refugee nation case study

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Addressing refugee health through evidence-based policies: a case study

Heike thiel de bocanegra.

University of California, San Francisco, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, 3333 California Street, Suite 335, San Francisco, CA 94118, United States

Olivia Carter-Pokras

University of Maryland, College Park, Department of Epidemiology and Biostatistics, 2234G SPH Building, 2242 Valley Drive, College Park, Maryland 20742, United States

J. David Ingleby

University of Amsterdam, Centre for Social Science and Global Health, Nieuwe Achtergracht 166, 1018 WV Amsterdam, The Netherlands

Kevin Pottie

University of Ottawa, Departments of Family Medicine and Epidemiology and Community Medicine, Bruyere Research Institute, 85 Primrose St, Annex E, Ottawa ON K1R 7G5, Canada

Nedelina Tchangalova

University of Maryland, College Park, Engineering and Physical Sciences Library, 1403 William E. Kirwan Hall, College Park, MD 20742, United States

Sophia I. Allen

Pennsylvania State University , Department of Public Health Sciences, College of Medicine, MC CH69 500, University Drive, P.O. Box 850, Hershey, PA 17033, United States

Julie Smith-Gagen

University of Nevada, Reno, School of Community Health Sciences, 1664 N. Virginia Street/MS 274, Reno, NV 8557, United States

Bertha Hidalgo

University of Alabama at Birmingham, Ryals Public Health Bldg, Suite 220D, Birmingham, AL 35294, United States

The cumulative total of persons forced to leave their country for fear of persecution or organized violence reached an unprecedented 24.5 million by the end of 2015. Providing equitable access to appropriate health services for these highly diverse newcomers poses challenges for receiving countries. In this case study, we illustrate the importance of translating epidemiology into policy to address the health needs of refugees by highlighting examples of what works as well as identifying important policy-relevant gaps in knowledge. First, we formed an international working group of epidemiologists and health services researchers to identify available literature on the intersection of epidemiology, policy, and refugee health. Second, we created a synopsis of findings to inform a recommendation for integration of policy and epidemiology to support refugee health in the US and other high-income receiving countries. Third, we identified eight key areas to guide the involvement of epidemiologists in addressing refugee health concerns. The complexity and uniqueness of refugee health issues, and the need to develop sustainable management information systems, require epidemiologists to expand their repertoire of skills to identify health patterns among arriving refugees, monitor access to appropriately designed health services, address inequities, and communicate with policy makers and multidisciplinary teams.

Introduction

Large numbers of people are currently fleeing from persecution or organized violence. By the end of 2015, the cumulative total of displaced persons in the world had reached 65.3 million, the highest ever: this included 40.8 million internally displaced persons and 24.5 million who had left their country and were dispersed over more than 164 other countries. Among the latter group, 51 percent were under 18 years of age [ 1 ]. In 2015, 12.4 million people worldwide were newly displaced due to conflict or persecution; more than half (54 percent) originated from the Syrian Arab Republic (4.9 million), Afghanistan (2.7 million) and Somalia (1.1 million) [ 1 ].

High-income countries have unique resources for sheltering refugees, but they shoulder only a small part of the burden compared to many low- and middle-income countries. Indeed, developing regions host 86 percent of the 16.1 million refugees under the mandate of the United Nations High Commissioner for Refugees (UNHCR) [ 1 ]. Refugees and asylum seekers migrate to other countries to escape persecution and violence, with the hope of successful resettlement or voluntary repatriation to their own countries. Refugee and asylum-seeker groups vary widely in education, health literacy, cultural beliefs, knowledge, attitudes, and behaviors. There is no “one size fits all” approach to identifying health needs and facilitating integration into each country’s health care system. The legal status of refugees and asylum seekers is a key factor in obtaining government assistance such as housing, food, vocational training and health insurance [ 2 , 3 ]. Traditionally, early-stage health assessment focused on communicable diseases (to avoid infection of the local population) and on mental health issues (to help cope with trauma caused by conditions in the home country, during transit, and on arrival in the receiving country) [ 2 , 4 ]. Increasingly, however, policy-makers are concerned with ensuring equitable, long-term access to appropriate health services, including management of chronic diseases and development of comprehensive programs that address social determinants of health and evaluate the health impact of policies [ 5 – 7 ].

In 2009, the American College of Epidemiology initiated an effort to illustrate the contributions and role of epidemiologists in health policy for a wide range of public health issues. The initiative has resulted in more than 2 editorials and 11 peer-reviewed articles [ 8 ]. All papers in this series have used a similar methodology—convening experts in the field to identify lessons learned, and participating in an in-person working meeting to develop this and other case narratives on the role of epidemiology in health policy. In this article, we discuss the importance of epidemiology in policies on refugee health and related issues, highlighting lessons learned from effective examples and from challenges that have arisen in attempting to implement these examples, as well as identifying important policy relevant gaps in knowledge. The focus will be on refugee movement over the past 15 years to Europe, the United States, Canada and Australia.

The American College of Epidemiology’s (ACE) Policy Committee convened in April 2016 an ad hoc working group of international experts in refugee health, epidemiology, policy, and program administration.

The workgroup consisting of representatives from the US, Canada, and the Netherlands (European Union), developed this paper through an iterative review process. The workgroup searched commercial library databases for peer-reviewed papers, reference lists, books, reports from international agencies and relief organizations, and unpublished data at national, state and local levels from 1999 to 2016. The scoping review focused on definitions of refugees and migrants, their health needs, and existing refugee policies. We used a combination of key terms and various synonyms as search terms ( Table 1 ).

Concepts and key search terms used in the search process

Using EBSCO databases, we searched the literature using search features inherent to each database to refine the results by source types, publication year, subject, publications, language, age, geography and more. For illustration purposes, a sample search limited to 1999–2016 year range using the following searching strategy produced a similar number of articles across all databases searched:

(refugees OR asylum seekers OR asylum applicants OR migrants OR unaccompanied minors) AND ("mental health" OR "infectious diseases") AND ("United States" OR US OR Europe OR Canada OR Australia) AND (polic* OR law OR guidelines) AND (health assessment OR health screening)

Search Results

The most relevant articles from this initial search came from EBSCO databases (a total of 448 hits), including PsychINFO (81 hits), Academic Search Complete (77 hits), MEDLINE (33 hits), Health Policy Reference Center (32 hits), and Health Source: Nursing/Academic Edition (28 hits). In addition, unique articles were identified in databases from other vendors and publishers, such as PubMed (73 hits), ScienceDirect (80 hits) from Elsevier, and Web of Science from Thomson Reuters (34 hits). In contrast to these low numbers of hits, Public Health from ProQuest retrieved 7,622 results. The high number of hits in Proquest Public Health database is due to the inclusion of dissertations and theses (1,299) and peer reviewed articles (5,141) that are unique to this particular database compared to the others. We excluded dissertations and theses from our review due to their length and comprehensive overview of a specific health problem. We also examined online reports in addition to grey literature to which we had previous awareness due to prior research experience.

The background information was focused on policies and statistics from high-income countries (United States, Europe, Canada, and Australia), excluding movement between low-income countries (e.g. from one African country to another). We excluded articles and reports on refugee health that were unrelated to epidemiologic research (e.g. descriptions of refugee programs without data or local descriptive case studies). In addition, we also excluded studies with convenience sample or descriptive case studies. The following migrant groups were not included in our final samples of references: internally displaced persons, economic migrants, and people entering the US, Canada, Europe and Australia illegally from refugee sending countries who do not apply for refugee status. The languages of articles were restricted to English, French, German, and Spanish because of authors’ language proficiency and lack of time to arrange translating resources. Using Zotero, a citation management software, we removed duplicates of references and irrelevant studies based on previously defined exclusion criteria.

Based on our findings and group discussion, we developed an outline for the paper, and workgroup members were assigned to write and/or review sections based on their area of expertise. All members reviewed and commented on the manuscript and any inconsistencies or presentations of national differences were discussed via email and conference calls in an iterative process until consensus was reached.

We identified eight key lessons from effective examples and from challenges that have occurred in providing services to refugees ( Table 2 ).

Summary of lessons learned

Lesson 1: Nomenclature and definitions for refugee and asylum seekers often vary

One of the first challenges epidemiologists face is identifying an agreed definition of “refugees.” Unfortunately, no such definition exists. A distinction is often made between refugees being forced to leave and economic migrants voluntarily seeking a better life, but the distinction between “forced” and “voluntary” is hard to sustain. Refugees who leave have made a deliberate choice to flee rather than face danger and possible death. Economic migrants may be escaping conditions at least as threatening: natural disasters, climate change, grinding poverty, “failed states” and other possibly life-threatening circumstances not covered by refugee law [ 9 ].

What are the existing legal definitions? The United Nations 1951 Refugee Convention and its 1967 Protocol define a refugee as any person who “owing to well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country […..]” [ 10 ]. Each person seeking “Geneva” refugee status must therefore show he or she have good cause to fear such persecution. Simply coming from a country where there is organized violence is not usually considered sufficient.

However, other forms of protection are available. The 1969 Organization of African Unity Convention Governing the Specific Aspects of the Refugee Problem in Africa extended protection in Africa to those coming from war-torn countries. Weaker but more accessible “complementary” forms of protection have also been introduced in most countries, including temporary protection (requiring a return to the country of origin when circumstances permit) and humanitarian or discretionary protection. All these types of status are usually included in the general category of “refugee.” The UNHCR even adds a category “persons in refugee-like situations” for certain groups which in its view should be treated as refugees, but are not covered by existing legislation [ 1 ].

In this paper, we use the term “refugee” to refer to people whose claim to this status has been allowed. For researchers, however, the problem with this definition is that the legal assessment procedure can take years. Thus, research on “recognized” refugees is often carried out long after they have left their country. Even then, it is often difficult to locate this group because their refugee status may not be recorded in population registers. Before the grant of a status, the only way to identify refugees is by using empirical rather than legal criteria, but there is no general agreement on which criteria should be used. One can study groups of people in transit from a conflict-ridden country to a safe one, but there is no guarantee that all of them will acquire refugee status ( Figure 1 ).

Pathways to safety for victims of persecution or organized violence

Before they receive this status, most refugees will have spent some time seeking asylum. Useful research can be carried out on the category of asylum seekers, though here again there are formal and informal definitions. Legally speaking, an “asylum seeker” or “asylum applicant” only counts as such after they have made an application for asylum. However, in everyday usage, those still searching for a place to apply (e.g. “boat people”) are often called asylum seekers as well. Some of these may apply for refugee settlement in a high-income country while they are sheltering in a neighboring country; others may enter a high-income country legally using a tourist or student visa and subsequently apply for asylum; and others will enter without authorization. Article 31 of the 1951 Refugee Convention forbids States Parties from penalizing unauthorized entrants if they present themselves without delay to the authorities. However, if they fail to make a timely application, or are rejected and refuse an order to leave the country, they will become “undocumented” or “irregular” migrants. In this position, they will usually enjoy very limited entitlements to health services. By contrast, once a person is officially an asylum applicant they will usually be able to count on a reasonable level of health service provision, especially if they remain in government-run centers.

