Building Capacity in Crisis: Evaluating a Health Assistant Training Program for Young Rohingya Refugee Women

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

On theoretical framework - anchoring this study in an evidence-based or evidence-informed program evaluation framework (or even a TOT framework) would be helpful. Research shows that among targeted communities (such as refugees or other people with lived experiences of forced migration), capacity building is imperative, to ensure the spreading of essential knowledge and skills with community members (addressing shortages in some fields, trust issues and language barriers).

On methodology: I find it peculiar that no IRB approvals were required - as you did conduct interviews with community leaders that would normally fall under the purview of an IRB. However, it is good to know you are following ethical standards - would be interested to know if any consent forms were used with the participants in the interviews and focus groups? Also, the trainees were ages 14-19 (minors?) - any special considerations related to their age?

In regards to participants (HAT trainees and community leaders) - maybe some information on who they were - women/girls (only?), age groups, etc. - would be helpful. Also, how were they recruited? Were there any incentives used to encourage participation?

As this is a training program, were there any pre/post measures utilized to provide additional insight on outcomes and impact? 

As is, this is more of an evaluation of participants' and community leaders' perception of the program, and the potential impact. Not really an evaluation of impact or effectiveness. If you make that distinction clear, then you can use this evaluation to support the introduction of the program as a regular training program (training of trainers program?) that you can then evaluate for effectiveness and impact (how many people trained, to what extent their knowledge/skills improve following the training, how many become trainers, how many more they train, how many get employed, how does the community knowledge on reproductive/maternal health care change/improve, any indicators of increased reproductive health, etc.).

The article is well written, but it needs to be strengthened as per the points raised above. Much needed work! Thank you.

 

 

Author Response

Comment 1: “On theoretical framework - anchoring this study in an evidence-based or evidence-informed program evaluation framework (or even a TOT framework) would be helpful. Research shows that among targeted communities (such as refugees or other people with lived experiences of forced migration), capacity building is imperative, to ensure the spreading of essential knowledge and skills with community members (addressing shortages in some fields, trust issues and language barriers).”

Response 1: We added the following (including relevant references) to Section 2: “From a theoretical and methodological perspective, this study is informed by evidence-based and evidence-informed program evaluation frameworks that emphasize capacity building within marginalized and crisis-affected communities. Research across humanitarian and refugee settings consistently demonstrates that training community members as frontline health workers is a critical strategy for addressing service gaps, strengthening trust, and overcoming linguistic and cultural barriers to care (Istaiteyeh & Al-Delaimy, 2025; Koutsouradi et al., 2025; Miller et al., 2020). Capacity-building approaches, specifically those embedded within community health worker and workforce-development models, prioritize the diffusion of essential knowledge and skills through locally trusted actors, thereby enhancing both program acceptability and sustainability (Brownson et al., 2018; Ramanadhan et al., 2020). For example, evidence from integrated maternal-child interventions in the Rohingya camps suggests that capacity building is most effective when accompanied by structured supervision, provider support, and attention to implementation fidelity, particularly in low-intensity, community-based programs (Nguyen et al., 2024). Within refuge contexts such as Bangladesh, these approaches are especially salient given restrictions on formal employment, shortages of skilled personnel, and mistrust of external service providers. Although the HAT Program was not formally structured as a training-of-trainers initiative, it draws on similar principles by equipping young Rohingya women with transferable health knowledge and skills that can be shared within households and the broader community. In humanitarian settings where formal professional pathways are restricted, such capacity-building models are often a pragmatic strategy for extending reach and impact (Jack et al., 2020; Lowrie et al., 2005). Anchoring this evaluation within a capacity-building and empowerment-oriented framework therefore provides a lens for examining not only individual skill acquisition, but also anticipated community-level effects, including improved access to care, enhanced health literacy, and strengthened social cohesion.”

 

Comment 2: “On methodology, I find it peculiar that no IRB approvals were required - as you did conduct interviews with community leaders that would normally fall under the purview of an IRB. However, it is good to know you are following ethical standards - would be interested to know if any consent forms were used with the participants in the interviews and focus groups?”

