The number of humanitarian expatriates and aid agencies working in areas of complex emergency and natural disasters has greatly increased over the last two decades.1 In 2008 alone, 211 million people were affected by natural disasters2 and 25 million people were displaced within their own countries through conflict or human rights violations in 2007.3 Studies have highlighted that humanitarian expatriates are at a higher risk of having health problems and fatalities when they are directly exposed to human suffering and crises.4,5 However, there are few data available on the profile and general health status of humanitarian aid workers. Much of the available research comes from publications focusing on specific health issues (eg, sexual behavior, risk of HIV, infections, and malaria).6–9 More extensive knowledge of factors related to the health of aid agency staff is necessary to develop strategies aimed at reducing the burden of illness among expatriates, especially in terms of their recruitment training and preparation.
Objective. To assess self-reported health risk and risk-taking behavior of humanitarian expatriates.
Methods. A self-administered anonymous questionnaire was completed by International Committee of the Red Cross (ICRC) expatriates returning during May 2003 to September 2004, covering perceived health status before and after mission, malaria prevention, prevalence of exposure to stress, accidents and violence, and risk-taking behaviors.
Findings. More than one-third (36.4%) reported worse health on return from the mission. A third (35%) of expatriates returning from Sub-Saharan Africa excl. South Africa reported not having followed ICRC's recommendation on taking malaria prophylaxis in spite of stating a high degree of awareness of the risks and availability of effective drugs. Over 40% reported the mission having been more stressful than expected, mostly due to the working environment; 10% reported injury or accidents and 16.2% exposure to at least one act of violence. Almost one-third of the respondents reported having engaged in casual sexual relationships. Of these, 64% reported using condoms at every sexual contact, and women reported lower usage of condoms than men. Many (27%) reported involvement in risk-taking behavior.
Conclusion. This study shows that humanitarian aid workers experience significant worsening of their health during overseas missions. Many are at risk of experiencing violence, accidents, or injuries. Despite awareness of the risks, many expatriates engage in behaviors that could endanger their health. Improved selection of expatriate staff, training programs emphasizing areas of concern, strengthening social support locally, and follow-up in field may help to alleviate these problems.
Between May 2003 and September 2004, all recently returned International Committee of the Red Cross (ICRC) humanitarian aid workers were asked to complete a self-administered anonymous questionnaire about their time spent abroad, during the systematic debriefing at ICRC Headquarters in Geneva.
The inclusion criteria of the study were having been on an ICRC mission of at least 1 month and having returned for debriefing at ICRC in Geneva. Expatriates returning from missions shorter than 1 month were excluded from the analysis, since the living conditions during these short trips were different from the rest of the sample.
This questionnaire covered health status, health-related problems, malaria prevention, accidents, exposure to violence, stress, exhaustion, lifestyle, and risk-taking behavior. The development of the questionnaire and the data analysis were conducted independently at the Unit for Travel and Migration Medicine at Geneva University Hospitals (HUG). The anonymously completed questionnaires were returned in sealed envelopes to the unit at HUG for processing. Regular control of the number of debriefed expatriates at ICRC and the number of questionnaires received was performed by the unit.
Permission for this study was obtained from the Health Unit, Human Resources Department, ICRC, Geneva, Switzerland, before undertaking the survey. The questionnaire was considered an extension of the routine confidential debriefing procedure.
We studied the associations between expatriate and mission characteristics and the following outcomes: worse health at the end of the mission compared to the beginning, fever, diarrhea, not taking malaria prophylaxis medications as recommended, exposure to violence, having an injury, finding the mission more stressful than anticipated, exhaustion for 1 week or more, starting or increasing smoking, increasing coffee consumption, increasing alcohol consumption, and sexual contact with someone who was not the regular partners.
We also studied “high-risk” behavior, defined as reporting one or more of the following: frequently driving a motor vehicle faster than allowed, frequently driving a motor vehicle after consumption of alcohol above the legal limit, unprotected sex with someone who was not the usual partner, frequent change of sexual partners, excess use of alcohol, excess use of medication, illicit drug use, and risky sports.
