https://orcid.org/0000-0001-6634-391X
Figures
Abstract
Introduction
Over 100 million displaced people rely on health services in humanitarian contexts, defined as unstable or transitory settings created in response to complex emergencies. While services are often described, there is a dearth of evidence on best practices for successful implementation to guide efforts to optimize health delivery. Implementation science is a promising but underutilized tool to address this gap. This scoping review evaluates implementation science in health services for forced migrants in humanitarian settings.
Methods
We conducted a scoping review according to JBI methodologies. A search of eight databases yielded 7,795 articles, after removal of duplicates, that were screened using PRISMA-ScR guidelines. Data extraction assessed study descriptors, implementation objects, barriers, facilitators, implementation strategies, and use of implementation frameworks in service delivery.
Results
Data from 116 studies represented 37 countries and 11 topic areas. Methods were mainly cross-sectional with low-medium evidence rigor. Mental health programs (25%) and vaccination services (16%) were the most common objects of implementation. Thirty-eight unique barriers were identified including resource limitations (30%), health worker shortages (24%), and security risks (24%). Among 29 facilitators, the most common were health worker availability (25%), pre-existing partnerships (25%), and positive perceptions towards the intervention (20%). More than 90% of studies collectively identified 35 implementation strategies, the most common being capacity building (44%), stakeholder engagement (35%), information dissemination (38%), and feedback mechanisms (25%). Only 10 studies used formal implementation models, with RE-AIM (n = 3) and Intervention mapping (n = 2) being most frequent.
Conclusions
In this scoping review, we found similar barriers, facilitators, and implementation strategies across diverse humanitarian migrant settings and services. However, the use of rigorous methods and formal implementation models was rare. Frameworks included RE-AIM, CFIR, and Precede-Proceed. Increased use of implementation science frameworks and methods will help humanitarians more rigorously and systematically evaluate and develop best practices for implementation of health services for migrants in humanitarian settings.
Citation: Reynolds CW, Rha JY, Lenselink AM, Asokumar D, Zebib L, Rana GK, et al. (2024) Innovative strategies and implementation science approaches for health delivery among migrants in humanitarian settings: A scoping review. PLOS Glob Public Health 4(12): e0003514. https://doi.org/10.1371/journal.pgph.0003514
Editor: Nnodimele Onuigbo Atulomah, Babcock University, NIGERIA
Received: April 19, 2024; Accepted: October 22, 2024; Published: December 2, 2024
Copyright: © 2024 Reynolds et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: The literature search strategy and full-list of citations can be found in the data repository available from: https://dx.doi.org/10.7302/22500.
Funding: The authors received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
With an increase in complex emergencies, over 100 million people are forcibly displaced worldwide [1]. Many reside within refugee camps, congregate settlements, or transitory housing in urban settings. Displaced persons’ access to essential health care is often hindered due to multiple factors, including limited funds or insurance, a lack of knowledge, and restrictive host country policies which limit integration into formal health systems [2]. At the same time, migrants often have increased health needs, including physical and mental sequelae which are secondary to stressors before and during migration [3]. Today, the average length of migrant displacement is 17 years, indicating a need for chronic, longitudinal care systems [4]. In place of formal systems, migrant health services are often provided through a complex web of local and international actors, non-government organizations (NGOs), and government partnerships [5]. United Nations High Commissioner for Refugees, Médecins Sans Frontières, and International Committee of the Red Cross are some of the most well-known organizations, but more than 11,000 exist today in the United States alone [6].
Efforts to optimize migrant health have focused overwhelmingly on improving care access once resettled in high-income host countries [7]. However, the majority of refugees remain displaced in low- and middle- income countries (LMIC), and there is a paucity of data on how care is effectively delivered within transitional spaces prior to being resettled [8]. Many argue that ineffective care in complex emergencies can be attributed to a lack of culturally appropriate interventions, inadequate coordination, and financial constraints [9]. With the chronicity of protracted humanitarian events and increased difficulties to access pathways for resettlement, the number of individuals within transitional settings is likely to rise. Therefore, it is imperative to understand best practices for delivering acute and chronic care in such transitional humanitarian settings to prevent morbidity and mortality.
