case study of refugees

• Skip to main content
• Keyboard shortcuts for audio player

They Came To The U.S. As Afghan Refugees. Now They Hope Their Story Will Help Others

Marisa Peñaloza

Hossein Mahrammi, his wife, Razia Mahrami, and their four sons came from Kabul to the U.S. on a Special Immigrant Visa or SIV in March 2017. Marisa Peñaloza hide caption

Hossein Mahrammi, his wife, Razia Mahrami, and their four sons came from Kabul to the U.S. on a Special Immigrant Visa or SIV in March 2017.

Scenes of violence in Afghanistan triggered painful memories for Hossein Mahrammi and his wife, Razia Mahrami, refugees living in the U.S. He sees the hope of a democratic, peaceful Afghanistan vanishing as the Taliban take over the country and the future of family and friends there uncertain. The couple know all too well the hardships that await the thousands of refugees fleeing.

"What we are watching in the news is real to us," Mahrammi says referring to the gruesome scenes of people desperately trying to leave his home country and the massive attack at the Kabul Airport.

The rapid withdrawal of American armed forces from Afghanistan brings out a mixture of feelings, the couple say — pain, helplessness, stress, anxiety. They worry to death about those trapped in their country and at times they feel guilty because they are safe here in America — Mahrammi says he often asks himself, "Why am I here?" while Mahrami nods in agreement.

Sitting in their sunlit living room one recent morning, Mahrammi and Mahrami reflect on the news from their homeland. The couple and their four boys, ages 2 to 12 then, arrived from Kabul in March 2017 to the Washington, D.C., area, with suitcases stuffed with few belongings, including their beloved hand-woven Afghan rugs.

Mahrammi, a trained economist, worked with the U.S. government in Kabul for more than a decade and received a Special Immigrant Visa. He feared for his family's safety, he says, not only because of the work he did, but because the family is Hazara Shiite, a minority ethnic group that's been highly persecuted by the Taliban.

After these past four years in the U.S., the family is doing well. Mahrami, 42, is studying for a business degree at a local college and she has learned to drive, the boys are thriving and the family has moved from a small cramped apartment to a bigger more comfortable place. While Mahrammi says that starting a new life in the U.S. hasn't been easy at times, they've embraced the culture and customs of their new country.

Their eldest son, Shahid, a tall, lanky 17-year-old with an easy smile, sits silently between his parents. He has vivid memories of attending school in Kabul, where he says he left behind a lot of friends.

"I think about them, my uncles, aunts, cousins. What's going to happen to them?" He softly answers his own question, "I don't really know."

Here's Why Biden Is Sticking With The U.S. Exit From Afghanistan

A Quarter-Million People Have Fled Their Homes As Violence In Afghanistan Escalates

Hossein Mahrammi and his wife, Razia Mahrami, bought these rugs after they got married in 2003. They are hand-woven by Hazara weavers and the couple brought them in their suitcases from Afghanistan to the U.S. in 2017. Marisa Peñaloza hide caption

Hossein Mahrammi and his wife, Razia Mahrami, bought these rugs after they got married in 2003. They are hand-woven by Hazara weavers and the couple brought them in their suitcases from Afghanistan to the U.S. in 2017.

Family and friends in Afghanistan count on their kin in the U.S. for help to escape

Last month President Biden announced that U.S. and NATO ally troops would leave Afghanistan by Aug. 31 and the withdrawal proceeded.

"Since the day the Taliban entered Kabul, I've had no sleep," Mahrammi says, adding that he's consulted a neurologist for help. While he speaks, he alternates between holding his phone to keep an eye on the news and caressing a Tasbeh or prayer beads in his hand, "It helps me relax and focus," he says.

Suddenly his phone beeps and after glancing at it, Mahrammi closes his eyes and sighs quietly. It's the news of a massive explosion at the Kabul airport that killed at least 13 U.S. troops and nearly 200 Afghan civilians.

"We know our families are hunkering down," and that gives the couple some peace of mind, he says.

"I am worried about the thousands and thousands of those who worked hard in the last 20 years for a better future," says the soft-spoken 48-year-old Mahrammi, "but in return, they get the darkest, the most unexpected and unwanted situation."

The Taliban rapidly regained control of Kabul , and effectively the entire country on Aug.15, after only a few weeks of fighting and when former Afghan president Ashraf Ghani fled the country.

The Taliban sheltered Osama bin Laden as he was plotting the Sept. 11 attacks in U.S. soil in 2001 and it had previously ruled Afghanistan from 1996 until the U.S. invaded the country searching for bin Laden after the terrorist attacks.

Mahrammi and Mahrami say family and friends in Afghanistan count on them for help to escape.

"It's 10:30 in the morning," says Mahrammi glancing at the wall clock, "and I've had five phone calls already with my brothers and my father." He says he listens quietly to their hardships, "we don't have any income, no job. Nothing," his relatives tell him. Mahrammi says he tries to give them hope, "I'm still here for you," he reassures them.

How to make the resettlement process for refugees better

NPR first interviewed Hossein Mahrammi within a week of his arrival in 2017. In the following months, his wife says, she questioned their decision to flee their country, "Why did we come here? Life is so difficult," she remembers asking herself and her husband. Razia Mahrami's English was limited and she missed her family terribly, money was tight and their future uncertain.

One of their boys had to have surgery soon after they arrived, she says. The couple received a bill for $37,920.00 for a three-day hospitalization. "It was very stressful," Mahrammi says. "We had nothing, no insurance. We don't know the rules, we are so new here." Eventually the bill was covered by Medicaid.

Hossein Mahrammi struggled to find a job and after originally telling himself that driving Uber was beneath him, he had to be humble. But to drive for Uber he needed a car. To buy a car he needed a loan.

"I was struggling," he says, "nobody has enough cash and I didn't have credit [history,]" it took him many months to finally secure a loan with the help of a co-signer, an Afghan friend with a solid credit history who came to the U.S. years before Mahrammi did, he says.

"The resettlement process could be better," Mahrammi says. He adds he's grateful for the federal assistance the family got for several months of rent, the help enrolling the children in schools and guidance to get their social security cards, but his family at times felt lost, he says.

The U.S. government has contracts with nine NGOs to resettle refugees and their mandate is narrow — primarily, to house refugees and enroll kids in school. But some agencies also provide other help, like food or clothing, as well.

Mahrammi says that he'd welcome a financial literacy workshop and even a class about American cultural norms, would be helpful, he says.

"In Afghanistan it's very important that you don't look at someone's wife, don't talk to people you don't know," Mahrammi says, "but here, you're expected to say 'good morning' to strangers, regardless of gender, when you enter an elevator or a building or at the park." Small talk is part of American culture, not so much in Afghanistan, he says.

The challenges the family has overcome are nothing, Mahrammi insists, compared to what people in Afghanistan go through, and then, he says, the positives, from big to small, are so much greater than the challenges.

"Walking my kids to school and knowing that they are getting a world-class education," is a great feeling, Mahrammi says. He also notes that the family has medical insurance now. Plus, "I'm not worried that my wife walks outside by herself," he says. "From the very bottom of my heart, I feel relaxed and blessed and happy."

Since the Taliban took over, Hossein and Razia say their phones constantly beep with texts and calls from family and friends in Afghanistan asking for help. Marisa Peñaloza hide caption

Since the Taliban took over, Hossein and Razia say their phones constantly beep with texts and calls from family and friends in Afghanistan asking for help.

The family offers some tips for newly arrived refugees

The SIV visa the family came on automatically turned into a green card, allowing each member of the family to become a lawful U.S. permanent resident soon after arriving in the U.S. When the family hits their fifth year residency anniversary come March 2022, they will be eligible to apply for U.S. citizenship. "We'll apply immediately," Mahrammi says with a big smile on his face.

After years of juggling multiple jobs, Mahrammi is now a technical advisor for a local nonprofit, Enterprise Development Group , that provides micro loans to low-income individuals.

The Mahrammi kids ages 6 to 17 are all in school and exceling – their English is perfect.

Shahid is a rising junior and says that he doesn't know what he'll study in college or what college he'll attend yet, but he's certain of one thing, "I'll have a lot of choices here."

The family has many plans. The mom dreams of opening an Afghan food restaurant after finishing school and the couple wants to buy a home. Then there is college for the boys who are already thinking about scholarships, "There is a very bright future waiting for us," Mahrammi says.

He and his wife say that hearing news of the thousands of new refugees arriving in the U.S. stirs hardship memories for them because resettling in a new country can be painful, and even disorienting, they say, it forces people to start from the ground up and it makes you question whether your decision to leave your country was the right one.

They offer some advice for newly arrived refugees.

"Be flexible, be open-minded, take risks," Mahrammi says. He cautions new refugees to lower their expectations, "It doesn't matter the type of work you do, just work hard and keep going," he says. "This is the land of opportunity."

The couple is helping organize volunteers and donations for the thousands of refuges arriving at Dulles International Airport in Virginia.

• Afghanistan War
• Afghanistan refugees
• Afghanistan withdrawal

Case Studies

Since late 2015, we have studied the refugee crisis in Europe and the Middle East. In this page, we present three case studies in three different cities in Germany. Refugees are everywhere in Germany, even in smaller towns and villages. The case study cities are at different scales and include Borken (15,000 people), Kassel, a mid-size city (200,000), and Essen, a larger city (600,000) which is part of the still larger Ruhr Area Megacity. In these cities we try to understand the life of refugees from their original escape city and country to their arrival in these new communities. Our research focuses on the social-spatial aspects of refugee experiences, and the impacts on urban morphology and building typology. We also try to understand how refugees manage their new life in partial safety of place, shelter, food and financial support, but also in uncertainty and insecurity until officially accepted as refugees. Beyond crisis, we are looking at how refugees can and will try to integrate into their host countries, cities, and neighborhoods and start a new life. Urban architecture projects for housing and work opportunities that help the process of integration are part of this study. Particularly, we investigate the reality on the ground of the positive Wilkommen Kultur (welcome culture) and the high expectations and implied promises that were set in 2015 by Angela Merkel and German society.

Case study by Professor Hajo Neis, Briana Meier, and Tomoki Furukawazono has been published on the “ Urban Planning ” (ISSN: 2183-7635). https://www.cogitatiopress.com/urbanplanning/article/view/1668

Neis, H., Meier, B., & Furukawazono, T. (2018). Welcome City: Refugees in Three German Cities. Urban Planning , 3(4), 101-115. doi: http://dx.doi.org/10.17645/up.v3i4.1668

Population: 582,614 (2015.12.31)

Refugee Population 2015: 4,391 (new) 2016: 4,125 (new) total: approx. 20,000

Refugees in Essen https://www.essen.de/leben/fluechtlinge_1/fluechtlinge_in_essen.de.jsp

Kassel County

Population: 235,813 (2015.12.31)

Refugee Population total: approx. 1,500

Refugees in Kassel County http://www.landkreiskassel.de/cms09/bildung/fluechtlingshilfeLKKS/Unterbringung/

Refugee Population total: approx. 200

Refugees in Borken http://www.borken-hessen.de/cms/B%C3%BCrgerinfo/Bekanntmachungen/Kommunales%20Aktuell/Fl%C3%BCchtlingsarbeit%20in%20Borken%20sucht%20und%20braucht%20weitere%20Helfer.cshtml

• Search Menu
• Advance articles
• Special Issues
• Editor's Choice
• Submission Site
• Author Guidelines
• Open Access
• About Journal of Refugee Studies
• Editorial Board
• Early-Career Researcher Prize
• Advertising and Corporate Services
• Journals Career Network
• Self-Archiving Policy
• Books for Review
• Dispatch Dates
• Journals on Oxford Academic
• Books on Oxford Academic

Simon Turner Megan Bradley

Call for Proposals

The Journal of Refugee Studies has launched a call for proposals for special issues. We welcome proposals that engage with and significantly advance scholarly debates in the field of refugee and forced migration studies.  Closing date for proposals 30th April 2024.

Journal of Refugee Studies Early-Career Researcher Prize

The annual Prize will recognize an outstanding article published in an issue of the Journal of Refugee Studies in the preceding calendar year by an early-career researcher.

Find out more about the Prize

New Reviews section of  Journal of Refugee Studies

From 2021,  Journal of Refugee Studies  has replaced the Book Reviews section of the journal with a more inclusive Reviews section. We encourage submissions of materials and sources including written texts and academic manuscripts, but wish to expand significantly beyond these formats.

Find out more

High Impact Research

Keep up to date with the latest research your peers are reading and citing, with a collection of the most cited articles published in  Journal of Refugee Studies  in recent years. 

LGBTIQ+ Refugees Virtual Issue

The  Journal of Refugee Studies'   latest virtual issue brings together articles highlighting the progression of scholarly research on LGBTIQ+ refugees. 

Read the articles

Browse our first virtual issue on unaccompanied minors

Latest articles

Editor's choice.

Call for Papers: LGBTIQ+ People in Situations of Forced Displacement

Refugee studies on the OUPblog

• The important role of animals in refugee lives
• Performing for their lives: LGBT individuals seeking asylum
• Europe’s real refugee crisis: unaccompanied minors

View all articles by Khalid Koser on the OUPblog.

Special section

This December 2023 issue features a special section exploring education for refugees.

View a list of special issues

Email alerts

Register to receive table of contents email alerts as soon as new issues of Journal of Refugee Studies are published online.

Why submit to the Journal of Refugee Studies ?

Discover why you should publish your next paper with the journal.

Forced Migration and Refugee Studies

Explore a collection of leading refugee studies research from Oxford University Press books, journals, and online resources. This collection covers a diverse breadth of regions and topics, including climate migrants, asylum policy in rich democracies, and the impact of COVID-19 on refugees. 

Browse the collection

Developing countries initiative

Your institution could be eligible to free or deeply discounted online access to Journal of Refugee Studies through the Oxford Developing Countries Initiative.

Related Titles

• Recommend to Your Library

Affiliations

• Online ISSN 1471-6925
• Print ISSN 0951-6328
• Copyright © 2024 Oxford University Press
• About Oxford Academic
• Publish journals with us
• University press partners
• What we publish
• New features  
• Open access
• Institutional account management
• Rights and permissions
• Get help with access
• Accessibility
• Advertising
• Media enquiries
• Oxford University Press
• Oxford Languages
• University of Oxford

Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide

• Copyright © 2024 Oxford University Press
• Cookie settings
• Cookie policy
• Privacy policy
• Legal notice

This Feature Is Available To Subscribers Only

Sign In or Create an Account

This PDF is available to Subscribers Only

For full access to this pdf, sign in to an existing account, or purchase an annual subscription.

• Meeting report
• Open access
• Published: 19 March 2019

Critical reflections, challenges and solutions for migrant and refugee health: 2nd M8 Alliance Expert Meeting

• Nefti-Eboni Bempong 1 ,
• Danny Sheath 1 ,
• Joachim Seybold 2 ,
• Antoine Flahault 1 ,
• Anneliese Depoux 3 &
• Luciano Saso 4  

Public Health Reviews volume  40 , Article number:  3 ( 2019 ) Cite this article

29k Accesses

19 Citations

20 Altmetric

Metrics details

Throughout recent years, we have witnessed an increase in human migration as a result of conflict, political instability and changes in the climate. Despite the growing number of migrants and refugees, provisions to address their health needs remain inadequate and often unmet. Whilst a variety of instruments exist to assert and emphasise the importance for migrant and refugee health, the lack of shared priorities between partners and stakeholders results in poor access to healthcare and essential medicines.

In response to the growing health challenges faced by migrants and refugees, members of the M8 Alliance launched an annual Expert Meeting on Migrants ’ and Refugees ’ Health . This report is shaped by discussions from the second M8 Alliance Expert Meeting (Sapienza University of Rome, Italy, 15–16 June 2018) and is supported by supplementing literature to develop a framework addressing critical reflections, challenges and solutions of and for migrant and refugee health. This report aims to inform decision-making fostering a humanitarian, ethics and rights-based approach. Through a series of country-specific case studies and discussions, this report captures the most prominent themes and recommendations such as mental health, tuberculosis (TB) and best practices for increased access.

Narrative of migration: Moving lives

As a complex and social phenomenon, the process of migration has become increasingly political, with adequate healthcare often low on the list of priorities. Over the past decade, there has been an influx of migrants crossing borders, primarily due to political instability, military conflict and extreme climatic conditions. These events have been accompanied by a growing burden of disease, with data suggesting that infectious disease, accidents, injuries, musculoskeletal disorders and violence disproportionately affect migrant groups compared to long-settled populations in the European Union [ 1 ]. Amongst these health challenges, mental health disorders and TB remain a major problem. Disease prevalence varies between migrant groups, and therefore it is important to be aware of the different types of migrants that exist [ 1 ].

Whilst a refugee is a type of migrant, stark differences exist between refugees and other type of migrants. The Convention and Protocol relating to the status of Refugees defined refugees as “Individuals who, owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion, are outside the country of their nationality, and are unable to, or owing to such fear, are unwilling to avail themselves of the protection of that country or return because of fear of persecution” [ 2 ]. Other migrant status may include international migrants, internal migrants, irregular migrants and tourists [ 3 ]. The main difference that exists between refugee populations (asylum seekers, resettled and relocated refugees) and other types of migrant groups is that refugees are survivors of persecution and multiple violent events, including war and torture, and their migration experience is forced [ 4 ]. The differences in these lived experiences may therefore have a profound effect on their overall wellbeing and in particular on their mental health [ 4 ]. In addition to categorising the type of migrant, the process of migration may also be categorized. Factors that dictate the type of migration include the following: boundary crossed (national, international, political, and administrative), duration of stay (temporary, permanent), distance (regional, national, and international) and lastly, the decision-making approach for migration [ 5 ]. The latter can be further subcategorised into voluntary, instigated or forced, or impelled [ 5 ]. Migration, both voluntary and forced, is increasing at an unprecedented rate, leaving many unanswered questions for public health. Therefore, migrant and refugee health requires a collective response, addressing health challenges by mobilizing stakeholders, trade unions and partners globally.

The migration process can increase migrant and refugees vulnerability to ill health, through increased exposure to risk factors (see Fig.  1 ). The process may be subcategorised into the following: pre-departure and at the border, travel and transit, host communities and return. Compulsory medical screening is often a major concern for migrants and refugees pre-departure or at the border, as unsuccessful screening could result in denial to enter their chosen host country. The purpose of screening is to address the introduction of potential health threats that may endanger the health of host populations, specifically for the case of infectious disease [ 6 , 7 ]. However, the legitimacy of medical screening has been questioned, as it disregards the moral and ethical implications, and also does not adequately address diseases with latent periods [ 8 ]. The migratory journey itself affects the health of many migrants, due to physical and environmental threats, the lack of access to the most basic services, alongside increased exposure to both violence and trauma having significant repercussions on their mental health [ 9 ].

Aspects of the various migrant stages that can affect migrants’ health [ 9 ]

Once within the host country, there are still many obstacles hindering health for migrant populations, such as occupational health and safety. Migrants and refugees are more commonly exposed to occupational hazards via physical labour in occupations such as mining, agriculture and construction, whilst also having increased exposure to sexual exploitation [ 10 ]. Upon return to their country of origin, health problems that have been acquired in the host country may surface—this is especially true for mental health conditions, which may increase in severity [ 11 ].