Separate regression analyses were conducted for each outcome. As the outcomes from the study were not rare (ie, their prevalence was not less than 10%), the odds ratios obtained from logistic regression would not be good estimates of relative risks. Therefore, we conducted Poisson regressions with robust error variances to estimate associations, while adjusting for numerous characteristics.10 Likelihood ratio tests were used to compare models with and without specific variables. The final models included statistically significant variables (p value <0.1) as indicated by the likelihood ratio tests.
A total of 1190 (95.2%) of the 1250 expatriates who underwent debriefing during the study period (May 2003 to September 2004) completed the questionnaire at the ICRC Headquarters in Geneva and met the inclusion criteria. Those that were omitted (n = 60) did not return the questionnaire (n = 21) or reported returning from a mission of less than 1 month (n = 39). The expatriate staff included delegates (40%), administrative personnel (20%, eg, secretaries, logistics), and different specialists like medical staff and engineers (40%) (Table 1). The mean duration of a mission was 11 months (median 11.8 mo, range 1–67 mo). Most expatriates returned from missions in Africa (n = 522, 44%) and Asia (n = 505, 42%) and were of European origin (n = 939, 80.1%).
|Geographical distribution of missions|
|Nationality of expatriates|
|Length of mission (mo)|
|Type of contract|
|HOD (Head of Delegation)||24||2.0|
|DHOD (Deputy Head of Delegation)||27||2.3|
|Medical (doctors, nurses, etc.)||247||20.9|
|Ecosec (Economic Security Unit)||72||6.1|
|Wathab (Water and Habitat)||60||5.1|
|Other family member||20||1.8|
|First mission ever||211||18.2|
|First ICRC mission||354||30.7|
|Number of previous ICRC missions|
Self-Perceived Health Status and Medical Problems
Of the participants, 1,026 (86.2%) reported excellent or very good health before the mission. After returning, more than one-third (36.4%, n = 433) reported worsened health, 2.4% (n = 29) improved health and the rest no change (60.6%, n = 721). Approximately three-fourths (72.8%, n = 867) of the expatriates reported at least one medical problem during mission (Table 2). Overall, one-in-ten missions were interrupted prematurely and 13.6% of the interruptions (n = 18) were attributed to illness and 28.8% (n = 38) to personal reasons.
|Medical problem*||Africa n = 522||Asia n = 505||Americas n = 94||Europe n = 69||Total n = 1190|
|Diarrhea||274 (52.5)||199 (39.4)||36 (38.3)||14 (20.3)||523 (44.0)|
|Fever||177 (33.9)||104 (20.6)||19 (20.2)||8 (11.6)||308 (25.9)|
|Headache||64 (12.3)||53 (10.5)||8 (8.5)||10 (14.5)||135 (11.3)|
|Fatigue||119 (22.8)||89 (17.6)||17 (18.1)||12 (17.4)||237 (19.9)|
|Dermatological||91 (17.4)||79 (15.6)||22 (23.4)||2 (2.9)||194 (16.3)|
|Respiratory||46 (8.8)||37 (7.3)||7 (7.5)||0 (0)||90 (7.6)|
|Dental||63 (12.1)||67 (13.2)||12 (12.8)||8 (11.6)||150 (12.6)|
|Urological||25 (4.8)||14 (2.8)||4 (4.3)||2 (2.9)||45 (3.8)|
|Sexually transmitted diseases||1 (0.2)||3 (0.6)||0 (0)||0 (0)||4 (0.3)|
|Allergies||44 (8.4)||57 (11.3)||12 (12.8)||2 (2.90)||115 (9.7)|
|Neuropsychological||75 (14.4)||78 (15.5)||12 (12.8)||9 (13.0)||174 (14.6)|
|Cardiovascular||8 (1.50)||6 (1.2)||3 (3.2)||3 (4.4)||20 (1.7)|
|Gastrointestinal not diarrhea||97 (18.6)||75 (14.9)||11 (11.7)||3 (4.4)||186 (15.6)|
|Musculoskeletal and joint||57 (10.9)||58 (11.5)||7 (7.5)||4 (5.8)||126 (10.6)|
|Gynecological-obstetric||26 (10.3)||15 (6.9)||3 (7.7)||2 (6.7)||46 (8.5)|
|Other||55 (10.50)||40 (7.9)||6 (6.4)||4 (5.8)||105 (8.8)|
Two-fifths of the expatriates (41.5%, n = 494) returned from missions in Sub-Saharan Africa (SSA) excluding South Africa. A majority of these reported having been briefed on malaria risk in the area (97.4%, n = 481) and 82.2% (n = 406) having been recommended malaria chemoprophylaxis. About one-third (35.5%, n = 144) of those who reported having been recommended malaria chemoprophylaxis stated they had complied and used the prophylaxis as prescribed. There was no gender difference in reporting the use of malaria prophylaxis. A linear decline was observed in compliance with mission time (Figure 1). Being a specialist (RR = 0.76, 95% CI 0.56–1.03) or a delegate (RR = 0.91, 95% CI 0.67–1.24) was associated with a higher probability of taking the treatment compared with an administrator.