In a system of limited resources, effective implementation of interventions and practice changes is critical to ensure optimized and ethical care delivery [10]. Implementation science is the transdisciplinary study of methods and strategies that promote the adoption and integration of scientific evidence, implementation of interventions, and efforts to sustain and scale them [11]. Implementation outcomes are distinct from clinical outcomes and focus on the adoption of evidence-based practice, appropriateness of the evidence for local context, and cost, feasibility, and sustainability of interventions. Implementation science seeks to bridge the research-to-practice gap and has been effectively utilized within high-income country (HIC) health systems to optimize service delivery and enhance health outcomes [12, 13].
Within global health, implementation science is becoming recognized as a cornerstone to improve equity by tailoring strategies to complex social needs and ensure scalability of proven approaches [14, 15]. However, there has been little emphasis on using implementation science to improve care delivery in humanitarian settings. Within refugee resettlement, implementation science has highlighted barriers to implementation that may be universal and impact healthcare implementation such as lack of time, budget constraints, and language barriers [16]. One scoping review of conflict zones found that implementation experts are often engaged after research is already conducted, and that most humanitarian organizations lack expertise in technical research skills [17]. The very nature of humanitarian crises, including socio-political instability, population mobility, and limited infrastructure creates research challenges for the proper use of implementation science and its principles [18].
To align with growing practices encouraging collection of empirical results, many NGOs and governments have adopted methods to evaluate their programs objectively [19, 20]. Specifically, process evaluations offer a way to understand the dynamic interplay among human factors, local context, and material resources that facilitate program success [21]. However, it is unknown whether, and if so how, specific implementation science approaches and frameworks are utilized to investigate factors influencing program outcomes in health care service delivery for migrants in transitional, humanitarian settings.
Accordingly, the purpose of this scoping review was to understand the extent and type of evidence for effective implementation of health care to migrant populations in humanitarian settings. Specifically, we aimed to determine what programs are being implemented, the rigor with which objects are being studied, which barriers and facilitators exist to program implementation, the availability and use of evidence-based implementation strategies, and the extent to which formal implementation theories, models, or frameworks were used for designing and evaluating health programs. First, we sought to identify and categorize objects of implementation: the health interventions delivered to migrants in transitory settings. Second, we describe the determinants, barriers and facilitators, identified by study authors. Lastly, we describe utilization of implementation strategies and formal theories, models, and frameworks for study design. This review seeks to comprehensively identify the key uses and existing gaps in the use of implementation science for care delivery among humanitarian migrant populations. Improving understanding of effective implementation within humanitarian settings is essential to improving health outcomes and equity for this vulnerable population.
Materials and methods
This study utilized the JBI Manual for Evidence Synthesis for Scoping Reviews methodology [22]. JBI presents a comprehensive framework for conducting scoping reviews and covers why a scoping review should be conducted, how to develop a protocol, and the search strategies, data extraction, and results presentation to do so with a rigorous and validated approach.
Review questions
The following study questions guided our review:
- What objects of implementation are being studied among migrants in humanitarian settings?
- Which determinants (barriers and facilitators) are described regarding program implementation among migrants in humanitarian settings?
- Which implementation strategies are being used to implement programs among migrants in humanitarian contexts?
- How often and which implementation theories, models, and frameworks are being used to guide humanitarian research among migrant populations?
Search strategy
A search of the literature was conducted by a health sciences informationist (GKR) in October 2022 and a search update was implemented in February 2024. Eight scholarly databases were searched: MEDLINE (via Ovid interface), EMBASE (via Embase.com), CINAHL (via EBSCOhost), Scopus, PsycINFO (via EBSCOhost), Web of Science Core Collection (via Thomson Reuters), CENTRAL (Cochrane Central Register of Controlled Trials) in Cochrane Library (via Wiley) and the Cochrane Covid-19 Study Register (via Wiley). Keywords and controlled vocabulary search terms were used to represent the three main search concepts: 1) displaced persons; 2) humanitarian settings: and 3) health care delivery or disease management. The three main search concepts were combined to develop the final search strategies. Test searching was used to determine variation in controlled vocabulary terminology and search syntax. A revised version of University of Alberta’s refugee camps search hedge for Ovid MEDLINE was utilized in each database search [23]. Search results were limited to English or Spanish articles published from 2000 to February 2024 in six of the eight databases. Language limits were not used in the search of the CENTRAL; and language or year limits were not required for the search implemented in the Cochrane Covid-19 Study Register.
