Introduction

More than 108 million individuals worldwide have been forcibly displaced. Of those, more than 35 million are refugees, 62 million internally displaced people and 5.4 million asylum seekers (United Nations High Commissioner for Refugees [UNHCR] 2023).

Nearly 83% of refugees are hosted by low- and middle-income countries, which puts a strain on host communities and resources (European Commission 2022). The UNHCR works with non-governmental organizations (NGOs) to guarantee the AS&R access to basic needs (UNHCR 2017). Most of the non-professional NGOs are composed of people without educational or specific skills to work with vulnerable populations (European Economic and Social Committee 2017). People without proper training do not have the capacity to evaluate the safety threats, potential mitigation strategies, and personal risk tolerance. Untrained people are not prepared to deal with illness, injury, disability, or death (Bailey and Kaplan 2022). Even if they are doing simple tasks, non-health professionals and volunteers (NHPV) face the major challenge of dealing with the asylum seekers and refugees (AS&R) suffering as they are exposed to their traumatic pre-, during, and post-migration trajectories (Wirth et al. 2019). NHPV intend to help AS&R in post-migration scenarios, when they are facing conditions that contribute to experiences of post-migration stress (Gleeson et al. 2020). However, lack of experience or training may strongly lead to post-traumatic stress disorder in unprepared volunteers (Aldamman et al. 2019; Jaffe et al. 2012) increasing the volunteers’ vulnerability to anxiety, burnout, depressive feelings, apathy, callousness, self-destructive behaviour, interpersonal conflict, over-involvement with AS&R and secondary traumatic stress (Bundesministerium für Familie Senioren, Frauen und Jugend 2017; Apostolidou 2016; Guhan and Liebling-Kalifani 2011). The psychological distress that volunteers may suffer can variate according to the previous training (Deering 1996; Birck 2001; Collins and lONG 2003).

The trainings available are dispersed mostly in NGO websites, developed based on their front-line expertise and mainly focused on one or two topics (Teixeira-Santos et al. 2022, 2023). Therefore, it is crucial to understand the NHPV’ training needs to develop and improve training programs and make them useful. Even the NGOs applying the selection criteria and giving them basic training to work in a project/mission, does not mean that it suits their training needs.

This study aims to understand the perception of NHPV who worked, work or will work with AS&R, about their training needs in organizational management, communication, cultural abilities, and health domains trough four experimental questionnaires developed for the purpose of this study. It also intends to know if training or experience background can influence the perception about the training needs for their work role.

Methods

This study is part of the APT4U2, a PhD project, funded by the Portuguese Foundation for Science and Technology (FCT), that aim to develop, validate, and assess feasibility, adequacy, and meaningfulness of the APT4U2 program, a mental health and well-being training program for NHPV to work with AS&R. The study employed a cross-sectional design based on a self-administered online survey. Data was collected between April–June of 2022. The project was approved by the Ethics Committee of the Health Sciences Research Unit: Nursing (Opinion nº 0 P742 12/2020) and each participant provided an informed consent before engaging in the study. Participants did not receive any type of incentive.

Study sample

The study targeted worldwide NHPV, aged ≥ 18 years, who had worked, are working, or intend to work on projects involving asylum seekers and/or refugees. Individuals with educational backgrounds in health or mental health were excluded, as the study aimed to explore the training needs of laypersons in healthcare matters, encompassing mental health.

Instruments

The participants were invited to complete the online survey (sociodemographic questionnaire and four questionnaires as a training needs assessment). The sociodemographic questionnaire was divided into two parts, the first focused on the participants’ general characteristics, and the second was dedicated to their training and work experiences with AS&R. The training needs assessment comprised a total of 49 items organized into four questionnaires, namely 16-item Organisational Management Questionnaire, 16-item Cultural Ability Questionnaire, 9-item Health Questionnaire, and 8-item Communication Questionnaire. The questionnaire items were developed based on literature review and theoretical models, including the UNHCR competency framework (United Nations 2017a, b), the Giger and Davidhizar Transcultural Assessment Model (Giger and Davidhiza 1999), and the Campinha-Bacote’s model of cultural competence (Campinha-Bacote 2002). A multidisciplinary focus group of NHPV with work experience with the population of interest in multicultural contexts was undertaken to establish content validity of the questionnaires’ items. Based on the feedback provided, the questionnaires’ items were revised and refined whenever necessary. A previous exploratory factor analysis revealed a presence of three components (Accountability & Management; Learning Share; and Team Collaboration) in the Organisational Management Questionnaire, two components (Knowledge & Awareness; and Encounter & Engagement) in the Cultural Ability Questionnaire and two components (Mental Health and Physical Health) in the Health Questionnaire. Below, these domains are denominated as components. Communication Questionnaire showed to be unidimensional. In all questionnaires, Cronbach’s alpha coefficient was greater than 0.9.