Overall, the most frequent reasons stated for non-compliance with malaria chemoprophylaxis were the preference of treatment to prophylaxis, use of other preventative measures, and fear of side effects. Most of the respondents (89.4%, n = 440) returning from missions in Africa reported having used other malaria prevention methods including bed nets, repellents, or insecticides.
Most of the expatriates returning from SSA (80.6%, n = 391) reported having been recommended the use of stand-by emergency treatment (SBET) in case of suspected malaria. Of the 86 expatriates stationed in SSA who reported having used SBET, 62 (72.1%) stated having seen a doctor and 70 (81.4%) had a laboratory test performed. In 50 cases (71.4%) this locally performed laboratory test was positive for malaria, corresponding to 3.81 possible malaria cases per 1,000 expatriates per month. This represents one-in-ten (10.1%) of those returning from SSA and 4.2% of all participants who may have acquired malaria, understanding that locally performed laboratory tests may over-diagnose malaria.
Injury, Accident, and Violence
Approximately one-in-ten expatriates (10.3%, n = 123) reported having been injured or having had an accident during their mission (Table 3). The regression analysis showed that expatriates on their first mission (RR = 1.76, 95% CI 1.13–2.74) and those who reported exhaustion (RR = 1.52, 95% CI 0.99–2.34) were more likely to report an injury. Specialists were twice as likely to report an injury compared to administrative staff (RR = 2.07, 95% CI 1.14–3.77). Those staying on missions from 6 to 12 months (RR = 2.18, 95% CI 1.18–4.03) and 12 to 18 months (RR = 2.37, 95% CI 1.31–4.30) reported an injury twice as often as compared to returnees from missions shorter than 6 months. Car crashes were the most frequent type of accident reported, however with few reported health consequences. Seatbelt use was reported as follows: always (ICRC policy) 70.4% (n = 794), frequently 19.2% (n = 216), sometimes 8.4% (n = 95), never 2% (n = 23). Sports injuries were the second most commonly reported. Four incidents of dog bites were reported, representing 0.305 dog bites per 1,000 expatriates per month. Accidental needle stick was reported by five medical staff in the open-ended portion of the questionnaire and was not systematically asked about, therefore it may have been underreported.
|Type of accident||Job category||Gender|
|Administrators n = 226||Delegates n = 482||Specialists n = 473||Female n = 540||Male n = 638|
|Car crash||9 (4.0)||17 (3.5)||17 (3.6)||22 (4.1)||20 (3.1)|
|Bike||0||1 (0.2)||2 (0.4)||1 (0.2)||2 (0.3)|
|Motorcycle||0||0||4 (0.9)||2 (0.4)||2 (0.3)|
|Sport||5 (2.2)||13 (2.7)||10 (2.1)||9 (1.7)||19 (3.0)|
|Animal bite||0||3 (0.6)||9 (1.9)||6 (1.1)||6 (0.9)|
|Falls/contusions||2 (0.9)||9 (1.9)||9 (1.9)||12 (2.2)||7 (1.1)|
|Lacerations||0||1 (0.2)||4 (0.9)||2 (0.4)||3 (0.5)|
|Needle sticks||0||0||5 (1.1)||3 (0.6)||2 (0.3)|
A total of 193 (16.2%) reported having been exposed to at least one act of violence with verbal/psychological threat being the most common form experienced (11.7%, n = 139) (Table 4). Report of exposure to violent events was more common among younger aid workers. Compared to expatriates younger than 30, those over 50 were 60% (RR = 0.4, 95% CI 0.22–0.73) less likely to report exposure to violence followed by the 40–49 (RR = 0.48, 95% CI 0.29–0.80) and 30–39 (RR = 0.69, 95% CI 0.46–1.02) age groups. Other characteristics associated with exposure to violence included exhaustion (RR = 1.68, 95% CI 1.21–2.32), finding the mission more stressful than expected (RR = 1.60, 95% CI 1.17–2.18), and increased alcohol consumption (RR = 1.77, 95% CI 1.23–2.54). There were no significant geographical differences in exposure to violence.