Understanding the issue

The portrayal of migration in the media often leads to false beliefs, stereotypes, and negative perceptions of migrants and refugees. This widely circulating narrative often dilutes the severity of the phenomena, focusing only on negative aspects and shedding no light on the positives of migration. As a result, host societies often neglect to understand migration in its entirety (from departure to arrival and integration), especially within its political framework [ 1 ]. The Wroclaw Medical University , Poland , further explored public opinion regarding migration by Attitudes and opinions of Polish society about immigrants and refugees in Poland [ 12 ]. Results were drawn from a survey on public acceptance of refugees and migrants, including 367 respondents (of which 100 were within medical professions), conducted in cooperation with the Polish Association of Healthcare Managers (STOMOZ). Results of the survey seemed contradictory at times, indicating that many respondents perhaps misunderstood or misinterpreted the concept of migration. For instance, when asked if “every person should be able to move to another country fleeing war or prosecution” 62% of respondents answered “totally agree”, however when asked “would you feel uncomfortable if your new neighbour was an immigrant of refugee”, 54% of respondents answered “yes” [ 12 ]. This indicated that whilst respondents seemed to understand the reason for leaving, they were less receptive to the practical realities of migration.

Findings from the survey concluded that a possible reason for the negative opinions could be deduced to (1) misunderstanding of migration, (2) fear of an unknown situation or (3) stereotypes [ 12 ]. However, it is also important to note that the migrant population in Poland consists mostly of Ukrainian immigrants, who due to proximity have acclimatized well in Polish society. Similarities within the neighbouring regions, as well similarities in ethnicity, may have therefore accounted for some of the discrepancy between responses in this case [ 12 ]. Additionally, it is important to note that a rather small sample size of the Polish society were included in the survey and are thus not representative of the Polish society as a whole.

Evidence-based narrative on migration to promote reliability, coherence and consistency

In order to move beyond simply understanding migration and to better foster admission and integration, the narrative of migration needs to be transformed by evidence-based, reliable and sustainable data sets. A primary example in which migrant groups are often misrepresented is with regard to economic resources. Migrants are often perceived as a long-term drain on the economy, when in reality it is a short-term cost for long-term benefits. For example, whilst initial absorption may be costly, it has been estimated that in the UK, refugees are projected to grow the GDP more than two-fold (€126.6 bn) in the next 5 years, through the creation of jobs, increased demand for services and products, and also filling gaps in EU workforces [ 13 ]. Additionally, findings from Addressing the income gap of ethnic groups : impact of health on livelihoods conducted by the University of Economics in Bratislava demonstrated that proxies for migrant discrimination played a substantial role in explaining the poverty differences between migrants and nationals in the EU. Therefore, it remains imperative to change the narrative of migrants through the use of data, to support and promote the evidence on the positive effects of migration.

The inclusion of evidence-based tools also needs to be reinforced and adopted at country-level. In Italy, two guidelines, namely the Guidelines to control TB among migrants in Italy and Boarder checks kept in check , were developed in collaboration with the National Institute of Health, the National Institute for Health, Migration and Poverty, and the Italian Society of Migration Medicine to promote evidence-based guidance for decision-makers [ 14 ]. The guidelines were drawn from systematic and rigorous literature reviews, which aimed to draw recommendations and best practices focused primarily on infectious diseases, chronic-degenerative conditions, pregnancy and vaccinations [ 14 ]. Rewriting the true narrative of migration should be based on both values and human rights, in hopes of triggering further engagement and acceptance. Similarly, shaping perception is also part of the Global Compact, which as part of its framework, aims to “eliminate all forms of discrimination and promote evidence-based public disclosure to shape perceptions of migration” [ 15 ].

International frameworks and policy: Translating abstract concepts into sustainable action

Due to the political nature of migration and the implications for the economic and legal system, it remains essential that there are just and robust frameworks and policy to advocate for the human rights of migrant populations. In collaboration with the WHO framework of priorities and guiding principles to promote health of refugees and migrants, the Global Compact for Migration seeks to set out comprehensive and holistic guidelines for healthier lives of migrant and refugees [ 15 ]. Objective 15f in the Global Compact for Migration seeks to provide access to basic services for migrants and states the following:

Expand and enhance national health systems, incorporating the needs of migrants in national and local health care policies and plans, including by strengthening capacities for service provision, facilitating affordable and non-discriminatory access, reducing communication barriers, and training health care providers on culturally-sensitive service delivery, in order to promote physical and mental health of migrants and communities overall.

There is a clear link which exists between migration and development, not only demonstrated by the Global Compact acting as a response to the sustainable development goals, but also by the proliferation of universal health care for migrants and refugees in Iran. There has been an influx of Afghan refugees into Iran, which currently hosts 951,142 documented refugees and is estimated to also host 1.5 to 2 million undocumented refugees (see Fig.  2 ) [ 16 ]. In the case for documented refugees, insurance coverage for refugees is endorsed by Iran’s development programs, namely through the 6-year development plan (2016–2021; Article 70, number 5). Examples of free primary healthcare services in Iran include vaccinations, maternal and child health, family planning and psychological consultations [ 17 ]. Health is also a main pillar of the United Nations Sustainable Development Goals, as a healthier population will also reinforce greater financial sustainability.

Where refugees from the top five countries of origin found asylum (UNHCR, 2015)

According to Lee’s push and pull theory, there may be various push and pull factors which influence migrants’ choice of host destination, and access to medicines may be categorised as a pull factor to migrate to said host country [ 18 ]. However, pull factors may be extremely conditional at times, widening the gap between expectation and reality. For instance, in France, a health protection scheme for undocumented migrants was created in 2000, named the State Medical Assistance [ 19 ]. Whilst the scheme had a period of entitlement for up to one renewable year, the legitimacy of assistance for undocumented migrants has been subject to debate and regular criticisms. The reasons for this being the requirements needed to access the healthcare are not only were undocumented migrants expected to have lived in the territory for over 3 months, but also beneficiaries were expected to bring forward supporting documents such as proof of identity, address of domiciliation and administrative documents proving their 3-month presence in France [ 19 ]. These criteria increase the difficulty to actually access these services, with only 10.2% of eligible candidates gaining effective access to medicine and primary health care services [ 19 ]. This echoes the need to have clearer laws and regulations, and research also concluded that it might be more beneficial to reintroduce undocumented migrants into a common law system opposed to maintaining a specific defined system for undocumented migrants [ 19 ].

• Mental health

Mental health remains a major challenge for migrant and refugee health, with a notable increase in schizophrenia, depression and anxiety. Due to the stress-inducing nature of migrations, difficulties may arise as a result of poor social skills, the concept of self and further exposure to psychological, social and biological vulnerabilities [ 20 ]. Mental health may afflict both children and adults, with exposure to violence, internalising difficulties and unaccompanied transit identified as the key risk factors for poor mental health in children [ 21 ]. Poor social interaction and integration have been hypothesised as key factors affecting mental health adjustment in adults [ 20 ]. Cultural shock plays a major role in reduced acclimatisation and has been hypothesised to occur in six stages: strain; sense of loss and feelings of deprivation; rejection by and members of the new culture; confusion in role and role expectation, values, feelings and self-identity; surprise, anxiety, disgust and indignation; and feelings of impotence [ 22 ]. Furthermore, the novel environment with uncertainties potentially caused by residence status, limited access to basic infrastructures and health services due to living conditions in provisional refugee shelters can cause emotional distress likely to increase prevalence rates of mental disorders amongst refugees in comparison to the general population [ 23 , 24 , 25 ]. Post-traumatic stress disorder (PTSD) has been observed in most migrant and refugee populations, due to the heterogenic nature of the migration process itself [ 20 ].

Trauma is especially prominent in refugee populations, often categorised as either “collective traumas”, which refer to shared injuries to a population’s social, cultural and physical ecologies [ 26 ], or “social suffering” described as “interconnected adversities on the level of individual, family, community and society” [ 27 ]. It is important to note that trauma may manifest pre-migration, but also post-migration and post-displacement adjustment [ 28 ]. Displacement and pre-migration situations of war and conflict may involve: witnessing or being subjected to torture, killings, atrocities, incarceration, starvation/deprivation, rape, sexual assault and physical beatings [ 28 ]. Trauma often results in PTSD, and the four main resettlement stressors predictive of PTSD have been identified as (1) social and economic strain, (2) loss of status corresponding with racism and discrimination, (3) threats and violence and (4) alienation [ 28 ]. However, exposure to other stressful and traumatising experiences may also contribute, such as abuse by law enforcement officers, separation from families and fear of detention and/or deportation. Trauma has also been associated with major depressive disorders and suicide [ 29 ]. To start healing from traumatic events, it requires refugees, both individually and collectively, to make meaning of their trauma [ 4 , 30 ].

More recently, the Centre for Civic Engagement and Community Service , at the American University of Beirut ( AUB ) launched the Ghata school project in Lebanon [ 31 ]. The aim of these schools was to produce a restorative built environment to impact refugee’s mental health, promoting the notion of a “safe place” via the following objectives: (1) to assess the frequency of mental health problems and trauma outcomes (PTSD, depression, anxiety) amongst children aged 12–14 attending Ghata versus tented schools; (2) to assess the perception of children and parents on their schools as a restorative built environment; and lastly, (3) to assess the need for mental health service interventions within the built environment [ 31 ]. The design of the Ghata unit is derived from refugees’ own shelter construction practices that are based on simplicity, portability, adaptability, scalability, climatic responsiveness and economic efficiency (see Fig.  3 ) [ 31 ]. AUB student volunteers assembled the first prototype in 2013, and two refugees built the second in six working hours; specifically choosing land in close proximity of refugee resettlements. Following rigorous simulation analysis, the project was scaled up across the country with support from the Ministry of Education. To date, 10 portable school campuses located within refugees’ informal tented settlements have been assembled, serving around 5000 students annually—with attendance rates over 80% [ 31 , 32 ].

Ghata school unit [ 31 ]

Results from the MHPSS surveys allowed informants to learn more about their experiences and trauma. For instance, 59.3% described their journey as “terrifying and scary”, whilst 35.6% shared their experience of seeing someone being “beaten up, shot or killed by another person”, and 45.8% admitting that they “felt like they were going to die” [ 31 ]. Ghata aims to fill the gap for needs and resource assessment, and it has also been noted that education can be used as an instrument to foster social integration, by increasing engagement and acceptance within resettled communities. Mental health within migrant communities remains a major challenge, and therefore it is important to also immobilise stakeholders and trade unions for an interagency approach. It is important to not only address the fear, anxiety and doubts pre-migration, but also assess mental health needs post-migration, guaranteeing cohesion of migrant communities.

• Tuberculosis

Tuberculosis (TB) is an airborne infectious disease caused by the bacterium Mycobacterium tuberculosis , which affects the lungs most commonly, and is spread from person to person by coughing and sneezing [ 33 ]. TB is entirely preventable and treatable yet it is one of the top 10 causes of death globally, responsible for the deaths of 1.7 million in 2016, with most of these (over 95%) deaths occurring in low- and middle-income countries [ 34 ]. Clearly, TB disproportionally affects poor and vulnerable populations hence migrant populations are at a heightened risk of contracting the infection. Further, migration increases TB-related morbidity and mortality due to the conditions they are exposed to during migration itself including malnutrition, overcrowding in camps and treatment interruption, which can increase the risk of drug resistance [ 35 ]. Even when migrants reach their final destination countries, their TB-associated morbidity and mortality is elevated. This is particularly true for undocumented migrants where fear of deportation or detention prevents individuals seeking medical attention for diagnosis or treatment. Those that do identify themselves may end up in detention centres where conditions are often crowded, proliferating the spread of infection and disrupting access to treatment. The situation is not much better for migrants with legal status, whose access to care and treatment is often reliant on their working permits and health insurance, exposing a significant proportion of this group to inadequate services [ 35 ]. As an example, in Germany, the highest incidence of TB (18.2/100,000) was found in young adults aged 20 to 24 years (male 25.9 vs. female 9.7). Furthermore, TB was diagnosed significantly higher in the foreign population at all ages (42.6/100,000) compared to the general population (2.2/100,000) [ 36 ]. Therefore, all screening activities for tuberculosis should take into account that particularly migrated adolescents and young adults are at a much higher risk to be diagnosed with TB.

A particular migrant subgroup that requires attention is the unaccompanied asylum-seeking minors (UASM). UASM are defined as “third-country nationals or stateless persons below the age of 18, who arrive on the territory of the Member States unaccompanied by an adult responsible for them whether by law or custom, and for as long as they are not effectively taken into the care of such a person; it includes minors who are left unaccompanied after they have entered the territory of the Member States” [ 37 ]. Given the scale of migration amongst this vulnerable subgroup, it is important that they are not missed from screening and treatment programs.

At the 2014 World Health Assembly, the WHO End TB Strategy was introduced as a blueprint for countries to end the TB epidemic by reducing TB deaths and incidence and eliminating the terrible costs of the epidemic. The End TB Strategy outlines global impact targets to reduce TB deaths by 90%, to cut new cases by 80% between 2015 and 2030, and to ensure that no family is burdened with catastrophic costs due to TB [ 38 ]. This goal of 2030 is shaped somewhat by the inclusion of the End TB strategy in the health targets of the Sustainable Development Goals (SDGs). WHO has gone a step further than this by setting the target of 95% reduction in deaths and a 90% decline in TB incidence globally by 2035; this is similar to current levels in low-TB incidence countries today and represents a commitment to bring high-burden countries in line with this.

The End TB Strategy faces a number of challenges on the path to achieving these goals, including the growing threat of multidrug resistance, but the status of TB amongst the migrant populations also represents a key challenge. In fact, these two challenges are not mutually exclusive, and migrant populations can accelerate the prevalence and spread of multidrug resistant TB as seen with the arrival of new strains of drug-resistant TB in the Western Cape province in South Africa, thought to be a result of the large migrant population [ 39 ]. Such introductions of new resistant strains of TB emphasise the need for the inclusion of strain data in screening and notification systems within countries with large migrant populations, when there are sufficient resources available [ 39 ].

A key component of the primary pillar for the End TB Strategy is systematic screening of contacts and high-risk groups, one such high-risk group is migrant populations, hence the importance of clear and effective screening procedures in the context of migrant and refugee health. Screening is defined as “a process of identifying apparently healthy people who may be at increased risk of a disease or condition. They can then be offered information, further tests and appropriate treatment to reduce their risk and/or any complications arising from the disease or condition” (UK National Screening Committee, 2012). Healthcare workers who are in contact with a person coming from a TB high-prevalence country (> 100/100.000) should collect TB history and check for any TB symptoms or signs as standard practice. If TB is suspected, full diagnostic exams should be carried out immediately, and full preventive therapy must be offered. As previously mentioned, there are challenges unique to the migrant population, particularly regarding unregistered migrants, and these permeate down to make effective and comprehensive screening difficult. UASM present a special case, where a more general medical screening is conducted, with more in-depth examinations carried out (e.g. X-rays) in cases of risk of TB exposure or suspected infection.

Adherence remains a challenge at all stages from comprehensive screening procedures to the completion of preventative and treatment courses. Adherence is favoured through integrated management of cases, but many challenges to achieving this exist. Preventive therapy is usually well accepted amongst migrants, but major obstacles that derive from a lack of information or bad communication and organisational problems still persist. For example, in Italy more than 40% of screened patients testing positive for possible TB infection fail to undergo follow-up diagnoses. Around 25% of those patients that do undergo diagnostic X-rays and test negative choose not to use preventive prophylaxis, and of those that do 64% still fail to complete the course. That said, such problems have started to be overcome in recent years, and whilst a 64% failure to complete figure is still too high, this is a marked improvement over recent years.

Whilst migration can have positive impacts—particularly for development, there are also a number of challenges that exist as a by-product of increased migration. A major problem is the effect of increased workload on humanitarian and health workers. Greece has experienced many health workers prone to burn out, resulting in the development of a brain drain culture (the emigration of highly trained or skilled persons). For instance, a thematic analysis “ Understanding healthcare access for refugees in Greece ” conducted by the Imperial College London highlighted how socio-cultural differences such as language acted as a major barrier in communicating. The study also noted a low presence of translators exacerbating the negative consequences. Within the Greek experience, in addition to inadequate staffing, the lack of coordination and changes in available healthcare provision also contributed to the burn out of healthcare workers [ 40 ]. The language barrier may also contribute to the lack of adherence to treatment, delays or misdiagnosis, unnecessary examinations and incorrect treatments [ 9 ]. Linguistic problems are closely tied with cultural issues. More recently, the need for “culturally competent” conduct has been pushed on the healthcare agenda, which in the case of migrant health, means putting aside personal biases and being familiar with the health, social, cultural, religious and gender-related issues regarding the experience of migrant populations [ 41 ].

Another persisting problem that has been noted is the increased incidence of work-related injuries—the ILO estimated that there were 2.3 million occupational fatalities from a variety of sources in 2014, globally [ 42 ]. The department of public health and infectious diseases at the Sapienza University of Rome concluded in their study Work-related injuries and mortality among immigrant workers in Italy : a national perspective , that occupational injuries have more frequently been observed in migrant populations with increased hazardous exposure, which may include physical, chemical, biological or increased levels of psychosocial stress. Migrants are often engaged in what is known as 3-D jobs, dirty, dangerous and demanding, in which they experience a combination of increased workplace demands, lack of safety standards and frequent workplace abuse [ 42 ].

Writing a true narrative of the migration experience remains a challenge, as the narrative of migration needs to be evidence based in order to promote a future in which we build with trust. Amongst the need to mobilise stakeholders and trade unions, shape perception via media outlets, and enhance international cooperation, many other challenges exist. It is therefore crucial that migrant and refugee health continues to be addressed, through shared priorities and the vision of involved partners and stakeholders. With a changing landscape in the climate and demographics, unpredictable political outcomes and the growing emergence of infectious disease outbreaks, migration will continue to occur, and therefore advocating for health for all and issuing calls for action remain of up most importance.

“Ultimately, the challenge is to make migration work for all.” -Antonio Vitorino, IOM Director General

Recommendations

The symposium highlighted several critical areas for action, including the following:

There is a need for an evidence-based narrative on migration to promote reliability, coherence and consistency.

Migrant and refugee health must become a shared priority mirrored in the commitment of member states to ensure access to healthcare for all.

The need to raise awareness of migrant group barriers to accessing care, and training health care professionals to overcome language barriers

Support social integration through education, housing and employment

Mladovsky P. “Migrant health in the EU.” Eurohealth- London- 13.1 (2007): 9.

UN General Assembly. Convention and protocol relating to the status of refugees. Geneva: UNHCR; 1951.

Google Scholar  

Zimmerman C, Kiss L, Hossain M. Migration and health: a framework for 21st century policy-making. PLoS Med. 2011;8(5):e1001034.

Article   Google Scholar  

Matos L, Indart M, Park C, Leal IP. Meaning-making and psychological adjustment following refugee trauma. In: Actas do 12° Congresso Nacional de Psicologia da Saúde; 2018. p. 513–21.