Response 2: All participant completed a verbal consent process. These details are included in Section 3 on methodology.

 

Comment 3: “…the trainees were ages 14-19 (minors?) - any special considerations related to their age?”

Response 3: We have included the following sentence in Section 3.3: “For Health Assistant Training (HAT) Program trainees, parental consent was obtained at the time of program enrollment, covering both participation in the training program and any related program monitoring and evaluation activities.

 

Comment 4: “In regards to participants (HAT trainees and community leaders) - maybe some information on who they were - women/girls (only?), age groups, etc. - would be helpful.”

Response 4: We have included more details in the text and in Table 1 in Section 3.3.

 

Comment 5: “Also, how were they recruited?”

Response 5: We have added this paragraph into Section 2, which describes the HAT Program: “HAT trainees were recruited through a purposive, community-based process led by the Hope Foundation in close coordination with camp leadership. Community leaders from blocks surrounding the Hope Field Hospital were informed about the program objectives and invited to nominate young women. Eligibility criteria were intentionally flexible to reflect the educational realities of the camps and included basic literacy (ability to read and write), interest in health-related work, and family consent to participate. Following nomination, candidates were invited to an orientation session at the hospital where the program structure, time commitment, and expectations were explained. Final selection was based on availability, willingness to complete the full training period, and perceived ability to engage meaningfully with staff and classmates. This recruitment approach prioritized community acceptance and feasibility rather than representativeness, consistent with the pilot and exploratory nature of the program.”

 

Comment 6: “Were there any incentives used to encourage participation?”

Response 6: In section 2, we added a sentence that HAT Program trainees “received standard program supports, including daily meals during training days, a small stipend, uniforms, and learning materials.” No additional compensation was tied to participation in the evaluation.

 

Comment 7: “As this is a training program, were there any pre/post measures utilized to provide additional insight on outcomes and impact?”

Response 7: Given the low literacy level of the candidates, no formal pre- or post-tests were administered. Instead, the initial focus group discussions with trainees included questions assessing their understanding of the healthcare system. Additional exit focus group discussions were also conducted beyond the scope of this manuscript, exploring trainees’ learning experiences and perceived personal and professional growth. 

 

Comment 8: “As is, this is more of an evaluation of participants' and community leaders' perception of the program, and the potential impact. Not really an evaluation of impact or effectiveness. If you make that distinction clear, then you can use this evaluation to support the introduction of the program as a regular training program (training of trainers program?) that you can then evaluate for effectiveness and impact (how many people trained, to what extent their knowledge/skills improve following the training, how many become trainers, how many more they train, how many get employed, how does the community knowledge on reproductive/maternal health care change/improve, any indicators of increased reproductive health, etc.).”

Response 8: We added a paragraph near the end of the paper: “Importantly, the findings of this study should be interpreted in light of its scope. This evaluation focused on participants’ and community leaders’ perceptions of the HAT Program, its acceptability, and its anticipated benefits, rather than on direct measurement of health outcomes or training effectiveness. As a next phase, the HAT Program could be formalized and evaluated as a structured training initiative (potentially incorporating a training-of-trainers (ToT) model) focused on community-based health promotion rather than formal professional credentialing to assess effectiveness and longer-term impact. Such an evaluation could include indicators such as changes in participants’ knowledge and skills pre- and post-training, the number of graduates who become health assistants, employment or volunteer engagement, and shifts in community-level knowledge and practice related to maternal and reproductive health. Framing the present study as a formative evaluation provides an evidence-informed foundation for these future, outcome-focused assessments.”

Reviewer 2 Report

Comments and Suggestions for Authors

GENERAL ASSESSMENT

This manuscript presents an important and timely evaluation of a Health Assistance Training (HAT) programme for young Rohingya refugee women. The topic is relevant to ongoing efforts to strengthen community-based health services within the Rohingya refugee camps in Cox’s Bazar. The paper is clearly written and presents insightful findings, particularly through the effective use of participant quotations.