A final complication of terminology concerns whether a refugee or asylum seeker should be considered a type of migrant, or in a class by themselves. UNHCR has long maintained that refugees are not migrants and should not be classified as such. However, according to the UN’s own official definition, migrants are people who have changed their country of usual residence, irrespective of the reason. Within the UN system both definitions tend to be used alongside each other, which does little to reduce confusion in an area where clarity is badly needed [ 11 ].

Lesson 2: It is necessary to develop efficient systems to identify health needs upon arrival and lay the foundation for integration into health care

Port of entry screening and use of quarantine facilities dates back centuries [ 12 ]. Historically, immigration officials focused on detecting, treating and containing infectious diseases that migrants may carry. Present-day guidelines also address infectious diseases, such as Tuberculosis (TB), Human Immunodeficiency Virus (HIV), Hepatitis, Malaria and intestinal parasites, as well as childhood vaccinations [ 6 , 13 , 14 ]. Over time, a more rights-focused approach developed alongside the public health approach. This has recently been referred to as the health settlement approach [ 6 ]. It aims to vaccinate, screen, treat and integrate refugees into local primary health care systems. Rights-focused guidelines have placed greater emphasis on promoting health [ 15 ] and progressed on to consider non-communicable conditions such as mental health problems and chronic diseases [ 16 ]. Evidence-based approaches consider both the benefits and harms of interventions [ 17 ].

While it may not be possible to identify all needs in the initial health exam, basic questions on pregnancy or pregnancy intention and contraceptive needs and chronic diseases should be part of a standard assessment. Current practices vary by country. For instance, Canadian national guidelines include screening for unmet contraceptive needs during the initial assessment period [ 7 ], while in the US, national guidelines for refugee arrivals require only documentation of pregnancy status [ 13 ], leaving it to individual states to require more comprehensive assessments of sexual and reproductive health needs.

Beyond the initial screening, we must explore how integration into primary care is handled. Some screening locations (e.g., public health clinics providing follow-up visits at the same location) facilitate care continuity and coordination; others do not. It is also necessary to establish surveillance systems that allow us to monitor refugees’ and asylum-seekers’ access to care and health outcomes over time, as discussed in Lesson 3.

Lesson 3: Data sources need to be integrated and linked to allow ongoing monitoring of refugee health indicators

Interdisciplinary population-based studies are critical for evidence-based refugee health. These studies can detect inequities at both the disease and the health care system level. Large national longitudinal studies have been conducted in Australia [ 18 ] and Canada [ 19 ]. These studies have helped us appreciate the risk factors for decline in health including low health literacy, poor health of migrants from low-income countries, and gender differences. However, following highly mobile and multilingual populations over time is expensive and not very feasible, except in countries like Sweden, where multiple databases covering the entire population can be linked with each other.

Two examples of initiatives to improve surveillance for refugees in the US include the Centers for Disease Control and Prevention (CDC) funded Electronic Disease Notification System (EDN), and the Centers of Excellence in Refugee Health (COE-RH) in Colorado and Minnesota. The EDN is an electronic reporting system that collects health information on newly arriving refugees and immigrants [ 20 ]. However, one challenge for epidemiologic research is linking different data sources together (e.g., a unique linking identifier may not be available, refugee status is not always captured in data sources). One linking approach is the creation of a quasi-relational database and employing a probabilistic matching methodology as described in the Florida 2009 Refugee Health Status and Healthcare Utilization Report [ 21 ].

In the US, the federally-funded Centers of Excellence in Refugee Health (COE-RH) in Colorado and Minnesota have the mission to assess long-term health outcomes of refugees, multi-state surveillance of chronic and infectious diseases among refugees, and the development of clinical guidelines relevant for refugee populations settling in the US. The Colorado COE-RH [ 22 ] strives to collect and better analyze the medical screening data from refugees in the initial health-intake screening and to standardize data collection, which differs from state to state, and display it in a business intelligence platform. This will help providers, state partners, community leaders, and the public in accessing refugee health data and patterns. The Minnesota COE-RH works to improve the guidelines [ 23 ] and demonstrates how providers should conduct the initial health-intake medical screening as well as a few quality improvement projects such as Hepatitis B prevention. A women’s health guideline is planned to be included that will serve as a nationwide standard.

There remains a need to consider the inclusion of variables in electronic health records and data systems that allow ongoing monitoring of refugees, such as Country of birth, Language preference, Entry date, and Refugee/asylum status to the extent that privacy and ethical concerns can be addressed. For example, in the US refugees and asylum applicants have specific aid codes when using publicly funded health services, however the accuracy and completeness of the aid code has not been assessed. Current methods are still inadequate to differentiate between refugees, asylum seekers and other migrants in the US, making it challenging to calculate denominator data for these groups.

Lesson 4: It is important to assess social determinants of health and adopt an intersectoral “health in all policies” approach to create health-promoting environments for refugees and asylum seekers

Recognizing and improving living conditions and other social determinants is crucial for preventing and treating illness. Since the publication of the World Health Organization (WHO) Report of the Commission on Social Determinants of Health [ 24 ], increasing priority has been given to tackling the causes of illness through the strategy of “health in all policies”, a collaborative approach to improving the health of all people by incorporating health considerations into decision-making across sectors and policy areas [ 25 ]. This pragmatic approach is as relevant to refugees as it is to all other groups, while epidemiological research is essential to provide its evidence base.

A wide range of factors may influence the health of refugees before, during and after forced migration. Pre-migration factors can be further subdivided into factors that occur before and during the conflict. Average living conditions in the home country may be harsh, yet it is often not the worst-off who succeed in obtaining asylum: considerable personal or family resources may be necessary to succeed in obtaining protection in a safe country. Stereotypes regarding the socio-economic background of refugees from a given country can therefore be misleading.

Traditionally, researchers have regarded violence, deprivation and loss during the conflict and forced migration phase as the main source of physical and mental ill-health among refugees [ 12 ]. What is often overlooked is that serious health threats also exist in the pre-conflict situation and the processes of reception and integration in a new country [ 26 ]. Threats to health during forced migration can be fatal. Thousands of people – the true number will never be known – die each year while trying to reach safety; for those who survive, the journey may be accompanied by acute deprivation, exploitation, and violence of all kinds. Safe and legal pathways to claiming asylum would obviate most of these risks, but high-income countries are reluctant to provide these for fear of being overwhelmed by the demand.

Humane asylum procedures and effective integration policies are essential to ensure successful resettlement in a new country. Since the seminal work of Silove et al. [ 27 ], it has been increasingly recognized that the conditions in which asylum seekers are kept can be a major source of mental health problems. Prolonged uncertainty, inactivity and social isolation delays and undermines social integration. Resettlement support for employment, language skills, health care and housing support varies widely by country and region and over time within a country. This support is normally limited to recognized refugees, excluding asylum seekers. After acquiring a residence permit and potentially some limited resettlement support, refugees are all too often left to sink or swim in the new society without the long-term targeted, proactive support they need. If their claim for international protection is rejected, asylum seekers will very often remain in the country as “undocumented migrants,” with an even higher risk of marginalization and ill-health.

A recent report [ 28 ], mainly focused on Europe but drawing also on insights from the rest of the world, points out that the integration of refugees has frequently been unsuccessful in the past, resulting in marginalization, deterioration in living conditions and health, and chronic dependency on welfare. A proactive approach could save governments a lot of money in the end, yet few appear to realize this. Successful integration policies are described as “work-focused but not myopic, pre-emptive, coordinated and collaborative”; these priorities apply to migrant integration in general, not just to refugees. Advocating for enlightened policies needs to be backed up by sound epidemiological evidence. For example, Hjern [ 29 ] showed that most of the barriers to the successful integration of refugees in Sweden are more likely to be the cause, rather than the result, of impaired mental and physical health.

Lesson 5. Refugees and asylum seekers must be granted equitable access to appropriate health services

When the health system does not respond to the needs of any group to the best of its abilities, preventable and treatable illnesses become health inequities (i.e., unjust and avoidable disparities). Research on health service provision for migrants has shown that services provided to migrants are very often less affordable, harder to reach, and of lower quality (because they are often not adapted to the patient’s needs). Therefore, providing the best available services will often mean challenging or circumventing existing policies, for example, when these disallow reimbursement of service providers for providing treatment or interpretation services [ 30 , 31 ].

Many studies on inequities in health service provision to migrants have been carried out on an ad hoc basis, using a variety of different approaches, methods and samples that are difficult to combine and compare with each other. However, in 2015, the first round of a systematic longitudinal project in 38 countries was carried out to monitor levels of inequity for migrants in health care systems. This was part of a larger study, the Migrant Integration Policy Index (MIPEX), which has been gathering data since 2003 on different “strands” of migrant integration such as access to education and the labor market [ 32 ]. The addition of a “health strand” in 2015 [ 33 ] acknowledged the importance of health as an aspect of migrant integration [ 34 ].

MIPEX now measures health policies applying to migrant workers, asylum seekers and undocumented migrants, using a standardized set of 38 indicators. These indicators map two dimensions of policy:

• Access — consisting of migrants’ entitlements to health services (i.e., affordable health care coverage) and accessibility (“reachability”) of health services for migrants.
• Quality—consisting of responsiveness of health services to migrants’ needs and measures to achieve change, (i.e., to improve equity).

For epidemiologists working in refugee health, the most relevant findings of the MIPEX 2015 survey were:

• Entitlements are best for migrants with a work permit and lowest for undocumented migrants, with asylum seekers in between. After protected status has been officially granted, refugees usually have the same entitlements as nationals.
• A lack of information for migrants on how to use health services can be another serious barrier to access. A more outreaching approach, possibly employing “health navigators” or “cultural mediators”, may be needed.
• Countries vary widely in their readiness to make services responsive to migrants’ needs. In English-speaking countries the concept of “cultural competence” has been propagated for several decades [ 35 ]; by contrast, eight of the European countries studied in MIPEX scored zero on this dimension, which includes attention for language barriers.
• Measures to promote change include data collection and research, as well as coordinated efforts to link up stakeholders and provide leadership. These were more often found in countries with tax-based, rather than insurance-based, health systems.

Lesson 6: Health services for refugees and asylum seekers must be evidence-based, integrated into the mainstream health care system, and delivered in accessible and effective ways

Integrating refugees into robust health care systems must be a primary aim for public health, as separate programs for refugees will be vulnerable to budget cuts [ 36 ].