Sinah BRK. Human migration: concepts and approaches. 2005. Available: http://www.mtafki.hu/konyvtar/kiadv/FE2005/FE20053-4_403-414.pdf . Last accessed 15/05/2018.

Cetron M and Simone P. Battling 21st-centry scourges with a 14th-century toolbox. Emerg Infect Dis J. 2004;10(11): 2053–2054. Available from: www.cdc.gov/ncidod/eid/vol10no11/04-0797_12.htm . 96 Last accessed: 15/10/2018.

Arcury TA, Quandt SA. Delivery of health services to migrant and seasonal farm workers. Annu Rev Public Health. 2007;28:345–63.

Coker. Compulsory screening of immigrants for tuberculosis and HIV. Br Med J. 2004;328:298–300.

International Migration, Health and Human Rights. IOM, WHO and UN Human Rights: https://www.ohchr.org/Documents/Issues/Migration/WHO_IOM_UNOHCHRPublication.pdf Last accessed: 16/10/2018.

Flyvholm M. Results from a Danish intervention project on immigrants in the cleaning trade, Barents Newsletter on Occupational Health and Safety. 2011; 14(2):46–47. Available from: www.ttl.fi/en/publications/electronic_journals/barents_newsletter/Documents/BarentsNewsletter2_2011.pdf. Human Rights Watch, World Report 2010, p. 346 (New York, 2010). Last accessed: 15/10/2018.

UNPD, IOM and UNIFEM. HIV Vulnerabilities of migrant women: from Asia to the Arab states. Colombo: UNDP Regional Centre in Colombo; 2008.

Mapping exclusion: Mental Health Europe. https://mhe-sme.org/mapping-exclusion/ Last accessed: 15/10/2018.

Legrain, P. Refugees work: A humanitarian investment that yields economic dividends. 2016. Available: http://www.opennetwork.net/wp-content/uploads/2016/05/Tent-Open-Refugees-Work_V13.pdf . Last accessed 15/10/2018.

Marcea M, Baglio G, Tosti ME, Geraci S, Vella S, Villari P. The evidence-based approach in protecting the health of migrants and host communities: the Italian guidelines produced by ISS, INMP and SIMM; 2018.

Global Compact for Migration https://refugeesmigrants.un.org/sites/default/files/180713_agreed_outcome_global_compact_for_migration.pdf Last accessed: 16/10/2018.

UNHCR. Global trends: Forced displacement in 2015. Available: http://www.unhcr.org/statistics/unhcrstats/576408cd7/unhcr-global-trends-2015.html8June. Last accessed 20/08/2018. Last accessed: 16/10/2018.

Takian A, Akbari-Sari A. Sustainable health development becoming agenda for public health academia. Iran J Public Health. 2016;45(11):1502.

PubMed   PubMed Central   Google Scholar  

Lee ES. A theory of migration. Demography. 1966;3(1):47–57.

Jean-Marie A, Azzedine F. Access to healthcare for undocumented migrants in France: a critical examination of state medical assistance. Public Health Rev. 2016.

Bhugra D. Migration and mental health. Acta Psychiatr Scand. 2004;109(4):243–58.

Article   CAS   Google Scholar  

Fazel M, Reed RV, Panter-Brick C, Stein A. Mental health of displaced and refugee children resettled in high-income countries: risk and protective factors. Lancet. 2012;379.

Oberg K. Culture shock: adjustment to new culture environments. Practical Anthropol. 1960;7:177–82.

Georgiadou E, Morawa E, Erim Y. High manifestations of mental distress in Arabic asylum seekers accommodated in collective centers for refugees in Germany. Int J Environ Res Public Health. 2017;14(6):E612.

Fazel M, Wheeler J, Danesh J. Prevalence of serious mental disorder in 7000 refugees resettled in western countries: a systematic review. Lancet. 2005;365:1309–14.

Porter M, Haslam N. Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons: a meta-analysis. JAMA. 2005;294:602–12.

Saul J. Collective trauma, collective healing. New York and London: Routledge; 2014.

Kleinman A, Das V, Lock M, Lock MM. Social suffering. In: Univ of California press; 1997.

Bemak F, Chung RCY. Refugee trauma: culturally responsive counselling interventions. Journal of Counseling & Development. 2017;95(3):299–308.

Lindencrona F, Ekblad S, Hauff E. Mental health of recently resettled refugees from the Middle East in Sweden: the impact of pre-resettlement trauma, resettlement stress and capacity to handle stress. Soc Psychiatry Psychiatr Epidemiol. 2008;43(2):121–31.

Park CL. Making sense of the meaning literature: an integrative review of meaning making and its effects on adjustment to stressful life events. Psychol Bull. 2010;136(2):257.

Centre for Civic Engagement and Community Service, at the American University of Beirut (AUB). Ghata: a restorative built environment impacting refugees’ mental health in Lebanon. 2018.

Decreasing tensions between Lebanese and Syrian students in Zgharta. https://website.aub.edu.lb/ccecs/Documents/Success%20Story_Decreasing%20Tensions%20between%20Lebanese%20and%20Syrian%20Students%20in%20Zgharta.pdf

http://www.who.int/news-room/fact-sheets/detail/tuberculosis . Last accessed: 16/10/2018.

Goosby E, Jamison D, Swaminathan S, Reid M, Zuccala E. The Lancet Commission on tuberculosis: building a tuberculosis-free world. Lancet. 2018;391(10126):1132–3.

Tuberculosis prevention and care for migrants. http://www.who.int/tb/publications/WHOIOM_TBmigration.pdf . Accessed 16 OCt 2018.

Robert Koch Institut, Berlin, Germany: Bericht zur epidemiologie der tuberkulose in. Deutschland für 2016: https://www.rki.de/DE/Content/InfAZ/T/Tuberkulose/Download/TB2016.pdf?__blob=publicationFile Last accessed: 16/10/2018.

Council directive https://eur-lex.europa.eu/legal-content/en/TXT/?uri=CELEX:32004L0083 Last accessed: 16/10/2018.

Implementing the End the TB Strategy: The essentials http://apps.who.int/iris/bitstream/handle/10665/206499/9789241509930_eng.pdf?sequence=1&isAllowed=y . Accessed 16 Oct 2018.

Theron G, Jenkins HE, Cobelens F, et al. Dara for action: collection and use of local data to end tuberculosis. Lancet. 2015;386:10010.

Khan MS, Osei-Kofi A, Omar A, Kirkbride H, Kessel A, Abbara A, Dar O. Pathogens, prejudice, and politics: the role of the global health community in the European refugee crisis. Lancet Infect Dis. 2016;16(8):e173–7.

College of Nurses of Ontario. Practice guideline: culturally sensitive care, Ontario 2004. http://tools.hhr-rhs.ca/index.php?option=com_mtree&task=viewlink&link_id=8612&Itemid=109&lang=en . http://www.cno.org/globalassets/docs/prac/51040_culturesens.pdf . Accessed 16 Oct 2018.

Moyce SC, Schenker M. Migrant workers and their occupational health and safety. Annu Rev Public Health. 2018;39:351–65.

Download references

Acknowledgements

The authors are grateful to Sapienza University, Rome for hosting the meeting, and the German Embassy, Rome for its support of the event and the M8 Alliance. The authors thank the participants in the Expert Meeting for their contributions to the presentations and discussions, on which this report was drawn. Participant include: Jean-Marie André, Fabienne Azzedine, Lisa Matos, Alexander Krämer, Amirhoessein Takian, Aula Abbara, Giuseppe La Torre, Alessandra Talamo, Iwona Mazur, Piotr Karniej, Maurizio Marceca, Anna Paola Massetti, Paula Puskarova, Gillian Bentley, Rabih Shibli.

The funding source had no involvement in writing the manuscript or decision to submit the manuscript for publication. Authors had full access to all the data in the study, and also the final responsibility for the decision to submit for publication.

Availability of data and materials

Not applicable.

Author information

Authors and affiliations.

Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland

Nefti-Eboni Bempong, Danny Sheath & Antoine Flahault

Charité – Universitätsmedizin Berlin, Berlin, Germany

Joachim Seybold

Centre Virchow-Villermé for Public Health Paris-Berlin–Paris Office, Paris, France

Anneliese Depoux

Faculty of Pharmacy and Medicine, Sapienza University of Rome, Rome, Italy

Luciano Saso

You can also search for this author in PubMed   Google Scholar

Contributions

The idea was conceptualised by AF and LS. NB, DS, AD and LS drafted the first version of the report. NB and DS conducted the writing, and a final review for improvements to the manuscript was conducted by JS, AF, AD and LS. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Nefti-Eboni Bempong .

Ethics declarations

Ethics approval and consent to participate, consent for publication, competing interests.

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Cite this article.

Bempong, NE., Sheath, D., Seybold, J. et al. Critical reflections, challenges and solutions for migrant and refugee health: 2nd M8 Alliance Expert Meeting. Public Health Rev 40 , 3 (2019). https://doi.org/10.1186/s40985-019-0113-3

Download citation

Received : 25 October 2018

Accepted : 15 February 2019

Published : 19 March 2019

DOI : https://doi.org/10.1186/s40985-019-0113-3

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Migrant health
• Refugee health
• Health policy
• M8 Alliance

Public Health Reviews

ISSN: 2107-6952

• Submission enquiries: Access here and click Contact Us
• General enquiries: [email protected]

Partnership for Refugees

Case studies.

© UNHCR/Diana Diaz

Cross-sector partnerships can help catalyze the development and implementation of innovative and strategic long-term solutions to address critical refugee challenges. Below are several examples of previous and existing partnerships by target impact areas.  To learn which companies have responded to the Call to Action with new pledges ,  click here .

Education: Creating access to education

Microsoft & nonprofit partnerships.

Through its nonprofit partnerships, Microsoft is currently supporting refugee education efforts in Turkey, Lebanon, Greece and Jordan. For instance, in Germany, Microsoft has made its YouthSpark Schlaumause (Arabic to German language training) program available to 3,000 elementary schools, serving approximately 30,000 refugee children. In the coming months, Microsoft will commit more resources to this initiative to double Schlaumause's impact.

At the Zaatari Refugee Camp in Jordan, Microsoft has supported the establishment of The Norwegian Refugee Council's technology lab, which teaches adult refugees computer skills, improving their future employability.

Finally, through its support for NetHope, Microsoft has helped bring connectivity services to Syrian refugees in Jordan, Turkey and Lebanon. With connectivity, refugees have been able to access information and resources, and connect to family. Going forward, Microsoft aims to work across the industry to help provide much-needed infrastructure, as well as longer-term aid. In the coming months, Microsoft will deepen its commitment and expand its ability to prepare for, and respond to, humanitarian and natural disasters.

Employment: Increasing support for employment transition and workforce development

Accenture & upwardly global.

As one of Accenture's largest Skills to Succeed partners, Upwardly Global ("UpGlo") helps work-authorized immigrants, refugees, and asylum seekers who are skilled and foreign educated to overcome the barriers to entering professional careers in the US.

In 2013, Accenture teamed up with UpGlo to launch a new online employment training program focused on developing the skills necessary to be successful in landing on professional jobs in the U.S. Developed with an Accenture grant, the program helps skilled refugees and immigrants gain relevant job search skills by offering remote access to interactive training on job searching, resume writing, interviewing and networking skills, and providing industry-specific technical and career pathways training for foreign-trained healthcare and IT professionals.

Accenture helped expand UpGlo's services in 2015-2016 by equipping 1700 refugees and immigrants with career skills and securing jobs for up to 750 per year with the help of Accenture volunteers and a mix of cash donations and pro bono support. Together, Accenture and UpGlo have succeeded in empowering over 3,000 refugees and immigrants through its training program, and aim for 10,000 users over the next three years. Close to 2,000 Accenture staff have volunteered over 5,000 hours to help UpGlo provide job training counseling, mock interviews and networking training to immigrants. Job seekers from UpGlo are encouraged to apply for jobs at Accenture upon completion of the program.

Read the Accenture & Upwardly Global News Release

Chipotle & International Rescue Committee

Since 2009, the IRC and Chipotle have developed a multi-faceted partnership that includes refugee and asylee employment, urban farming and culinary entrepreneurship grants, support of nutrition incentives and healthy food access programs and event sponsorship. IRC and Chipotle share important core values of investing in promoting healthier people and communities - and our collaboration has centered around cultivating a better world via the food sector.

Chipotle acknowledges that many immigrants come to the U.S. with a knowledge-base and passion for cultivating and cooking fresh food. The IRC is a preferred employment partner for Chipotle, and IRC works side-by-side with Chipotle restaurant managers and regional HR recruiters in every US city where IRC offices and Chipotle restaurants overlap (~24 cities).

Chipotle has underwritten IRC's initiative to equip refugee and immigrant farmer entrepreneurs with the tools they need to pursue urban farming to grow fresh, culturally appropriate produce to feed themselves, their families, and their communities in 9 US cities. More recently, Chipotle is also bolstering the IRC's gardening and nutrition education programs for youth.

Together, IRC and Chipotle are growing healthier neighborhoods by harnessing the valuable, diverse skills that refugees bring to this country, as well as their value as committed, resilient employees and community members.

LinkedIn & Various Multi-Sector Initiatives

In February 2016, LinkedIn launched its first pilot initiative in Sweden, Welcome Talent, to help address the refugee crisis. Using the LinkedIn platform, LinkedIn created a microsite that served as an entry point to connect newly settled refugees with employers that have committed to hiring them. The site has information, resources and case studies to help refugees create optimal profiles. To date, more than 1,000 jobs have been posted from potential employers. This is a multi-sector initiative working with the Swedish government, NGO community, universities and the private sector. LinkedIn is also one of the founding partners of the Tent Foundation private sector alliance that has formed to address the refugee crisis. LinkedIn is currently exploring other markets where we might expand this work.

Enablement: Strengthening infrastructure and access to resources needed for refugees to become self-reliant and to support countries that welcome them

Google, mercy corps & international rescue committee.

In response to the ongoing refugee crisis in Europe, the International Rescue Committee, Mercy Corps, and Google partnered to create Refugee Info Hub.

Humanitarian organizations like the IRC and Mercy Corps were early responders to the crisis and recognized that access to accurate and credible information was a priority and safety concern for refugees arriving in Greece. Refugee Info Hub was a strong compliment to ongoing information and protection activities to protect the most vulnerable already underway. Google’s partnership allowed organizations to come together and collaborate quickly on an effective digital solution.

In October 2015, the site was created and launched in 36 hours using Google Docs. The site has since transitioned to an alternative open source CMS as it expanded to new countries outside of Greece.

In the past seven months, more than 60,000 refugees in over 20 locations have used the site with more than 30 NGOs providing content.

JPMorgan Chase & International Rescue Committee

The JPMorgan Chase Foundation is supporting innovative programming to enhance the quality and scale of IRC's financial coaching services in its domestic network of 22 offices in 13 states. Refugees arrive with little savings, no assets, and no understanding of the complex US financial system in which they find themselves. The absence of basic budgeting skills and a lack of understanding of credit can result in poor financial management and early missteps that can haunt a refugee family for many ears after their arrival. Once refugees - like many other immigrant and low-income families - have a negative credit score, they are essentially excluded from mainstream and affordable financial products.

JPMC's investment has enabled IRC to 1) bolster the integration of existing financial coaching efforts in the Oakland and San Diego offices and 2) to develop a model for financial coaching that meets the unique needs of IRC's refugee and immigrant clients and provide learning for service providers working with low income populations more broadly.

MasterCard & World Food Program

In 2013, WFP and MasterCard rolled out an electronic payment (e-card) program in Jordan and Lebanon within a broader partnership that aimed to expand the use and delivery of “digital food” – in the form of cash and vouchers – to the hungry poor around the world. The partnership linked MasterCard’s expertise in payment systems with WFP’s expertise in providing food assistance. MasterCard provided technology and expertise in pre-paid card solutions and set up the e-card system that would be the backbone modality of WFP’s food assistance to refugees in Jordan and Lebanon.

Families received a card loaded with US$27 per person each month, which could be redeemed for a list of items at participating local stores. These included fresh produce not normally found in traditional food rations. The e-cards enabled refugees to meet their needs and helped boost the local economy in these two countries – Jordan being host to the largest number of refugees.

Besides being more efficient than in-kind food aid and even paper vouchers, the new e-cards broadened people’s food choices and served as an excellent example of how our combined efforts can offer powerful, cutting-edge ways to fight hunger.

UPS & UNICEF

For over 10 years, UPS has partnered with the US Fund for UNICEF, providing grant funding to a range of UNICEF programs, in-kind shipping, freight and expertise. UPS has supported UNICEF's work in emergency preparedness and relief efforts, girls’ education, child protection, and UNICEF’s School-in-a-Box program.

In 2013 and 2014, UPS mobilized its worldwide network of staff, warehouses, and shipping and freight services to help UNICEF in the refugee emergency, culminating in one of the most complex relief efforts UPS and UNICEF have partnered. Over this two-year period UPS helped send nearly 44,000 winter clothing kits to refugee children in Lebanon and Northern Iraq. UPS were involved throughout the project planning and a critical partner to its execution.

Other Leading Examples:

Pfizer & international rescue committee.

The International Rescue Committee is partnering with Pfizer to address the low immunization coverage of children under one year old and high unmet need for family planning in Ethiopia and Uganda, while simultaneously building evidence about delivery models that reach the most underserved women and children. IRC is implementing integrated family planning (FP) and immunization service delivery models and supporting routine immunization activities in some of the countries' most remote and difficult to reach areas. More specifically, IRC is supporting health facilities to enable and strengthen FP and expanded immunization services, improve referrals to additional services, build health provider capacity, and support supply provision. To improve overall use of FP, health providers are trained on FP counseling and how to administer a variety of methods, expanding the range of options women can access at health facilities

In both countries, robust community engagement strategies are enabling outreach workers to increase awareness and demand for immunization services. Additionally, IRC is strengthening family planning service delivery models and is developing targeted community outreach strategies to transform community leaders, religious figures, men and youth into powerful advocates for family planning.

Airbnb & International Relief Organizations

Airbnb is partnering with leading international relief organizations including UNHCR, the International Rescue Committee, and Mercy Corps, in responding to the global refugee crisis. Our support includes the donation of travel credits to relief organizations, which allow their humanitarian workers to book accommodations on the front lines where they are responding to some of the most urgent refugee needs.

Airbnb has encouraged its community to join it in supporting this important cause by donating financial resources through a dedicated landing page on its website. This summer, Airbnb is working with UNHCR to develop a renewed global call to action during the Olympics in Rio. Additionally, Airbnb has signed on as a pledge partner with the Tent Alliance to encourage and catalyze other private sector engagement as this humanitarian crisis evolves. Airbnb is working with a range of partners domestically and around the world to continue to assess how we can support this global response.