The abstract is concise and sufficiently clear. However, improvements are needed in the introduction, literature review, referencing accuracy, and methodological transparency. With these enhancements, the paper would offer a significantly stronger contribution to the field.

MAJOR COMMENTS

INTRODUCTION

1. Strengthening the Introduction and Literature Review

While the introduction provides useful background, key contextual references are missing. To situate the study within the broader humanitarian response, it is essential that the authors engage with authoritative sources such as:

• The Joint Response Plans (JRPs) for the Rohingya Humanitarian Crisis (2024; 2025/26), which synthesise needs and responses from over 113 partner organisations
• The Joint Multi-Sector Needs Assessment (J-MSNA, 2023), which presents household-level insights on education, health access, and barriers to care.
• The Bangladesh Annual Results Report 2025, which documents significant gains in skilled birth attendance and reductions in maternal mortality, due in large part to the Community Health Working Group.
• The Public Health Global Review 2024, which highlights national and camp-based interventions that mirror the aims of the HAT programme.

Additionally, the current manuscript would benefit from a more rigorous synthesis of peer-reviewed literature. Several relevant studies on maternal, reproductive, and psychosocial health in Rohingya settings should be included—for example, works by Islam et al. (2021), Halim et al. (2024), Nguyen et al. (2024), and Agarwal et al. (2024). These represent a small selection of a broader body of work the authors should review to contextualise their contribution.

2. Updating and Correcting References

Several references require revision:

• Reference 3 relies on outdated information; up-to-date demographic and operational data should be sourced from the UNHCR Operational Data Portal.
• Reference 4 incorrectly attributes authorship to UNHCR; the correct author is USA for UNHCR.
• Human Rights Watch and UNICEF news items (References 8 and 9) should be replaced with more robust analytical reports relevant to humanitarian response, maternal health, and community health in the camps.

3. Cultural and Contextual Considerations

The paper would benefit from deeper engagement with the cultural and contextual dynamics of the Rohingya community. The UNHCR 2025 report Culture, Context and Mental Health: Rohingya Refugees provides essential insights into cultural norms, gender dynamics, and psychosocial factors, and would strengthen the manuscript’s framing of participant experiences.

METHODS

4. Need for Clearer Description of Sampling and Data Collection

The methodology section is generally clear but lacks precision regarding participant numbers and categories. Currently, the paper notes only nine trainees (aged 14–19), yet the results include perspectives from community leaders and NGO staff. A table outlining: 1) participant categories, 2) number of interviewees in each category, and 3) whether they participated in individual interviews or focus groups would enhance methodological transparency.

5. Language Considerations

Given that Chittagonian is related to but not equivalent to the Rohingya language, the authors should specify whether interviewers were fluent in Rohingya, and  ow translation or interpretation challenges were addressed.

This is essential for assessing data quality and reliability.

RESULTS

6. Results and Interpretation

The results are well presented, with effective use of quotations. The insights into trainees’ experiences and stakeholder perspectives are valuable. However, it is concerning that the HAT programme is reportedly not linked to the Working Group for Community Health, a central coordination mechanism. Establishing such a connection should be highlighted as a key recommendation.

DISCUSSION

7. Add a discussion section

Although it is often challenging in qualitative research to draw a strict boundary between the results and the discussion, I believe the manuscript would benefit from a dedicated discussion section. Alternatively, the current conclusion section could be reframed as a discussion, as it already contains substantial interpretation. This section should then end be followed by with a concise section with Conclusions & recommendations’ that includes clear, actionable recommendations.

8. Add limitation section

In addition, an explicit description of the study’s limitations is needed. One key limitation is the small sample size and the fact that participant selection was facilitated by the NGO implementing the programme. This raises the possibility of selection bias and limits the generalisability of the findings. A brief section acknowledging these limitations would strengthen the transparency and credibility of the manuscript.