A total number of 10,857 citations were exported to the citation manager EndNote (Clarivate Analytics) for processing and removal of duplicate articles. After removal of duplicates using a variation on the Bramer method [24], 7,795 citations were exported to the evidence synthesis screening tool Rayyan [25] for assessment and initial screening. Due to the comprehensive search strategies implemented, keywords needed in the search strategy, and complexity of displaced person status, it was not always possible to clearly differentiate between articles addressing displaced persons in humanitarian settings from those with resettlement experiences during the search process. As such, a higher proportion of literature not relevant to this review was retrieved. Articles addressing resettlement experiences were removed in the initial screening. The literature search strategies and citation files are available at https://dx.doi.org/10.7302/22500 [26].
Inclusion criteria
For this review, we selected research which met the following inclusion criteria:
- Studies of migrant persons, including refugees, asylum seekers, and internally displaced persons (IDPs) of all ages who have received physical or mental health care services in a humanitarian setting.
- Studies that were conducted in a humanitarian setting, defined as an unstable, transitory, or externally-supported context or infrastructure created in response to a complex emergency or crisis. Examples included refugee or IDP camps, United Nations or governmental transitional spaces, and congregate settlements.
- Studies that described the implementation planning, process, and/or outcomes of a health service provided in these settings.
Exclusion criteria
We excluded studies deemed to be not sufficiently within the inclusion criteria. Specific exclusion points were studies on migrants who had been resettled in a host country and were no longer in a humanitarian setting, observational or cross-sectional studies which solely described health status or outcomes without descriptions of implementing a health service, and studies that postulated theoretical health services or presented pre-implementation acceptability data without an actual experience of implementing care. Studies which were not published in English or Spanish were excluded from this scoping review. Given the nascency of implementation science in humanitarian research, we did not exclude studies that failed to explicitly define determinants, implementation strategies, and frameworks with academic terms. Instead, this information was extracted by hand during the review process by researchers familiar with implementation literature. In some cases, implementation information was not the main focus of the study but was described sufficiently in the methods. Such articles were still included. We also did not exclude studies which failed to report on health outcomes, as our primary objective was to evaluate implementation processes. Editorials, letters to the editor, and opinion articles which did not report on original research were excluded.
Article screening and data extraction
Following the database search, we screened article titles and abstracts for alignment with the study inclusion criteria. First, a team of researchers was assembled and trained on article screening in accordance with our study objectives. This process involved two authors randomly selecting 25 articles and independently labeling them as ‘include’ or ‘exclude’. These researchers met and discussed any discrepancies to reach consensus on the 25 pilot articles. As a method to train the complete study team, all members involved in screening first underwent a study orientation and independently screened the same select 25 articles. Their answers were then compared to the consensus decision and each individual met with the lead authors to identify discrepancies in their screening decisions in order to clarify accurate procedures. This process was continued until each individual screener reached at least an 80% consensus decision.
The formal article screening followed PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Scoping Review extension) guidelines [27]. We began first with an abstract and title review of the 7,795 retrieved articles (Fig 1). Each article title and abstract was reviewed independently by at least two researchers. When screening decisions between researchers agreed, the article was either excluded or passed to the full-text screening phase. If there was disagreement, a third, more senior team member resolved the conflict with a final decision. Following the abstract screen, we conducted a full-text screen of the remaining 394 articles. This phase used the same process as the initial screening, utilizing at least two researchers with conflict resolution by a third researcher when necessary [28].
Diagram describing study selection and inclusion beginning with the database searches and following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) to screen abstracts and articles.
Data extraction included study titles, authors, year, location by country, methods type, topic area, key findings from the study, and descriptions of determinants (barriers and facilitators), implementation strategies, and formal implementation science theories, models, or frameworks. We also determined if each article reported on the scope of care delivered (i.e. how many patients the service reached) and if health outcomes such as clinical effectiveness data were studied. We classified the rigor of each study from one to seven according to the Melnyk and Fineout-Overholt evidence hierarchy classification [29]. Results were organized primarily by topic area then alphabetically by study title.
