Outreach to internally displaced persons in Bogotá, Colombia: challenges and potential solutions

Abstract

Programs that provide services for internally displaced persons (IDPs) in Colombia, South America face challenges when attempting to engage and enroll the target population of forced migrants they intend to serve. Innovative multi-strategy outreach approaches must be used in order to effectively seek, recruit, provide services, monitor, and retain IDPs.

Here is the paradox: while Colombia has consistently ranked either first or second in numbers of armed conflict-displaced persons each year for more than a decade,^1,2 IDP households are notoriously hard to pinpoint geographically. IDPs essentially masquerade as a hidden population, an assertion that seems implausible at face value. How can such a numerically large aggregate, estimated at 5.7 million IDPs in 2013,² remain relatively covert? The answer is that Colombian IDPs are not out of sight but they are not clearly visible. There exist no IDP camps or designated IDP neighborhoods. Most IDPs reside in impoverished metropolitan areas, thoroughly intermingled with other types of victims of armed conflict and the urban poor. Certainly, some urban areas are known to harbor a higher concentration of forced migrants, but there are no clearly demarcated venues that are populated exclusively by IDPs. This feature of the IDP landscape makes outreach for conducting research and providing evidence-based interventions difficult (Fig. 1).

Figure 1.

Outreach neighborhood with high proportion of IDPs – overlooking downtown Bogotá.

Historically, many Colombian victims of conflict-induced displacement who have relocated to urban centers have attempted to disguise their status as IDPs. They have been realistically fearful of discrimination and stigmatization, as well as further violence and persecution from urban factions of the armed groups that displaced them. Migration from rural areas of expulsion to urban areas of resettlement typically has not conferred safety.³

For perceived self-protection, many IDPs have eschewed attempts to be formally registered and therefore, the Colombian government's official estimate of numbers of IDPs has long been recognized as an undercount. The higher tally of IDPs provided by the Observatory on Human Rights and Displacement (La Consultoría para los Derechos Humanos y el Desplazamiento - CODHES) is regarded as a closer approximation.² Regardless, in relation to conducting outreach, the true census and spatial distribution of IDPs is not fully known.

Meanwhile, in a startling turnabout, the long-standing problem of IDP counting and tracking is undergoing a major reversal, and one that presents new and very different challenges for conducting outreach to IDPs. With the passage of Law 1448, the Law of the Victims and Restitution of Lands, in 2011,⁴ Colombia has boldly defined a sweeping spectrum of “victims of armed conflict.” Collectively, these victims are designated as a protected class. Not surprisingly, IDPs comprise the largest proportion. IDPs are now eligible to receive an assortment of legal, social, medical, and psychosocial services. For example, among these services, the Colombian Ministry of Health and Social Protection has launched the Program for Psychosocial and Integrated Health Care for Victims (Programa de Atención Psicosocial y Salud Integral a Víctimas - PAPSIVI), a comprehensive approach that focuses human resources on the provision of psychosocial care at the individual, family and community levels (available at: http://www.minsalud.gov.co/proteccionsocial/Paginas/Victimas_PAPSIVI.aspx).

Moreover, as a direct outcome of Law 1448, some IDPs are currently being processed for financial reparations for their losses, dating from the time of displacement, and a smaller number are being prepared for the prospect of returning to their communities of origin and reclaiming their lands. This newly launched combination of program services and monetary payments has transformed the incentives and contingencies that are operating. Not only are IDPs registering in record numbers, but many persons who are not victims are also attempting to defraud the system to receive services for which they are not eligible. Also now that IDPs are protected, the environment for providing services is much more restrictive and generally new programs for persons who qualify as victims of armed conflict must be reviewed and approved by the district or national government.

Case Example

We are currently engaged in piloting an evidence-based stepped-care mental health intervention program for women IDPs residing in Bogotá, the nation's sprawling capital district and the major “receptor” city for IDPs. Funded by Grand Challenges Canada, the title of the project is, “OSITA: Outreach, Screening, and Intervention for Trauma for Internally Displaced Women Living in Bogotá, Colombia.” This project is examining the feasibility of recruiting and enrolling the target population and administering internationally-standardized screening instruments to assess symptoms of 3 common mental disorders (CMDs): major depression, generalized anxiety disorder, and posttraumatic stress disorder. Upon completion of screening, the IDP women receive immediate post-assessment psycho-education tailored to the screening results. Women IDPs with elevated symptom levels on one or more CMDs are referred to multiple sessions of interpersonal psychotherapy (IPT).

The critical front end of the project requires outreach to women IDPs, a process that is complicated by the living environment and the political context. Bogotá IDPs live in marginalized urban settings characterized by widespread community violence at the hands of gangs, criminal bands (‘bandas criminals” or “BACRIM”), and urban-dwelling tentacles of the guerrilla and paramilitary groups whose rural counterparts perpetrated their displacement (Figs. 2 and 3).

Figure 2.

Neighborhood served by primary care clinic outreach teams, Bogotá.

Figure 3.

Outreach neighborhood with high levels of gang presence and activity.