However, the implementation and delivery of refugee services must also consider how much refugee populations value the main outcomes of interventions, how acceptable and feasible are the interventions and what equity impacts could arise as a result of special services [ 37 ]. For example, routine testing during medical visits may not be acceptable to refugees coming from areas with a high degree of HIV-related stigma, while testing at community sites may be more acceptable and effective at reaching –the refugees– at highest risk for HIV exposure [ 38 ].

When we link a delivery approach with an intervention, we create a complex intervention. Research on delivery of services requires pilot testing, feasibility and on-going evaluation. A systematic and explicit process can be used to determine the effects and the certainty of these effects. Canada, US, and Australia have developed guidelines including delivery considerations for refugees [ 39 ]. Programs that show signs of effectiveness and efficiency nationally, and internationally, may be good candidates for scaling up. Similar to other interventions, benefits and harms, certainty of effect, cost effectiveness, and values and preferences should be considered evidence for all interventions and programs.

In 2015, with the Syrian war and refugee crisis, Europe was pressed to improve healthcare and other services for refugees and other migrants. As massive numbers of migrants arrived on the beaches of Greece, the European Union gained support for launching many research initiatives. Movements of refugees and other migrants across Europe left many non-government organizations and public health officials asking how Europe can improve health care delivery for newly arriving migrants. One such initiative is the European Centre for Disease Prevention and Control evidence-based guidelines for health assessment and prevention for newly arriving migrants. These guidelines will hopefully encourage consistent and evidence-based health assessments that can begin at port of entry, play a role in detention centers and help deliver services at the community and public health level.

Lesson 7: Initiatives to improve access to and quality of health care need to be evaluated

The seventh lesson learned is that evaluation of initiatives to improve health care will not only help public and private organizations deliver better programs but also help sustain programs by documenting their quality and effectiveness. Refugee health program evaluation should be guided by the general principles of program evaluation, with particular emphasis on clarity and agreement among stakeholders regarding program components and outcomes, participation by the targeted community and knowledge of community complexities [ 30 ]. Innovative methods to evaluate refugee programs include using feedback loops, multilevel and mixed method data collection, and pre-post designs when the use of control groups present ethical challenges.

Agreement of clear outcome definitions among all stakeholders and partners remove excuses for inaction [ 30 ]. The multiple partners of the Australian Changing Cultures Project experienced time-consuming difficulties identifying the outcomes of a refugee education program [ 40 ]. Successful collaborations can involve State leadership in initiatives [ 41 , 42 ]. A Colorado initiative that developed a single point of access including interpreting services, comprehensive health assessments, education, data collection, and evaluation [ 43 ].

Refugee and community involvement are useful partners in evaluation; they can identify meaningful questions, interpret non-verbal cues and understand cultural perspectives [ 44 , 45 ]. An intervention to improve mammography screening among Serbo-Croatian speaking refugees in a Massachusetts hospital hired a patient navigator who was also a displaced person from the same war as the patients. She helped develop trusting relationships with the patients facilitating implementation and evaluation [ 46 ]. An intervention involving a prenatal educational video among a Minnesota Somali refugee population sought out refugee acceptability of the video before implementation [ 47 ].

Knowledge of community complexities is also important when evaluating health initiatives. Self-proclaimed community leaders representing subgroups rather than the entire community disrupted social structures, and decision-making complexities within refugee groups must be taken into account [ 48 ]. An intervention in Salinas, California among unaccompanied Central American minors unknowingly put adolescents who fled violence and death threats in the same room as adolescents who may have been related to or acquainted with the perpetrators [ 48 ]. Complexities in evaluation can also include community resilience [ 49 – 52 ]. Evaluation studies examining the mental and physical health of unaccompanied minors in high-income countries show long-term improvement years after initial resettlement [ 49 ]. Cultural differences in parenting practices lead US welfare services to remove refugee children from their homes. The Bridging Refugee Youth and Children's Services (BRYCS) evaluated the issue and conducted a series of community conversations between refugees and child welfare services that reduced tensions between refugee parenting culture and US child welfare practices [ 53 ].

Evaluations involving feedback loops, audit, reflection and modification cycles, can improve interventions. In Australia, refugee youth can receive up to a year in language education before they join their peers in school. The Changing Cultures Project used feedback loops and realized that language skills alone could take several years to obtain, thus, modified six refugee language and health programs [ 40 ]. An occupational therapy program aimed at refugee high school students in Australia used feedback loops and changed significantly over three cycles; from a focus on individual task mastery in the classroom environment to a focus on the development of social competence through an activity-based group program [ 54 ]. In addition to feedback loops, interventions through high school populations are a convenient way to minimize financial, structural and cultural barriers faced by refugee children [ 54 , 55 ].

Many refugee programs use multiple interventions and collaborations. A successful evaluation of a Federally Recognized Health Center program serving Cambodian refugees in Massachusetts included data collected by community-based organizations, who provided advocacy, peer support, stress management, and education, as well as data from the health centers [ 56 , 57 ]. Torres et al. used multiple evaluation strategies to evaluate the effectiveness of community health works (CHW) employed by a service provider organization compared to independent CHW. They used direct observation, in-depth interviews, analysis of policy documents and quantitative analysis of a caseload database [ 58 ]. This method allowed identification of nuances as well as evaluation [ 58 ]. The Australian Changing Cultures project used mixed methods evaluation including routinely collected data, group interviews with refugees and staff, program audits and observation of management meetings [ 45 ].

Many evaluation studies targeting health interventions lack control groups or randomization for experiments, while some do not follow up for long enough to provide meaningful conclusions [ 59 ]. Fox et al. evaluated a cognitive-behavioral school-based program by measuring screening scores on the Children's Depression Inventory [ 60 ]. The authors noted that using a treated and non-treated group may have improved validity but also created an ethical dilemma because they were not aware of any other mental health services in the community. Based on this, the authors decided to include all vulnerable refugee children; they had no external comparison group but used a pre-post evaluation design involving an internal comparison group [ 60 ]. Evaluators of refugee programs frequently use pre-post design [ 46 , 55 , 60 , 61 ].

Lesson 8: Training of epidemiologists needs to provide the tools to engage with policy makers and the public

The seven lessons detailed above are essential for the training of epidemiologists seeking to engage in refugee health work and/or research. One final component involves training in risk- or health communication to prepare epidemiologists to work on refugee health issues and communicate with policymakers and the public including refugees. Such communication is necessary, but often an afterthought in refugee emergency response situations.

Epidemiologists need to learn to communicate to the public and policymakers with language and examples, which they will understand, to counterbalance misinformation and provide accurate data. However, they are typically not trained to communicate with findings to a larger audience. For example, media stories can help to humanize the refugee experience and make data on health risks and challenges of integration into health care and equitable policies meaningful to the public. They also facilitate ongoing awareness after the initial news interest has faded. Training in translating findings to different audiences needs to enable epidemiologists to balance between methodological rigor and the need to provide accurate data in a timely fashion. While useful and informative messages can be efficiently communicated via social media platforms such as Twitter and Facebook, messages of panic and concern, including misleading and false statements, may also be communicated. These platforms have evolving roles in the landscape of journalism and social media. For many, the internet and social media are a source for news. For the average user, considerations of “source” are null, making any piece of information shared on the internet or social media platforms appear as “fact.”

Finally, communication to and for those affected the refugees is of utmost importance during relocations. One of the aims of risk- or health communication is to ensure that relocated populations have access to necessary and accurate information about available services, sources of relief, and policies or laws of their new country [ 62 ]. Some challenges may be faced by epidemiologists when attempting to relay messages to these populations. While giving information in lay terms is necessary, language issues may also be a concern. Often the language of the host population will differ from that of the refugee population, making communication via mass media even more difficult. Identification of such challenges, which may also include factors such as values, attitudes and cultural practices, will enable epidemiologists to partner with individuals, organizations, media outlets, and others to develop an appropriate communication strategy and implement effective health communication interventions. These situations, of course, are all country and often refugee specific. As such, one must be cognizant of the fluidity of those re-settlements, as well as the changes in needs of individual refugee populations. Subsequently, these lessons can be used to inform grassroots efforts to study and understand individual refugee populations and derive research and policies accordingly.

Conclusions

By the end of 2015 more than 65 million persons had been displaced from their homes, the highest total displacement ever recorded [ 63 ]. This is a world-wide problem that epidemiologists interested in immigrant health can lend their skills and knowledge to address. However, epidemiologists should expand their repertoire of skills to go beyond identification of disease patterns of arriving refugees to also monitor access to quality health care, address inequities and communicate to policy makers. The complexity and uniqueness of refugee health issues requires the use of multidisciplinary teams and development of sustainable management information systems. In addition, epidemiologists face the challenge of the lack of a standard definition of “refugees.” Examination of refugee needs and health care barriers by country of origin could potentially reduce confusion, permit research, and facilitate comparisons across countries and settings.

There has been a gradual shift from health assessment of infectious diseases and mental health status towards chronic diseases and long-term follow up. The level of detail for assessing reproductive health needs varies widely by high income countries, ranging from nonexistent to national guidelines. While it may not be possible to identify all needs in the initial health exam, basic questions on pregnancy or pregnancy intention and contraceptive needs and chronic diseases should be part of a standard assessment. The focus of standard assessments should be on preventable and treatable needs that will be part of follow-up care. When the receiving country does not integrate refugees to the extent of its ability, preventable and treatable illness become health inequities with a high cost to the individual and society. Current data on refugee health have been limited in scope and comprehensiveness. Recent efforts have been made to expand data collection specific to refugees and provide linkages across databases. Understanding the unique health challenges this population faces will allow the development of innovative programming to positively affect refugee health outcomes over the long term.

To explain why it is necessary to allocate resources to this population, researchers need to describe refugees’ mental and physical health risks and vulnerabilities. These descriptions need to be complemented by a description of the communities’ resourcefulness and resilience to cope with adversity so that effective strategies to achieve and preserve health can be developed.

Epidemiologists have a unique skill set for addressing methodological challenges in working with a highly mobile population to produce reliable data that takes account of selection bias, loss to follow-up, lack of comparison groups, missing data points, cross comparisons and adaptions of current monitoring systems. However, epidemiologists can benefit from training in qualitative and participatory research methods to supplement their quantitative training given the interdisciplinary and mixed methods nature of addressing each of these eight lessons. In order to respond to the changing needs of refugee populations and respective contexts (e.g., geography, origin, health care system, laws), epidemiologists need to be flexible and adept in assessing refugee population needs on the ground using informal and formal surveillance methods, as well as formulation of related research and policy questions. In addition, epidemiologists need to be part of a multidisciplinary team and be able to convey at times complex methodological considerations in assessing and evaluating refugee health with researchers and policymakers. With scarce resources, we need to develop rapid response methodologies and surveillance systems that will provide reliable data in a timely fashion. Evaluation of the systems put in place by epidemiologists will ensure the goal of improving the health and quality of life for refugees is met for future generations.

