occupied Palestine, H4P has prioritized relevant training design and professional development for CHWs. CHWs are hired directly from the refugee communities they serve, and they receive four weeks of classroom-based training and two weeks of home visit training. Most are young, educated women eager to work in a society plagued by limited employment opportunities. They are supervised by a nurse manager, who communicates directly with UN and Ministry of Health providers. Patients are identified by the CHWs using classic community organizing methods of door-to-door outreach to neighbors; in other cases, patients identify themselves to the CHWs when they hear about the project via informal channels. A social worker meets with the CHWs weekly to address difficult cases and train them in effective listening skills and social support.
Program Results
Initial results of a qualitative investigation completed by a research team at Boston University are promising. Analysis of semi-structured interviews with the six CHWs describe their perceptions of their training and capacity-building journeys. In these interviews, the CHWs emphasized trust as a key pillar in maintaining the relationship between CHWs and patients in the camp. According to the CHWs, their patients are more prone to share experiences with them than with regular health service providers in clinical settings. The deep trust and positive relationships the CHWs have developed with their patients helped to spread interest in the program throughout the camps. Still, the CHWs noted multiple examples of when they were unsure how to properly support their patients (e.g. when family members were recently arrested) or felt that they did not have the requisite skills to do so.
The conclusions of the research highlight the need for increased training and support for the six CHWs in trauma-informed social justice approaches through a transdisciplinary curriculum, including social work and critical community psychology, to better support their work addressing physical, psychological, and sociopolitical problems. For example, one CHW shared how he supported a community member in post-incarceration re-entry:
“I met a guy, he was 18 and just released from prison. He didn’t want to talk to anyone, he was very isolated. He only talked to his mother, but no one else. So, his doctor told me, ‘there’s a guy, and you might be able to help him because you went to prison yourself’. So, I talked to him the first time and I saw that he was isolated and needed help from a psychologist… I’m not a psychologist… I kept meeting with him and talking with him, and I focused on helping him be a part of the community and to talk to people more. And after that, his situation got better…and he’s much better off now.”
While this example highlights the promising role of CHWs in supporting patients with significant psychological and social needs, it also points to significant limitations in access to trained psychologists for Palestinian refugees. H4P is currently establishing connections with local mental health providers to form an Interagency Collaborative Team (ICT) to better establish CHW roles and referrals. In another example from the qualitative interviews, a CHW reported that she understood her role as a “bridge”:
“I give primary help for my patients and I think that we [the CHWs] are the bridge between the doctor and the patient. We give, not medical, but social services, to the people… but we need more training from psychologists or specialists on how to better do this…”
CHWs are positioned to not only help their patients cope with chronic diseases, but to support them in navigating toward resilience and empowerment. One CHW’s experience caring for a community member addressed the synergy of social challenges they faced through accompaniment and bearing witness:
“I had a patient, though she wasn’t very sick with anything…. I noticed the patient didn’t have high blood pressure or any other chronic illnesses that we usually deal with as CHWs… but I still followed up with her. I accompanied her to the doctor, and I began to notice that what my patient really needed was someone to talk to, like, a psychologist, not a doctor. But I kept going to my patient’s house and she kept talking to me all the time… I don’t feel that I can really judge if my patient needs a psychologist or not because I am not qualified to do that. I would like more information on how to do this. Um, but, I did go ahead and I analyzed the situation – that her physical health was not too bad, that all her sons were married off, and that the relationship with her husband wasn’t very good, and so I believed that she needed someone to visit with her and to talk to her, so that’s what I did. She is doing much better now.”
Lessons Learned
This case study demonstrates the importance of incorporating trauma-informed, culturally-sensitive, social justice-oriented approaches to CHW training and capacity building that go beyond the standard biomedical model of disease and symptomology. One CHW shared that “most of the patients have psychological issues,” and that he hopes to learn “simple initial information” that he may use in his approach during patient home-visits.
Sustainability and Scale-up
CHWs indicate that the comfort patients feel confiding in them engenders great responsibility; no light burden given the CHWs suffer under the same oppressive sociopolitical conditions as participants. The need to support CHWs on the frontlines of military occupation and ongoing settler colonization in promoting health in their communities underscores the importance of integrating analysis of power and oppression into trauma-informed approaches. Informed by this research, an innovative initiative is being developed using an Interagency Collaborative Team (ICT) approach, seeking to engage Palestinian social workers, CHWs, local and international experts, and community stakeholders in designing, integrating and evaluating a trauma-informed and social justice-focused resilience promotion “guide” for CHWs. Through this collaboration, we hope to improve the CHWs’ capabilities and to strengthen the organizational partnerships of H4P. Our experience to date informs this ICT development process by: (1) providing insights into the necessary training processes by which H4P’s CHWs develop capabilities for trauma-informed mental and social care, and for providing a “bridge” to existing health systems; and (2) contributing to the practical understanding of community engagement and health provision in settings of urban poverty and ongoing conflict.
References
1. Harr R, Ghannam J. No safe space: Health consequences of tear gas exposure among Palestinian refugees. Law, Human Rights Cent – UC Berkley Sch. 2018.
2. Strange KC. The problem of fragmentation and the need for integrative solutions. Ann Fam Med. 2009. Mar; 7(2): 100-103.
Author Affiliations
- Devin Atallah, Laura Al Bast and Brian Stanley: Boston University, Boston, USA
- Seth Kramer: University of Washington, Seattle, USA
- David Scales: Weill Cornell Medicine, New York, USA
- Henry Louis and Bram Wispelwey: Brigham and Women’s Hospital, Harvard Medical School, Boston, USA
- Nashat Jawabreh, Shatha Alazzah, Mohammed Abu Srour, Hamza Abedrabbu, Rama Abu Srour, Sara Alazzah, Mahmoud Al Mashakhah, Mariam Darwish, Ashgan Ewise, Mohammed Rumi Ashgan Ewise, Mohammed Rumi: Health for Palestine, Lajee Center, Bethlehem, Palestine
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