Outreach Strategies

Our project is exploring a combination of options for conducting safe and effective outreach to Bogotá IDPs, given the hazards of reaching a population living in areas with security risks. The project will implement and test the following approaches, documenting and comparing these strategies in terms of safety, ease of recruitment, and effectiveness for retention of the target population .

Direct outreach to IDP households

This strategy is the most self-evident outreach approach involving direct visits to homes of women IDPs who have been pre-identified and who currently receive services from mobile health teams based at public hospitals, in coordination with the Bogotá public health authority. The health teams are comprised of street-experienced medical and public health workers who are able to identify the women IDP households within each “micro-territory.” The teams are recognized and trusted by the local population. They are able to serve as intermediaries to introduce OSITA project specialists and endorse the value of program.

Although there is considerable mobilty for all IDP populations, women IDPs accessed via street outreach represent a subset with greater residential stability compared to recent IDP arrivals whose living conditions are transient and changeable.

Nevertheless, there are important limitations regarding time, roles, and safety. The health teams are not able to “task shift” to accommodate mental health outreach duties within their own scope of activities. Moreover, health teams have a full case management schedule and they cannot extend their home visits to permit OSITA project specialists to conduct mental health screening and intervention sessions. Health teams also have a strict limit on numbers of home visits for “psychosocial” care and this does not allow for flexible scheduling of multiple intervention sessions for women IDPs who screen positive for CMDs.

The option for the project's mental health specialists to return for additional home visits is not viable. As relative newcomers operating in unfamiliar and dangerous environs, project specialists would face significant safety risks if they attempted to return apart from the company of the seasoned health teams. Moreover, the project has introduced the innovation of tablet computer-based screening, real-time results analysis, and tablet-generated psycho-education scripts based on results. However, carrying tablet computers during outreach in street settings increases personal security risks for the project specialists.

Outreach using the community network of primary care clinics

The hospital-affiliated mobile health teams operate from primary care clinics located in neighborhoods with high concentrations of victims of armed conflict (Fig. 4). As a variation on direct street/household outreach, women IDPs can be identified by the health team's “psychosocial” professional and referred to an appointment with the project specialist at the nearby primary care clinic. This would enhance both safety for the project specialist and privacy for the women IDP clients. The initial screening/psycho-education session, and as needed, follow-up IPT intervention sessions, could be conducted without inconveniencing the health teams. Focus groups conducted with women IDPs found them to be favorable to this option (Fig. 5).

Figure 4.

Primary care clinic in the “Los Laches” neighborhood of the Santa Fe section of Bogotá, Colombia. The name of the clinic is UPA Laches (UPA: Unidad Primaria de Atención).

Figure 5.

Health care personnel and psychosocial outreach team from the primary care clinic, “UPA Laches.”

The obvious limitation, shared with other options, is the need for women IDPs to find time and social support to be able to attend the initial and follow-up sessions and they may also need a nomimal amount of monetary support for transportation such as bus fare. One possibility is to have the heath teams transport the client from her home to the first session at the primary care clinic and make the introduction to the project specialist. Regardless, adherence and retention are important challenges to be addressed.

Outreach through IDP registration centers

Following passage of Law 1448,⁴ multiple sites (called “Centros Dignificar” – Dignity Centers) have been opened in Colombia's major metropolitan areas to register and process “victims of the armed conflict”; newly-displaced persons represent a high proportion of these clients (Fig. 6).

Figure 6.

Registration center for victims of armed conflict in Champinero, Bogotá, Colombia. There are 6 Dignity Centers (“Centros Dignificar”) in Bogotá, Colombia.

The logistics that are contemplated involve either an on-site project specialist or a psychosocial professional from the Centro conducting recruitment and referral to our OSITA screening and intervention project. The chance of conducting the initial screening session on-site is being explored. This approach presents several distinct advantages. The Centros have a very high flow rate of IDPs and could serve as a productive source for recruitment. Moreover, the IDPs receiving services at the Centros are more homogeneous than community samples; many have just been displaced and represent a group that has recently sustained the trauma of expulsion and is now grappling with the multiple loss experience in the immediate aftermath.

However, the limitations of this approach are notable. Clients served by the Centros are often in transition and many do not yet have a stable residence, creating difficulties for follow-up and retention of clients. Also, with the displacement experience so recent, the focus on mental health may be subordinate to other survival priorities including safety, housing, employment, and medical care. The environment at the Centros, with masses of victims being served daily, is not particularly conducive for conducting the initial screening and educational assessment – and even less ideal for providing confidential IPT sessions. However, the alternative of referring clients to a session with a project specialist at a nearby clinic carries a high risk that the referral appointment will not be completed. Therefore, if access is actually granted to screen prospective clients, the major impediment will be completion of referrals and retention of recruited clients who need multiple sessions of IPT.

However, there is a much more resistant barrier that has been encountered. Gaining access to clients served at the Centros requires a time-consuming, permission-granting process involving meetings with officials at multiple levels in several government agencies, preparation of extensive documentation, presentation to an ethics committee, and bureaucratic delays. Given the brevity of the pilot project funding period, access to IDP women through this channel, if achieved, will come late and recruitment from this source will likely be limited.

