Feasibility of COVID-19 Self-Testing in Refugee Learning Centres(FOSTER Project): Empowering Refugee Communities through Inclusionand Health Innovation

Abstract

Despite equitable coronavirus disease 2019 (COVID-19) treatment and vaccination policies, the pandemic disproportionately affected refugees in Malaysia, exacerbating their vulnerability to infection due to lack of legal status, financial precarity, unstable and overcrowded housing, and limited healthcare access. Self-testing for diseases like COVID-19 facilitates early detection and intervention for populations facing healthcare-access barriers, and schools provide a crucial entry point to reach the broader refugee community. This implementation research focused on the feasibility of COVID-19 self-testing within refugee schools in Malaysia. It involved training community health workers (CHWs) and teachers to conduct mass COVID-19 self-testing in refugee schools and to connect refugee communities with health and governmental resources.

The intervention provided critical insights into the significance of the inclusion of marginalized communities—such as refugees and migrants—in pandemic-management strategies, promoting multisectoral collaboration and fostering community agency through participation.

Introduction

The Feasibility of COVID-19 Self-Testing in Refugee Learning Centres (FOSTER) study was a collaboration between Monash University Malaysia, the Health Equity Initiative (HEI), and the Foundation for Innovative New Diagnostics (FIND), with support from the Office of the United Nations High Commissioner for Refugees (UNHCR) Malaysia and the Ministry of Health Malaysia. 

FOSTER was launched to tackle the severe challenges faced by underfunded refugee schools. By building their capacity to stay open as the country returned to endemicity, the programme aimed to mitigate the pandemic’s exacerbation of educational inequalities, the digital divide, and the negative impact on students’ mental health and access to essential services, like school meals, thereby promoting health equity for a marginalized population.

Guided by community-based participatory research approaches, the project was initiated in response to a refugee school’s request for COVID-19 self-testing kits and personal protective equipment (PPE). The service delivery package, comprising training for teachers and CHWs and the creation of educational materials, was finalized following substantive contributions by the community, facilitated by UNHCR. Monash spearheaded the research aspects; FIND contributed funding, technical expertise, and self-testing kits; and HEI was instrumental in study implementation, community engagement, and materials development.

Who should benefit?

Children represented 28% of the 186,490 refugees and asylum-seekers registered with UNHCR in Malaysia as of January 2024, with most living below the poverty line. Malaysia’s lack of ratification of the 1951 Refugee Convention and the absence of legal frameworks for refugees deny these children access to state education, and make private education inaccessible due to high costs and lack of legal status. Under-resourced schools run by refugee communities and non-governmental organizations (NGOs) often struggle with issues of certification, high teacher turnover, security, and a lack of recreational activities crucial for holistic development.

FOSTER emerged as a critical intervention that sustained educational continuity and kept schools operational, transforming them into community hubs. By engaging parents and teachers through an acceptability survey, distributing self-testing kits, and launching inclusive education on self-testing, FOSTER enhanced the community’s health literacy and resilience. An 8-week surveillance period following the implementation of school-wide self-testing was essential for evaluating the initiative’s impact and refining its protocols. This strategy empowered students and teachers with the skills for early detection and management of COVID-19 cases. Enabling teachers to liaise with parents broadened the impact of self-testing education and capacity-building across the refugee community. FOSTER also facilitated valuable multisectoral engagement between refugee schools, CHWs, NGOs, and the Ministry of Health through a technical working group, which addressed the immediate needs of the pandemic and also laid the groundwork for tackling other infectious diseases.

FOSTER addressed the consistent evidential links between early childhood education (ECE) and adult and child health outcomes, and the relationship between social determinants of health and outcomes. It is a model for inclusive health and education interventions in urban refugee settings lacking formal UNHCR or international assistance, and provides a scalable framework for improving healthcare access for other marginalized populations in complex environments.

Engagement

Aligned with our community-based participatory research ethos, we have established collaborations with various community organizations and NGOs. During our engagement in social-emotional learning research at a refugee school, we observed significant challenges exacerbated by COVID-19 outbreaks, leading to multiple closures. Prompted by the school’s urgent request for face masks and PPE in order to remain operational, and an opportunity from FIND to research COVID-19 self-testing in refugee communities, we proposed refugee schools as our research sites in response to the immediate needs articulated during the pandemic’s peak. 

Following the success of our pilot intervention, UNHCR assisted in extending the project to additional refugee schools across the country, ensuring broader inclusion. After transparent communication, 11 schools in Kuala Lumpur and Kedah consented to participate. Focus groups and interviews with the principals and head teachers refined our approach, leading to the augmentation of community-based organization (CBO)-run schools with CHWs, and the independent implementation of self-testing by NGO-run schools, as per their specific needs.

We trained teachers and CHWs to carry out an acceptability survey to assess parents’ interest in the initiative. Positive parental feedback, coupled with obtained consent, facilitated the execution of COVID-19 self-testing rollouts, supported by customized training. This iterative process included regular feedback and follow-up meetings with school leaders, leading to adaptive changes in the rollout protocol to cater to the diverse needs of the participants.

Our technical working group served as a vital platform for refugee representatives to engage in constructive discussions with NGOs and the Ministry of Health. This underscored the importance of including marginalized communities in policy and programme development, enhancing the Ministry of Health’s capacity to manage health crises effectively, and ensuring the visibility of at-risk populations.

Research

This initiative was launched in response to the pressing needs of a refugee community school that faced recurrent shutdowns due to COVID-19 outbreaks and the economic hardships of parents—many reliant on daily wages—who were unable to afford time off for their children’s isolation. These challenges highlighted the critical need to support refugee schools in maintaining their operations. Our decision to conduct a feasibility assessment in this implementation research stemmed from the lack of prior studies on the unique combination of a teacher- and CHW-assisted model of service delivery. The approach aimed to forge partnerships and address the challenges faced by the urban refugee community in Malaysia, with a particular focus on the limitations of their capacity to manage pandemic-related issues. Additionally, the project was anchored in a community-based participatory research framework that included schools and CHWs in the processes of research and intervention implementation, with a view to integrating knowledge production as a co-learning exercise and optimizing social impact. The consequent building of capacities of refugee schools in implementing COVID-19 self-testing on a mass scale was secondary to the project’s primary goal to promote prevention and infection control among students and teachers.

A convergent, parallel, mixed-methods design facilitated the collection of complementary quantitative and qualitative data for a comprehensive analysis. Formative qualitative research helped identify contextual barriers that could affect the successful implementation of interventions in refugee schools and refine the self-testing service delivery package (including both paper-based and video tools) and the model (peer- or CHW-assisted). This process, informed by the qualitative findings, allowed customization of the self-testing protocol to suit the varied resources of CBO- and NGO-run schools, adapting to their specific constraints.

Quantitative methods evaluated the acceptability, implementation, and practicality domains related to the feasibility of the COVID-19 self-testing approach in these settings. This was further supplemented by qualitative and quantitative data from monitoring tools used during the rollout and the 8-week surveillance period.

Refugee teachers and CHWs led the data collection and self-testing intervention, fostering community engagement. This confirmed the importance of self-testing for disease management and expanding access for disadvantaged communities, and showcased the resilience, agency, and positive contribution made by refugees and migrants to host nations.

Highlighting these aspects was vital for forging local stakeholder partnerships and ensuring multisectoral collaboration.