OVERALL EVALUATION

This manuscript presents valuable research on a promising initiative to build health capacity among young Rohingya refugee women. With revisions to strengthen the literature base, update and correct references, clarify methodology, and contextualise findings within broader humanitarian health systems, the paper could make a strong contribution to the field.

References

• Agarwal, A., Surti, V., & Terry, M. A. (2024). Recommendations to improve maternal mortality among Rohingya women in Bangladeshi refugee camps. Health Care for Women International, 1–12. https://doi.org/10.1080/07399332.2024.2349820
• Government of Bangladesh, United Nations, & Partners. (2024). Joint Response Plan (JRP) for the Rohingya Humanitarian Crisis in Bangladesh: 2024. https://data.unhcr.org/en/documents/details/111224
• Government of Bangladesh, United Nations, & Partners. (2025/2026). Joint Response Plan (JRP) for the Rohingya Humanitarian Crisis in Bangladesh: 2025/2026. https://data.unhcr.org/en/documents/details/115687
• Halim, A., Abdullah, A. S. M., Rahman, F., Bazirete, O., Turkmani, S., Hughes, K., … & Homer, C. S. (2024). Midwife-led birthing centre in the humanitarian setup: An experience from the Rohingya camp, Bangladesh. PLOS Global Public Health, 4(12), e0004033. https://doi.org/10.1371/journal.pgph.0004033
• Islam, M. M., Khan, M. N., & Rahman, M. M. (2021). Factors affecting child marriage and contraceptive use among Rohingya girls in refugee camps. The Lancet Regional Health – Western Pacific, 12, 100174. https://doi.org/10.1016/j.lanwpc.2021.100174
• Nguyen, A. J., Murray, S. M., Rahaman, K. S., Lasater, M. E., Barua, S., Lee, C., … & Le Roch, K. (2024). Psychosocial impacts of Baby Friendly Spaces for Rohingya refugee mothers in Bangladesh: A pragmatic cluster-randomised controlled trial. Cambridge Prisms: Global Mental Health, 11, e64. https://doi.org/10.1017/gmh.2024.60
• (2024). Bangladesh Annual Results Report 2024. https://www.unhcr.org/media/bangladesh-annual-results-report-2024
• (2024). Annual Public Health Global Review 2024. https://www.unhcr.org/sites/default/files/2025-04/annual-public-health-global-review-2024.pdf
• (2023). Culture, Context and Mental Health: Rohingya Refugees. https://www.unhcr.org/media/culture-context-and-mental-health-rohingya-refugees
• (2023). Joint Multi-Sector Needs Assessment (J-MSNA): Camp-Level Findings, December 2023. https://data.unhcr.org/en/documents/details/107061
• UNHCR Operational Data Portal. (n.d.). Bangladesh Country Data. https://data.unhcr.org/en/country/bgd

Comments for author File: Comments.pdf

Author Response

Comment 1: “While the introduction provides useful background, key contextual references are missing. To situate the study within the broader humanitarian response, it is essential that the authors engage with authoritative sources such as:

• The Joint Response Plans (JRPs) for the Rohingya Humanitarian Crisis (2024; 2025/26), which synthesise needs and responses from over 113 partner organisations
• The Joint Multi-Sector Needs Assessment (J-MSNA, 2023), which presents household-level insights on education, health access, and barriers to care.
• The Bangladesh Annual Results Report 2025, which documents significant gains in skilled birth attendance and reductions in maternal mortality, due in large part to the Community Health Working Group.
• The Public Health Global Review 2024, which highlights national and camp-based interventions that mirror the aims of the HAT programme.

Additionally, the current manuscript would benefit from a more rigorous synthesis of peer-reviewed literature. Several relevant studies on maternal, reproductive, and psychosocial health in Rohingya settings should be included—for example, works by Islam et al. (2021), Halim et al. (2024), Nguyen et al. (2024), and Agarwal et al. (2024). These represent a small selection of a broader body of work the authors should review to contextualise their contribution.”