|Type of violence||Job category||Gender|
|Administrators n = 226||Delegates n = 482||Specialists n = 247||Female n = 540||Male n = 638|
|Armed attack and threat||16 (7.1)||48 (9.9)||31 (12.6)||39 (7.2)||56 (8.8)|
|Unarmed attack/ threat/||6 (2.6)||27 (5.6)||14 (5.7)||18 (3.3)||29 (4.5)|
|Sexual aggression||0||3 (0.6)||2 (0.8)||4 (0.7)||1 (0.2)|
|Verbal/psychological threat||21 (9.3)||80 (16.6)||38 (15.4)||55 (10.2)||84 (13.2)|
|Robbery||8 (3.5)||29 (6.0)||10 (4.0)||24 (4.4)||23 (3.6)|
Stress, Exhaustion, Sleeping Problems
The mission was reported as being more stressful than expected by 42.6% (n = 503) of the participants, and the most frequently reported causes of stress in this group were related to working environment (56.2%, n = 280) and living arrangement including housing (15.7%, n = 78). Almost one-third of expatriates (30.3%, n = 361) reported having experienced exhaustion for more than a week, to the point of interfering with their ability to work. The most stated sources of exhaustion reported were: working environment (56.5%, n = 204), superiors and colleagues (23.0%, n = 83), and living environment incl. housing (6.4%, n = 23). Regression analysis revealed that expatriates who reported having had someone to talk to during mission were 28% (RR = 0.72, 95% CI 0.51–1.03) less likely to report exhaustion. Approximately one-third of the respondents (31.1%, n = 367) stated having had sleeping problems during the mission. Regular use of sleeping pills was reported by 9.1% (n = 33).
Most expatriates (82.1%, n = 942) reported having had someone to talk to during the mission, with small geographical variations. In many cases this was a colleague (61.1%, n = 559), while 18.8% (n = 172) reported having talked to health professionals and 14.1% (n = 129) reported having approached friends as confidants.
Lifestyle and Risk-Taking
Of the 1,029 participants (accounting for 90% of the sample) who reported using alcohol, 14% (n = 139) reported an increase in use, 19.8% (n = 197) a decrease, 3.8% (n = 38) stopped, and 62.4% (n = 621) reported no change in alcohol consumption during the mission. Mission time did not have an influence on reporting increased alcohol intake.
Forty-one percent (n = 456) reported smoking. Of these, 198 (43.4%) stated increased consumption during the mission. A minority had decreased (4.6%, n = 21) or stopped smoking (5.5%, n = 25). However, another 43.4% (n = 198) had not changed their smoking habits and just over one-in-ten (10.1 %) expatriates reported having started smoking during the mission. Stating increased smoking or starting smoking during the mission was significantly associated with being female, increase in alcohol consumption, and experiencing exhaustion. There was no relation between the length of mission and starting or increasing smoking.
A small minority (2.9%, n = 34) across all geographical regions reported having used recreational drugs during the mission. Most of these expatriates reported having used cannabis and were returning from missions in Africa and Asia.
Almost one-third of expatriates (29.3%, n = 337) admitted having had a sexual relationship with someone other than their regular partner during the mission. Approximately half of this group reported having had a relationship with one partner during the mission (49.0%, n = 164) whilst 35.5% (n = 119) had a relationship with two to three partners and 15.5% (n = 52) had relationships with four or more. Those returning from longer missions (6–12 and 12–18 mo) were approximately twice as likely to report having had sexual contacts (RR = 1.52, 95% CI 1.03–2.23 and RR = 1.97, 95% CI 1.4–2.78), as those from missions shorter than 6 months.