Acknowledgments

We gratefully acknowledge comments from participants of the June 2016 American College of Epidemiology policy committee workshop in Miami, Florida. We also acknowledge travel support from the University of Maryland's School of Public Health (OCP); and the Academic Senate, University of California, San Francisco and an anonymous private foundation (HTB) to attend the workshop. Efforts by Dr. Lorna Thorpe to coordinate the workshop where these case studies were discussed were partially supported by the Centers for Disease Control and Prevention (CDC) Grant U48DP001904. Dr. Bertha Hidalgo is supported by an award from the National Heart, Lung, and Blood Institute (K01 HL130609-01). The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the US Department of Health and Human Services.

List of abbreviations and acronyms

Contributor information.

Heike Thiel de Bocanegra, University of California, San Francisco, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, 3333 California Street, Suite 335, San Francisco, CA 94118, United States.

Olivia Carter-Pokras, University of Maryland, College Park, Department of Epidemiology and Biostatistics, 2234G SPH Building, 2242 Valley Drive, College Park, Maryland 20742, United States.

J. David Ingleby, University of Amsterdam, Centre for Social Science and Global Health, Nieuwe Achtergracht 166, 1018 WV Amsterdam, The Netherlands.

Kevin Pottie, University of Ottawa, Departments of Family Medicine and Epidemiology and Community Medicine, Bruyere Research Institute, 85 Primrose St, Annex E, Ottawa ON K1R 7G5, Canada.

Nedelina Tchangalova, University of Maryland, College Park, Engineering and Physical Sciences Library, 1403 William E. Kirwan Hall, College Park, MD 20742, United States.

Sophia I. Allen, Pennsylvania State University , Department of Public Health Sciences, College of Medicine, MC CH69 500, University Drive, P.O. Box 850, Hershey, PA 17033, United States.

Julie Smith-Gagen, University of Nevada, Reno, School of Community Health Sciences, 1664 N. Virginia Street/MS 274, Reno, NV 8557, United States.

Bertha Hidalgo, University of Alabama at Birmingham, Ryals Public Health Bldg, Suite 220D, Birmingham, AL 35294, United States.

• Original Article
• Open access
• Published: 06 August 2019

How do refugees affect social life in host communities? The case of Congolese refugees in Rwanda

• Veronika Fajth 1 ,
• Özge Bilgili 2 ,
• Craig Loschmann 3 &
• Melissa Siegel 3  

Comparative Migration Studies volume  7 , Article number:  33 ( 2019 ) Cite this article

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This paper investigates how social dimensions of life in local communities are affected by the long-term presence of Congolese refugees in Rwanda, paying particular attention to feelings of safety, social networks and trust. To gauge whether increased probability of interaction with refugees reduces cohesion, these outcomes are compared across local households at varying distances from a refugee camp. This paper is based on mixed methods approach including new data originating from a household survey conducted in host communities surrounding three refugee camps, as well as information from focus group discussions. The quantitative analysis shows no statistically significant differences between host communities with the exception of informal social networks, which are higher in communities closer to refugee camps. However, qualitative evidence illustrates how greater (economic) interaction between the two populations helps increase trust between refugees and host communities over time. Moreover, locals argue that economic and social support given to refugees plays a key role in reducing and preventing conflict between the two groups. These findings map the experiences and give voice to host communities’ perspectives on social life in their community.

Introduction

Low and middle income countries host the majority of refugees worldwide, with recent estimates as high as 85% in 2017 (UNHCR, 2018a ). In most of these countries hosting large numbers of refugees, local communities often experience a high level of poverty and face increased chances of economic vulnerability. In this regard, their economic conditions are not necessarily better than those seeking refuge in their communities. This situation as a result may lead to economic competition over scarce resources between host and refugee communities and cause increased social tensions within the society. Despite this evident potential threat to social cohesion, the social impact of hosting refugees on local communities has remained an understudied field of inquiry. The impact of displacement on host communities has been primarily investigated in relation to economic and environmental effects (see, e.g., Kreibaum, 2016 ; Maystadt & Verwimp, 2014 ; Ruiz & Vargas-Silva, 2015 ; Whitaker, 2002 ). In this paper, we argue that it is important to go beyond the analysis of economic impacts and look into how social life is affected by the presence of refugees in order to promote not only prosperous, but also cohesive, peaceful and inclusive societies.

This study helps to fill the gap in the literature by investigating how the presence of Congolese refugees affect some of the most important dimensions of social life in Rwandan host communities. Two main factors make this a particularly interesting case for the study of this topic. The first factor relates to the size and protracted nature of the displacement situation of Congolese refugees in Rwanda. Nearly half of the 170,000 refugees residing in Rwanda are from the Democratic Republic of Congo (DRC), and most have been living in their respective camps for more than two decades (UNHCR, 2018b ). This long-term presence of refugees has allowed for social interaction between groups to become part of everyday life, and makes it all the more interesting to study the social dynamics within society. Second, this case is noteworthy because of the political context within which social relations take place. Namely, the Rwandan government has a relatively unrestrictive, integrative policy approach to hosting refugees which gives them increased rights of mobility, access to social services such as health and education and opportunities for economic interactions (O’Connor, 2013 ; UNHCR, 2011 ). This unique context gives us the opportunity to investigate how social life is affected in host communities that have more opportunities to interact with refugees on a daily basis. It should be noted that our case is also particular in terms of cultural proximity between hosts and refugees, as many Congolese refugees are associated with some Rwandan ancestry and more often than not speak the same language as the host population. Even though our analysis is specific to the Rwandan case, the results and discussion should be relevant to other refugee-hosting settings where displaced populations and local communities interact regularly, particularly in contexts where hosts and refugees come from similar cultural backgrounds.

Examining the effects of refugees on social dimensions of life is a challenging task due to the absence of a standard, theoretically derived conceptual definition of social cohesion (Guay, 2015 ). Elements commonly used to describe a cohesive society include a principle of inclusivity, cooperation, a sense of belonging, trust, and overall strong, positive relationships. Low cohesion in a society, on the other hand, is often characterised by social tension and/or fragmentation, conflict and negative feelings like resentment, anxiety, perceptions of threat among members of the community (Guay, 2015 ; OECD, 2011 ; Stanley, 2003 ). Given the multifaceted nature of a community’s social life and considering data availability, we look at a range of selected manifestations of social cohesion: perceptions of safety within the community, presence of formal and informal social networks and trust within a host community towards different groups including the community itself, refugees, international organizations (IOs) and non-governmental organizations (NGOs). To explore possible differences in contact between refugees and hosts, we compare these outcomes for local households within communities at varying distances from – and therefore exposure to – the three largest Congolese refugee camps, namely Gihembe, Kigeme and Kiziba. The empirical analysis relies on data from a unique household survey conducted among host communities outside of these three camps in 2016. Moreover, we make use of insights from in-depth focus group discussions (FGDs) to better understand the statistical results and bring to the fore the experiences and perceptions of host communities concerning their relations with refugees.

Social cohesion in forced displacement contexts

The interest to understand the impact of displaced populations on host communities has led to a growing literature in recent years. A review of this literature, however, reveals various shortcomings of the research field. First, there has been a strong thematic focus on the economic and environmental effects of refugee hosting while the social impact often remains unstudied. This is especially true for African countries and the Global South in general, compared to the European and North American contexts where social effects of immigration – even if not of refugees specifically – have been studied more extensively (e.g. Gesthuizen, van der Meer, & Scheepers, 2009 ; Kesler & Bloemraad, 2010 ). Second, the existing studies on the topic are small scale and mostly qualitative in nature (e.g. Porter et al., 2008 ; REACH, 2014 ; Whitaker, 1999 ). While this type of research has been useful in identifying the types and sources of possible social effects, there is a clear need for more studies that combine quantitative and qualitative insights based on innovative research designs to more robustly assess the ways in which the refugees’ presence may influence host communities’ social life. In the following, we discuss how living nearby a refugee population may affect formal and informal social networks, feelings of safety and trust among locals towards different segments of the society.

Engagement with formal and informal social networks

Social networks, both formal and informal, are cornerstones of a connected and cooperative community. For instance, engagement in formal networks (e.g. organizational membership) indicates an individual’s level of civic engagement and active participation in the life of the community, while informal networks may reflect an individual’s access to social support mechanisms (Gesthuizen et al., 2009 ). Indeed, informal networks may reflect to what extent an individual is able to count on others (beyond their household) for financial, social or emotional help in time of need.

The relationship between the presence of refugees and locals’ social networks can be discussed in various ways. An often-used approach interprets the arrival of refugees as an increase in diversity within the host community. In his ‘Hunkering Down’ Theory, Putnam predicts an increase in diversity in a population will lead inhabitants to ‘withdraw from collective life, […] to withdraw even from close friends, […] to volunteer less […]’ (Putnam, 2007 , pp. 150–151). The inflow of a displaced population from a neighbouring country may also be understood as an increase in diversity. Considering Putnam’s theory, this inflow could therefore lead to a decrease in social networks, both formal (for example, through community organizations and other organised collective activities) and informal (close friends). Alternatively, building upon Intergroup Contact Theory, one can also argue that diversity in terms of larger outgroup size provides opportunities for positive intergroup contact and increased contact, especially when on equal terms, can also enhance positive experiences and out-group attitudes (Allport, 1954 ; Pettigrew, 1998 ). Given the lack of empirical studies focusing on the social network effect of hosting refugees in particular, we draw conclusions based on research that looks at the effects of migrant stocks, which in our view is comparable considering the protracted nature of Congolese refugees in Rwanda.

With regards to organizational membership, in a cross-country study focusing on developed countries between 1981 and 2000, Kesler and Bloemraad ( 2010 ) find that on average, the relative migrant stock has a significant positive association. Similarly, using data from 28 European countries, Gesthuizen et al. ( 2009 ) examine the role of migrant stock and find a significant positive association with organizational membership in the country as well as inhabitants’ propensity to give informal help. Both studies stress the key role of institutional and political contexts. In another cross-European study with a more limited topical focus, Benos and Kammas ( 2018 ) examine the effect of ethnic diversity on workers’ participation in trade unions and find a significant negative association. In summary, most evidence from developed countries challenges the claim that the presence of migrants in general would weaken formal and informal social networks within the community, but the role of differing social environments is stressed.

In this research, we seek to examine the nature of these links in a low-income country context. In Indonesia, Mavridis ( 2015 ) finds a negative association both for willingness to help (a measure of informal networks) and community participation (formal networks). To the best of our knowledge, only Whitaker ( 1999 ) examines the influence of refugees on social networks in a low-income setting, in his case Tanzania. He explains that Tanzanian hosts establish extensive social relations with refugees, especially in areas close to the camps. These relations include visiting one another, attending social functions such as weddings and funerals and even competing in local sport competitions. We believe such evidence underlines the need to examine the issue in more depth and on a larger scale.