UPS & UNHCR

The UNHCR-UPS Foundation partnership is a multi-year collaboration that uses a multi-tasking approach to respond to the refugee crisis. UPS contributes its expertise in logistics, supply and communications, as well as flexible funding to enhance UNHCR’s emergency response. To date, UPS has provided freight services to transport critical relief supplies, charter planes aid and assistance during fast-breaking emergencies, technological training to UNHCR staff and partners, and has signed up to help improve global fleet management solutions for UNHCR. Additionally, UPS’ signature “Relief Link” program has enhanced the distribution of supplies to refugees through the “last-mile” delivery tracking of food and other essential items. UPS’ contribution has benefitted thousands of displaced families and individuals in several locations, from Nepal to Greece to Mauritania.

Johnson & Johnson & Save the Children

Johnson & Johnson is addressing the needs of all children affected by the Syrian conflict. They are addressing the needs of refugees through the entire corridor; from origin, to transition, to destination countries. Together, with Save the Children, Johnson & Johnson is looking at both the immediate humanitarian response as well as resiliency efforts.

In addition, Johnson & Johnson is implementing a targeted project in Lebanon to address the rise of child labor where refugee children are targets for exploitation, and missing out on years of schooling. Save the Children's partnership with Johnson & Johnson will enhance caregiver knowledge on the risks of child labor, building the capacity of children to engage in their own protection, and provide education and skills building activities.

aidrefugees.gov

• Open access
• Published: 11 May 2018

The Syrian conflict: a case study of the challenges and acute need for medical humanitarian operations for women and children internally displaced persons

• Rahma Aburas 1 ,
• Amina Najeeb 2 ,
• Laila Baageel 3 &
• Tim K. Mackey   ORCID: orcid.org/0000-0002-2191-7833 3 , 4 , 5  

BMC Medicine volume  16 , Article number:  65 ( 2018 ) Cite this article

26k Accesses

28 Citations

20 Altmetric

Metrics details

After 7 years of increasing conflict and violence, the Syrian civil war now constitutes the largest displacement crisis in the world, with more than 6 million people who have been internally displaced. Among this already-vulnerable population group, women and children face significant challenges associated with lack of adequate access to maternal and child health (MCH) services, threatening their lives along with their immediate and long-term health outcomes.

While several health and humanitarian aid organizations are working to improve the health and welfare of internally displaced Syrian women and children, there is an immediate need for local medical humanitarian interventions. Responding to this need, we describe the case study of the Brotherhood Medical Center (the “Center”), a local clinic that was initially established by private donors and later partnered with the Syrian Expatriate Medical Association to provide free MCH services to internally displaced Syrian women and children in the small Syrian border town of Atimah.

Conclusions

The Center provides a unique contribution to the Syrian health and humanitarian crisis by focusing on providing MCH services to a targeted vulnerable population locally and through an established clinic. Hence, the Center complements efforts by larger international, regional, and local organizations that also are attempting to alleviate the suffering of Syrians victimized by this ongoing civil war. However, the long-term success of organizations like the Center relies on many factors including strategic partnership building, adjusting to logistical difficulties, and seeking sustainable sources of funding. Importantly, the lessons learned by the Center should serve as important principles in the design of future medical humanitarian interventions working directly in conflict zones, and should emphasize the need for better international cooperation and coordination to support local initiatives that serve victims where and when they need it the most.

Peer Review reports

The Syrian civil war is the epitome of a health and humanitarian crisis, as highlighted by recent chemical attacks in a Damascus suburb, impacting millions of people across Syria and leading to a mass migration of refugees seeking to escape this protracted and devastating conflict. After 7 long years of war, more than 6 million people are internally displaced within Syria — the largest displacement crisis in the world — and more than 5 million registered Syrian refugees have been relocated to neighboring countries [ 1 , 2 ]. In total, this equates to an estimated six in ten Syrians who are now displaced from their homes [ 3 ].

Syrian internally displaced persons (IDPs) are individuals who continue to reside in a fractured Syrian state now comprising a patchwork of government- and opposition-held areas suffering from a breakdown in governance [ 4 ]. As the Syrian conflict continues, the number of IDPs and Syrian refugees continues to grow according to data from the United Nations High Commissioner for Refugees (UNHCR). This growth is continuing despite some borders surrounding Syria being closed and in part due to a rising birth rate in refugee camps [ 5 , 6 ]. This creates acute challenges for neighboring/receiving countries in terms of ensuring adequate capacity to offer essential services such as food, water, housing, security, and specifically healthcare [ 4 , 7 , 8 ].

Though Syrian refugees and IDPs face similar difficulties in relation to healthcare access in a time of conflict and displacement, their specific challenges and health needs are distinctly different, as IDPs lack the same rights guaranteed under international law as refugees, and refugees have variations in access depending on their circumstances. Specifically, there are gaps in access to medical care and medicines for both the internally displaced and refugees, whether it be in Syria, in transit countries (including services for refugees living in camps versus those living near urban cities), or in eventual resettlement countries. In particular, treatment of chronic diseases and accessing of hospital care can be difficult, exacerbated by Syrian families depleting their savings, increased levels of debt, and a rise in those living in poverty (e.g., more than 50% of registered Syrian refugees in Jordan are burdened with debt) [ 9 ].

Despite ongoing actions of international humanitarian organizations and non-governmental organizations (NGOs) to alleviate these conditions, healthcare access and coverage for displaced Syrians and refugees is getting worse as the conflict continues [ 4 , 10 ]. Although Syria operated a strong public health system and was experiencing improved population health outcomes pre-crisis, the ongoing conflict, violence, and political destabilization have led to its collapse [ 11 , 12 , 13 ]. Specifically, campaigns of violence against healthcare infrastructure and workers have led to the dismantling of the Syrian public health system, particularly in opposition-held areas, where access to even basic preventive services has been severely compromised [ 14 , 15 , 16 , 17 ].

Collectively, these dire conditions leave millions of already-vulnerable Syrians without access to essential healthcare services, a fundamental human right and one purportedly guaranteed to all Syrian citizens under its constitution [ 4 ]. Importantly, at the nexus of this health and humanitarian crisis are the most vulnerable: internally displaced Syrian women and children. Hence, this opinion piece first describes the unique challenges and needs faced by this vulnerable population and then describes the case study of the Brotherhood Medical Center (the “Center”), an organization established to provide free and accessible maternal and child health (MCH) services for Syrian IDPs, and how it represents lessons regarding the successes and ongoing challenges of a local medical humanitarian intervention.

Syria: a health crisis of the vulnerable

Critically, women and children represent the majority of all Syrian IDPs and refugees, which directly impacts their need for essential MCH services [ 18 ]. Refugee and internally displaced women and children face similar health challenges in conflict situations, as they are often more vulnerable than other patient populations, with pregnant women and children at particularly high risk for poor health outcomes that can have significant short-term, long-term, and inter-generational health consequences [ 10 ]. Shared challenges include a lack of access to healthcare and MCH services, inadequate vaccination coverage, risk of malnutrition and starvation, increased burden of mental health issues due to exposure to trauma, and other forms of exploitation and violence such as early marriage, abuse, discrimination, and gender-based violence [ 4 , 10 , 19 , 20 ]. Further, scarce medical resources are often focused on patients suffering from acute and severe injury and trauma, leading to de-prioritization of other critical services like MCH [ 4 ].

Risks for women

A 2016 United Nations Population Fund (UNFPA) report estimated that 360,000 Syrian IDPs are pregnant, yet many do not receive any antenatal or postnatal care [ 21 , 22 ]. According to estimates by the UNFPA in 2015, without adequate international funding, 70,000 pregnant Syrian women faced the risk of giving birth in unsafe conditions if access to maternal health services was not improved [ 23 ]. For example, many women cannot access a safe place with an expert attendant for delivery and also may lack access to emergency obstetric care, family planning services, and birth control [ 4 , 19 , 24 , 25 , 26 , 27 , 28 ]. By contrast, during pre-conflict periods, Syrian women enjoyed access to standard antenatal care, and 96% of deliveries (whether at home or in hospitals) were assisted by a skilled birth attendant [ 13 ]. This coverage equated to improving population health outcomes, including data from the Syrian Ministry of Health reporting significant gains in life expectancy at birth (from 56 to 73.1 years), reductions in infant mortality (decrease from 132 per 1000 to 17.9 per 1000 live births), reductions in under-five mortality (from 164 to 21.4 per 1000 live births), and declines in maternal mortality (from 482 to 52 per 100,000 live births) between 1970 and 2009, respectively [ 13 ].

Post-conflict, Syrian women now have higher rates of poor pregnancy outcomes, including increased fetal mortality, low birth weights, premature labor, antenatal complications, and an increase in puerperal infections, as compared to pre-conflict periods [ 10 , 13 , 25 , 26 ]. In general, standards for antenatal care are not being met [ 29 ]. Syrian IDPs therefore experience further childbirth complications such as hemorrhage and delivery/abortion complications and low utilization of family planning services [ 25 , 28 ]. Another example of potential maternal risk is an alarming increase in births by caesarean section near armed conflict zones, as women elect for scheduled caesareans to avoid rushing to the hospital during unpredictable and often dangerous circumstances [ 10 ]. There is similar evidence from Syrian refugees in Lebanon, where rates of caesarean sections were 35% (of 6366 deliveries assessed) compared to approximately 15% as previously recorded in Syria and Lebanon [ 30 ].

Risks for children

Similar to the risks experienced by Syrian women, children are as vulnerable or potentially at higher risk during conflict and health and humanitarian crises. According to the UNHCR, there are 2.8 million children displaced in Syria out of a total of 6.5 million persons, and just under half (48%) of Syrian registered refugees are under 18 years old [ 1 ]. The United Nations Children’s Fund (UNICEF) further estimates that 6 million children still living in Syria are in need of humanitarian assistance and 420,000 children in besieged areas lack access to vital humanitarian aid [ 31 ].

For most Syrian internally displaced and refugee children, the consequences of facing lack of access to essential healthcare combined with the risk of malnutrition (including cases of severe malnutrition and death among children in besieged areas) represent a life-threatening challenge (though some studies have positively found low levels of global acute malnutrition in Syrian children refugee populations) [ 24 , 32 , 33 , 34 ]. Additionally, UNICEF reports that pre-crisis 90% of Syrian children received routine vaccination, with this coverage now experiencing a dramatic decline to approximately 60% (though estimating vaccine coverage in Syrian IDP and refugee populations can be extremely difficult) [ 35 ]. A consequence of lack of adequate vaccine coverage is the rise of deadly preventable infectious diseases such as meningitis, measles, and even polio, which was eradicated in Syria in 1995, but has recently re-emerged [ 36 , 37 , 38 ]. Syrian refugee children are also showing symptoms of psychological trauma as a result of witnessing the war [ 4 , 39 ].

A local response: the Brotherhood Medical Center

In direct response to the acute needs faced by Syrian internally displaced women and children, we describe the establishment, services provided, and challenges faced by the Brotherhood Medical Center (recently renamed the Brotherhood Women and Children Specialist Center and hereinafter referred to as the “Center”), which opened its doors to patients in September 2014. The Center was the brainchild of a group of Syrian and Saudi physicians and donors who had the aim of building a medical facility to address the acute need for medical humanitarian assistance in the village of Atimah (Idlib Governorate, Syria), which is also home to a Syrian displacement camp.

Atimah (Idlib Governorate, Syria) is located on the Syrian side of the Syrian-Turkish border. Its population consisted of 250,000 people pre-conflict in an area of approximately 65 km 2 . Atimah and its adjacent areas are currently generally safe from the conflict, with both Atimah and the entire Idlib Governorate outside the control of the Syrian government and instead governed by the local government. However, continued displacement of Syrians seeking to flee the conflict has led to a continuous flow of Syrian families into the area, with the population of the town growing to approximately a million people.

In addition to the Center, there are multiple healthcare centers and field hospitals serving Atimah and surrounding areas that cover most medical specialties. These facilities are largely run by local and international health agencies including Medecins Sans Frontieres (MSF), Medical Relief for Syria, and Hand in Hand for Syria, among others. Despite the presence of these organizations, the health needs of IDPs exceeds the current availability of healthcare services, especially for MCH services, as the majority of the IDPs belong to this patient group. This acute need formed the basis for the project plan establishing the Center to serve the unique needs of Syrian internally displaced women and children.

Operation of the Center

The Center’s construction and furnishing took approximately 1 year after land was purchased for its facility, a fact underlining the urgency of building a permanent local physical infrastructure to meet healthcare needs during the midst of a conflict. Funds to support its construction originated from individual donors, Saudi business men, and a group of physicians. In this sense, the Center represents an externally funded humanitarian delivery model focused on serving a local population, with no official government, NGO, or international organization support for its initial establishment.

The facility’s primary focus is to serve Syrian women and children, but since its inception in 2014, the facility has grown to cater for an increasing number of IDPs and their diverse needs. When it opened, facility services were limited to offering only essential outpatient, gynecology, and obstetrics services, as well as operating a pediatric clinic. The staffing at the launch consisted of only three doctors, a midwife, a nurse, an administrative aid, and a housekeeper, but there now exist more than eight times this initial staff count. The staff operating the Center are all Syrians; some of them are from Atimah, but many also come from other places in Syria. The Center’s staff are qualified to a large extent, but still need further training and continuing medical education to most effectively provide services.

Though staffing and service provision has increased, the Center’s primary focus is on its unique contribution to internally displaced women and children. Expanded services includes a dental clinic 1 day per week, which is run by a dentist with the Health Affairs in Idlib Governorate, and has been delegated to cover the dental needs for the hospital patients . Importantly, the Center facility has no specific policy on patient eligibility, its desired patient catchment population/area, or patient admission, instead opting to accept all women and children patients, whether seeking routine or urgent medical care, and providing its services free of charge.

Instead of relying on patient-generated fees (which may be economically prohibitive given the high levels of debt experienced by IDPs) or government funding, the Center relies on its existing donor base for financing the salaries for its physicians and other staff as well as the facility operating costs. More than an estimated 300 patients per day have sought medical attention since its first day of operation, with the number of patients steadily increasing as the clinic has scaled up its services.

Initially the Center started with outpatient (OPD) cases only, and after its partnership with the Syrian Expatriate Medical Association (SEMA) (discussed below), inpatient care for both women and children began to be offered. Patients’ statistics for September 2017 reported 3993 OPD and emergency room visits and 315 inpatient admissions including 159 normal deliveries and 72 caesarean sections, 9 neonatal intensive care unit cases, and 75 admissions for other healthcare services. To better communicate the clinic’s efforts, the Center also operates a Facebook page highlighting its activities (in Arabic at https://www.facebook.com/مشفى-الإخاء-التخصصي-129966417490365/ ).

Challenges faced by the Center and its evolution

The first phase of the Center involved its launch and initial operation in 2014 supported by a small group of donors who self-funded the startup costs needed to operationalize the Center facility’s core clinical services. Less than 2 years later, the Center faced a growing demand for its services, a direct product of both its success in serving its targeted community and the protracted nature of the Syrian conflict. In other words, the Center facility has continuously needed to grow in the scope of its service delivery as increasing numbers of families, women, and children rely on the Center as their primary healthcare facility and access point.

Meeting this increasing need has been difficult given pragmatic operational challenges emblematic of conflict-driven zones, including difficulties in securing qualified and trained medical professionals for clinical services, financing problems involving securing funding due to the shutdown of banking and money transferring services to and from Syria, and macro political factors (such as the poor bilateral relationship between Syria and its neighboring countries) that adversely affect the clinic’s ability to procure medical and humanitarian support and supplies [ 40 ]. Specifically, the Center as a local healthcare facility originally had sufficient manpower and funding provided by its initial funders for its core operations and construction in its first year of operation. However, maintaining this support became difficult with the closure of the Syrian-Turkish border and obstacles in receiving remittances, necessitating the need for broader strategic partnership with a larger organization.

Collectively, these challenges required the management committee and leadership of the Center to shift its focus to securing long-term sustainability and scale-up of services by seeking out external forms of cooperation and support. Borne from this need was a strategic partnership with SEMA, designed to carry forward the next phase of the Center’s operation and development. SEMA, established in 2011, is a non-profit relief organization that works to provide and improve medical services in Syria without discrimination regarding gender, ethnic, or political affiliation — a mission that aligns with the institutional goals of the Center. Selection of SEMA as a partner was based on its activity in the region; SEMA plays an active role in healthcare provision in Idlib and surrounding areas. Some other organizations were also approached at the same time of this organization change, with SEMA being the most responsive.

Since the Center-SEMA partnership was consummated, the Center has received critical support in increasing its personnel capacity and access to medicines, supplies, and equipment, resulting in a gradual scale-up and improvement in its clinical services. This now includes expanded pediatric services and the dental clinic (as previously mentioned and important, as oral health is a concern for many Syrian parents and children). The Center also now offers caesarean deliveries [ 41 ]. However, the Center, similar to other medical humanitarian operations in the region, continues to face many financial and operational challenges, including shortage of medical supplies, lack of qualified medical personnel, and needs for staff development.

Challenges experienced by the Center and other humanitarian operations continue to be exacerbated by the ongoing threat of violence and instability emanating from the conflict that is often targeted at local organizations and international NGOs providing health aid. For example, MSF has previously been forced to suspend its operations in other parts of Syria, has evacuated its facilities after staff have been abducted and its facilities bombed, and it has also been subject to threats from terrorist groups like the Islamic State (IS) [ 42 ].

The case study of the Center, which evolved from a rudimentary medical tent originally located directly in the Atimah displacement camp to the establishment of a local medical facility now serving thousands of Syrian IDPs, is just one example of several approaches aimed at alleviating the suffering of Syrian women and children who have been disproportionately victimized by this devastating health and humanitarian crisis. Importantly, the Center represents the maturation of a privately funded local operation designed to meet an acute community need for MCH services, but one that has necessitated continuous change and evolution as the Syrian conflict continues and conditions worsen. Despite certain successes, a number of challenges remain that limit the potential of the Center and other health humanitarian operations to fully serve the needs of Syrian IDPs, all of which should serve as cautionary principles for future local medical interventions in conflict situations.

A primary challenge is the myriad of logistical difficulties faced by local medical humanitarian organizations operating in conflict zones. Specifically, the Center continues to experience barriers in securing a reliable and consistent supply of medical equipment and materials needed to ensure continued operation of its clinical services, such as its blood bank, laboratory services, operating rooms, and intensive care units. Another challenge is securing the necessary funding to make improvements to physical infrastructure and hire additional staff to increase clinical capacity. Hence, though local initiatives like the Center may have initial success getting off the ground, scale-up and ensuring sustainability of services to meet the increasing needs of patients who remain in a perilous conflict-driven environment with few alternative means of access remain extremely challenging.

Despite these challenges, it is clear that different types of medical humanitarian interventions deployed in the midst of health crises have their own unique roles and contributions. This includes a broad scope of activities now focused on improving health outcomes for Syrian women and children that are being delivered by international aid agencies located outside of the country, international or local NGOs, multilateral health and development agencies, and forms of bilateral humanitarian assistance. The Center contributes to this health and humanitarian ecosystem by providing an intervention focused on the needs of Syrian women and children IDPs where they need it most, close to home.