Condoms had reportedly always been used by 64% (n = 212), but nearly one-in-five (18.8%, n = 62) had used condoms only sometimes or never. Significant discrepancies were reported in condom use between genders (Figure 2).
One-in-five (20.4%, n = 68) reported having taken an HIV test during the mission and another 20.5% (n = 67) stated they had a reason to believe they needed to take an HIV test. Approximately 12% (n = 41) thought they had taken a risk of acquiring a sexually transmitted disease they would not have taken at home.
Males were 38% (RR = 1.38, 95% CI 1.08–1.75) more likely than women to report having had sexual relationships while on mission and the likelihood of engaging in sexual risk behavior was 2.56-fold (RR = 2.56, 95% CI 1.62–4.05) greater in those living alone.
Regression analysis revealed that the older groups, those in the 40–49 age group and those aged >50 years were 22% (RR = 0.78, 95% CI 0.51–1.20) and 55% (RR = 0.45, 95% CI 0.25–0.81) less likely, respectively, to engage in this behavior.
Many expatriates (27%) had engaged in at least one risk-taking activity (Table 5). Regression analysis revealed that those who had engaged in at least one risk-taking activity were twice as likely to be men (RR = 1.98, 95% CI 1.54–2.55), had begun or increased smoking during the mission (RR = 1.61, 95% CI 1.24–2.09), and were single (RR = 1.58, 95% CI 1.14–2.21).
|Characteristic||Number of persons||% who reported a high-risk behavior*||Adjusted** relative risk||95% Confidence interval|
|Age group (y)|
|Began or increased smoking|
|during the mission|
|Mission more stressful|
|Region of mission|
The need for international humanitarian relief efforts remains critical and the protection of aid workers who provide this relief is essential.11 However, in order to understand health risks and needs, more comprehensive data are needed on health status and health problems, including potential work-related stressors and risk-taking behaviors of expatriate aid workers. Several authors have reported that despite having been briefed, aid workers had not followed preventive measures for their health.12–14 Over one-third of ICRC workers reported worse health after a mission, similar to findings in humanitarian relief workers and journalists.14,15 Humanitarian aid workers are ready to take risks for people in need and attend to their health and well-being before their own. It can therefore not be excluded that a certain selection bias takes place when they are recruited. Barron noted that ignoring or burying their own needs can become a second nature or may even have drawn them to relief work in the first place.16
Self-Perceived Health Status and Medical Problems
Interestingly, the 86.4% who reported excellent or very good health before mission were twice as likely to report worse health at the end of the mission compared to those who reported good or fair health at beginning of the mission. Those aged 50 or over were less likely to report worse health than other age groups. Their greater experience possibly led them to better compliance with care-taking measures and handling of stressful situations.
Interruption of the Mission
Our survey showed that one-in-ten interruptions of missions were premature, and 13% of these were due to medical problems. Brierly17 reported data from a global survey of missionary personnel and found an attrition rate of 3.8% per year in larger organizations and up to 60% in agencies that have less that 10 employees. Preventable infectious diseases and accidents have been reported by others as the main medical problems and account for the majority of medical evacuations.4,14,18
Briefing on malaria prophylaxis by the ICRC appeared to be more successful than in an earlier study in humanitarian aid workers,4 where only two-thirds reported having been briefed. However, it is important to highlight that the briefing did not appear to translate into optimal levels of use of malaria chemoprophylaxis among the expatriates, especially as 10% of those returning from SSA may have acquired malaria.
We found compliance rates of 35% for malaria chemoprophylaxis in expatriates returning from SSA. A recent questionnaire-based study in expatriates on a mine in Mali revealed higher compliance rates of 78%.19 Our findings suggest a decline in compliance over time. This result is supported by Carme and others.20–22
The fear of side effects was one of the reasons stated by a number of the expatriates for poor compliance with malaria chemoprophylaxis. Much research has been published regarding the prevalence of malaria, recommended prophylactic measures, and the efficacy of different regimens23–28 and it is essential that humanitarian expatriates have access to this data and accurate educational material, in order to dispel any unsubstantiated fears.29 The fact that medical specialists had a better compliance rate than other groups suggests that improved education in this area would be beneficial. The use of bed nets and other vector-controlling measures by the ICRC expatriates was somewhat encouraging. Eono and colleagues30 found a bed net use rate of only 7.5% among expatriates in Ghana, and Jute and Toovey17 a 13% usage in Mali.