Results
Study characteristics
This review included 116 studies that met inclusion criteria. Studies were situated within a range of humanitarian contexts across five continents. Most occurred in the Middle East and Sub-Saharan Africa, followed by Asia. The Americas were the least represented regions (5%). Thirty-seven countries were included, with Bangladesh (18%), Uganda (12%), and Lebanon (9%) with the most studies. We categorized implemented programs into 11 overarching health topic areas. The most frequent were infectious disease (31%), mental health (26%), maternal and child health (12%), preventive or non-communicable disease care (10%), and health technology (9%). Less common were sexual and reproductive health (6%), ophthalmology (2%), surgery (2%), pharmacy (1%), and nutrition (1%) (Table 1, S1 Appendix).
Study rigor and methodologies varied from weak to strong evidence. The most common methodologic approach was a single-site case study (55%), many of which used descriptive, cross-sectional, and qualitative methods. For example, Murphy et al. used a qualitative nested design to determine that fixed-dose combination therapy was acceptable and feasible for cardiovascular disease prevention among Syrian refugees in Lebanon [30]. The second most frequent method was quasi-experimental implementation cohort studies, which regularly utilized pre- and post-evaluation measures to evaluate program impact within a migrant population (16%). Amsalu et al. used a pre- and post-descriptional study to evaluate a neonatal survival program across refugee camps in Somalia, Niger, Chad, and Cameroon [31], while Phares measured the impact of an oral cholera vaccination campaign among 35,000 refugees in Thailand [32]. Only ten studies (9%) were randomized control trials (RCTs) [33–38]. Randomization occurred at the patient or cluster level most commonly across sections of refugee camps. Trials that were randomized at the cluster level justified their approach through ethical concerns of randomizing individuals to humanitarian interventions considered basic rights [33]. Use of more complex methods for multi-intervention testing was rare, as was the case with a 2 x 2 factorial design to evaluate the impacts of conditional cash transfers and an mHealth program on vaccine coverage and malnutrition in Somalia [39]. Four reviews, one scoping [40] and three systematic [41–43], were included, but none were level 1 rigor representing a systematic review of RCTs.
Studies were analyzed for reach (i.e. number of patients impacted) and clinical outcomes (i.e. change in disease state). While 99 studies reported reach (85%), only 37 provided clinical outcomes data (32%). Generally, studies with stronger evidence ratings of 4 and above were more likely to report clinical outcomes. For example, Lawrence et al. quantified a significant decrease in psychological dysfunction among IDPs in Nigeria through a quasi-experimental factorial design using randomized cohort trial and cluster sampling [44]. By summing information extracted on the scope of each study, we determined that at least 4,991,937 migrants were impacted by the implemented programs in this review.
Objects of implementation
Implemented programs reflected topic areas (Table 1). The most frequently implemented interventions were mental health therapy programs (25%) and vaccination services (16%). Mahmuda et al. described a group integrative adaptation therapy among Rohingya refugees [45] and Sheikh et al. evaluated oral polio distribution within Kenyan refugee camps [46]. Almost all programs focused on a single area with a vertical care delivery approach, as only 7 studies reported on enhancing health services delivery in a horizontal approach that prioritized health systems strengthening [41, 47–51]. Examples of other objects of implementation included novel medication administration programs [52], eye disease screening [53, 54], obstetric ultrasound training [55], substance use screening [56], and breastfeeding or nutrition programs [57, 58]. Seven studies utilized novel technologies in their programs. Moreau et al. from MSF in Jordan used 3D technologies and telemedicine to customize and provide facial ortheses and limb prostheses to 53 patients [59]. Others established technology infrastructure in hospitals for health data [60, 61], mHealth screenings and reminders through text-messaging or applications [62, 63], and global information systems for disease control [64]. Two studies described floating boat hospitals which delivered preventive care in Greece [65] and orthopedic surgical services in Southeast Asia [66].
Determinants
Almost all studies (95%) reported key determinants–barriers and facilitators–to program implementation. In total, 38 unique barriers were identified among the 116 studies (Table 2). Resource limitation was the most frequently mentioned barrier (30%). This included a lack of diagnostic tools, treatment therapy, or health access infrastructure such as cell phones for mobile health programs. Second was a shortage of trained health workers (24%), due to limited training, high staff turnover, and poor retention working in humanitarian settings. High staff turnover posed a barrier to implementing newborn health interventions in South Sudan [67]. Security risks from conflict (24%), environmental conditions including natural disasters and extreme weather (21%), and negative perceptions of the migrant community towards the intervention (17%) were all commonly reported. Some barriers were likely unique to migrant populations in humanitarian settings. These included nonexistent health insurance coverage (1%), inability to access public health systems (1%), and the transitory nature of migrant populations, which limited patient follow up, increased dropout, and may have demotivated transitory migrants from accessing services at all (16%). In Haiti, the evaluation of rapid monitoring vaccination campaigns was limited by continual migration out of and between multiple IDP camps [68].