In the present study, participants were asked to rate each item on a 5-point scale for the importance of being included in training for NHPV. The response options varied from “not at all important to include” to “very important to include.”

Procedures

The assessment of training needs through the questionnaires was conducted in Portuguese and English, through the Google Forms platform. The participants were recruited through three NGOs and nine European NHPV social media groups. The invitation included the participation criteria and the link to assess the informed consent and the survey.

Statistical analysis

Due to the non-normal distribution of the results, non-parametric statistical tests were used in the comparative analyses. The variance of continuous variables for two groups was analyzed using the Mann–Whitney U test, with the effect size being calculated based on the following formula: r = Z /√N. For intragroup comparisons, the Friedman test was used. In this case, the effect size was indicated by Kendall’s W value. If differences were statistically significant, pairwise comparisons were performed. The probability of type I error (α) of 0.05 was considered. Data were analyzed using IBM SPSS Statistics software (version 25, IBM SPSS, New York).

Results

Participants profile

Ninety-four adults responded to the invitation to participate in the study; of those, 91 (62 women and 29 men from 6 continents and 35 countries, with an average age of 42 years and an average formal education of 14 years) completed the survey and were considered in further analyses (Table 1).

Table 1 Sociodemographic characteristics and geographical distribution of the study sample
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Most respondents (80%) claimed to have experience of working with AS&R. In most cases, this experience was gained in European countries (62%), in the context of voluntary work (47%) in NGOs (75%) and lasted 13 months or more (52%). The intention to collaborate with NGO for a period of 13 months or more also stood out in the responses of the participants with no previous experience of working with AS&R (50% and 33%, respectively). However, a great number of these respondents have not yet defined the work context and/or the geographic destination of the future collaboration (Table 2). Only 48% of respondents claimed to have training to work with AS&R. The training received was quite diversified in terms of format and content (Table 3). Still, it’s worth emphasizing the role of NGOs in providing facilities (39% of reported cases) and trainers (52% of reported cases), necessary for the implementation of training actions.

Table 2 Summary of actual or planned work experience with refugees and asylum seekers
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Table 3 Summary of training experience to work with refugees and asylum seekers
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Training needs assessment

The assessment of training needs began with the question about the extent to which the participants agree that NHPV who work with the population of interest should be trained to perform their role. Of all 91 participants, 74% agree. Partial and total disagreement rates were 10% each. Remaining answers fall into the category “neither disagree nor agree.” There were no significant differences in the level of agreement between participants with and without work experience (U = 550.50; p = 0.217). However, participants with training experience presented a significantly higher level of agreement than participants without training (U = 759.50; p = 0.011), although the effect size was small (0.266).

The participants were also asked to select the most important reason for training to work with AS&R. Most respondents (55%) pointed to increase knowledge about strategies to help these vulnerable populations and themselves to deal with stressful situations. This selection did not depend on working or training background. The second and third most frequently mentioned reasons were related to increase in knowledge about the contextual and legal conditions in which they live (23%) and to clarification about forced migration issues and their consequences on population of interest (11%), respectively. Increase in knowledge about ways to help the population of interest was the least selected reason (10%).

Intergroup comparisons

The means and standard deviations for all questionnaires and components, organized according to work and training background, are presented in Table 4. Comparison of questionnaires scores showed no significant differences in the importance given to the training needs by participants with different backgrounds of work (Organization Management U = 642.00, p = 0.881; Cultural Ability U = 621.50, p = 0.723; Health U = 618.50, p = 0.700; Communication U = 638.00, p = 0.850) and training (Organization Management U = 962.50, p = 0.570; Cultural Ability U = 852.00, p = 0.148; Health U = 891.50, p = 0.256; Communication U = 832.00, p = 0.108). Participants with and without work experience also did not differ in components scores. As for participants with and without training experience, one significant difference was found, namely in the importance given to the Encounter & Engagement-related needs, although the effect size was small (U = 779.00, p = 0.042, r = 0.21).