Response 1: Thank you very much for recommending these references. We have done our best to include these in the manuscript, especially Islam et al. (2021), Halim et al. (2024), Nguyen et al. (2024), and Agarwal et al. (2024). The inclusion of these publications has definitely strengthened the writing. But if there are additional resources you would like to see included, please let us know.

 

Comment 2: “Reference 3 relies on outdated information; up-to-date demographic and operational data should be sourced from the UNHCR Operational Data Portal.”

Response 2: We have modified this reference.

 

Comment 3: “Reference 4 incorrectly attributes authorship to UNHCR; the correct author is USA for UNHCR.”

Response 3: We have replaced this reference.

 

Comment 4: “Human Rights Watch and UNICEF news items (References 8 and 9) should be replaced with more robust analytical reports relevant to humanitarian response, maternal health, and community health in the camps.”

Response 4: We believe that Human Rights Watch and UNICEF are very robust sources, oftentimes reflecting urgent and timely content that is not available in peer-reviewed publications, which may take much longer to come to light. Therefore, we have not deleted these references, but rather bolstered them with additional references to support the statement of fact.

 

Comment 5: “The paper would benefit from deeper engagement with the cultural and contextual dynamics of the Rohingya community. The UNHCR 2025 report Culture, Context and Mental Health: Rohingya Refugees provides essential insights into cultural norms, gender dynamics, and psychosocial factors, and would strengthen the manuscript’s framing of participant experiences.”

Response 5: We have included reference to this report in the introduction. However, we weer only able to find and integrate the 2018 version. Is there a 2025 version? If so, we would be happy to reference that within the next revision of the manuscript.

 

Comment6: “The methodology section is generally clear but lacks precision regarding participant numbers and categories. Currently, the paper notes only nine trainees (aged 14–19), yet the results include perspectives from community leaders and NGO staff. A table outlining: 1) participant categories, 2) number of interviewees in each category, and 3) whether they participated in individual interviews or focus groups would enhance methodological transparency.”

Response 6: In Section 3.3, we have now included Table 1, which details the participant categories and data collection characteristics.

 

Comment 7: “Given that Chittagonian is related to but not equivalent to the Rohingya language, the authors should specify whether interviewers were fluent in Rohingya, and how translation or interpretation challenges were addressed. This is essential for assessing data quality and reliability.”

Response 7: We have added the following to Section 3.1: “Two evaluation team members—one male (the fifth author) and one female (the sixth author)—were responsible for recruitment and data collection. Both team members were from Bangladesh, with the male team member originating from the local Cox’s Bazar region, where the local dialect is Chittagonian. While Chittagonian is linguistically distinct from Rohingya, it is closely related and widely used as a lingua franca in the refugee camps. Both interviewers routinely worked in Rohingya-speaking settings and were familiar with Rohingya-specific vocabulary, expressions, and cultural norms, which facilitated effective communication and rapport-building during data collection.” We have also added clarification about the process in Section 3.5 on data analysis. Finally, we have added this as a limitation to the study: “although Chittagonian is closely related to the Rohingya language and widely used as a lingua franca in the camps, data collection may have benefited from the inclusion of an interviewer who was fully fluent in Rohingya and from the Rohingya community. While steps were taken to address potential interpretation challenges through bilingual transcription, contextual translation, and internal review, this linguistic and cultural distance remains a limitation. At the same time, the involvement of locally-based team members with extensive experience working in Rohingya-speaking contexts supported rapport-building and culturally appropriate engagement.”

 

Comment 8: “The results are well presented, with effective use of quotations. The insights into trainees’ experiences and stakeholder perspectives are valuable. However, it is concerning that the HAT programme is reportedly not linked to the Working Group for Community Health, a central coordination mechanism. Establishing such a connection should be highlighted as a key recommendation.”