Subjective safety within community

There are a few theoretical arguments as to why hosting refugees may threaten (real or perceived) safety: firstly, refugees’ prior exposure to violence may increase their likelihood to perpetrate future violence; secondly, the relative social and economic deprivation from opportunities may increase propensity to engage in criminal activity (Depetris-Chauvin & Santos, 2018 ). Whitaker ( 1999 ), on the other hand, argues that host populations do not always blame refugees for changing social dynamics but see the events as an inevitable result of the drastic population increase in the area. Another, more optimistic, perspective argues that an influx of immigrants might ‘revitalize’ communities and spark beneficial neighbourhood social processes which will ultimately increase safety (Feldmeyer, Madero-Hernandez, Rojas-Gaona, & Sabon, 2019 ).

The empirical evidence on the security effect of hosting refugees for local communities is not clear-cut. A considerable body of literature has examined the actual prevalence of security risks among refugee-hosting populations, such as a rise in criminal and violent activities (see e.g. Amuedo-Dorantes, Bansak, & Pozo, 2018 ; Collier & Hoeffler, 2004 ; Depetris-Chauvin & Santos, 2018 ; Jacobsen, 2002 ; Masterson & Yasenov, 2018 ; Salehyan, 2007 ; Schmeidl, 2002 ; Whitaker, 1999 ), but the findings of this literature remain inconclusive (sometimes even for the same country, see, e.g., UNHCR, 2003 , versus Rutinwa & Kamanga, 2003 , in Tanzania).

Evidence on how the hosting community’s feelings of safety are affected is more scarce: two recent studies, for instance, examine the effect of general diversity (not only refugee presence), with different results: positive in the case of a US study (Feldmeyer et al., 2019 ) and negative in the case of Indonesia (Mavridis, 2015 ). The lack of consistency in both types of results challenges the assumption of a negative link between hosting refugees and feelings of safety within a community and highlights the need to examine the relationship in different contexts. In this paper we focus on hosts’ subjective perceptions of safety and investigate this in a low-income, conflict-neighbouring environment in which hosts and refugees, share some cultural familiarity.

Trust in own community, refugees and organizations

Putnam’s ( 2007 ) ‘Hunkering Down’ Theory predicts community trust to be threatened by higher diversity within the community. However, the empirical evidence on this issue is almost non-existent in low-income country contexts and inconclusive for other countries. In a comparative study across European countries, Hooghe, Reeskens, Stolle, and Trappers ( 2008 ) find no clear confirmation of the hypothesised negative relationship between rising ethnic diversity and trust. In another cross-European analysis Gesthuizen et al. ( 2009 ) find different results for dynamic and static diversity measures: net migration exhibits a negative association with interpersonal trust in society, but the size of the migrant stock and the degree of ethnic fractionalization does not seem to affect trust. Ultimately, Gesthuizen and colleagues conclude that both trust and social engagement are influenced less by diversity per se and more by institutional and political contexts.

In their comparative study of developed countries, Kesler and Bloemraad ( 2010 ) find no ‘general’ link between change in diversity and social trust, but also point to the moderating role of the country context: in more economically equal and multicultural societies the potential negative relationship between immigration and trust is mitigated or even reversed. Laurence, Schmid, and Hewstone’s ( 2019 ) UK case study finds that neighbour-trust is reduced by diversity only in cases when the out-group is viewed as threatening, a perception that is exacerbated by socio-economic precariousness. Delhey and Newton ( 2005 ) are the only ones, to our knowledge, to include less developed and African countries in their 60-country comparison. Looking at the static indicator of ethnic heterogeneity, they find a negative relationship with generalised trust in all countries, but the link is weak outside of Nordic societies. Indeed, Goldschmidt ( 2017 ) finds further evidence for the negative link in Sweden – but so does Mavridis ( 2015 ) in Indonesia.

Country context thus shapes the relationship between immigration and social cohesion; however, prior evidence from low-income, refugee-hosting contexts is scarce. Considering the factors above, the Rwandan context is mixed: inequality and socio-economic precarity are present, but the negative effects may be counteracted by the cultural proximity between hosts and refugees (potentially reducing out-group threat) and the fairly inclusive policy approach.

In addition to trust within the community, in this paper we also examine the host communities’ trust in refugees as well as in IOs and NGOs providing support for the refugee population. Negative attitudes towards refugees, thereby weaker trust, can stem from multiple sources such as real or perceived competition over jobs, public goods and scarce resources, as well as differences in values and conventions (Christophersen, Liu, Thorleifsson, & Tiltnes, 2013 ; Harb & Saab, 2014 ; Mercy Corps, 2013 ; Porter et al., 2008 ; REACH, 2014 ; World Bank, 2013 ). Trust in refugees can also depend on the quality of interactions: in a cross-European study, Laurence and Bentley ( 2018 ) find a positive net effect of rising diversity on attitudes towards immigrants that is mediated by (positive) interethnic contact (while instances of negative contact, although rarer, increase negative attitudes). Locals’ trust and general attitudes towards IOs and NGOs can be influenced by the perceived (un)fairness of the aid and support provided to refugee populations, which is often seen as neglecting the local poor (Christophersen et al., 2013 ; REACH, 2014 ; World Bank, 2013 ). To our knowledge, no research to date has explored the feelings of trust of the host community with regards to these segments of the society, which we believe is of great importance. Firstly, because there is very little evidence on this issue in a time where the media and public debate portrays the presence of refugees as a predominantly a negative matter for local communities. And secondly, because giving voice to locals’ feelings and perceptions can help develop solutions that are beneficial for all members of the society and prevent feelings of distrust, anxiety and resentment.

In short, even though there exist theoretical arguments pointing to a potentially negative relationship between the influx of a large refugee population and local social cohesion, there also exist considerable evidence that goes in the opposite direction portraying positive social impacts. What is more, it is clear these effects are context-specific and highly conditional on local policies towards refugees as well as cultural (dis)similarities. In this paper we take into account formal and informal networks within community, feelings of safety and trust towards refugees, IOs and NGOs as central components of a cohesive, inclusive and peaceful refugee hosting community (Fig. 1 ). These perception-based indicators may not be sufficient for assessing the objective state of social life in a refugee hosting society, however we believe they are essential in bringing to the fore subjective perspectives regarding how locals experience living close to refugees. In the following section, we zoom into the specific situation of Rwanda and their history of hosting Congolese refugees to contextualise the current study.

Conceptual framework: links between proximity to refugee camps and social cohesion in local communities. Legend: none

Congolese refugees in Rwanda

Conflict and political instability have been notoriously widespread across the Central Africa and Great Lakes sub region in past decades. Most recently, recurring security problems in the DRC and Burundi have caused relatively considerable displaced populations to seek refuge in Rwanda and other neighbouring countries. Despite having experienced massive forced displacement itself during the conflicts of the early 1990s, the Rwandan population has been hosting refugees – primarily from the DRC, but also other neighbouring countries – for decades. By the end of 2017, over 170,000 refugees were hosted by Rwanda including more than 80,000 from the DRC (UNHCR, 2018b ).

Congolese refugees hosted in Rwanda generally originate from the North Kivu area of the DRC and are mostly of Banyarwanda background, which refers to Rwandan ancestry (UNHCR, 2014 ). North Kivu borders Rwanda and has received waves of Rwandan immigrants throughout the twentieth century. Although hardly a homogenous or united entity, the Banyarwanda have historically been the largest ethnic group in North Kivu and Kinyarwanda, an official language of Rwanda, is widely spoken in the area (Stearns, 2012 ). The Banyarwanda – and its subgroups – have been key actors in the violent political power struggles of the DRC in past decades and have repeatedly fled from violence and persecution to Rwanda (ibid., UNHCR, 2014 ). While a majority of Congolese refugees have some Rwandan origins, the precise extent and meaning of this heritage are unclear. Footnote 1 In conclusion, while its implications should not be overstated, the potential socio-cultural familiarity between refugees and hosts is an important factor to be taken into consideration while interpreting the findings.

Approximately 90% of Congolese refugees in Rwanda reside in one of the five camps spread throughout the country: Gihembe and Nyabiheke camps in the North, Kiziba camp near the western border, and Kigeme and Mugombwa camps in the southern part of the country. Four of these camps host ‘old caseload’ refugees, referring to refugees who entered the country during the first or the second Congo wars that respectively took place between 1996 and 1997, and between 1998 and 2003. Due to a new outbreak of violent conflict in Eastern DRC, Kigeme camp was opened in 2012 to accommodate an inflow of nearly 30,000 new Congolese refugees.

The Rwandan government has adopted a relatively permissive policy for refugees, allowing for the freedom of movement and work. Moreover, the government has promoted a community-integrated approach to social services, meaning that where possible refugees and local Rwandans have access to the same public services (e.g. health and education services) and the labour market. The Rwandan government also makes land available for refugee camps. This approach in essence allows refugees to be present in local communities even though they still predominately reside in the camps, and provides opportunities for social and economic interaction with host populations. Furthermore, Congolese refugees have the right to apply for Rwandan citizenship, which can facilitate refugees’ integration into their host communities.

This approach has been under development since October 2009, when UNHCR proposed a comprehensive strategy to bring to a closure the Rwandan refugee situation following the post-war period (UNHCR, 2011). It can be considered as part of the broader reintegration assistance provided for repatriated Rwandans, which has been extended to include other vulnerable groups such as foreign refugees (O’Connor, 2013 ). The minister for Disaster Management and Refugee Affairs (MIDIMAR), Seraphine Mukantabana has summarised this community-integrated approach as follows:

‘We have introduced community-integrated approach whereby programs meant to benefit refugees have to also benefit local communities and programs for citizens’ development benefit refugees.’ (MIDIMAR, 2014 )

The long-term goal of this approach is to implement measures that mutually benefit different segments of the society, to stimulate the socio-economic inclusion of refugees and to reduce their dependency on humanitarian aid. In practice, however, the freedom of movement and the access to employment opportunities for refugees are limited by bureaucratic procedures and costs (Bilgili & Loschmann, 2018 ; Easton-Calabria & Lindsay, 2013 ). As a result, many of the Congolese refugees remain dependent on humanitarian aid for decades (Hovil, 2011 ). Nonetheless, Rwanda’s comparatively inclusive and unrestrictive system makes it a particularly interesting case study, allowing us to observe the social implications of protracted refugee hosting in a context where there are few official policies blocking interaction and cooperation between hosts and refugees. Hence, it may be interpreted as an example for what happens to community social life when, at least in principle, social interaction between locals and refugees is unrestricted.