However, the success of the Center and other initiatives working to end the suffering of Syrians ultimately relies on macro organizational and political issues outside Atimah’s border. This includes better coordination and cooperation of aid and humanitarian stakeholders and increased pressure from the international community to finally put an end to a civil war that has no winners — only victims — many of whom are unfortunately women and children.

Abbreviations

the Brotherhood Women and Children Specialist Center

Internally displaced persons

Maternal and child health

Medecins Sans Frontieres

Non-governmental organizations

Outpatient department

Syrian Expatriate Medical Association

United Nations Population Fund

the United Nations High Commissioner for Refugees

The United Nations Children’s Fund

UNHCR. Syria Regional Refugee Response: Inter-agency Information Sharing Portal [Internet]. data.unhcr.org. 2017. http://data.unhcr.org/syrianrefugees/regional.php . Accessed 17 July 2017.

iDMC. Syria [Internet]. 2017. http://www.internal-displacement.org/countries/syria . Accessed 31 Aug 2017.

Connor P, Krogstad JM. About six-in-ten Syrians are now displaced from their homes [Internet]. pewresearch.org. 2016. http://www.pewresearch.org/fact-tank/2016/06/13/about-six-in-ten-syrians-are-now-displaced-from-their-homes/ . Accessed 31 Aug 2017.

Akbarzada S, Mackey TK. The Syrian public health and humanitarian crisis: a “displacement” in global governance? Glob Public Health. 2017;44:1–17.

Article   Google Scholar  

Albaster O. Birth rate soars in refugee camp as husbands discourage use of contraception [Internet]. 2016. independent.co.uk . http://www.independent.co.uk/news/world/middle-east/birth-rate-soars-in-jordan-refugee-camp-as-husbands-discourage-wives-from-using-contraception-a6928241.html . Accessed 21 Nov 2017.

Reliefweb. Closing Borders, Shifting Routes: Summary of Regional Migration Trends Middle East – May, 2016 [Internet]. reliefweb.int. 2016. https://reliefweb.int/report/world/closing-borders-shifting-routes-summary-regional-migration-trends-middle-east-may-2016 . Accessed 21 Nov 2017.

Schweiger G. The duty to bring children living in conflict zones to a safe haven. J Glob Ethics. 2016;12:380–97.

Article   PubMed   PubMed Central   Google Scholar  

Arcos González P, Cherri Z, Castro Delgado R. The Lebanese–Syrian crisis: impact of influx of Syrian refugees to an already weak state. RMHP. 2016;9:165–72.

UNHCR and partners warn in Syria report of growing poverty, refugee needs. Geneva: UNHCR; 2016.

Devakumar D, Birch M, Rubenstein LS, Osrin D, Sondorp E, Wells JCK. Child health in Syria: recognising the lasting effects of warfare on health. Confl Heal. 2015;9:34.

Ferris E, Kirişçi K, Shaikh S. Syrian crisis: massive displacement, dire needs and a shortage of solutions. Washington, DC: Brookings Institution; 2013.

Google Scholar  

Abu-Sada C, Serafini M. Humanitarian and medical challenges of assisting new refugees in Lebanon and Iraq. Forced Migr Rev. 2013:1:70–3.

Kherallah M, Sahloul Z, Jamil G, Alahfez T, Eddin K. Health care in Syria before and during the crisis. Avicenna J Med. 2012;2:51–3. Available from: https://doi.org/10.4103/2231-0770.102275

Heisler M, Baker E, McKay D. Attacks on health care in Syria — normalizing violations of medical neutrality? N Engl J Med. 2015;373:2489–91.

Cook J. Syrian medical facilities were attacked more than 250 times this year [Internet]. huffingtonpost.com . 2016. http://www.huffingtonpost.com/entry/syria-hospital-attacks_us_56c330f0e4b0c3c550528d2e . Accessed 31 Aug 2017.

Ozaras R, Leblebicioglu H, Sunbul M, Tabak F, Balkan II, Yemisen M, et al. The Syrian conflict and infectious diseases. Expert Rev Anti-Infect Ther. 2016;14:547–55.

Article   CAS   PubMed   Google Scholar  

Fouad FM, Sparrow A, Tarakji A, Alameddine M, El-Jardali F, Coutts AP, et al. Health workers and the weaponisation of health care in Syria: a preliminary inquiry for The Lancet-American University of Beirut Commission on Syria. Lancet. 2017:390:2516–26;

Women in the World. Women and children now make up the majority of refugees [Internet]. nytimes.com. 2016. http://nytlive.nytimes.com/womenintheworld/2016/05/16/women-and-children-now-make-up-the-majority-of-refugees/ . Accessed 31 Aug 2017.

Yasmine R, Moughalian C. Systemic violence against Syrian refugee women and the myth of effective intrapersonal interventions. Reprod Health Matters. 2016;24:27–35.

Article   PubMed   Google Scholar  

Elsafti AM, van Berlaer G, Safadi Al M, Debacker M, Buyl R, Redwan A, et al. Children in the Syrian civil war: the familial, educational, and public health impact of ongoing violence. Disaster Med Public Health Prep. 2016;10:874–82.

Save the Children. A devastating toll: the impact of three years of war on the health of Syria's children [Internet]. 2014. http://www.savethechildren.org/atf/cf/%7B9def2ebe-10ae-432c-9bd0-df91d2eba74a%7D/SAVE_THE_CHILDREN_A_DEVASTATING_TOLL.PDF . Accessed 12 Jan 2016.

UNFPA. Women and girls in the Syria crisis: UNFA response [Internet]. unfpa.org. 2015. https://www.unfpa.org/sites/default/files/resource-pdf/UNFPA-FACTSANDFIGURES-5%5B4%5D.pdf . Accessed 31 Aug 2017.

UNFPA. Shortage in funding threatens care for pregnant Syrian refugees [Internet]. unfpa.org. 2015. http://www.unfpa.org/news/shortage-funding-threatens-care-pregnant-syrian-refugees . Accessed 31 Aug 2017.

Bilukha OO, Jayasekaran D, Burton A, Faender G, King’ori J, Amiri M, et al. Nutritional status of women and child refugees from Syria-Jordan, April-May 2014. MMWR Morb Mortal Wkly Rep. 2014;63:638–9.

PubMed   PubMed Central   Google Scholar  

Reese Masterson A, Usta J, Gupta J, Ettinger AS. Assessment of reproductive health and violence against women among displaced Syrians in Lebanon. BMC Womens Health. 2014;14:25.

Samari G. Syrian refugee women’s health in Lebanon, Turkey, and Jordan and recommendations for improved practice. World Med Health Policy. 2017;9:255–74.

Hakeem O, Jabri S. Adverse birth outcomes in women exposed to Syrian chemical attack. Lancet Glob Health. 2015;3:e196. https://doi.org/10.1016/s2214-109x(15)70077-x

West L, Isotta-Day H, Ba-Break M, Morgan R. Factors in use of family planning services by Syrian women in a refugee camp in Jordan. J Fam Plann Reprod Health Care. 2016. doi:10.1136/jfprhc-2014-101026.

Benage M, Greenough P, Vinck P, Omeira N, Pham P. An assessment of antenatal care among Syrian refugees in Lebanon. Confl Heal. 2015;9:8.

Huster KMJ, Patterson N, Schilperoord M, Spiegel P. Cesarean sections among Syrian refugees in Lebanon from December 2012/January 2013 to June 2013: probable causes and recommendations. Yale J Biol Med. 2014;87:269–88.

UNICEF. Humanitarian Action for Children - Syrian Arab Republic [Internet]. unicef.org. 2017. https://www.unicef.org/appeals/syria.html . Accessed 31 Aug 2017.

Hossain SMM, Leidman E, King’ori J, Harun Al A, Bilukha OO. Nutritional situation among Syrian refugees hosted in Iraq, Jordan, and Lebanon: cross sectional surveys. Confl Heal. 2016;10:26.

Mebrahtu S. The struggle to reach Syrian children with quality nutrition [Internet]. 2015. https://www.unicef.org/infobycountry/syria_83147.html . Accessed 31 Aug 2017.

Nolan D. Children of Syria by the numbers [Internet]. 2016. http://www.pbs.org/wgbh/frontline/article/children-of-syria-by-the-numbers/ . Accessed 31 Aug 2017.

Roberton T, Weiss W, The Jordan Health Access Study Team, The Lebanon Health Access Study Team, Doocy S. Challenges in estimating vaccine coverage in refugee and displaced populations: results from household surveys in Jordan and Lebanon. Vaccine. 2017;5:22.

Al-Moujahed A, Alahdab F, Abolaban H, Beletsky L. Polio in Syria: problem still not solved. Avicenna J Med. 2017;7:64–6.

Mbaeyi C, Ryan MJ, Smith P, Mahamud A, Farag N, Haithami S, et al. Response to a large polio outbreak in a setting of conflict — Middle East, 2013-2015. MMWR Morb Mortal Wkly Rep. 2017;66:227–31.

Sharara SL, Kanj SS. War and infectious diseases: challenges of the Syrian civil war. PLoS Pathog. 2014;10:e1004438.

Hassan G, Ventevogel P, Jefee-Bahloul H, Barkil-Oteo A, Kirmayer LJ. Mental health and psychosocial wellbeing of Syrians affected by armed conflict. Epidemiol Psychiatr Sci. 2016;25:129–41.

Sen K, Al-Faisal W, AlSaleh Y. Syria: effects of conflict and sanctions on public health. J Public Health (Oxf). 2013;35:195–9. https://doi.org/10.1093/pubmed/fds090 .

Pani SC, Al-Sibai SA, Rao AS, Kazimoglu SN, Mosadomi HA. Parental perception of oral health-related quality of life of Syrian refugee children. J Int Soc Prev Community Dent. 2017;7:191–6.

Liu J. Syria: Unacceptable humanitarian failure [Internet]. 2015. http://www.msf.org/en/article/syria-unacceptable-humanitarian-failure . Accessed 31 Aug 2017.

Download references

Author information

Authors and affiliations.

Joint Masters Program in Health Policy and Law, University of California - California Western School of Law, San Diego, CA, USA

Rahma Aburas

Brotherhood Medical Center for Women and Children, Atimah, Syria

Amina Najeeb

Department of Anesthesiology, University of California, San Diego School of Medicine, San Diego, CA, USA

Laila Baageel & Tim K. Mackey

Department of Medicine, Division of Global Public Health, University of California, San Diego School of Medicine, San Diego, CA, USA

Tim K. Mackey

Global Health Policy Institute, San Diego, CA, USA

You can also search for this author in PubMed   Google Scholar

Contributions

We note that with respect to author contributions, all authors jointly collected the data, designed the study, conducted the data analyses, and wrote the manuscript. All authors contributed to the formulation, drafting, completion, and approval of the final manuscript.

Corresponding author

Correspondence to Tim K. Mackey .

Ethics declarations

Ethics approval and consent to participate.

This community case study did not involve the direct participation of human subjects and did not include any personally identifiable health information. Hence, the study did not require ethics approval.

Competing interests

Amina Najeeb and Laila Baageel, two co-authors of this paper, were part of the foundation of the Center, remain active in its operation, and have a personal interest in the success of the operation of the clinic. The remaining authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Cite this article.

Aburas, R., Najeeb, A., Baageel, L. et al. The Syrian conflict: a case study of the challenges and acute need for medical humanitarian operations for women and children internally displaced persons. BMC Med 16 , 65 (2018). https://doi.org/10.1186/s12916-018-1041-7

Download citation

Received : 05 September 2017

Accepted : 20 March 2018

Published : 11 May 2018

DOI : https://doi.org/10.1186/s12916-018-1041-7

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Maternal child health
• Syrian crisis
• Humanitarian health aid
• Internally displaced people

BMC Medicine

ISSN: 1741-7015

• Submission enquiries: [email protected]
• General enquiries: [email protected]

TNE impact case study: Refugee Protection and Forced Migration Studies

Background and overview of the case study.

The University of London has a long history of engagement with national and multinational agencies in the field of refugee policy and practice. Its Refugee Law Initiative (RFI) is the only academic centre in the UK to concentrate specifically on international refugee law. As a national focal point for leading and promoting research in this field, the RFI works to integrate the shared interests of refugee law scholars and practitioners, stimulate collaboration between academics and non-academics, and achieve policy impact at the national and international level.

In response to need identified through the RFI, and to help address urgent UN priorities, in 2016 the University launched a new online MA in Refugee Protection and Forced Migration Studies. Since then, it has become one of the largest programmes on forced migration anywhere in the world. With students across the globe, the programme provides a legal, practical and theoretical understanding of refugee protection and forced migration. The programme enables students to become more independent in managing and critiquing law, policy and practice, and in gathering, organising and deploying evidence to form balanced judgements and develop policy recommendations.

Graduates pursue careers in a range of professional contexts in the refugee, human rights or humanitarian fields; and employers include international agencies, such as the United Nations High Commission for Refugees (UNHCR), the International Committee of the Red Cross (ICRC) and the International Organization for Migration (IOM), governmental bodies and non-governmental organisations.

Recently the University established a partnership with the UNHCR to provide bursaries for Commission employees around the world. The University’s collaboration with the UNHCR extends also to representation on the Commission’s panel of specialist advisors; and the University has developed a MOOC on Internal Displacement, Conflict and Protection to support the UN’s heightened focus on the growing global challenge of internal displacement.  The programme also attracts talented scholars funded by the Commonwealth Scholarships Commission.

Impact and value

MA Refugee Protection and Forced Migration Studies: graduate stories

Yasha Mirzashev, Kyrgyzstan

Yasha has worked for the Danish Refugee Council across diverse contexts including South Sudan and in Bangladesh, working with Rohingya refugees from neighbouring Myanmar.

“I learned great skills in refugee, human rights and humanitarian law. I now know about statelessness and asylum, about Geneva conventions, child rights, women rights, about regional conventions and how UN works in terms of human rights. I became a humanitarian professional with knowledge of important legal components. I use the above skills in training sessions during my work and I’ve shared those with my colleagues.”

Noah Ssempijja, Uganda

Noah heads Opportunity International UK’s Refugee Financial Inclusion Programme which enables refugees in Uganda to access financial products, training and services as well as business advisory support.  To date, this programme has benefited over 4,000 refugees.  Noah manages the programme’s key partnerships with the Office of the Prime Minister, UNHCR, and other refugee Implementing partners.

Noah also runs Youth Initiative for Community Empowerment (YICE), a social enterprise that he founded in rural Uganda. His team of 20 trains farmers to adopt regenerative farming practices that enable them to produce food in small spaces in a sustainable and eco-friendly way, throughout the year, using a mobile drip irrigation kit that Noah invented. YICE carries out community-based activities including permaculture training and regenerative farming, water harvesting, irrigation, organic fertilizers and mobilizing beneficiaries into savings groups. Since 2016, they have directly benefited over 1,500 households.

Sylvester Chapotari, Malawi

While studying for his MA, Sylvester undertook field work with the UN Refugee Agency (UNHCR) in Malawi. A year before graduating, he was promoted to the role of Reporting Officer with the Africa Bureau at UNHCR headquarters in Geneva. 

“The humanitarian crisis in the Sahel and Lake Chad region is becoming ever more interlinked with other factors. In the Lake Chad region, for instance, the continuing conflict and violence there is impeding physical and economic access to food, particularly through the disruption of livelihoods and markets. In turn, these factors are not only fuelling the conflict but also preventing returns. In order to effectively analyse complex humanitarian situations, one needs to be equipped with a solid interdisciplinary understanding of forced displacement, including appraising a range of non-legal sources. The MA has provided me with the required perspective as well as all the necessary skills and competencies to deliver in my current job.”

Similar Case Studies

TNE impact case study: ISU / NTU Education Hub

TNE impact case study: Keele/BFSU double degree partnership

TNE impact case study: The first public Vietnamese university established in binational cooperation

Henri’s story

Matur’s story

Michael’s story

Zimnako’s story

Refugee stories.

Puran’s story

Puran tells his refugee story, being forced to leave Bhutan and living in a refugee camp in Nepal for over 19 years. He and his immediate family were resettled in Australia, but find it very difficult to be separated...

Jean’s story

Roderick’s story.

Roderick sought asylum in Australia from Zimbabwe and now works as a firefighter.

Daniel’s story

Nazem’s story

Dabessa’s story

My name is Dabessa and I am an Australian citizen, originally from Oromia, Ethiopia. My wife and I are members of the Oromo community, a group that have been persecuted in our home country for many years. In Ethiopia...

More stories

Aduc’s story.

Aduc fled the civil war in Sudan to Ethiopia and then Kenya before coming to Australia, where she works as a nurse in Gosford.

Natalie’s story

My-yen tran’s story.

Suite 4A6, 410 Elizabeth Street Surry Hills 2010 NSW Australia Phone: +61 (02) 9211 9333 Fax: +61 (02) 9211 9288

• Privacy policy
• Refugee Foundation
• Refugee Week
• Refugee Alternatives

We acknowledge the traditional owners of the land we work on - the Gadigal people of the Eora nation, and the Wurrundjeri people of the Kulin nation. We pay respects to elders past and present, and acknowledge sovereignty was never ceded. We also acknowledge the unique role Aboriginal & Torres Strait Islander people have in welcoming refugees and people seeking asylum to this land.

• Refugees in the world
• Offshore processing
• Resettled refugees
• Settling in Australia
• Education & employment
• Reports & other publications
• Help refugee families reunite
• Raise YOUR voice to secure safety for 32,000 refugees
• Operation #NotForgotten
• Join the refugee self-Representation list
• Refugees & people seeking asylum
• Local government
• Interagency networks
• Face-to-Face: Schools & community program
• Refugee Education Special Interest Group
• Researchers
• Media centre
• Media releases
• Submissions
• Bright ideas
• Service directories
• Legal or migration advice
• Information and fact sheets
• Donating goods
• Films, books & more

• Open access
• Published: 24 April 2024

Housing and health for people from refugee and asylum-seeking backgrounds: findings from an Australian qualitative longitudinal study

• Anna Ziersch 1 ,
• Moira Walsh 1 &
• Clemence Due 1 , 2  

BMC Public Health volume  24 , Article number:  1138 ( 2024 ) Cite this article

310 Accesses

Metrics details

For people from asylum-seeking and refugee backgrounds, housing and the re-establishment of home are key social determinants of health. Research highlights the inequities faced by asylum seekers and refugees in the housing markets of high-income resettlement countries, resulting in their overrepresentation in precarious housing. There is also emerging evidence of the relationship between housing and health for this population relating to lack of affordability, insecurity of tenure, and poor suitability (physical and social). The mechanisms by which housing impacts health for this group within these housing contexts, is however, understudied - especially overtime. This qualitative longitudinal study aimed to address this gap.

Semi-structured interviews were conducted with 25 people from asylum-seeking and refugee backgrounds in South Australia, recruited through a community survey. Thematic analysis of interview data across three time points over three years identified four material and psychosocial mechanisms through which housing contributed to health outcomes via psychological and physical stressors - physical environment; stability; safety; and social connections, support and services. The study also identified additional health promoting resources, particularly elements of ontological security. The dynamics of these indirect and direct mechanisms were further illuminated by considering the impact of international, national and local contexts and a range of intersecting social factors including gender, country/culture of origin, family circumstances, immigration status, language skills, income, and health status.