Response 8: Yes, this is so important, and we have revised Section 4.4 to reflect this: “Our evaluation also uncovered the importance of formally integrating the HAT program within existing health coordination mechanisms in the camps. An advisor from a local NGO operating clinics and schools emphasized that the HAT program should be linked to the Bangladesh Rohingya Community Health Working group (CHWG), a UNHCR-led, multi-agency coordination platform that oversees community health worker (CHW) strategies across the camps. The CHWG plays a central role in coordinating community-based surveillance, health promotion, outbreak response (e.g., COVID-19, dengue, diptheria), and first aid training, with technical leadership from the WHO and implementation support from partners such as the Bangladesh Red Crescent Society and international NGOs (Inter Sector Coordination Group (ISCG) & Rohingya Refugee Response Bangladesh, 2024). Formal alignment with the CHWG would help ensure that HAT-trained health assistants are integrated into existing referral pathways, surveillance systems, and emergency response structures, while avoiding duplication of efforts and strengthening legitimacy within the humanitarian health architecture. Establishing this connection is particularly important given ongoing challenges faced by Rohingya CHWs, including limited formal recognition, movement restrictions, and constrained pathways for skills accreditation and employment (UNHCR, 2025). While some stakeholders viewed the HAT Program as a potential step toward more advanced health roles, such as midwifery, discussions with a midwife program coordinator indicated that formal integration into midwifery training remains highly challenging due to national policy constraints, including requirements related to Bangladeshi nationality and completion of formal secondary education, criteria that most Rohingya girls do not meet. In this context, linking the HAT Program to the CHWG offers a more realistic and system aligned pathway for strengthening women’s participation in community health, by aligning training standards, supporting supervision and continuing education, and strengthening coordination with sexual and reproductive health services, nutrition programming, and gender-based violence referral pathways already operating in the camps. As such, formal engagement with the CHWG should be considered a key recommendation for the future sustainability, scalability, and system-level impact of the HAT Program. Such alignment could also support future training models by situating HAT graduates within recognized community health structures.” We have also mentioned this as one of our recommendations in Section 6.

 

Comment 9: “Although it is often challenging in qualitative research to draw a strict boundary between the results and the discussion, I believe the manuscript would benefit from a dedicated discussion section. Alternatively, the current conclusion section could be reframed as a discussion, as it already contains substantial interpretation. This section should then end be followed by with a concise section with Conclusions & recommendations’ that includes clear, actionable recommendations.”

Response 9: This is good advice that has strengthened the paper. We have created a separate discussion section based on what was already in the conclusion. We also added a limitations section and a section with concrete recommendations.

 

Comment 10: “In addition, an explicit description of the study’s limitations is needed. One key limitation is the small sample size and the fact that participant selection was facilitated by the NGO implementing the programme. This raises the possibility of selection bias and limits the generalisability of the findings. A brief section acknowledging these limitations would strengthen the transparency and credibility of the manuscript.”

Response 10: We have added an extensive limitations section near the end of the paper in Section 5.1

Reviewer 3 Report

Comments and Suggestions for Authors

Abstract
- In line 41, the mention of "replicable" is too assertive for a qualitative study. "promising" could be a better word. 

Introduction

• Line 58 and 59; the sentence needs a citation
• Line 60; "recent effort" mentioned. It would be helpful to add "by whom" so that the sentence is clear
• Line 77, 78; needs a citation. The citation immediately below this sentence could be used
• Line 115; same comment, avoid using the term "replicable" for a qualitative study
• Overall, it would be valuable to provide some information on how HAT trainees were recruited 