Injury, Accident, and Violence
It is a cause for concern that one-in-ten expatriates reported at least one accident or injury during their mission. The use of seatbelts reported by the aid-workers was somewhat encouraging. Okpala and colleagues31 reported much lower compliance in military personnel where only 52% stated they always used seat belts and nearly one-fifth (22%) never used them. Sport accidents during leisure time were more frequent among men and comparable to the European average.32 There were fewer dog bites reported than observed in other studies. Steffen33 found seven dog bites per 1,000 travelers per month. Accidental needle sticks were reported by a few medical specialists. This is a serious problem, with possible severe consequences, likely to be underreported in our study as in other health care settings.34
Stress and Exhaustion
The high proportion of expatriates reporting exhaustion and finding the mission more stressful than expected is worrying. A study by Britt and Adler,35 in humanitarian expatriates in Kazakhstan, shows similar patterns. Both stress and exhaustion can have a negative influence on judgement and increase the risk of incidents with health consequences. These problems are interrelated and need to be dealt with in an integrated way. ICRC already has a program in place for stress management; however the study highlights that there is more work needed to improve on this issue. Social support is important for good stress management. Our study showed that those who had someone to talk to reported less exhaustion.
Lifestyle Factors and Risk-Taking
Risk-taking behavior has been reported as prevalent among humanitarian staff.36 Our study suggests that the most important characteristics associated with high-risk behavior were: being a man, single, and younger than 30. The new lifestyle and increased personal freedom were stated as reasons by some subjects, whereas others reported that a difficult work and living environment had influenced their behaviors. Unlike earlier reports by Britt and Adler35 in medical humanitarian expatriates and by Mehlum37 in UN peacekeepers, which showed an increase in alcohol consumption, most of the ICRC expatriates reported no change in alcohol intake during the mission; however nearly half of the smokers stated having increased levels of smoking. Aid agencies are concerned about the fact that humanitarian expatriates are more likely to engage in casual sexual activity whilst abroad than any other type of traveler.6,38 Despite the well-documented dangers of contracting sexually transmitted diseases,39–41 more than one-third of the expatriates reported having had sexual contact with at least one person who was not their regular partner, and only two-thirds reported always using condoms. This is in line with findings by Ward and Plourde showing that 33–50% of travelers do not consistently use condoms.6 Interestingly, in this study significant differences were found between men and women in the reported use of condoms. To our knowledge, this is the first time that gender differences in the use of barrier prophylaxis have been reported in humanitarian expatriates.
Strengths and Limitations of the Study
This study has some limitations that should be considered. Because it is cross-sectional, the study can identify associations but cannot determine causation. A social desirability bias leading to under-reporting of sensitive risk-taking behaviors cannot be excluded even if the participants completed the questionnaires anonymously at ICRC. There is also the possibility of under-reporting of events or exposures due to lapses in memory. Strengths of this study include a high participation rate among a defined group of aid workers and the comprehensive nature of our questionnaire.
The importance of appropriate training programs has been recognized.42–46 Interventions by organizations like ICRC become more and more challenging, and can only be performed effectively by healthy staff. Being a humanitarian aid worker is difficult and stressful, and reporting worse health after a year of mission is not surprising. Although the various risk-taking behaviors observed were fewer than expected, they cannot be overlooked, and should be given serious consideration in the development or planning of future training programs. This is especially important with regard to the preparation of younger expatriates, who perhaps due to the exuberance of youth might engage in high-risk activities in an environment where there is less control.
ICRC already has an extensive program in place in the promotion of physical and mental well-being of their expatriates. New approaches to solve problem areas highlighted in our study need to be integrated in the selection process, briefing, and training of expatriates before departure, and followed up in field by regular reminders and support.47–50
It is essential to review and update the contents of health programs to accommodate the changing needs of humanitarian workers and create an optimal working environment and continuous support.
Declaration of Interests
The authors state they have no conflicts of interest to declare.