Table 4 Means and standard deviations of scores obtained in the assessment of training needs
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Intragroup comparisons

Regarding the importance given to the training needs addressed in the four questionnaires, intragroup comparison of the proportions of the total scores obtained, performed for the total sample, did not show significant differences (χ2F (3) = 5.492, p = 0.139). The same was verified in relation to the subgroups with and without work experience (χ2F (3) = 2.923, p = 0.404; χ2F (3) = 4.200, p = 0.241; respectively) and with and without training experience (χ2F (3) = 3.568, p = 0.312; χ2F (3) = 5.039, p = 0.169; respectively). However, when the analyses considered components scores, the differences observed revealed to be statistically significant in the total sample (χ2F (7) = 41.585, p < 0.001, w = 0.07), in the subgroups with work and training experience (χ2F (7) = 36.335, p < 0.001, w = 0.07; χ2F (7) = 20.807, p = 0.004, w = 0.07; respectively) and in the subgroup without training experience (χ2F (7) = 28.397, p < 0.001, w = 0.09). In the subgroup without work experience, the differences remained non significant (χ2F (7) = 13.228, p = 0.067).

Pairwise comparisons performed for the total sample showed that greater importance was given to training needs related to Accountability & Management as compared to Learning Share, Team Collaboration and Communication, as well as to training needs related to mental health as compared to Learning Share and Communication. In the subgroup with work experience, Accountability & Management-related needs were valued more than needs from the scope of Learning Share, Communication, and Physical health, and Mental health-related needs were more valued than Learning Share-related needs. Participants with and without training experience recognized as more important Accountability & Management-related needs as compared to Learning Share-related needs. The subgroup without training experience also valued more mental-health related needs than Learning Share-related needs.

Discussion

Organizational management, communication, cultural abilities, and health competences are the main domains on which the participants had to decide whether they should be included in a training program to work with AS&R. All the participants considered it important to include the competencies presented in the questionnaires, regardless of the training background or working experience with AS&R.

This study’s results show that NHPV agree with the inclusion of content promoting organizational management competences in the training programs. Meaning they are aware of the importance of knowing how to manage resources to improve peoples’ lives, working collaboratively and effectively with all people irrespective of their background or function, and assuming a professional conduct of responsibility about the outcomes (United Nations 2017a, b). While Accountability & Management training competences are more related to the NHPV’ role in the organization (action plan, strategies, and resources), topics related to the Learning Share and Team Collaboration concern sharing knowledge and increasing the effectiveness of work with others through contributions of health professionals with fieldwork experience.

Cultural abilities are the ones that most interest NHPV and the trained participants seem to care more about Encounter & Engagement-related competences than untrained ones. Nonetheless, to enhance the cultural Encounter & Engagement, NHPV should be aware of their cultural Knowledge & Awareness to respect AS&R norms and cultural beliefs (European Union 2019). It is no coincidence that cultural abilities are of most interest, as they can influence the way people relate to each other, and how people understand the others’ needs and behaviors (Bundesministerium für Familie Senioren, Frauen und Jugend 2017; Jaffe et al. 2012). Cultural abilities training is of paramount importance for those working in multicultural complex contexts. Health professionals such as nurses, as the AS&R’s first contact with health services and as health educators par excellence, are the cornerstones of caring for AS&R (International Council of Nurses [ICN] 2019; ICN 2018, 2006). Nurses can contribute with in-depth knowledge about cultural competencies helping NHPV to learn about AS&R cultural and religious characteristics; and they know these characteristics influence relationships and encounters.

In multicultural contexts, communication is one of the most necessary skills to work and it is also one of the major barriers for AS&R (UNHCR 2021a), as it can easily be influenced by interlocutors’ cultural competencies. NHPV use verbal and non-verbal communication to engage with AS&R, colleagues, and partners, who have different cultural, religious, linguistic backgrounds (European Union 2019; ICN 2019). NHPV ability to communicate, based on cultural abilities (European Union 2019; ICN 2019, 2018), is the key to understand behaviors, cultures, and ways to help AS&R. In this field, health professionals can provide training on basic principles of cross-cultural communication, contextual, cultural, and religious factors that affect communication and strategies to communicate.

Regarding the health domain, participants unanimously agree about the need for training in physical and mental health. In this study, the health concept highlights the physical and mental needs related to the asylum process, such as referring to specialized health care and providing first-aid support. Training by health professionals, who are prepared to teach how an individual’s beliefs, values, and cultural attitudes contribute to the AS&R concept of health (ICN 2018) and the manifestations of physical or mental illness, is crucial for the NHPV, as they need to be alert to daily manifestations of diseases or the help-seeking behavior. With proper training by health professionals, NHPV can advocate for the health rights and resources for AS&R, but only if they are aware of AS&R’ needs and strategies to help them.