Methods

• Line 121-123; It would be helpful to provide a document that confirms IRB determination as not needed. This could be a supplementary file
• Authors declare no conflict of interest but line 131 clearly suggests that members of the research team were also employees of the program implementation agency when the research was conducted. This should be mentioned in the conflict of interest statement.
• Line 140; the rationale "due to high illiteracy" does not need to be mentioned. literacy is not a limitation for written consent. There are many other ways to obtain a written consent including the use of impartial witness when necessary and using thumb print in place of signature. I suggest not mentioning literacy as a reason. Just keep the verbal consent approach. 
• Line 149 suggest a serious ethical breach. Including minors (less than 18)in research without IRB and more importantly without parents consent for study participation is not ethically acceptable. Minors should only given assent but consent has to be obtained from the parents. An IRB review would have helped the team here.
• Line 159-160; makes a statement that deviates from the stated research objectives and more importantly suggest conflict of interest from the researchers. If a major goal of this research is to provide supporting evidence for sustained funding and it is conducted by employees of the implementing agency, it brings questions about data interpretation bias.
• Line 163-165; statement "Unlike quantitative surveys" is unnecessary
• Line 169; again, "replicable" should be rephrased
• In Line 174; semi structured interview conducted in English were not audio recorded. however the study findings presented participant quotes in a way that communicates verbatim. How was this achieved? In hindsight, recording all interviews would be a preferred approach. 
• Line 180; Mentions field notes which were included in the analysis. In the findings section, these field notes were not clearly emphasized. Were the notes unused? Also, Observational data was reported to have been collected. Are those observational data the field notes?

Results

• A participant demographic table would be valuable
• There is no mention of findings from the observational data. Was this because it was not used? If so, then what is the purpose of mentioning it's collection?

Author Response

Comment 1: “Abstract - In line 41, the mention of "replicable" is too assertive for a qualitative study. "promising" could be a better word.”

Response 1: We have changed this word. Thank you for the suggestion.

 

Comment 2: “Line 58 and 59; the sentence needs a citation.”

Response 2: We have added two references here.

 

Comment 3: “Line 60; "recent effort" mentioned. It would be helpful to add "by whom" so that the sentence is clear.”

Response 3: We have added that the recent efforts are from agencies such as UNICEF, Save the Children, and partners.

 

Comment 4: “Line 77, 78; needs a citation. The citation immediately below this sentence could be used.”

Response 4: It is not clear which sentence requires a citation, as the sentence in Lines 77-78 of the original document already included a reference.

 

Comment 5: “Line 115; same comment, avoid using the term "replicable" for a qualitative study.”

Response 5: Thank you. We have removed this word.

 

Comment 6: “Overall, it would be valuable to provide some information on how HAT trainees were recruited.”

Response 6: We have added this paragraph into Section 2, which describes the HAT Program: “HAT trainees were recruited through a purposive, community-based process led by the Hope Foundation in close coordination with camp leadership. Community leaders from blocks surrounding the Hope Field Hospital were informed about the program objectives and invited to nominate young women. Eligibility criteria were intentionally flexible to reflect the educational realities of the camps and included basic literacy (ability to read and write), interest in health-related work, and family consent to participate. Following nomination, candidates were invited to an orientation session at the hospital where the program structure, time commitment, and expectations were explained. Final selection was based on availability, willingness to complete the full training period, and perceived ability to engage meaningfully with staff and classmates. This recruitment approach prioritized community acceptance and feasibility rather than representativeness, consistent with the pilot and exploratory nature of the program.”

 

Comment 7: “Line 121-123; It would be helpful to provide a document that confirms IRB determination as not needed. This could be a supplementary file.”

Response 7: We have shared this document with the editor and would support its publication as a supplementary document.

 

Comment 8: “Authors declare no conflict of interest but line 131 clearly suggests that members of the research team were also employees of the program implementation agency when the research was conducted. This should be mentioned in the conflict of interest statement.”

Response 8: We have revised the conflict of interest statement and included this in the body of the manuscript, as well as in the end matter. We have also noted this as a limitation.

 

Comment 9: “Line 140; the rationale "due to high illiteracy" does not need to be mentioned. literacy is not a limitation for written consent. There are many other ways to obtain a written consent including the use of impartial witness when necessary and using thumb print in place of signature. I suggest not mentioning literacy as a reason. Just keep the verbal consent approach.”

Response 9: We have deleted the mention of high illiteracy.

 

Comment 10: “Line 149 suggest a serious ethical breach. Including minors (less than 18)in research without IRB and more importantly without parents’ consent for study participation is not ethically acceptable. Minors should only given assent but consent has to be obtained from the parents. An IRB review would have helped the team here.”