Methodology

The data used in this study were gathered through both household and community surveys as well as focus group discussions (FGDs) implemented in May 2016 across multiple locations in Rwanda. The surveys and FGDs were conducted around the camps of Gihembe, Kigeme and Kiziba. The camps were chosen for accommodating the largest Congolese refugee populations in the country as illustrated in Table  1 , as well as for representing a diverse range of contextual factors. For instance, the Kiziba and Gihembe camps mostly host protracted refugees who arrived in the late 90s, whereas the Kigeme camp only opened its doors in 2012. Differences are also found in the geographical characteristics of the locations. Kiziba, for example, is located several hours drive from the nearest commercial hub, Kibuye, making it the most remote of the three camps. Gihembe and Kigeme, by contrast, are located along main national roads fairly close to important cities, Byumba and Gikongoro, respectively. The differences in these characteristics among the three camps can be expected to provide markedly different potential for interaction between refugees and host communities.

Host communities were included in the sample primarily based on their distance from each camp. Footnote 2 Figure 2 shows the research design used to define potential candidates for enumeration, including all cells located within a 10 km radius from a camp (indicated in orange) and the same absolute number of cells from 20 km onwards (indicated in red). Footnote 3 From the resulting list of eligible cells, we randomly selected four from both the within 10 km and the above 20 km areas around each camp and chose one community in each with the largest population. Footnote 4 Next, households were randomly chosen for enumeration from a master list of all households located in the selected community, created in consultation with a community representative. Household surveys were conducted by an adult member of the household who could provide detailed information on all members of the household as well as relevant household characteristics (e.g. housing, economic situation). The household respondent also provided their personal opinion for more subjective questions like the ones used in this study.

Sampling strategy at the cell level. Legend: Note: Own generation based on publicly available administrative GIS data. Yellow cells indicate the location of each refugee camp. Orange cells are those within 10 km of each camp. Red cells are those above 20 km of each camp

As for the FGDs, two focus group discussions took place in a randomly chosen community from both the within 10 km and over 20 km areas from each camp, resulting in 12 discussions in total. Each group was comprised of six members, one being made up entirely of women and the other men. The groups were split by gender due to the concerns raised by local stakeholders that female participants might feel hesitant to voice their opinion in the presence of male participants. The discussions were led by a local moderator who was assisted by a dedicated note-taker. The moderator was provided with an interview guide in order to steer the discussion towards certain topics of interest related to our research questions, however the open nature of the discussion allowed participants freedom to emphasise and expand on issues they saw of particular importance. The discussions were conducted entirely in the local language, Kinyarwanda, and were transcribed and translated by the note-taker afterwards.

Empirical approach and description of variables

The empirical approach both from a quantitative and qualitative perspective relies on the comparison of households within communities that are more vs. less ‘exposed’ to refugees due to their proximity to a refugee camp. This 10 km vs. 20 km setup was decided following pre-survey site visits and extensive discussions with stakeholders on the ground in order to gauge a high vs. low potential for interaction between refugees and host communities. As Alloush, Taylor, Gupta, Valdes, & Gonzalez-Estrada ( 2017 , p. 334) explain in their own study focusing exclusively on the 10 km area, “A 10-kilometer radius captures the main markets in which refugees transact. Given poor transportation infrastructure, refugees rarely engage directly with markets outside this radius.” The distinction in the sample between 10 and 20 km communities serves to provide a counterfactual scenario, therefore our variable of interest indicates whether the household is located in a community nearby (< 10 km) or further from (> 20 km) a refugee camp. However, we also look across the three specific camp areas in order to see notable differences based on local context.

The outcomes used to gauge social life around the camps include subjective safety, formal and informal social networks, and trust in various groups. Subjective safety is assessed by asking the respondent ‘Do you currently feel safe in this community?’ with possible responses on a five-point Likert scale: ‘Not at all safe’; ‘A little safe’; ‘Neutral’; ‘Mostly safe’; and ‘Completely safe’. For the statistical analysis, we construct a binary version of the variable which takes a value of one for the latter two response choices and zero for the former two. Having a formal network is defined as the respondent being an active member of at least one community organization, for example an agricultural cooperative, a trader’s association or women’s association, among others. Having an informal network is determined by the respondent having at least one person beyond their immediate household whom they could count on for sudden financial help. Trust indicators are measured in relation to different segments of society: the respondent’s own community, refugees and IOs or NGOs. Similar to subjective safety, we use a constructed binary version of trust variable that takes a value of one if the respondent answered ‘Quite a lot of trust’ or ‘Completely trust’, and zero if ‘Little trust’ or ‘No trust at all’.

In line with previous research that highlights differences in experiences driven by individual background characteristics, we account for potential confounding factors by including a variety of controls in all models. At the individual level, we control for the respondent’s gender and marital status (one if married, either monogamously or polygamously, and zero otherwise) and literacy. At the household level, we include a binary variable measuring whether the respondent’s household has at least one member who is employed in paid work, total monthly income (in Rwandan Franc) normalized using the inverse hyperbolic sine transformation, the share of children (as compared to adults) in the household, and the size of the household. Finally, we control for the closest refugee camp to account for location-specific differences.

In the following section, we present the results beginning with a descriptive account of the sample and mean differences among the outcomes in question based on distance to a refugee camp. We next report the estimates from a logistic regression analysis Footnote 5 controlling for individual and household level factors, indicating the influence of residing in proximity to a camp in general as well as to a specific camp in particular using interaction terms. Finally, to triangulate and deepen our findings we review relevant evidence coming out of the FGDs which provide valuable insight.

Descriptive analysis

We first identify the descriptive mean differences in respondent and household characteristics in communities nearby (< 10 km) versus further from (> 20 km) a refugee camp.

Table  2 presents the demographic and socio-economic characteristics that serve as controls in our models. By design, host communities of varying distance to a nearby camp are represented roughly equally among respondents, as are the three camps, Gihembe, Kiziba and Kigeme. Female respondents are slightly overrepresented, around 59%, across both groups based on distance to the nearest camp. There is no difference in terms of the average age of the respondents per group. Around 70% of respondents are married, and roughly two-thirds are literate in both groups. Over 90% of households in both communities have at least one member who is employed in paid work with that share slightly higher for those further from a camp. The average share of children per adult within the household is close to being balanced in both groups, as is the average household size of five individuals. The most notable difference between the two groups is in the monthly household income, with households in close proximity to a camp producing an average monthly income nearly twice as high as that of households further away (49,000 vs. 27,000 RWF; equivalent to roughly 56 vs. 30 US dollars).

Table  3 reports the descriptive mean differences in relation to outcome variables of interest. We find that the level of perceived safety is roughly the same in communities nearby and further away from a refugee camp. The share of people with access to a formal network, namely formal membership in an organization, is just under half for those living nearby the camps and exactly half for those living further away. In terms of informal networks, that is being able to count on someone outside the household when in financial need, the difference is slightly larger: about half of the respondents within 10 km can count on help compared to 41% outside of 20 km.

Trust outcomes are fairly high in general – around or over 80% in all three categories – and are roughly similar regardless of proximity to refugee camp. The most notable differences are found for trust in own community, for which the share of ‘trusting’ respondents is somewhat lower in nearby a refugee camp, 81%, compared to those further away, 86%.

In summary, the descriptive analysis of the household data reveals little notable differences between local communities that are closer and farther away from refugee camps.

Alternatively, disaggregating the data by each of the refugee camps instead of distance to the nearest refugee camp shows similar variation across the three areas (see Table  4 ). Namely, while in Kiziba every second person has access to informal network for assistance, this share goes down to 41% in Gihembe and Kigeme. At the same time, feeling of safety seem to be lowest in Kiziba relative to the other two camps, but still within a quite narrow range.

Quantitative analysis

Going a step further, we now turn to the results of logistic regression analysis with models controlling for the general demographic and socio-economic characteristics previously described and shown in Table 2 . Overall estimates, reported as odds ratios, are presented in Table  5 which highlight the influence of living in proximity to a refugee camp, less than 10 km vs greater than 20 km. Alternatively, Table  6 reports the same estimates but with an interaction term between camp proximity and each individual refugee camp to identify differences across the three contexts. Since we are reporting odds ratios, a coefficient greater than one points to a positive association. Robust standard errors are clustered at the community level and reported in parentheses.

First, model 1 in Table 5 finds no statistically significant association between living nearby a refugee camp and perceptions of safety within a community. Still, regardless of proximity to the camp, respondents outside of Gihembe camp seem to feel greater security in comparison to the reference group of respondents outside Kiziba. Looking at the interaction terms in Table 6 , even though there is evidence that respondents within 10 km of Kigeme camp feel their community is less safe in comparison to respondents outside of 20 km from Kigeme camp, this relationship is only marginally statistically significant at the 10% level.

In the case of formal networks gauged by membership in a local organization, proximity and camp location are not statistically significant overall. Yet, as shown in model 2 of Table 6 , the camp-specific effect derived by interacting proximity and camp location reveals that living nearby Kigeme camp in comparison to further away increases the chances of having a formal network by a factor of 2.32. Conversely, for Gihembe, living in the vicinity of the camp lowers the odds of having a formal network by a factor of 0.36. The proximity is not statistically significant in the case of the Kiziba camp.

As for informal networks measured by whether the respondent is able to count on someone outside the household in times of financial need, we find an overall statistically significant result based on proximity to a refugee camp. Living within 10 km of a camp relative to outside 20 km increases the chances of being able to count on an informal network by a factor of 1.41. The camp-specific effects, however, show that this result is largely driven by households living nearby Kigeme camp and to a lesser extent Kiziba. Namely, the odds of having access to informal social network is higher by a factor of 2.47 for households living closer to Kigeme refugee camp in comparison to living further away from it. It is important to note however that overall, compared to those living around Kiziba camp, households around Kigeme are less likely to have access to informal social networks. In other words, the results indicate that outside Kigeme access to informal social networks are relatively low in general, but this is more so the case for those living further away from the camp.

In terms of measures of trust, we find mixed results. Overall, model 4 in Table 5 indicates that residing close by a camp is associated with lower levels of trust within ones’ own community. Footnote 6 However, Table 6 illustrates how this negative result is largely driven by respondents outside Kigeme camp, with no relationship in the case of Gihembe and Kiziba. Alternatively, we find no relationship with respect to trust in IOs or NGOs, nor the refugee population itself. On the other hand, respondents living within 10 km of Kiziba camp in particular have considerably higher levels of trust towards refugees compared to respondents further away from the same camp, suggesting, at least in that case, a link between exposure and warmer relations.

Overall, the quantitative analysis provides mixed results and does not point to a consistent positive or negative social impact due to living nearby a refugee camp. Indeed, many of the model estimates are statistically insignificant which implies that the refugee population does not influence the social lives of local hosts in obvious ways, good or bad, that we are able to capture with our household survey data. This may be due to the limited statistical power with a sample of this size, or the difficulty in measuring principally subjective social indicators. Alternatively, the influence of refugees on the lives of hosts may be more subtle and therefore likely to come out of nuanced qualitative approaches to which we now turn.