The literature about the capacity building of the refugee-related workforce reveals that the training in health and well-being topics covers child protection, women empowerment, and violence, even for those volunteers without a health background (Teixeira-Santos et al. 2023). These facts are corroborated in the survey’s descriptive part of this study where participants described the topics, they would include in a training program.

This study’s results also show that participants agree that mental health training is essential to empower them to deal with stressful situations. Surprisingly, participants found learning the basic principles of helping others to be just as important as learning about the strategies for protecting their own mental health, revealing that they are aware that working with AS&R can lead to mental health challenges. In fact, mental health training is crucial not only for providing adequate care for AS&R, but also for the NHPV’ mental health preparation and safety. Psychologically trained refugee helpers had lower burnout levels and somatic symptoms when compared with untrained aid workers (De Jong et al. 2021; Jobst et al. 2018; Pell 2013). The UNHCR defend that primary well-being intervention with AS&R can be provided for trained and supervised non-specialized mental health volunteers (UNHCR 2021b).

Most of the participants (74%) agreed that it is necessary to receive training to work with AS&R, especially to increase knowledge about strategies to help refugees, asylum seekers, and themselves to deal with stressful situations. Although there are no significant differences in the level of agreement between participants with and without professional experience, participants with training had a significantly higher level of agreement than participants without such background.

In this study, most of the participants (62%) had experience working with AS&R acquired in European countries as part of voluntary work in NGOs for more than a year. These findings may have been influenced by the invitation through NGO groups with greater intervention in Europe as they are dealing with the largest number on record of forcibly displaced people (UNHCR 2023; World Economic Forum 2022; Carrera 2019; Kalogeraki 2018; Bernát et al. 2016).

Even though the majority of NHPV agree with prior training to work with AS&R, as there is no specific and mandatory training to work/intervene with AS&R (Godin 2020), less than half (48%) of the NHPV with field experience, included in this study, have training to work with AS&R. When the training-related information is analyzed, it is possible to verify that 50% of participants receive the training while working with AS&R and that, on average, the training covers just one topic and has a duration of 1 to 9 h. The average of topics per training and the training duration do not seem to meet the training of competencies that participants revealed to need when completing the questionnaires of this study.

Volunteers often receive inadequate training (Jobst et al. 2018; Save the Children 2017; Fletcher 1987). Moreover, the training is frequently under-emphasized because most volunteers are perceived as competent and employed professionals who are donating their spare time (Kende et al. 2017; Starnes and Wymer 2001). Consequently, unexperienced volunteers must rely on unsupervised on-the-job training as well as solicited support from other volunteers (Save the Children 2017; Guhan and Liebling-Kalifani 2011; Fletcher 1987). Experienced volunteers usually have a diverse range of skills, including logistics, human resources, finance, health, engineering, and so on, and we can assume that most participants have differentiated skills due to the average of 14 years of education. However, given the diversity of field situations and the fact that most experienced participants have worked more than a year in the field, they should also have competencies across a whole set of other areas, including management, communication, negotiation, teamwork, etc. (Dempsey-Brench and Shantz 2022; Clarke et al. 2019).

This study’s results clearly show a deficit in the training of NHPV who can identify training needs beyond those they received, being in line with the conclusions of a recent scoping review that denounce the insufficiency of training programs for NHPV (Teixeira-Santos et al. 2023) and their ineffectiveness in meeting the training needs identified by this study’s participants as necessary to work with AS&R.

This study’s major strength is that we can use the questionnaires to construct or adapt a training program as needed. The level of agreement between NHPV with different training and working background regarding the concepts of interest show that all of them could be included in training programs that prepare NHPV to work with AS&R.

These results show that health professionals could invest in training NHPV not only to better prepare them for their daily work but also to empower them to care for and refer AS&R to health care. This study indicates that organizational management, communication, cultural abilities, and health domains are fundamental to design training programs for NHPV working with AS&R where health professionals can lead.

The limitation of this study is the inclusion of participants with specific interest in the topic as they were recruited through NGOs or social media groups focused on helping AS&R. Future studies could increase the sample size and include people with more diversified educational and professional backgrounds. In future research, it would also be valuable to investigate the efficacy of novel training approaches and to contrast the training requirements of volunteers and non-healthcare professionals with those of healthcare professionals aiding refugees and asylum seekers.

Conclusions

NHPV receive limited and inadequate training to work with AS&R. They unanimously agree that organizational management, communication, cultural abilities, and health domains should be included in training programs. Health professionals can have a vital role in developing and improving the training programs for NHPV working with AS&R, which can easily be adapted to the training needs and contexts using this study’s questionnaires.