Conclusions

Rebuilding a sense of home and ontological security is a key resettlement priority and crucial for wellbeing. More comprehensive strategies to facilitate this for refugees and asylum seekers are required.

Peer Review reports

Introduction

There are currently, 108 million people displaced worldwide as refugees and asylum seekers [ 1 ]. Involuntary displacement, experiences of persecution, violence, and loss of family, community resources, signals disconnection from place that cannot be easily rebuilt, especially in resettlement countries [ 2 , 3 ]. Recent studies have also shown much higher prevalence rates of anxiety, depression, and post-traumatic stress disorder (PTSD) in refugees that are resettling in high-income countries compared to non-refugee populations [ 4 , 5 ]. For those who are forced to seek refuge, accessing appropriate housing, re-establishing a connection to place and creating a sense of home provide a pathway to rebuilding ontological security [ 6 , 7 , 8 ]. Conversely, difficulties accessing suitable housing present barriers to this - contributing to and compounding post migration stressors [ 9 , 10 ].

Housing is established as a key social determinants of health (SDH), and a recent review highlights housing context/location (neighbourhood), physical elements, affordability, housing markets and housing policies as key areas through which housing impacts health [ 11 ]. Emerging research shows that this association may be especially critical for refugees and asylum seekers [ 12 , 13 , 14 ]. This article builds on this work through the analysis of interviews undertaken over three-years with refugees and asylum seekers in South Australia. Specifically, this paper seeks to examine what the mechanisms are that drive the relationship between housing and health over time for people from asylum- seeking and refugee backgrounds? To answer this question, we employed a SDH framing [ 15 ], drawing on socio-ecological understandings of health [ 16 ] and elements of integration [ 17 ]. This framing considers the multilevel, cumulative, and reciprocal relationship between housing and health and the wider contexts (social, political, material, and economic) that influence day-to-day lives and shape health outcomes [ 18 ].

Terminology

Refugee and asylum seeker.

The terms ‘refugee’ and ‘asylum seeker’ are used in this paper to refer to people who meet the criteria for refugee status as defined by the United Nations High Commissioner for Refugees [ 19 ], and those still waiting for their claims to be assessed, respectively. The term ‘refugee’ is used in this paper to also cover asylum seekers unless immigration determination status is pertinent. However, we acknowledge the limitations associated with both these terms in describing only one aspect of identity.

Health and wellbeing

Our use of the term ‘health’ aligns with the World Health Organisation’s definition as “a state of complete physical, mental and social wellbeing, and not merely the absence of infirmity [ 20 ].

Housing and health

The relationship between housing and health is complex [ 21 , 22 , 23 ], and may also be bi-directional with factors such as poor health/disability, education, race and ethnicity, gender and access to services/resources, influencing one’s capacity to secure appropriate housing as well as the health impacts of housing experiences [ 24 , 25 , 26 ].

At a more specific level, tangible factors like inadequate shelter, overcrowding, cold and damp, and toxins have a range of negative health consequences [ 15 , 27 ]. Housing has also been linked to health in terms of psychosocial elements such as privacy, agency/control, empowerment/autonomy, and a sense of being at home. In turn, these factors all contribute to ontological security [ 6 , 7 ] – a concept defined by Giddens [ 28 ] as a sense of identity and constancy in relation to self, as well as social and physical environments. When this sense of constancy is deeply disrupted through fractures in an individual’s life, such as through forced displacement, this can bring about ontological insecurity, “which is both a disruption of the cognitively ordered world of self and other, and the management of individual wants” [ 29 ].

According to Dupuis and Thorns [ 30 ], the markers of ontological security in one’s home are: (1) material and social constancy; (2) a place where daily routines can be performed; (3) a sense of control and freedom from public surveillance; and (4) a place of security where identities can be constructed. Precarious housing – defined by Mallett and colleagues [ 24 ] as comprising two or more of the following elements: (un)suitability, (un)affordability and (in)security of tenure – has been shown to inhibit ontological security vis-a-vis the associated lack of agency and control over housing and neighbourhood, with negative impacts on health [ 6 , 29 , 31 , 32 , 33 ].

Housing and health for refugees

Key links between housing and health for refugees have been established in prior research (see [ 14 ] for a review). Physical health effects, for example, have been linked to poor housing conditions (cold, damp), size and layout leading to overcrowding and lack of space, and instability contributing to challenges managing health needs. Mental health outcomes, the focus of most studies in the review, were linked to many of the issues detailed above such as housing condition, security of tenure, mobility, and overcrowding as well as safety, social connections, and experiences of discrimination. While negative mental health effects are associated with precarious housing for migrants more generally, and the general population, the risk of poor mental health to refugees is significantly increased given the higher rates of mental ill health experienced by this group [ 13 , 34 , 35 ]. Housing precarity may also be compounded by precarities related to the refugee journey, such as those associated with employment, access to healthcare and education, legal status, and limited social connections and support [ 36 ]. Moreover, in resettlement, refugees and asylum seekers, particularly those who are ‘visibly different’, are more likely than other migrant groups to experience precarious housing [ 14 ].

As above, forced migration and heightened levels of threat to personal safety, as well as ongoing uncertainty, constitute major disruptions to one’s life, contributing to an affective state of ontological insecurity. Rebuilding a sense of ontological security is therefore of particular importance for refugees [ 37 ]. Challenges in post migration and resettlement contexts, such as prolonged detention, prolonged family separation, limited access to supports and services, discrimination, insecure residency, and limited access to education and employment have been shown to having a compounding impact on mental health and ontological insecurity [ 38 , 39 , 40 ].

A range of studies from Australia and other high-income countries have provided insights into the housing experiences of refugees and other migrants [ 41 , 42 , 43 , 44 , 45 , 46 , 47 ]. These studies highlight problems associated with limited affordable housing stock, experiences of housing discrimination, and risks of homelessness, as well as the importance of social connection to positive housing pathways. Two longitudinal studies have identified that refugees experience the least improvement in their housing circumstances over time [ 48 , 49 ]. To our knowledge, there is only one longitudinal study on the housing experiences of refugees that focuses on health [ 13 ]. Martino and colleagues examined longitudinal quantitative data from Australia across a five-year period from two longitudinal surveys – one focused on the resettlement experiences of refugees and the other on the household, income, and labour statistics of the whole population. They found negative mental health effects that could be attributed to precarious housing for both groups, but this effect was more pronounced for refugees.

SDH, socio-ecological and integration framing

We situate this longitudinal exploration of housing and health for refugees within a SDH framing [ 15 ], which draws on socio-ecological understandings of health [ 16 ] and elements of integration [ 17 ]. SDH are the ‘conditions in which people are born, grow, work, live, and age...[which] are shaped by the distribution of money, power and resources at global, national and local levels’ [ 50 ]. SDH influence health at a range of levels - individual factors (e.g. age, sex), individual lifestyle factors (e.g. smoking, exercise), social and community networks, living and working conditions (e.g. housing, neighbourhood, education, work environment) and general socioeconomic, cultural and environmental conditions [ 51 ]. In terms of refugees, these conditions contribute to resettlement and integration experiences, as well as health outcomes.

Integration is a contested concept but is understood here as a two-way process of adaptation that occurs between incoming and receiving communities [ 17 ]. Ager and Strang’s [ 17 ] influential framework includes ten indicators of integration across four domains. In the ‘Means and Markers’ domain, housing, along with education, employment, and health, are viewed as markers of, and means to, successful integration. The ‘Social Connection’ domain includes social bonds, bridges, and linkages, the ‘Facilitators’ comprises language and cultural knowledge, and safety and stability, and ‘Foundation’ covers rights and citizenship. This model and Dahlgren and Whitehead’s model of the SDH overlay significantly, particularly in relation to the shared markers of SDH and inclusion of health [ 52 ] and the potential ways that these features can mutually reinforce one another for refugees [ 47 ]. Importantly, a greater focus on the social context of receiving communities and the interrelatedness of the different levels has been called for [ 53 , 54 ] and to account for intersectional forms of oppression [ 55 ] and various aspects of identity and personal histories in the integration process.

As such, we look at health and housing, alongside SDH and integration, in a social-ecological context where it is possible to examine the social policies and processes that influence the housing experiences of refugees and associated impacts on health.

Materials and methods

The findings in this paper form part of a larger study of the relationship between housing, social inclusion and health for asylum seekers and refugees in Australia, which involved surveying of over 400 people who arrived in Australia as asylum seekers or refugees and interviewing 50 people who indicated in the survey that they were interested in participating further [ 56 ]. For this paper we report on 25 participants who took part in at least two rounds of interviews. First wave interviews were conducted March-November 2016. Second round interviews were conducted with 25 participants in May 2018-February 2019, an average of 22.85 months later. Nineteen people then took part in a third-round interview (conducted January-July 2020), an average of 21.26 months after second round interviews.

In Australia at the time of the interviews around 30,000 people were on temporary refugee visas (TVs) (those who arrived by boat after 2012 without a valid visa and claimed asylum were not eligible for a permanent refugee visa (PV) even if their claim was upheld) or awaiting their refugee claims to be processed and were on bridging visas (BVs) [ 57 ]. These TVs generally entitled holders to fewer supports. For new arrivals on PVs, housing support was offered in the first 6 months (less than a month for asylum seekers) after which it was expected that they would source independent housing. This was overwhelmingly in the private rental market given extensive waiting lists for social housing.

Table  1 shows participant characteristics. At the time of the second-round interview, seven asylum seekers had had their claims for refugee status accepted and granted a temporary refugee visa, four remained on bridging visas awaiting a decision from immigration, and one remained on a temporary refugee visa. One citizen (at the time of the first round) took part in a second and third-round interview, and one permanent resident (PR) became a citizen between the first and second-round interviews. The remaining 11 second-round participants were PRs. 11 of the 12 TV holders took part in a third-round interview, with two asylum seekers being granted temporary refugee visas just prior. Three third-round participants became citizens between the second and third rounds, and three remained PRs, with plans to apply for citizenship when eligible. In this paper, we use pseudonyms to describe participants and include their gender, visa status and region of origin for any direct quotes we use.

The study received ethics approval from the Flinders University (then) Social and Behavioural Research Ethics committee, and the researchers adhered to a range of ethical considerations crucial to working with refugees and asylum seekers. These included paying attention to issues of coercion, power imbalances between the researchers and participants, and ensuring confidentiality and anonymity [ 58 , 59 ]. A Community Advisory Group made up of refugees and asylum seekers, as well as a broader Reference Group of service providers and other stakeholders helped to guide all aspects of the study. In particular, the interviewing researchers were provided with guidance from experienced service providers in trauma informed and culturally appropriate approaches to engaging with refugees and asylum seekers from diverse backgrounds. This included taking time to connect with potential participants and earn their trust, meeting in a place that was most comfortable for participants, seeking ongoing consent during interviews, and referring participants to services if they required assistance. Over the course of the second and third round interviews, one participant was connected with a counselling service for her son who was described as experiencing depression.

Interview participants were initially recruited through the broader survey [ 46 , 56 ]. Participants for second (and then third round) interviews were recruited from the original interview pool and the interviewing researcher contacted no more than three times via telephone call or text to seek people’s approval to meet for an interview. Interpreters were offered and used by the same five participants in each round of interviews. In each case, the participants were happy with a professional interpreter.

In interviews, questions focused on participants’ housing experiences and broader resettlement and self-reported impacts on health, with round two and three interviews focusing on changes since last interview. First round interviews lasted between 16 and 70 minutes (mean = 32.23). Second round interviews lasted between 25 and 79 minutes (mean = 44.13). Third round interviews lasted between 22 and 93 minutes (mean = 51.11). Three non-migrant women conducted the first-round interviews. Another non-migrant woman conducted the second and third round interviews. All interviewers had extensive training and experience in conducting interviews with people from refugee backgrounds in relation to health.

Data analysis

In our analysis we were guided by a critical realist approach [ 60 ], which provided the philosophical underpinnings for examining institutional and structural factors to consider in relation to health promoting housing, frequently extending beyond the influence of individual agency. Specifically we used a framework thematic analysis approach informed by Ritchie and Spencer (1994), and Lewis [ 61 , 62 ]. This involved: familiarisation with the data, where transcripts from the whole data set (across the time points) were read by multiple team members; developing a coding framework and then indexing using the NVivo Version 12 qualitative software database (QSR International, Melbourne, Australia). The coding structure was adapted and refined during team meetings and as the coding took place to allow for outliers in the data. The charting phase involved the research team developing thematic matrices where participants were charted against the emergent themes across the three time points. These matrices were developed so that the team could look across all stages of data collection to “capture an essence of the journey travelled” over time by exploring how changes happened, what these changes looked like, changes to participants’ trajectories, and participants’ narratives of the impacts of their housing experiences over time on their wellbeing in the connect of their refugee journey [ 62 ]. All the data were then summarised by interview round and combined so that common and divergent themes across the whole data set could be identified. In the final mapping and interpretation phase, the health-related housing experiences of the participants over two and three waves were outlined, differences between groups and contexts were identified, and explanations for these developed. This final phase was undertaken during regular team meetings and at other times by individual team members in order to capture the ‘devil in the detail’ [ 63 ].

First round interviews (reported in more detail [ 46 ]) identified that housing had an impact on health - particularly mental health - through issues of unaffordability, unsuitability (including physical elements and the social environment where housing is located), and insecurity of tenure including difficulties securing housing. Importantly, in terms of participants’ self-reported baseline health status, many were living with mental and physical health challenges such as chronic pain, sleep disturbances, symptoms associated with anxiety, stress, and post-traumatic stress disorder (PTSD), and persistent negative emotional states that they attributed to pre and post migration factors including housing, as well as immigration status limbo, prolonged family separation, and barriers to employment, which collectively contributed to a sense of ontological insecurity.

Building on the findings from this paper on first round interviews, here we focus on the mechanisms that drive the relationship between housing and health over time. The mechanisms, which are often overlapping, are: physical environment; stability; safety; and social connections, support and services. We highlight the psychosocial elements contributing to ontological security as a pathway to health: belonging, control, living practices, privacy, and identity, and the direct health impacts via mental and physical stressors and access to health promoting resources (see Fig.  1 ). The findings also reflect a nested socio-ecological approach which considers the relationship between housing and health over time. This includes individual and community level moderating factors (gender, country/culture, family circumstances, immigration status, language skills, income, personal philosophy, and health status) through to features of the local housing context (affordability, security of tenure, suitability) which constitute degrees of precarity, through to the national policy context (e.g., immigration, welfare, housing and health policy and inequities) and international immigration context (e.g., conflict and displacement, the Refugee Convention).

Mechanisms linking housing and health for refugees

Physical environment

The analysis revealed that problems with the physical environment (including cold and damp, overcrowding and housing located near noisy traffic) were a key mechanism through which challenges with affordability and suitability impacted health. This included through increased physical and mental stressors, and barriers to rebuilding ontological security. For example, Nahal and her family had moved between the first and second round of interviews to a more affordable house; however, the new house was in poor condition, and she was worried about the impact of mould on her family’s health, especially her infant nephew:

... because of this mould the baby gets sick [...] so he been in hospital for five days, the baby, and my mum gets very bad pain in her legs and knee and her back because if there is mould (Nahal, woman, PR, Central and South Asia, 2 nd interview).

The family’s inability to afford housing that was in better condition and the housing management’s inadequacy in addressing the issue contributed to Nahal and her family’s distress and worry: “we’ve been there like two years now [...] just struggling, struggling, struggling.” This was compounded by their distress regarding the wellbeing and safety of family who remained in the family’s country of origin, and while her nephew was a welcome blessing – “the baby make our life more happy [...] When I come I see his smile, my care just go away” , their sense of ontological insecurity was high given their worry for his health. Nahal was too busy with study and caring responsibilities to take part in a third interview; however, she indicated in correspondence with the interviewing researcher, that the family had moved to a larger and much cleaner house, which had eliminated her concerns regarding the mould and improved her health.

Financial precarity and a sense of ongoing hopelessness with the physical environment of their housing was mainly evident in the narratives of TV holders subjected to ongoing visa insecurity. Adeeb, a single young man from Central and South Asia, had moved several times since arriving in Australia as an asylum seeker. At the time of the second interview, Adeeb said he had overstayed his welcome with family, was in significant debt, remained in limbo over his immigration status and did not have work rights. As a result, he had moved into a crowded share house with other single asylum seeker men that was “really old [with] lot of holes around it, [so] the wind come in.” He goes on:

It’s noisy. [I] can’t sleep at night, you can hear a lot of noise is – it is near the road. With the traffic the house is shaking at the night (Adeeb, man, TV, Central and South Asia 2 nd interview).

Because of the overcrowded physical environment, Adeeb slept on the couch to avoid sharing a room with three other men:

I just sleep in the lounge room because if you sleep in the [bed]room you need to share with someone else; I don’t like share [...] It’s difficult to stay at that home but because of the rent, it’s a bit cheaper, that’s why I need to stay until I fix all of the money I borrow from my friends, from family. Until six year I live in Australia without [support] because I wasn’t allowed to work .

By the third interview, Adeeb now had work rights and was working but remained in significant debt and uncertainty about his immigration status. After seven years, and in a housing situation that did not provide privacy or safety, Adeeb continued in a state of ontological insecurity and had all by given up: I’m just lying [to] myself. I will get a visa. I will buy a house, whatever. That’s all a lie. I’m just kidding myself. Adeeb’s feelings of hopelessness were further impacted by his confusion and sense of injustice that many members of his own community who arrived around the same time as him had been accepted as refugees and were able to be reunited with their families:

It’s really difficult for anyone but for me as well because the people, we come by the same boat, they all have visa, they’re applying for citizen, they bring their family here and [they visit] their family but for me still nothing. It’s very difficult. It’s a hard situation for me.

Lana, a TV holder from the Middle East and mother of two teenaged children discussed affordability in each of her interviews, particularly finding a suitable house in the area that they wanted their children to go to school. She and her husband were unable to find work and had therefore made a trade-off between their desired neighbourhood and a small and old unit on a busy road. By the time of her third interview, after six and a half years in the unit Lana was in despair, describing the impacts on her children’s sleep and mental state:

Now my son has depression, my daughter has depression. I asked them what happened to you, why they don’t like to talk, they’re always inside their room. They said oh mum, we don’t like this house, always shaking, a lot of noise, we cannot sleep well during the night. (Lana, woman, TV, Middle East, 3 rd interview).

For TV holders, the mental health impacts of living in an unsuitable physical environment were exacerbated by the participants’ lack of control in improving their situation and ongoing ontological insecurity, which were linked to financial precarity, and lack of financial support associated with their TVs, and compounded by stressors associated with forced migration, namely loss of status, language and employment difficulties, and family separation. For Lana and her husband, migrating to another country was not a choice: “we must do it. Because our country is not safe [...] people they live there already die.” Both in their late 40s, learning English and finding work that suited their age, skills and qualifications seemed impossible, adding to the family’s sense of ontological insecurity: “my husband has 30 years’ experience [in the electric] field, but he can’t work because he doesn’t have certificate [and] labour work for him is really hard because he has age”.