Perspective of locals regarding the influence of living close to a refugee camp on the social life in their community

The underlying assumption for the previous analysis was that exposure to and increased chances of interaction with refugee populations may have an influence on the social life within a community. Besides local differences, the quantitative results overall indicate that those living closer to a refugee camp do not necessarily feel less safe, have fewer formal social networks, or have less trust in refugees, IOs or NGOs. They do however seem to have more informal social networks. In this section, we seek to give a more informed explanation to these results on the basis of qualitative evidence derived from FGDs. In particular, we identify three main reasons why relations between refugees and hosts nearby the camps appear by-and-large constructive: cultural proximity to refugee population, increased social and economic interactions over time, and recognition of the importance of support given to refugees by IOs and NGOs.

To begin with, participants of FGDs living nearby the refugee camps convey a narrative of positive social and economic interaction between refugees and host communities. As mentioned, we may expect a degree of pre-existing cultural closeness between the two groups since most Congolese refugees already lived within close proximity to Rwanda before becoming refugees, share the language of locals, and often may even have Rwandan ancestry (Stearns, 2012 ; UNHCR, 2014 ). Focus group discussants generally confirmed the social closeness between locals and refugees:

Those refugees have already become Rwandans. The only difference arises from the fact that they are located in the camp. Otherwise, we consider them as Rwandans. -Participant 1, Kiziba community <10 km

While cultural similarities may have facilitated the process of acceptance, this is not explicitly mentioned: refugees still had to ‘become’ Rwandans, an achievement that may have also been enabled by the long timeframe in this protracted hosting experience. Another facilitating factor mentioned is the memory of Rwanda’s own not-too-distant conflict during which Rwandans themselves were refugees in the DRC’s North Kivu area:

There is no problem since we once were refugees too… that is why we should consider them as our relatives. -Participant 3, Kiziba community <10 km

At the same time, the fact that refugees and host communities have the opportunity to interact both in economic and social spheres of everyday life, for example in the local market place or schools, seems to play a role in the lack of tension and good relations. A common observation among focus group discussants is the building of trust over time due to increased economic interactions. Multiple participants recall fear, conflicts or negative incidents related to refugees when they first arrived, but report improved relations and a lack of problems in the present:

When [the refugees] arrived here, we were afraid of them since they are refugees but now we even work with them. -Participant 7, Kiziba community <10 km

Likewise, participants stressed the role of cooperation in economic activities in the strengthened relationship:

They didn’t have much to trade when they first arrived. But after they started receiving food, they could sell it to us so that they could also get some green vegetables. -Participant 4, Gihembe community <10 km

(…) But then we share[d] the production; he gives the morning milk to his kids and then I give the evening one to mine. And this creates a bond between us. - Participant 4, Kigeme community <10 km

These accounts on the positive role of extended contact and economic cooperation provide compelling support for the Rwandan government’s integrative policy towards refugees, which allows them to interact with locals in multiple aspects of everyday life. Aside from constructive economic interaction, it appears that the ability of refugees to utilise local social institutions also contributes to better relations and improved social cohesion. Focus group participants, for example, routinely express the positive nature of refugees attending local schools and how it has led to good relations:

[Refugee and local children] are visiting each other nowadays. They visit each other and they interact. They have a good relationship, (…) and this creates also love and interaction between their parents. -Multiple participants, Kigeme community <10 km

Finally, social cohesion within the community is perceived to be supported by the contributions of the IOs and NGOs that are working with and for refugees. Contrary to what one might expect, locals seem to be predominantly supportive of refugees receiving aid not only out of sympathy for their plight, but also because they believe that the provision of aid helps prevent potential security problems caused by refugees who would otherwise turn to theft and begging. This may help explain the lack of perceived safety threats and trust issues towards refugees in communities nearby the camps. Some key examples include:

Security is better when refugees are well treated. You understand that they can disturb the country’s security; if they are dying of hunger, they can steal from people in this community, and their kids cannot study well with an empty stomach. That is the reason they really need support. - Participant 2, Gihembe community >20 km

If they are not supported they don’t come out [of] the camp to steal from the community, (…) they don’t come to us to scrounge from the community, and they are not scattered everywhere. We are secure when they are supported. It is like supporting us too. -Multiple participants, Kigeme <10 km

It appears, therefore, that continued support for refugees is important not only to help refugees get back on their feet, but also to avoid negative incidents with host communities. In short, input of respondents from FGDs helped us identify three main reasons why cohesion, inclusiveness and peace are not necessarily undermined by the presence of Congolese refugees in areas close to refugee camps.

The findings of our study challenge the general assumption that the presence of refugees will damage social cohesion within refugee hosting communities. In fact, we learn that even in case of initial apprehension, over time, refugees and host communities may build close social relations and sustain a peaceful and inclusive social environment. The objective of this paper has been to look into this issue in more depth and understand in a comprehensive manner how living in close proximity to a Congolese refugee camp has an influence on social life within Rwandan local communities. We paid particular attention to differences among multiple areas of social life including subjective safety, engagement in formal and informal social networks and trust in own community, organizations and refugees themselves. Although the cross-sectional nature of our analysis does not allow us to draw causal relationships, we sought to identify first whether differences existed between host communities living at varying distances to refugee camps and second the mechanisms through which positive outcomes are achieved and maintained based on input from FGDs conducted with locals.

Overall, feelings of safety, access to formal social networks and trust to refugees and IOs or NGOs do not seem to be related to the proximity to refugee camps. In the long run, we found that Rwandan locals’ feelings of safety were not affected by the presence of refugees, which is an important contribution to the highly mixed and objective risk-focused previous evidence (e.g. Rutinwa & Kamanga, 2003 ; UNHCR, 2003 ). Our positive findings with regards to effect on informal social networks fall in line with Gesthuizen et al.’s ( 2009 ) cross-country comparison and Whitaker’s ( 1999 ) results from Tanzania. Beyond general associations, our diverging camp-specific results for both formal and informal networks echo Gesthuizen et al.’s ( 2009 ) and Kesler and Bloemraad’s ( 2010 ) final takeaway that local context plays a key role in shaping these outcomes. In line with Delhey and Newton ( 2005 ), Hooghe et al. ( 2008 ), and Kesler and Bloemraad ( 2010 ) we find some indication of a negative association with community trust, but the fact that this general result is driven by a single locality challenges the existence of a general negative link and points, instead, to the importance of local context. The fact that more exposure to refugees had an either null or even positive link to trust in refugees may be explained by the positive interactions between the two groups that became apparent from the focus group discussions (building on Laurence & Bentley, 2018 ). All in all, the study contradicts Putnam’s ( 2007 ) Hunkering-Down Theory: there is no consistent empirical evidence to suggest negative social implications of hosting refugees in Rwanda.

These results are an important contribution to the scarce empirical literature available concerning the social implications of hosting refugees in low-income countries, but are not without their limitations. The common cultural heritage of our hosts and refugee populations makes our case study particularly relevant to other contexts with a history of circular movements or internally displaced populations. On the other hand, the cultural similarities between Congolese refugees and Rwandan hosts make the findings less generalizable for settings where there are considerable differences across the two groups. The extended timeframe and the reciprocal refugee hosting experience between the two groups is also particular to our case. Nonetheless, these particularities shed light the importance of the contextual element, confirming the need to zoom into further diverse local contexts in developing countries and appropriately identify causal mechanisms that may differ across settings. Future research may also look more in-depth into objective and subjective measurements of social life and find ways to tackle the issue of socially biased answers regarding subjective assessment questions. For instance, the high occurrence of trust and feelings of safety in the various groups suggest that more scrutiny is needed for the measurement of such variables. Finally, research that is able to identify changes over time and address the same question in communities where there are more newly arrived refugees can be extremely important for the research field and for the identification of policy recommendations.

The long-term presence of Congolese refugees in Rwanda and their cultural proximity to the local population may have helped sustain a socially cohesive, inclusive and peaceful environment. However, qualitative evidence from the FGDs gives further ideas in terms of how to support social cohesion in host communities. Firstly, it is important to promote increased economic and social interactions between refugees and the locals. In this regard, despite the challenges it entails, the community integrated approach of the Rwandan government seems to be in the right direction. Secondly, refugee support by organizations should be continued until economic independence is achieved, because rather than leading to resentment by the locals, these support mechanisms are appreciated and are believed to decrease potential economic threats from the refugee populations. At the same time, to avoid potential resentment from vulnerable locals feeling overlooked in favour of refugees, it would be worth considering to provide comprehensive assistance to the community as a whole. In short, our mostly sanguine conclusions may be interpreted as evidence that offering refuge to desperate populations fleeing conflict does not have to be problematic even in the case of a country with limited resources.

Availability of data and materials

The datasets and related material (e.g. questionnaires, do-files) used for the study are available from the corresponding author on reasonable request.

For historical reasons, the subject of ethnicity is generally avoided in Rwanda including in our own research tools. Furthermore, some Banyarwanda groups’ Rwandan origins date back several generations. The proximity in culture and national/ethnic identity between refugees and hosts is thus difficult to assess, but we acknowledge its likelihood as an important characteristic of our case study. Nonetheless, evidence from cases of internal displacement shows that even co-national refugee inflows can affect host communities’ social cohesion (Amuedo-Dorantes et al., 2018 ).

For our purposes, we use ‘community’ to indicate the lowest administrative unit in Rwanda, otherwise known as a village.

A cell is the second lowest administrative unit above the village. Country-wide data at the village level was not readily available; therefore, pre-defined randomization took place at the cell level.

Population data at the village level for those selected cells was generously made available by the National Institute of Statistics Rwanda (NISR).

We report estimates from a logistic regression analysis considering the binary nature of outcomes in question, however using a linear probability model (i.e. OLS) results in no qualitative difference in the results.

When we do a robustness check of the result by including ‘neutral’ category as part of the individuals who have trust in their own community, this variable is not significant anymore, highlighting no negative association between living close to a refugee camp and trust in own community.

Abbreviations

The Democratic Republic of Congo

Focus group discussions

International organisations

Minister for Disaster Management and Refugee Affairs (Rwanda)

Non-governmental organisations

Rwandan Francs

Standard deviation

The UN Refugee Agency

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Acknowledgements

This paper is a result of a project funded by the United Nations High Commissioner for Refugees (UNHCR), but which was independently carried out by researchers from the Maastricht Graduate School of Governance | UNU-MERIT. We are thankful of the UNHCR’s sub-country office in Kigali, as well as the National Institute of Statistics Rwanda (NISR) for their support during fieldwork.

The authors would like to acknowledge UNHCR for funding the data collection efforts on which this analysis relies.