Common facilitators to successful program implementation were also described. Overall, 29 facilitating factors were identified (Table 2). The most common were health worker availability (25%), referring to physical presence and appropriate training to implement specific health programs by these individuals, and the effective leveraging of strong pre-existing partnerships (25%), which included collaboration with local NGOs, religious and community leaders, or health facilities. Fetters et al. demonstrated this strategy to train 300 health workers in sexual and reproductive health care in Bangladesh refugee camps [69]. Additional external facilitators included positive perceptions of the intervention from the migrant population (20%), availability of a pre-established health system to build on (19%), and alignment with political priorities of a supervisory organization, particularly the government (17%). Internal facilitators specific to interventions were also identified, including being low-cost with minimal resource requirements and culturally appropriate. For example, programs which reported success adapted interventions to local language and customs in consultation with community experts. In Uganda, Jordan, and Iraq, mental health programs were adapted to be self- or peer-administered to facilitate their implementation despite a lack of trained mental health professionals [70–72]. The fidelity of interventions was occasionally adapted successfully to low-resource contexts (12%), such as using vaccines with high thermostability to mitigate freezer supply chain barriers [73] or combining novel drug therapies to reduce distribution frequency [30]. Many facilitators and barriers mirrored one another across studies, including throughout diverse regions and topic areas. These juxtaposed factors included positive vs. negative migrant and other stakeholder perceptions of interventions, high vs. low population health literacy, affordable vs. expensive interventions, and trust vs. mistrust in the health system. Three studies undertook a determinant analysis with the primary objective of identifying barriers and facilitators rather than strategies or outcomes of program implementation [57, 74, 75].
Implementation strategies
To fulfill our primary review objective, we extracted and categorized strategies used to implement health services among displaced populations in humanitarian settings. In total, 35 unique strategies were identified among 106 (91%) studies that made any mention of implementation strategy (Table 3). Bundles of two or more implementation strategies were used in 102 studies (88%). The most common strategy was capacity building, which overwhelmingly included health worker training (44%). For example, capacity building through community and health worker training in Tanzania allowed for integration of a prevention of mother to child HIV transmission program into existing health systems [76]. Stakeholder engagement was the second most common strategy (35%) and included coordination and collaboration among diverse groups including government agencies [42], community and religious leaders [77], migrant patients [78], and product developers. Information dissemination and community education was the third most common (33%), followed by feedback and evaluation mechanisms (25%). The most common method used for feedback was checklists, which were used to facilitate service delivery for contraception [79, 80], diphtheria toxin [81], and meningitis and polio vaccines across eight countries [46, 82].
Many strategies highlighted the importance of local collaboration and human resource management, including collaborating with local partners (28%), local champions (22%), task-shifting to lower-level providers (20%), train-the-trainer models (9%), and community empowerment through intervention co-design (7%). In Bangladesh, Sullivan et al. used local collaboration, task-shifting, and a train-the-trainer distribution model to improve mental health perceptions of Rohingya refugees through acupressure and breathing techniques [83]. Intervention adaptability was an important theme which emerged, as adaptation often became necessary given changing contexts in resource constrained environments (18%). Specific actions included translation to local languages [38, 47, 58], mobile delivery components for geographically constrained and transitory populations [32, 53, 84, 85], and increasing cultural acceptability by accounting for sex differences [86]. Strategies less frequently utilized through these studies were remuneration (2%), social mobilization (2%), and motivating health workers (1%).