Conversely, improving the physical environment of one’s housing produced resources important to health, particularly through elements of ontological security such as a sense of control and independence. For example, Griva, a PR from Southeast Asia described the impact of her family living in cramped conditions for two years. She had moved into a larger house with four bedrooms just prior to being interviewed for the second time during which time she said:

The main thing that we have is our own privacy because honestly in that house I nearly got depression [...] sometimes you need time for yourself [...] I didn’t have that earlier. We have our own privacy [...] It’s much better. We have our own room and stuff (Griva, woman, PR, Southeast Asia, 2 nd interview).

When interviewed again, 18 months later, the family was in the same house and although Griva described being diagnosed with clinical depression over this period as a consequence of varied resettlement experiences such as adjusting to the Australian education system, loneliness, and concern for her mother’s mental health. She reiterated the positive impact that having a private space of her own had: “ I can just be myself and then have my own space.”

Georgieta, an Australian citizen from Africa, during her third interview also described the impact of attaining privacy and space: “My partner found this house [...] It feels good because just me and my partner living here. There’s no other third party, we have our privacy.” Over the study, Georgieta had gone from emergency youth accommodation due to multiple suicide attempts, to staying temporarily with an acquaintance while waiting to secure supported accommodation for young pregnant women at risk, to another share house, to a unit with her partner. She reported experiencing significant traumatic experiences associated with political unrest in her country of origin prior to coming to Australia, being shunned by her family and community after being sexually assaulted by a respected community member, having her young children removed from her care and experiencing intimidation and racist attacks from neighbours and sexual harassment from a flatmate. For Georgieta, having a place of her own with her partner provided a sense of privacy and independence, important to rebuilding ontological security.

A small number of participants also spoke of taking control of what they could to improve their physical environment and engage in living practices in housing that was unsuitable, in view of limited other options as highlighted above. Kazem, for example, a qualified tradesperson in his country of origin, spoke of making significant improvements to his rundown rental to cultivate a home more in keeping with his family’s needs:

[Interpreted] He renovated the kitchen himself for the wife because he knows how the wife likes to live in a nice house and with a nice kitchen and all that. He said back in [my country] we had a good life and good house and everything (Kazem, man, TV, Middle East, 3rd interview).

Likewise, Hiranjan spoke of his vegetable garden during the second and third interview. Although he was concerned about the associated cost of water, he “still love[s] to grow vegetables” (man, PR, Southeast Asia). At the time of the third interview, Hiranjan took great pride in showing the interviewing researcher his garden, and particularly the different vegetables native to his country of origin. Cultivating therapeutic spaces through living practices such as gardening, was a strong theme drawn from several of the first-round interviews [ 33 , 46 ].

Instability

Over the course of the study, all but one participant (a social housing tenant) remained in private rental housing. Broader housing unaffordability and difficulties securing housing meant that several participants had no choice but to remain in unsuitable housing rather than face the rental housing market. As above with Lana and Adeeb, this included navigating limited income, unaffordable rents in preferred areas (close to schools and safe neighbourhoods) and challenges having rental applications approved often due to their immigration status. For example, several TV holders from Central and South Asia and the Middle East remained in unsuitable housing over the course of the study due to the challenges associated with applying for rentals as non-citizens. All had unsuccessfully applied for multiple other rental properties, As Bijan shared:

We tried to move but we weren’t successful [...] It’s hard to find because most of the house here is old house and if you want to find [a real estate agent or owner] you can connect with it’s hard, you know. They’re asking too much [questions] they not give you [house] easy. You know, it’s hard. Moving is very hard (Bijan, man, TV Middle East, 2 nd interview).

TV holder Kazem who had taken control by improving the physical environment of his house (detailed in the previous theme) was similarly unable to find more suitable accommodation for his family: “ looking into the passports and knowing that you’re from Australian background, that’s one of the things that the landlords and the agents are mostly looking.”

Several participants spoke of renting housing directly from owners, and in some cases owners from the same country of origin. For example, Lachina, a TV holder from the Middle East had prioritised some sense of stability over suitability by renting from a landlord from the same country for seven years. At the second interview she said:

...my house is old and it was very damaged and it was so dirty, not clean. That house had one point, my owner was [from same country]... and I could very well connect to him (Lachina, woman, TV, Middle East, 2 nd interview).

By the third interview, the family was looking for a new rental because their landlord planned a redevelopment; however, their applications had been rejected several times including from a house that remained advertised. Lachina believed this was because: “when we sent our documents for [the real estate agent], oh, he finds that we are travel documents in passport”. The cumulative health effects that Lachina was experiencing were significant:

I am in stressed, affected in my sleeping, I can’t have a good sleep and more time my allergy comes up and I scratchy skin, and I can’t deep breath, easy breath I can’t. All time I use, I smoke cigarette, it’s very bad for me.

In terms of stable housing, participants indicated that a key goal was home ownership. While this is the goal of many people in Australia, home ownership and the security it presents was particularly important for this group. For example, Hiranjan from Southeast Asia was focused on his goal of buying a house soon along with other education, employment and travel goals aimed at improving his circumstances. He had experienced unsuitable housing at the time of the second interview while pursuing his education. However, when interviewed for the third time he was working fulltime, aiming to undertake further tertiary study and was resolute in the goal of stable housing through purchasing a home: “I’m working now, I feel that I can buy home” (Hiranjan, man, PR, Southeast Asia).

For those on TVs, home ownership was a symbol of a more certain future. For example, by the time of the third interview, Naweed had moved with his wife between rentals and accommodation with friends and then family. He described his wish to have a home of his own:

It’s my dream to – yeah, freedom with my wife and like our own property [...] I am tenant; I’m not the owner. It’s a big change for me is one day that I can get a good property for myself. I relax when I get home for myself, which is difficult [...] When I’m thinking after 10 years, we can’t do anything, it will affect me and I’m thinking that I do not belong to this country (Naweed, man, TV, Central and South Asia 3 rd interview).

Here Naweed’s TV status is a clear barrier to rebuilding elements of ontological security (belonging), where he has waited in limbo for over a decade for resolution of his asylum claim including long periods without work rights – where ‘we can’t do anything’. Other TV holders highlighted financial limitations associated with their visa as a barrier to home ownership including several who had unsuccessfully applied for a bank loan to purchase a home due to lending conditions associated with their TVs (larger deposit required compared to citizens and much higher interest rates), which made purchasing a house impossible. For example, Shabir, from the Middle East, had remained in unsuitable but affordable housing with the aim to relocate to his own home once he was able to afford to buy. Shabir arrived in Australia with no English and had worked hard to develop his language skills and to earn enough money for a deposit. He had moved from one form of shared accommodation to another much less suitable shared accommodation (more crowded and poorer condition) because the rent was cheaper and described the mental stressors he was experiencing largely due to his unsuccessful and hard-fought attempts to progress and build a sense of belonging and a future in Australia through buying his own house:

At this age, I’m now 23 or 24 but I look like 30, 35 now because I’m thinking ‘oh family; okay, this much [money] for family. I’ve got this much now’ I need to pursue my future and all these things. It’s not that easy; it’s really difficult [I’m] a lot depressed [...] There is not any option for me. The only option is to [keep going] (Shabir, man, TV, Middle East, 2 nd interview).

In contrast to the ongoing constraints experienced by TV holders, some participants who were PRs discussed improvements in housing situations over time due to factors such as secure immigration status, education, and English language skills and employment providing a sense of stability, control, belonging and optimism for the future. At the second interview Pazir, a PR from Central and South Asia, said he and his family had traded between elements of precarious housing by moving from a costly rental in an area populated with members of their cultural community where they were very happy, to more affordable supported accommodation which did not meet their other needs (space, condition, location). Five years on, as new citizens, Pazir described ‘paying his dues’ in his previous housing and finally relocating with his family to a house that was significantly more suitable:

...it’s a very good house, very, very good, and very – and a good price, as well [...] like the way my mum, she always wanted. So, we spent really hard time on that house [previous house] That time was like really tough, everything went slowly, slowly. The only thing you have to be [is] patient, I think. If you’re thinking everything will click [into place], or everything there will be magic, that’s not going to happen – with anyone (Pazir, man, citizen, Central and South Asia, 3 rd interview).

Having a sense of control over housing together with other elements of resettlement (employment and education) and stability in immigration status led to key elements of ontological security and positive health outcomes in resettlement. Notably, by virtue of the restrictions associated with their visas, TV holders experienced more barriers and frequently described the mental stressors of having limited control over their access to stable housing and associated sense of belonging. This state of ontological insecurity was compounded by family separation and remittance responsibilities and experiencing ongoing limbo.

The extent to which people felt safe in their neighbourhoods was identified as a key mechanism by which elements of housing (affordability and suitability in terms of location) influenced health and access to rebuilding ontological security. As identified in the first round interviews [ 46 ], threats to safety and proximity to social disorder (violence, drug and alcohol abuse, anti-social behaviour) were widely reported and prompted people to relocate to safer suburbs. For example, Edris a PR from the Middle East, detailed several burglaries in his first government-provided house, and the effect that feeling unsafe had on his mental health. At the second interview, Edris described having to leave his country of origin due to “problems with the government” that meant it was unsafe for him to stay. Feeling safe in his new environment was therefore critical to his chances of rebuilding a sense of ontological security. Edris and his partner had relocated at this time to an apartment block with a range of security features. Of the move, he said:

Positive is it’s a good area, as I said, a safe area. We don’t need to be worried [that we will be robbed] when we go out for one day or two days with friends which has happened in our first home two times [...] now we just go out and relax. Don’t need to think about the house.

Likewise, George a PR from Africa, had struggled through a period of living in a government-provided housing complex soon after arriving in Australia with his mother and siblings, where he and his family were in proximity to a range of anti-social behaviours that led him to feel unsafe. At the time of the second interview, George had a fulltime job in his area of expertise in another State of Australia and was living in a share house where a significant proportion of his neighbours were from his cultural community. He described his housing as “more peaceful.” At the third interview, he was still in the same house and expanded on his sense of feeling safe and at “home”, despite being separated from family still in his country of origin:

I do feel like home. Whenever you are safe you can call it home, however sometimes you may not be able to see your family members or your people who talk in your language. Sometimes it can be hard but as long as I’m safe, as long as I have very good friends here, so I’m very happy to call it home.

Edris and George described income from employment, subsidised accommodation and cultural community connections that contributed to their safer living environments. As an avenue to rebuilding ontological security, relocating to a safer neighbourhood contributed to feeling more at home.

Other participants who remained in unsuitable housing in safe neighbourhoods, also acknowledged the importance of safety particularly in the context of their experiences as refugees. For example, Nahal a PR from Central and South Asia and Lana a TV holder from the Middle East were in unsuitable housing that contributed to physical and mental stressors for themselves and their families. However, at their second interviews, they still described the safety they felt in their neighbourhoods as critical to their health:

I do feel safe. Oh my God, I feel really safe here. If I compare with my country, 90 percent I’m safe here. In my country 90 percent not, ten percent I’m safe. At home you just stay at home. [Here] I go to the beach by myself I’m not scared I’m happy (Nahal).

I am happy because when my children go outside I’m sure they come back but in [home country] it’s not possible, really difficult. You don’t know what happens (Lana).

Most participants over the course of the study had been able to relocate from neighbourhoods where they felt unsafe, through advances in their circumstance (education and employment) or by making trade-offs in terms of the condition of the actual dwelling as seen in a previous theme. However, a small number of participants described experiencing ongoing threats to their safety, which had consequences for their health. For example, William, a PR (at second interview) from Africa, described “facing hell with the neighbours now”. Although William expressed high levels of satisfaction with his housing previously, at the second interview, he had relocated to another flat in the same complex and described being harassed by a neighbour causing great worry for his children who all have medical conditions:

We are living in [continual] fear [the children] are not safe. If we are to take a decision to go back they are not safe in our country, so you see the situation we find ourselves? [...] why are we treated as if we are shit? What have we done? They are pushing people to the edge.

During the second interview, William was highly agitated and left abruptly after receiving a phone call from his wife, who was suffering from significant mental health issues related to their experiences with their neighbours. The importance of ongoing safety to rebuilding ontological security and health and wellbeing for people from refugee backgrounds is crucial precisely because of the extreme fear already experienced though forced migration and the significant ongoing concerns for family still in conflict zones.

Social connections, support and services

Over time, housing affordability and suitability (social and physical in terms of location) was reported to impact health through proximity to social connection, support and services. A significant proportion of participants indicated a cultural imperative to have good connections with close neighbours, primarily to aid the development of social and emotional resources important to health through elements of ontological security – namely belonging and identity. While some were able to develop these relationships over time and enjoy the associated resources, others had less success. For example, Chaghama, a PR from Central and South Asia described moving far from her preferred neighbourhood to a more affordable location. Of her new neighbourhood, Chaghama said:

“ If we live ten years still we don’t know who is our neighbour [...] because we were new. [...] We wanted to talk so when we see this we were shocked ‘oh God, it’s so difficult here because nobody, neighbour, not even asking ‘do you need any help? Do you need food or do you – any problem you can call us, you can get anything you want’. You know, if there is a new neighbour come in our side we go and ask ‘do you have food for yourself now? If you’re tired we can cook for you. If you need water, you need anything, please ask us’. When we came here that was a very difficult one, very difficult.

During the second interview, Chagma described having high levels of distress in relation to the safety and health of her family in her country of origin, including a son who was very unwell. Chagma described how important proximity to community connections was for emotional support around family separation. While she was able to visit with her cultural community connections from time to time, her new neighbourhood was mainly Anglo-Australian and she was yet to develop English language skills meaning she felt unable to make the sorts of connections that would provide longed for social and emotional resources, and which would enable living practices that support ontological security. With chronic physical and mental health issues, the absence of neighbourhood social supports was challenging “ even if I am dying, even something happening, they’re [neighbours] not going to come and check with me.”

Conversely, others described great success with developing strong social bonds with neighbours from the same and different cultural backgrounds, which yielded a range of social and emotional resources positive for health and wellbeing. Farhad and Hiranjan both PRs and from the Middle East and Southeast Asia respectively, described developing family-like bonds with neighbours from Anglo-Australian backgrounds that facilitated feelings of belonging:

[My neighbour] told me herself a few months ago – or last year I think – she said ‘I would never think that I will have a refugee friend like you that changed my life forever’. I said ‘my God, thank you so much’. [That] kind of conversation and talking just clear for everyone that we are human like you. We are not from a different planet, you know what I mean? [...] now she calls me ‘son’ which is really important. [O]ur friendship is very close and tight now (Farhad).

One of my neighbour is ...like my grandmother, yeah, she’s Aussie and she live alone I meet every day. We [have things] like presents on birthday and I invite her for dinner at my home and she always coming (Hiranjan).

Farhad was also linked in with other friends through his neighbour and took pleasure in noting the large network he now enjoyed where support was reciprocal: “ whenever they need help I’m there to help them and whenever I need help they are there to help.” While Farhad did not take part in a third interview, Hiranjan did and indicated that he had reluctantly moved to a different neighbourhood as the owner of his rental house was selling. He was hopeful of connecting with his new neighbours and reflected on how critical the relationship with his elderly Australian neighbour was, including the practical resources he gained from the connection, particularly English language skills and cultural knowledge:

When I was there, we used to pretty much every time we meet each other and having that conversation as well like every maybe I can say half an hour every day. So doing that one, see my English is improving as well, so yeah, it’s really great to chat with her because it’s good to have that all the experience and then like different cultures. Yeah, she shared me a lot (Hiranjan, man, PR, Southeast Asia 3 rd interview).

Developing good relationships with neighbours was also noted as a potential antidote to experiences of discrimination and harassment in one’s neighbourhood, enabling ontological security to be rebuilt. For example, in contrast to the second interview, described in the previous theme, William’s third interview described a close relationship that had developed between a neighbour and his family. The neighbour had recognised the strain that the family was experiencing and had offered to drive the children and William’s wife to where they needed to be if William was at work:

He’s a very good man, he’s a very generous man. This is one of the reasons that is really, really stopping at the moment to look beyond to seek other accommodation. Because my wife is not driving [...] we found this man, really, really, really helpful (William, man, PR, Africa, 3 rd interview).

In addition, a small number of participants noted changes in proximity to services and other places important to health. Pazir a PR from the Central and South Asia had previously described his time in unsuitable housing and during the third interview expressed great relief that he and his family were able to secure a rental that met all their needs. These needs included proximity to medical care for his mother, who had poor mental and physical health, as well as cultural shops, and the Mosque:

So comfortable and so amazing, and especially, it’s very near to all the - if you look to the city, it’s very easy. Like, my mum, her doctor’s sitting in [general practice], like 10 - 15 minutes to drive from here, and especially like all the halal butchers, and all the halal shops, Afghani shops, are there, and if you look, there is a mosque only six minutes’ drive from here [...] What else you want? (Pazir, man, citizen, Central and South Asia 3 rd interview).

At the time, Pazir had just become an Australian citizen and during the interview was in cultural dress having attended the citizenship ceremony. His new and more suitable housing was described in the context of this big change in his life, which was a key pathway to rebuilding ontological security and reflective of the layers of influence on health indicated in Fig.  1 : “I’m so satisfied, I’m so lucky, and now, finally, too, from today on, I’m a full Australian.”

This paper drew on SDH, integration, and socioecological framings to examine the mechanisms by which housing experiences affect health over time for refugees and asylum seekers. We considered the refugee resettlement journey and multilevel, cumulative, and reciprocal relationships between housing and health and the wider contexts (social, political, material, and economic) that influence day-to-day lives and shape health outcomes [ 18 ].

The findings add to relatively scarce literature highlighting the way housing acts as a SDH for refugees in high-income resettlement countries, mirroring previous findings in relation to the impact of affordability, security of tenure and suitability in the local housing context on health [ 14 ]. As outlined in Fig.  1 , the analysis identified several key mechanisms through which housing context (affordability, security of tenure and suitability) affected health negatively over time as mental and physical health stressors and positively through health promoting resources –namely the physical environment of the housing and neighbourhood, stability of housing, sense of safety, and access to social connections, support and services. These findings reflect those of the authors’ original study [ 46 ]. Individual elements of these have also been identified previously in the literature, for example in relation to precarious housing [ 13 ], overcrowding and lack of privacy [ 64 ], and the importance of gardens, physical condition, space, layout and privacy and, in relation to neighbourhood, safety, green spaces and proximity to services [ 33 ]. Through this model, however, we seek to identify the complex interplay between these features of housing over time, as well as highlighting the way that psychosocial elements of ontological security such as belonging, control, living practices, privacy and identity were key to these mechanisms [ 6 , 7 , 65 ] and important health resources for refugees and asylum seekers in the context of ontological insecurity that is a by-product of forced displacement [ 33 , 66 , 67 ].