Outreach using “snowball referral” from women IDPs working in the project

Several women IDPs, who are recognized community leaders, have been employed in the project to provide vocational screening and education as a complement to the mental health intervention. In the near future, these women IDPs will be “task-shifted” to provide the full complement of OSITA outreach services. Each has an extensive social network of friends and acquaintances including many study-eligible women IDPs. They are “influence leaders” within their local communities of victims and they are able to engage in active recruitment as insiders. They also have intimate knowledge of their local territories of residence so they are able to facilitate convenient meeting times and safe locations for recruitment, screening, and intervention.

This approach holds promise in terms of the relative stability of the recruited clientele and intermittent contact, encouragement, and follow-up of clients who are within the social networks of the women IDP outreach workers. Also these women IDP vocational specialists will work in tandem with the mental health project specialists, allowing for a “buddy system” approach to providing services for the women participants recruited through this channel.

The primary limitation is possible lack of representativeness, inherent in any respondent-driven sampling approach: the “seed” person for snowball sampling, who in this case is a project employee, and those they refer, are not necessarily representative of the larger community of eligible participants. However, this is a minor issue in the current pilot project where the focus is on demonstrating the feasibility of conducting outreach and intervention – and client diversity is assured by using multiple methods of outreach.

Outreach to women IDPs whose children attend special pre-schools

This novel approach to outreach takes advantage of the fact many women IDPs are mothers of young children (often single heads of household). Several of the “jardines infantiles” (preschool “kindergartens”) in Bogotá have a predominantly IDP clientele and the women drop off and pick up children at these locations daily, before and after work. These settings not only provide care and education for young children in safe, supervised settings, they also sponsor programs with the mothers and typically, a vital social support network develops among the mothers and grandmothers (Fig. 7).

Figure 7.

Preschool kindergarten outreach site: “Jardin Infantil La Alameda” in Bogotá, Colombia.

The plan is for project specialists to promote the program to IDP mothers at the preschools and to recruit interested clients into the OSITA program. Clear advantages of this approach include both the concentration of eligible and accessible IDP women for recruitment, and the constancy of contact; the women arrive daily to the preschools, morning and evening. Given that these are working mothers, a challenge to be addressed is the ability to provide multiple intervention sessions during a narrow window of available hours to those women who agree to participate and are found to have elevated symptom levels of CMDs.

Outreach via non-governmental organization (NGO) programs specifically for women IDPs

This approach will be piloted at an NGO that educates IDPs – especially indigenous and Afro-Colombian IDPs – on job skills and connects program graduates to actual job opportunities. This NGO has agreed to provide a safe and private space within the training center to conduct recruitment and initial screening for interested and eligible women IDPs. This appears to be a highly viable option for recruitment and in the initial months of the intervention, a substantial number of clients are entering the program through this avenue (Fig. 8).

Figure 8.

Outreach site at a non-governmental organization specializing in jobs training and placement particularly to indigenous and Afro-Colombian victims of armed conflict: “Gente Estrategica.”

Outreach to clients served by the department of social prosperity (Departamento para La Prosperidad Social - DPS)

Linkages are being established with this newly-invigorated national government department that focuses on family well-being, poverty eradication and job creation, and care (with special emphasis on integrated “psychosocial” care) of victims of armed conflict. The DPS case rosters include many identified IDPs and steps are underway to generate a flow of “victims” to participate in OSITA.

Outreach based on client referrals identified from the hospital databases

The project's primary community partner is a major public hospital serving the target population that operates mobile outreach teams based in primary care clinics and also provides psychiatric referral services at its central location when necessary for persons with more severe CMDs (Fig. 9). This hospital maintains a client database that will facilitate identification of women IDPs who have already received their maximum allotment of 3 “psychosocial” sessions permitted and funded by the Bogotá district health authority - and who would benefit from the evidence-based IPT interventions offered by the project.

Figure 9.

Urgent care center affiliated with Hospital Centro Oriente: “CAMI Perseverancia.” (CAMI: Centros de Atención Médica Inmediata).

Summary

In summary, outreach represents the pivot point for any health, research, or service program focusing on the unique needs of IDPs and other forced migrants. While outreach may be relatively straightforward in some countries, for example, where IDPs are displaced to stable camp environments, the situation in Bogotá, Colombia presents a series of complex challenges for reaching the population. We are currently defining and experimenting with a spectrum of outreach strategies that align with the Colombian primary care model; this includes joint planning activities with IDP women, coordination with area hospitals and the Bogotá district health authority, health and vocational information sharing, and referral pathways to specialty psychiatric consultations as necessary. Much of the present pilot project will be dedicated to examining the feasibility and efficiency of these outreach approaches as well as testing the efficacy of the screening and intervention components for women IDPs who are successfully recruited.

Disclosure of Potential Conflicts of Interest

No potential conflicts of interest were disclosed.

Funding

Preparation of this manuscript was partially funded by a grant from Grand Challenges Canada, Toronto, Canada.