Implementation science theories, models, and frameworks
Although most studies sought to identify determinants and implementation strategies, only 10 (8%) employed formal implementation science theories, models, or frameworks (Table 4). The most common framework employed was RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance). This framework was used in 3 studies for occupational health and non-communicable disease in Jordan [52, 61] and as an analytic tool as part of an 11-study scoping review [40]. The Dynamic Sustainability Framework (DSF) [52], Consolidated Framework for Implementation Research (CFIR) [74], and Precede-Proceed [87] were all used once. Intervention mapping (IM) guided the design of two programs. Ravicz et al. used intervention mapping to create a mental health intervention among Rohingya refugees, while Borja et al. used IM to determine where to implement HIV linkage interventions within a complex Ugandan care system [51, 88]. Additional models included Design, Implementation, Monitoring, and Evaluation (DIME) [89], and frameworks specific to global and humanitarian health: the Global Vaccine Action Plan and Humanitarian Health Response Coordination Framework [48, 90]. While these models are less common in implementation science, they contained similar components to well-known frameworks, including establishing priorities, implementation plans, and evaluation metrics. Only one study measured implementation factors, including uptake, feasibility, and acceptability, as a primary outcome [89]. None of the studies compared implementation frameworks, but eight explicitly described how using a framework positively enhanced their implementation planning, process, or outcomes measurement.
No studies could be considered rigorously evaluated implementation optimization trials which used methods such as Sequential Multiple Assignment Randomized Trial (SMART) or Multiphase Optimization Strategy (MOST). None compared outcomes of different implementation strategies, as could be done with effectiveness-implementation hybrid designs. A complete list of study references is available in S2 Appendix.
Discussion
In this scoping review, we found that common implementation science strategies were often utilized to deliver health care to migrants in humanitarian settings. Though studies came from diverse regions, populations, and topic areas, determinants (barriers and facilitators) and implementation strategies were well described, shared, and could be defined and categorized among the studies. The use of formal implementation models, frameworks, or theories to guide implementation and evaluation of health service programs was exceptionally rare. Models that were used included RE-AIM, Intervention Mapping, CFIR, and Precede-Proceed. The use of these models was associated with improved intervention planning, implementation, and evaluation. This main finding suggests that implementation science is an underutilized approach and promising option for humanitarian actors seeking to design, implement, and evaluate health programs in a more systematic, rigorous, and universally understood way.
We found that objects of implementation–the services being delivered–generally reflected the major health needs of migrants: mental health, infectious disease, and maternal/child health. In general, services focused on prevention including vaccine campaigns, mental health screening and therapy, and prenatal care. While a few studies were treatment oriented, particularly for HIV and mental health disorders, there was little cost-effectiveness or clinical evaluation metrics to influence policy and funding decisions. Additionally, our results showed a clear gap in subspeciality and procedural care including surgery, ophthalmology, physical and occupational therapy, and nutrition. There is now robust data demonstrating the health needs of migrants in each of these areas [91, 92]. This suggests the need for more efforts to understand effective implementation of these services, which often require increased coordination, resources, and patient monitoring and follow-up. Study rigor was quite low, with more than half being cross-sectional case studies and less than one-third reporting clinical outcomes. An additional gap was found with geographic representation of studies, with most coming from Africa, the Middle East, and Southeast Asia, and very few from the Americas. More work may be needed to understand context-specific implementation for Western migrant contexts including with asylum seekers at the US-Mexico border, Venezuelan refugees, and those fleeing violence throughout Central America and Haiti [93].
Nearly every study identified key determinants–barriers or facilitators–to implementing health services. Although we included studies from 37 countries and 11 topic areas, the barriers and facilitators were universal enough to be grouped into 38 and 29 unique items, respectively. The shared experiences of determinants across diverse settings is notable. These findings may help humanitarians planning projects to better identify, define, and categorize determinants they encounter in project implementation. Determinants included external (security risks, environmental conditions, political priorities) and internal factors (organization funding, intervention adaptability, cost and resource requirements), many of which career humanitarians have anecdotally described [94]. Though many of these determinants are likely common in low-resource environments, some were specific to migrant populations, including a lack of follow up from continued migration, demotivation for participants to engage while being in a transitory status, security risks, and ethical dilemmas related to study methods including randomization. While most studies identified determinants, few prospectively accounted for them in designing their implementation approach; rather, they were retrospectively described as they appeared to the study teams throughout service delivery. This retrospective approach, while less effective, seems to be common across humanitarian and conflict settings [17]. By using validated implementation science models from the beginning, humanitarian actors may be more likely to identify and account for determinants prior to project implementation, allowing them to mitigate barriers and enhance facilitators for greater project success.