In the accounts of the participants, the cumulative health impacts over time of negative housing trajectories were evident and noted as occurring alongside other overlapping elements of SDH and integration such as challenges with employment, access to education, financial precarity, English language acquisition, migration pathway/temporary visa status, and health status itself. These compounding problems mirror literature pointing to the harm caused by cumulative stressors associated with precarity in multiple aspects of life [ 13 , 68 , 69 , 70 ]. In contrast, those with existing resources such as English language skills, family networks, and importantly access to supports and services associated with their permanent residency/citizenship status were less susceptible to negative health impacts. The findings from this study highlight the particular precarity experienced by asylum seeker and refugee participants on temporary visas, with most noting the lack of control that they possess as temporary residents of Australia. This lack of (real and perceived) control is not only a psychosocial element of ontological insecurity, but a SDH in its own right [ 15 ]. Indeed, ontological insecurity is a key element in asylum seeker and refugee negotiations of agency and control, leading to “the oxymoron of being ‘safe in uncertainty”’ [ 71 ].

Intersectional differences across aspects such as gender, country/culture of origin, family circumstances, as well as immigration status, and income were evidenced in the narratives of participants – which reflect broader systems of oppression and privilege such as sexism, racism and classism [ 72 ]. These also reflect more broadly national welfare policies and international immigration and the ways that these shape social and health inequities – highlighting the value of a socioecological framing [ 16 ]. For example, temporary visa holders reported consistently worse outcomes, indicating how immigration policies around temporary visas and welfare policies around income support, set against a backdrop of increased international forced migration, can help to shape an individuals’ housing trajectory and subsequent health. Aspects of this model reflect the recent model by Swope and Hernandez [ 23 ] which seeks to link structures, mechanisms and housing ‘pillars’ to health disparities. We build on this to drill down into aspects of housing that were particularly pertinent to refugees and asylum seekers, who are at greater risk of ill health associated with housing issues [ 13 , 34 , 35 ].

While housing has been identified as an important means and marker of integration [ 17 ], the nuanced ways that refugee and asylum seeker housing experiences can (or cannot) support integration, or how the housing market might shape a two-way notion of integration has been less elucidated. We highlight that a hostile private rental market (reflective of broader national and international policy contexts) indicates a receiving community context that is not conducive for successful housing outcomes and integration in this regard [ 35 ], and identify the limits of individual agency in navigating this to be able to secure housing that is health promoting.

The housing that resettlement countries provide can support or hinder successful integration and contributes to shaping the health outcomes of resettled refugees. Additionally, consideration of ontological security and an understanding of broader contextual factors is crucial. Many participants continued to experience housing problems, suggesting that housing issues do not necessarily resolve over time and that some refugees and asylum seekers are forced into ‘housing niches’ [ 73 ] that are damaging for health. More supportive policies and programs are required to assist refugees and asylum seekers and to transform societies in true two-way integration. Key upstream policies to contribute to this include immigration policies that offer permanency in immigration status and more generous welfare policies to address cost issues, alongside greater regulation of housing markets and incentives for more affordable housing. At a more local level, greater support for refugees and asylum seekers in moving through the private rental market beyond the initial resettlement phase would be helpful, as would efforts to work within local neighbourhoods to foster greater social cohesion and ‘neighbourliness’.

This paper is one of only a small number that have examined the impact of housing and health for refugees and asylum seekers over time. This longitudinal approach assisted in identifying the complex interplay of factors involved and the power (and limits) of individual agency in navigating housing across the resettlement journey. However, limitations include the potential lack of representativeness of the initial sample and that an inability to follow up all of these participants means that those who continued in the study may have had more negative (or positive) trajectories than the initial broader sample.

This qualitative longitudinal study identified key pathways between housing and health for asylum seekers and refugees, building on a growing evidence base highlighting housing as a key SDH for general populations and extending this to a resettlement context. It also indicated influences at varying socioecological levels and pointed to key policy levers that must be pulled to improve outcomes for new arrivals. Rebuilding a sense of home is crucial for those experiencing forced relocation, and in the context of two-way integration receiving communities have a crucial role to play in facilitating this process.

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available due to the need to preserve the confidentiality of research participants.

UNHCR. Global Trends Report 2022. United Nations High Commissioner for Refugees; 2022.  https://www.unhcr.org/global-trends-report-2022 .

Papadopoulos RK. Refugees, home and trauma 1. Therapeutic care for refugees: Routledge; 2018. pp. 9–39.

Kibreab G. Revisiting the debate on people, place, identity and displacement. J Refugee Stud. 1999;12:384.

Article   Google Scholar  

Henkelmann J-R, de Best S, Deckers C, Jensen K, Shahab M, Elzinga B, et al. Anxiety, depression and post-traumatic stress disorder in refugees resettling in high-income countries: systematic review and meta-analysis. BJPsych Open. 2020;6(4).

Nickerson A, Hoffman J, Keegan D, Kashyap S, Argadianti R, Tricesaria D, et al. Intolerance of uncertainty, posttraumatic stress, depression, and fears for the future among displaced refugees. J Anxiety Disord. 2023;94:102672.

Article   PubMed   Google Scholar  

Easthope H, Liu E, Judd B, Burnley I. Feeling at home in a multigenerational household: The importance of control. Hous Theory Soc. 2015;32(2):151–70.

Hiscock R, Kearns A, MacIntyre S, Ellaway A. Ontological security and psycho-social benefits from the home: Qualitative evidence on issues of tenure. Hous Theory Soc. 2001;18(1–2):50–66.

Phillimore J, Goodson L. Making a place in the global city: The relevance of indicators of integration. J Refug Stud. 2008;21(3):305–25.

Pittaway E, Muli C, Shteir S. “I have a voice–hear me!’’ Findings of an Australian study examining the resettlement and integration experience of refugees and migrants from the Horn of Africa in Australia. Refuge Can J Refugees. 2009;26(2):133–46.

Kartal D, Kiropoulos L. Effects of acculturative stress on PTSD, depressive, and anxiety symptoms among refugees resettled in Australia and Austria. Eur J Psychotraumatology. 2016;7(1):28711.

Alidoust S, Huang W. A decade of research on housing and health: A systematic literature review. Rev Environ Health. 2023;38(1):45–64.

Cooper S, Enticott JC, Shawyer F, Meadows G. Determinants of mental illness among humanitarian migrants: longitudinal analysis of findings from the first three waves of a large cohort study. Front Psychiatry. 2019;10:545.

Article   PubMed   PubMed Central   Google Scholar  

Martino E, Li Y, Kali-Opio J, Bentley R. Between liminality and a new life in Australia: What is the effect of precarious housing on the mental health of humanitarian migrants? Cities. 2022;131:103900.

Ziersch A, Due C. A mixed methods systematic review of studies examining the relationship between housing and health for people from refugee and asylum seeking backgrounds. Soc Sci Med. 2018;213:199–219.

Marmot M, Wilkinson R. Social determinants of health. Oxford: Oxford University Press; 2005.

Book   Google Scholar  

Bronfenbrenner U. Toward an experimental ecology of human development. Am Psychol. 1977;32(7):513.

Ager A, Strang A. Understanding integration: A conceptual framework. J Refug Stud. 2008;21(2):166–91.

Stokols D, Allen J, Bellingham RL. The social ecology of health promotion: implications for research and practice. Am J Health Promot. 1996;10(4):247–51.

Article   CAS   PubMed   Google Scholar  

UNHCR. What is a refugee? 2020. https://www.unrefugees.org/refugee-facts/what-is-a-refugee/ . Accessed 2 May 2023.

World Health Organisation. Constitution. 1995. https://www.who.int/about/who-we-are/constitution . Accessed 12 Mar 2023.

Rauh VA, Landrigan PJ, Claudio L. Housing and health: intersection of poverty and environmental exposures. Ann N Y Acad Sci. 2008;1136(1):276–88.

Baker E, Bentley R, Lester L, Beer A. Housing affordability and residential mobility as drivers of locational inequality. Appl Geogr. 2016;72:65–75.

Swope CB, Hernández D. Housing as a determinant of health equity: A conceptual model. Soc Sci Med. 2019;243:112571.

Mallett S, Bentley R, Baker E, Mason K, Keys D, Kolar V, et al. Precarious housing and health inequalities: what are the links?: Summary report. Australia: Hanover Welfare Services, University of Melbourne, University of Adelaide, Melbourne City Mission; 2011.

Howden-Chapman P. Housing and inequalities in health. J Epidemiol Community Health. 2002;56(9):645–6.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Baker E, Mason K, Bentley R, Mallett S. Exploring the bi-directional relationship between health and housing in Australia. Urban Policy Res. 2014;32(1):71–84.

WHO. WHO housing and health guidelines. 2018. https://www.who.int/publications/i/item/9789241550376 . Accessed 27 June 2022.

Giddens A. Modernity and self-identity: self and society in the late modern age. Stanford: Stanford University Press; 1991.

Google Scholar  

Fozdar F, Hartley L. Housing and the Creation of Home for Refugees in Western Australia. Hous Theory Soc. 2014;31(2):148–73.

Dupuis A, Thorns DC. Home, home ownership and the search for ontological security. Sociol Rev. 1998;46:24–47.

Padgett DK. There’s no place like (a) home: Ontological security among persons with serious mental illness in the United States. Soc Sci Med. 2007;64(9):1925–36.

Henwood BF, Redline B, Semborski S, Rhoades H, Rice E, Wenzel SL. What’s next? A grounded theory of the relationship between ontological security, mental health, social relationships, and identity formation for young adults in supportive housing. Cityscape (Washington, DC). 2018;20(3):87.

Due C, Ziersch A, Walsh M, Duivesteyn E. Housing and health for people with refugee- and asylum-seeking backgrounds: a photovoice study in Australia. Hous Stud. 37(9):1598–624.

Fozdar F, Hartley L. Refugee resettlement in Australia: What we know and need to know. Refug Surv Q. 2013;32(3):23–51.

Brown P, Gill S, Halsall JP. The impact of housing on refugees: an evidence synthesis. Hous Stud. 2024;39(1):227–71.

Hynie M. The social determinants of refugee mental health in the post-migration context: A critical review. Can J Psychiatr. 2018;63(5):297–303.

Hynes T. New issues in refugee research. The issue of ‘trust’ or ‘mistrust’ in research with refugees: choices, caveats and considerations for researchers. Working Paper Number 98. Geneva: Evaluation and Policy Analysis Unit, The United Nations Refugee Agency; 2003.

Porter M, Haslam N. Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons: a meta-analysis. JAMA. 2005;294(5):602–12.

Bogic M, Njoku A, Priebe S. Long-term mental health of war-refugees: a systematic literature review. BMC Int Health Hum Rights. 2015;15(1):29.

Lindert J, von Ehrenstein OS, Priebe S, Mielck A, Brahler E. Depression and anxiety in labor migrants and refugees - A systematic review and meta-analysis. Soc Sci Med. 2009;69(2):246–57.

Beer A, Foley P. Housing need and provision for recently arrived refugees in Australia. Melbourne: Australian Housing and Urban Research Institute; 2003.

Flatau P, Smith J, Carson G, Miller J, Burvill A, Brand R. The housing and homelessness journeys of refugees in Australia. Melbourne: Australian Housing and Urban Research Institute; 2015.

Netto G. Identity negotiation, pathways to housing and “place’’: the experience of refugees in Glasgow. Hous Theory Soc. 2011;28(2):123–43.

Murdie RA. Pathways to housing: The experiences of sponsored refugees and refugee claimants in accessing permanent housing in Toronto. J Int Migr Integr/Rev l’integration Migr Int. 2008;9(1):81–101.

Weidinger T, Kordel S. Access to and exclusion from housing over time: refugees’ experiences in rural areas. Int Migr. 2023;61:54–71.

Ziersch A, Walsh M, Due C, Duivesteyn E. Exploring the relationship between housing and health for refugees and asylum seekers in South Australia: a qualitative study. Int J Environ Res Public Health. 2017;14(9):1036.

Ziersch A, Mahdavi EG, Levin I, Walsh M, Due C, Green E. Health and wellbeing impacts of experiences of public spaces for young people from refugee backgrounds in Australia. Wellbeing Space Soc. 2023;5:100178.

Simone D, Newbold KB. Housing trajectories across the urban hierarchy: analysis of the longitudinal survey of immigrants to Canada, 2001–2005. Hous Stud. 2014;29(8):1096–116.

Hiebert D. Newcomers in the Canadian housing market: a longitudinal study, 2001–2005. Can Geogr. 2009;53(3):268–87.

WHO. Social Determinants of Health. 2018. https://www.who.int/social_determinants/sdh_definition/en/ . Accessed 15 June 2023.

Dahlgren G, Whitehead M. Policies and strategies to promote social equity in health: Background document to WHO-Strategy paper for Europe. Stockholm: Institute for Future Studies; 1991.

Ziersch A, Miller E, Baak M, Mwanri L. Integration and social determinants of health and wellbeing for people from refugee backgrounds resettled in a rural town in South Australia: a qualitative study. BMC Public Health. 2020;20(1):1–16.

Phillimore J. Refugee-integration-opportunity structures: shifting the focus from refugees to context. J Refug Stud. 2021;34(2):1946–66.

Hynie M, Korn A, Tao D. Social Context and Integration for Government Assisted Refugees In Ontario, Canada. In: Poteet M, Nourpanah S, editors. After the Flight: The Dynamics of Refugee Settlement and Integration. Newcastle Upon Tyne: Cambridge Scholars Publishing; 2016. p. 183–227.

Bauer GR. Incorporating intersectionality theory into population health research methodology: challenges and the potential to advance health equity. Soc Sci Med. 2014;110:10–7.

Ziersch A, Due C, Walsh M, Arthurson K. Belonging begins at home: Housing, social inclusion and wellbeing for people from refugee and ayslum seeking backgrounds. Adelaide: Flinders Press; 2017.

DHA. Visa statistics- Statistical information on visit, study, work, migration and humanitarian visas: Department of Home Affairs. Australian Government; 2020. https://www.homeaffairs.gov.au/research-and-statistics/statistics/visa-statistics/live/humanitarian-program . Accessed 25 July 2023.

Ziersch A, Due C, Arthurson K, Loehr N. Conducting Ethical Research with People from Asylum Seeker and Refugee Backgrounds. In: Liamputtong P, editor. Handbook of Research Methods in Health Social Sciences. Singapore: Springer; 2017. pp. 1–19.

Block K, Warr D, Gibbs L, Riggs E. Addressing Ethical and Methodological Challenges in Research with Refugee-background Young People: Reflections from the Field. J Refug Stud. 2012;26(1):69–87.

Bhaskar R. The possibility of naturalism: A philosophical critique of the contemporary human sciences. London: Routledge; 2014.

Ritchie J, Spencer L. Qualitative data analysis for applied policy research. In: Burgess ABaRG, editor. Analyzing Qualitative Data. London: Routledge; 1994. pp. 173–94.

Lewis J. Analysing qualitative longitudinal research in evaluations. Soc Pol Soc. 2007;6(4):545–56.

Parkinson S, Eatough V, Holmes J, Stapley E, Midgley N. Framework analysis: a worked example of a study exploring young people’s experiences of depression. Qual Res Psychol. 2016;13(2):109–29.

Dudek V, Razum O, Sauzet O. Association between housing and health of refugees and asylum seekers in Germany: explorative cluster and mixed model analysis. BMC Public Health. 2022;22(1):1–9.

Mallett S. Understanding home: a critical review of the literature. Sociol Rev. 2004;52(1):62–89.

Palmer D, Ward K. ‘Lost’: listening to the voices and mental health needs of forced migrants in London. Med Confl Surviv. 2007;23(3):198–212.

Palmer D. Imperfect prescription: mental health perceptions, experiences and challenges faced by the Somali community in the London Borough of Camden and service responses to them. Prim Care Ment Health. 2006;4(1):45–56.

Nunn C, Gifford SM, McMichael C, Correa-Velez I. Navigating Precarious Terrains: reconceptualizing refugee-youth settlement. Refuge: Canada’s Journal on Refugees. 2017;33(2):45–55.

Caroz-Armayones JM, Benach J, Delclos C, Julia M. The double burden of precariousness: linking housing, employment, and perceived stress - a cross-sectional study. Int J Environ Health Res. 2023;33(11):1102–11.

Walsh M, Due C, Ziersch A. Financial precarity and health for temporary refugee and asylum-seeking visa holders in Australia. In: Billings P, editor. Regulating Refugee Protection Through Social Welfare. London: Routledge; 2022.

Hartonen VR, Väisänen P, Karlsson L, Pöllänen S. A stage of limbo: A meta-synthesis of refugees’ liminality. Applied Psychology. 2022;71(3):1132–67.

Crenshaw K. Demarginalizing the intersection of race and sex: A black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. Chicago: Univ Chicago; 1989. 139 p.

Saegert S, Evans GW. Poverty, housing niches, and health in the United States. J Soc Issues. 2003;59(3):569–89.

Download references

Acknowledgements

We would like to acknowledge and thank the people who generously shared their stories with us, on multiple occasions. We are very grateful to members of our Advisory Groups including people from refugee and asylum-seeking backgrounds and staff from key non-government and local government organisations, who helped guide all aspects of the research. We also acknowledge the contributions of Kathy Arthurson, Emily Duivesteyn and Rachel Sullivan.

The research was conducted on the traditional lands of the Kaurna people in South Australia, and we pay respects to Kaurna elders past, present and emerging.

The study was funded by the Australian Research Council (LP130100782), with a cash and in-kind co-contribution by AnglicareSA, and in-kind support from the Australian Refugee Association, Baptist Care SA and Shelter SA. The work was also supported by an Australian Research Council Fellowship (FT120100150).

The organisations providing cash and in-kind co-contributions to the project were members of the Reference Group, offering assistance in the design of instruments and recruitment of participants. They were not involved in the analysis of the data, interpretation of the results, the writing of the manuscript nor decision to publish the results.

Author information

Authors and affiliations.

Flinders University, College of Medicine and Public Health, Flinders Health and Medical Research Institute, Adelaide, Australia

Anna Ziersch, Moira Walsh & Clemence Due

School of Psychology; University of Adelaide, Adelaide, Australia

Clemence Due

You can also search for this author in PubMed   Google Scholar

Contributions

AZ designed the study, secured the funding, developed the data collection tools, assisted with data collection, undertook analysis, and led the writing of the manuscript. MW undertook data collection, led the qualitative analysis and co-wrote the manuscript. CD managed the project, designed the data collection tools, undertook data collection, contributed to the analysis and co-wrote the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Anna Ziersch .

Ethics declarations

Ethics approval and consent to participate.

This study was approved by the (then) Flinders University Social and Behavioural Ethics Committee. All participants provided informed consent.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Ziersch, A., Walsh, M. & Due, C. Housing and health for people from refugee and asylum-seeking backgrounds: findings from an Australian qualitative longitudinal study. BMC Public Health 24 , 1138 (2024). https://doi.org/10.1186/s12889-024-18616-5

Download citation

Received : 07 December 2023

Accepted : 16 April 2024

Published : 24 April 2024

DOI : https://doi.org/10.1186/s12889-024-18616-5

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Asylum seeker
• Neighbourhood
• Social determinant
• Integration
• Longitudinal
• Qualitative
• Ontological security/insecurity

BMC Public Health

ISSN: 1471-2458

• Submission enquiries: [email protected]
• General enquiries: [email protected]