Response 10: We have clarified this in the manuscript in Section 3.3: ” The evaluation team consulted with the University of Nebraska Medical Center’s (UNMC) Institutional Review Board (IRB), which determined that this project constituted program evaluation and monitoring activities and therefore did not meet the definition of human subjects’ research under 45 CFR 46.102. Nonetheless, the evaluation was conducted in accordance with rigorous ethical procedures consistent with international standards for ethical practice in humanitarian settings. For Health Assistant Training (HAT) Program trainees, parental consent was obtained at the time of program enrollment, covering both participation in the training program and any related program monitoring and evaluation activities. All participants completed a culturally appropriate verbal informed consent process prior to participation in any evaluation activities. Participants were informed of the purpose of the evaluation, the procedures involved, the voluntary nature of participation, and their right to decline or withdraw without any impact on services, training, or support received through the Hope Foundation. Verbal consent was documented only after participants’ understanding was confirmed, and additional consent was obtained for audio-recording interviews and focus group discussions. No incentives were provided for participation in the evaluation. No identifiable personal data were collected, no images of participants are included in the manuscript, and all findings are reported in a manner that protects participants’ privacy, confidentiality, and dignity, ensuring that individuals cannot be identified directly or indirectly.”

 

Comment 11: “Line 159-160; makes a statement that deviates from the stated research objectives and more importantly suggest conflict of interest from the researchers. If a major goal of this research is to provide supporting evidence for sustained funding and it is conducted by employees of the implementing agency, it brings questions about data interpretation bias.”

Response 11: We have clarified this in the revision of this paragraph in Section 5: “While the HAT Program demonstrates promise as a community-based capacity-building initiative, its sustainability and scalability are shaped by broader structural and system-level factors beyond the scope of this evaluation. These include the need for alignment with existing health coordination mechanisms, ongoing logistical and policy constraints, and limited formal pathways for education and employment within the refugee camp context. Rather than advocating for program expansion or funding, the findings highlight the importance of situating training initiatives such as the HAT Program within established health governance structures and coordination platforms to ensure coherence, accountability, and avoid duplication of efforts. Future program decisions would benefit from independent, outcome-focused evaluations that assess longer-term impacts and explore how community-based training initiatives can complement (not substitute) formal health systems operating in humanitarian settings.”

 

Comment 12: “Line 163-165; statement "Unlike quantitative surveys" is unnecessary.”

Response 12: We have deleted this sentence.

 

Comment 13: “Line 169; again, "replicable" should be rephrased.”

Response 13: We have deleted this sentence.

 

Comment 14: “In Line 174; semi structured interview conducted in English were not audio recorded. However the study findings presented participant quotes in a way that communicates verbatim. How was this achieved? In hindsight, recording all interviews would be a preferred approach.”

Response 14: Please view Table 1, which details how data were recorded.

 

Comment 15: “Line 180; Mentions field notes which were included in the analysis. In the findings section, these field notes were not clearly emphasized. Were the notes unused? Also, Observational data was reported to have been collected. Are those observational data the field notes?” and “There is no mention of findings from the observational data. Was this because it was not used? If so, then what is the purpose of mentioning it's collection?”

Response 15: The field notes and observational data refer to the same source of data and were collected concurrently during site visits to the Hope Field Hospital and training sessions. These notes captured contextual observations related to the training environment, participant interactions, and program implementation, rather than generating distinct analytic units or themes. Observational field notes were not analyzed as a separate dataset and therefore do not appear as standalone findings in the Results section. Instead, they were used to support data familiarization, inform interpretation, and aid triangulation of themes emerging from interviews and focus group discussions. In cases where observational insights informed interpretation, they were integrated implicitly into the narrative rather than presented as independent evidence. We have included this information in the manuscript.

 

Comment 16: “A participant demographic table would be valuable.”

Response 16: We have included more details in the text and in Table 1 in Section 3.3.

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you for addressing all the comments satisfactorily.