Implementation strategies were frequently reported. More than 90% of studies mentioned at least one strategy, and nearly all of these utilized multiple strategies. Similar to determinants, strategies employed were common despite diverse geographic and health specialties across studies. The most described strategies addressed human capacity building: health worker training and availability, stakeholder engagement, collaborating with local partners, and empowering local champions. Other strategies were process oriented: conducting needs assessments, information dissemination, feedback and evaluation mechanisms, and establishing specific infrastructure and supply chains. Strategies emphasized integration of the local community into planning and programming. Beyond stakeholder engagement, studies emphasized local autonomy and collaboration, co-designing interventions and implementation plans, adapting interventions and approaches to local and culturally appropriate methods, and raising meso- and macro-level political support for initiatives. These results suggest moving from the traditional approaches of aid as service delivery to instead empowering community members and leaders in skills and resource capital building while in humanitarian contexts [95, 96]. This highlights an opportunity to apply tools designed for stakeholder engagement when co-designing implementation, such as the 7P’s framework [97]. Strategies dealing with cost were described, but less commonly than human capacity building or adaptability. These approaches included remuneration and using low-cost materials, but only encompassed three studies.
Despite ubiquitous descriptions of determinants and implementation strategies, formal implementation theories, models, or frameworks were rarely employed. RE-AIM, Intervention mapping, CFIR, Precede-Proceed, DSF, and global-humanitarian specific frameworks were used for only 8% of studies. While leveraging implementation models for humanitarian aid could be highly beneficial, it is unsurprising that this approach is not more widely practiced. First, implementation science as a field itself is still maturing, particularly into areas outside of well-resourced health systems [98]. Implementation science in global health, for example, is rapidly growing due to its unique ability to address specific issues that have long affected global health and could provide helpful examples for those working in humanitarian aid [14]. Second, research among humanitarian aid organizations is still nascent. While there have been calls for increasing scholarship to optimize humanitarian aid, most organizations lack the resources and expertise to conduct independent evaluations [99]. Humanitarian aid-academic medical research partnerships have been proposed and could also help ameliorate this gap [99]. Additionally, smaller groups could replicate methods proven to be feasible from organizations known for research productivity including Médecins Sans Frontières and the World Health Organization [100]. Notwithstanding the novelty of the use of implementation science in designing and evaluating humanitarian aid interventions, there are efforts to promote this scholarship [101]. Recently, a rapid scoping review described implementation science strategies among resettled refugees, demonstrating barriers, strategies, and evaluation methods for refugee resettlement [16]. Barriers included time and funding constraints, workflow disruptions, and language barriers. Strategies were adapting interventions to local context, training stakeholders, and iterative evaluation. Our results complement this study by presenting results for migrants still in transit. While many of the common strategies are shared between the studies, ours revealed unique results specific to implementation in a humanitarian context, including mobile delivery components, integration into pre-existing health systems, and collaborating with local partners. In summary, determinants and health implementation strategies among transitory migrants may be quite distinct from those being resettled.
Limitations
This scoping review had several limitations. First, we limited our search to published, peer-reviewed articles within the last 20 years. While this was done intentionally to focus on rigorous studies with novel health services, excluding gray literature or reports from humanitarian organizations could limit results. Second, this study was limited in its scope to focus on migrants in humanitarian settings. Studies which reported on other types of global health programs, programs that may be similar but distinct from humanitarian contexts, were intentionally excluded. Contextualizing our results within this literature could help to enhance health services for other vulnerable populations and common challenges. Third, this review used scoping methods and was not a systematic review or meta-analysis. Therefore, we were unable to make claims about clinical outcomes or effectiveness across various health delivery strategies.
Conclusions
In this scoping review of migrants in humanitarian settings among diverse geographic regions and health topic areas, we found common and shared implementation determinants and strategies, varied evidence rigor and outcomes, and that use of formal implementation models and frameworks was rare. Implementation science provides an exciting opportunity for more effectively planning, implementing, and evaluating health services programming for migrants in humanitarian contexts.
Supporting information
S1 Appendix. Comprehensive data extraction from scoping review studies for displaced migrants in humanitarian settings.
This table presents all the extracted data from studies included in the review including study rigor, descriptors, determinants, strategies, location, and use of implementation science theories, models, or frameworks for each study.
https://doi.org/10.1371/journal.pgph.0003514.s001
(DOCX)
S2 Appendix. References for studies included in the scoping review presented in order as they appear in Table 1.
This file provides a complete list of studies included in the scoping review, in order of appearance of Table 1.
https://doi.org/10.1371/journal.pgph.0003514.s002
(DOCX)
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