Graduation Year
2024
Document Type
Dissertation
Degree
Ph.D.
Degree Name
Doctor of Philosophy (Ph.D.)
Degree Granting Department
Global Health
Major Professor
Jaime A. Corvin, PhD, MSPH, CPH
Committee Member
Anna Torrens Armstrong, PhD, MPH, CPH, MCHES
Committee Member
Roneé Wilson, PhD, MPH
Committee Member
Benjamin Jacob, PhD, MS, MSPH
Committee Member
Nellie Ghusayni, MS
Keywords
Community-based disease surveillance, Program evaluation, Forcibly displaced populations, Outbreak early warning and response, Community acceptance, Migration health
Abstract
Background: Community based surveillance (CBS) is the organized and rapid collection of information from health events identified in the community and includes the systematic detection and reporting of events of public health significance. While used globally to enhance the detection of priority diseases, CBS has not been routinely deployed in Iraq, where a once-robust health system has been devastated by decades of war, international sanctions, and large-scale population displacement. During infectious disease outbreaks, it is imperative to quickly detect and isolate suspect cases, investigate confirmed cases, and trace and monitor the contacts of confirmed cases. The COVID-19 pandemic underscored the importance of early detection. Therefore, the goal of this dissertation was to evaluate and assess the feasibility of a community-based surveillance program for COVID-19, along with seven other priority communicable diseases, among residents in camps for internally displaced populations (IDPs) supported by the International Organization for Migration (IOM) in Iraq. This dissertation aimed to provide monitoring and evaluation information on the performance and acceptability of a community-based surveillance modality for infectious diseases among displaced populations in a new geographic context.
Methods: This multi-phased (three study) evaluation employed a mixed method approach to evaluate a CBS program for diseases of concern among displaced populations in Iraq. Key indicators were informed by International Federation of Red Cross and Red Crescent Societies (IFRC)'s guidance on monitoring and evaluation for CBS programs, and recommendations for monitoring and evaluating public health surveillance systems informed the focus of these analyses. Selected indicators included general acceptability, flexibility, the positive predictive value of alert definitions, representativeness, simplicity, timeliness, and usefulness. Data quality was considered throughout the analyses, though not directly measured or assessed. Analyses focused on summarizing CBS activities, describing community participants, reporting community alert detection and referrals, understanding community perceptions on health information, and evaluation indicators for CBS programs. Multiple methods of evaluation were employed to understand and assess the acceptability of the CBS pilot program among key stakeholders and included phone surveys, key informant interviews (KIIs), and focus group discussions (FGDs).
Results: The CBS for COVID-19 and expanded CBS pilot programs were found to be acceptable, representative, timely, and useful. In Study 1, findings showed alignment between the positive predictive value (PPV) of the CBS alert definition and the PPV of COVID-19 suspect case definitions reported in recent literature. In Study 2, confirmed scabies outbreaks were identified in three locations within the first few weeks of implementation, further underscoring the effectiveness of the CBS approach. Importantly, the implementation of CBS referral codes allowed for CBS data to be linked with clinical data collected at the health facilities. Findings highlighted the usefulness of CBS programs beyond traditional early warning and suggest CBS can facilitates investigation into spatial clustering of CBS alerts, which can improve understanding of disease transmission dynamics and enable localized public health response measures. Results also underscored the importance of CBS in allowing health actors and responsible parties to better understanding community perspectives on and understanding of circulating information, their trusted sources of information, and COVID-19 vaccine hesitancy. Though CBS is not commonly employed in Iraq, the program was well-received among participating heads of households, the CBS field teams, primary health care center (PHCC) and camp management, and participating mukhtars. CBS was found to be an acceptable, valuable program that participants desired to see continued.
Discussion: The results underscore the importance of robust CBS programs for disease detection and broader community heath efforts. CBS enables earlier outbreak detection and response by getting suspect cases to health facilities for evaluation and treatment earlier in the disease process, thereby reducing disease transmission. Ensuring CBS field teams include both males and females from the communities of interest increases community comfort and trust, which is vital when disclosing or discussing family health information. Integrating documented best practices into CBS programs tailored to meet local needs can complement health facility-based disease surveillance efforts and strengthen the health system in Iraq (and elsewhere) as a whole. The findings from this dissertation add to the growing body of evidence and best practices pertaining to implementing and evaluating CBS programs, particularly among displaced populations.
Scholar Commons Citation
Wolfe, Caitlin M., "Community-Centered Early Warning for Outbreaks in Humanitarian Emergencies: Evaluating Community-Based Surveillance for Priority Communicable Diseases among Internally Displaced Populations in Iraq" (2024). USF Tampa Graduate Theses and Dissertations.
https://digitalcommons.usf.edu/etd/10835