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VF, OB and CL and contributed to writing the introduction. VF and OB contributed to the literature review section titled ‘Social cohesion in forced displacement contexts’. VF, OB and CL contributed to the sections titled ‘Congolese refugees in Rwanda’, ‘Methods’, and ‘Results’. VF and CL implemented the data analysis including robustness checks. VF, OB and CL interpreted the findings in ‘Results’ and contributed to the conclusion. MS participated in discussions on the paper’s approach and implementation of the project as the Principal Investigator of the larger project. All authors have read and approved the final manuscript.

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Fajth, V., Bilgili, Ö., Loschmann, C. et al. How do refugees affect social life in host communities? The case of Congolese refugees in Rwanda. CMS 7 , 33 (2019). https://doi.org/10.1186/s40878-019-0139-1

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DOI : https://doi.org/10.1186/s40878-019-0139-1

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Big (Crisis) Data in Refugee and Migration Studies – Case Study of Ukrainian Refugees

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This paper presents a review of Big Data sources that could be helpful in determining, estimating, and forecasting the forced emigration flows of refugees from Ukraine. The text shows how a Big Data approach can help assess refugees’ intentions. Using insights from social-media platforms such as Facebook, Instagram, and YouTube is useful, because data here are available faster than any official data in the refugee crisis triggered by the Russian attack on Ukraine on 24 February 2022.

Big (Crisis) Data: An Opportunity for Refugee and Forced Migration Studies

As shown many times over the recent past (e.g. UNHCR Global Trends 2016 ), the current refugee crisis of Ukrainians shows that reliable data about the flows of people and their intentions would assist the United Nations High Commissioner for Refugees (UNHCR) and governments in projecting such emergencies and creating the best possible conditions for those in need ( Jurić 2022c ). However, such data are unavailable when the crisis is ongoing, or at any rate available in a more systematic manner only with a considerable time lag. Traditional data sources, based either on surveys or registers, generally fail in quickly providing statistical information on refugee flows and do not facilitate short-term anticipation of these flows ( Wladyka 2017 ). This essay demonstrates how new methods based on alternative sources, so-called Big Data, could help (c.f. Jurić 2022a ). [1]

In 2014, the United Nations (UN) conducted the first research on the use of Big Data for demographic research, with its report released in 2018. Since the UN confirmed the relevance of these data, demographic research has been carried out on social networks ( Zagheni et al. 2017 ; Zagheni and Weber 2015 ), and several studies have used Big-Data sources to analyse migration-related phenomena directly (e.g. Dubois et al. 2018 ; Hawelka et al. 2014 ; State et al. 2014 ). The first successful analysis of this type in the field of migration was undertaken during the 2015 migration crisis. This study showed that digital prints left by internet searches could provide insight into the movement of migrants ( Connor 2017 ): during their travels, many migrants used smartphones that provided access to information and maps (c.f. Jurić 2022b ). As I will show, the analytical tool Google Trends (GT) can give valuable complementary data in migration and refuge studies and be useful in the current Ukrainian refugee crisis.

Although Facebook (FB), Instagram, and YouTube are the most used social platforms ( Statista 2022 ), very few studies have been undertaken about their potential for migration studies and integration insights (c.f. Jurić 2022c ; UNHCR Global Data Service 2021 ). I will show that there are several approaches to using insights obtained from digital traces left on social networks, in order to identify and model migration flows and, later, the integration of immigrants, in this case, refugees who did not leave their homes voluntarily.

FB and Instagram can provide insights into geolocation and particular interests of the observed population, based on many signals such as “likes”, pages visited and specific cultural interests, while insights from YouTube can be obtained by analysing keyword searches ( Jurić 2022b ). If one seeks with these tools, for example, to measure integration willingness, i.e. receive hints about whether refugees have any intention to stay, indicators that address issues of education, employment, and language (learning) are included.

When it comes to Ukrainian emigrants, the advantage of FB and Instagram over YouTube is that they provide more precise sociodemographic data. On the other hand, the advantage of YouTube is that it better reveals user intentions. Compared to data from Meta , the advantage of YouTube is that limitations related to penetration rates and double fake accounts are not prevalent ( Jurić 2022b ). The control mechanism for testing this sort of data was performed by comparing those insights with the official databases from UNHCR and national governments, which were available two months later.

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Original research article, do refugee camps offer a refuge from conflict a spatially explicit analysis of conflict incidence at 1,543 refugee camps across africa (1997–2020).

• Geography Program, College of Earth, Ocean, and Atmospheric Sciences, Oregon State University, Corvallis, OR, United States

By the end of 2020, 20.7 million refugees worldwide were under the protection of the United Nations High Commissioner for Refugees (UNHCR). Despite the intended role of refugee camps as sanctuaries for people fleeing conflict and persecution, recent empirical research has shown that many refugees continue to experience conflict even after settling in camps. Measuring refugee exposure to conflict, especially recurrent conflict, is important for the design and evaluation of refugee settlement and asylum policies, refugee-host relationships, as well as refugee security and protection. However, existing research is either nationally aggregated or highly localized at a small number of refugee camps and does not consider changes in conflict incidence following refugee arrivals, leaving uncertainty around near-camp conflict dynamics across refugee hosting countries. To address these gaps, we measured conflict event proximity, frequency, and trends around refugee and non-refugee settlements in all refugee-hosting countries in Africa over a 24-year period (1997–2020). We used georeferenced data on 1,543 refugee camps from UNHCR and conflict event data from the Armed Conflict Location Event Database (ACLED), and compared localized conflict incidence at refugee camps to 4,003 non-refugee settlements from the Global Rural-Urban Mapping Project (GRUMP). Our results show that 52% of all refugee camps and 94% of urban refugee camps were within 10 km of at least one armed conflict event after camp establishment. Conversely, only 82% of urban settlements without refugee camps were within 10 km of a conflict event, suggesting that urban refugee camps are subject to nearby conflict at a disproportionately higher rate compared to both rural refugee camps and non-refugee settlements. We also find that conflict events moved an average of 11.2 km closer to refugee camps after camp establishment, indicating a general encroachment of conflict upon camps. Such persistent and widespread conflict challenges the security of camps and the protections afforded to refugees, and merits increased attention from host countries and humanitarian actors.

Introduction

By the end of 2020, there were 20.7 million refugees worldwide under the protection of the United Nations High Commissioner for Refugees (UNHCR), the largest refugee population ever recorded 1 . This rise in the global refugee population corresponds to the proliferation of refugee camps; as of 2020, ~6.6 million refugees−22% of the global population—lived in UNHCR refugee camps 2 . Refugee camps are “exceptional spaces” ( Turner, 2016 ) that are often established in remote border regions but also sometimes within cities, and are maintained to shelter those forcibly displaced across international borders by violent conflict or the threat of persecution. However, refugee camps do not always offer refuge from conflict. Many refugees continue to experience conflict such as armed clashes, interpersonal violence, and violent demonstrations after settling in camps, which affects psychological welfare (e.g., Harder et al., 2012 ; Gladden, 2013 ; Jabbar and Zaza, 2014 ; Namakula and Witter, 2014 ) and livelihood development (e.g., Jacobsen, 2002 ; Halabi, 2004 ; Werker, 2007 ). Such conflict may represent a continuation of the conflict that affected refugees before displacement (e.g., Grabska, 2011 ; Turner, 2017 ) or result from novel conditions faced by refugees in the host country (e.g., Loescher and Milner, 2005b ). Conflict at or near refugee camps can insidiously shape host country populations' perceptions of refugee populations (e.g., Loescher and Milner, 2005b ; Savun and Gineste, 2019 ). Even when conflict is not instigated by refugees, conflict near refugee camps can contribute to national governments viewing refugees as a security threat ( Loescher and Milner, 2005b ). When refugees and refugee camps are securitized, host governments tend to enact exclusionary refugee policies that limit the economic and educational opportunities of refugees, relegate and isolate refugee camps to a country's ecological and social margins, impacting the well-being of already vulnerable communities (e.g., Kaiser, 2000 ; Johnson, 2011 ; Chkam, 2016 ).

Studies on the relationships between the arrival of refugees and conflict incidence in the host country most often aggregate data on refugee populations and conflict events at the nation-level in order to compare measures of refugee population, demographics, humanitarian aid, or economic conditions (e.g., Salehyan and Gleditsch, 2006 ; Salehyan, 2008 ; Böhmelt et al., 2019 ; Rüegger, 2019 ; Savun and Gineste, 2019 ). Salehyan and Gleditsch (2006) found that the presence of refugees correlates with increased probability of conflict in host nations, though the vast majority of refugees were never directly involved in conflict events. Proposed mechanisms to explain this increased probability of state-sponsored conflict following refugee settlement include refugee-hosting states engaging in militarized disputes to prevent further refugee movements, refugee-sending states violently pursuing refugees over international borders ( Salehyan, 2008 ), refugee populations exacerbating tensions and tipping power dynamics between politically marginalized co-ethnic groups and host states ( Rüegger, 2019 ), and host governments scapegoating refugee populations and launching retaliatory attacks in response to terrorist attacks and other crises ( Savun and Gineste, 2019 ). Böhmelt et al. (2019) found that even if host states do not actively engage in conflict with refugees, weak state capacity can limit host government responses to non-state conflict between refugees and local populations.

More spatially explicit sub-national studies on conflict-refugee relationships have helped to elucidate some of the contextual factors that influence conflict likelihood. In an early study, Loescher and Milner (2005a) explicitly investigated the role of refugee camp location on nearby conflict, working with camp-level case studies in Africa and Asia. They argued that the isolated locations typical of refugee camps made it easier for militant groups from refugee origin countries to infiltrate a given camp. This infiltration contributed to securitized perceptions of refugee camps; countries hosting refugee camps may be concerned about militant groups gaining a hold in the host country, and combatants from refugees' home countries may view refugee camps as shelters for militants. In a separate study, Loescher and Milner (2005b) found that isolated refugee camps have increased risk of both conflict between refugees and host-government forces, as well as cross-border conflict with militants from refugees' home countries. More recently, Fisk (2019) found higher rates of communal conflict in regions hosting large encamped refugee populations, corroborating nation-level studies that link refugee populations and conflict. Additional work by Fisk (2016) highlighted the directionality of this conflict by showing that refugee-hosting regions experienced more conflict events targeting civilians, including refugees. Johnson (2011) also directly linked conflict events to individual refugee camps and determined that the likelihood of attack on a refugee camp was associated with the number of male refugees, the age of residents, and the size of the settlement. These results suggest that the increase in conflict often measured near refugee camps is driven by attacks targeting refugees. While valuable, these studies do not systematically examine the spatial relationships between conflict events and refugee camps nor do they consider the ways in which conflict patterns near refugee camps may change over time.

The goal of this descriptive study is to measure the proximity of conflict events and refugee camps, and determine whether conflict events encroach upon refugee camps in the years following refugee camp establishment and the initial arrival of refugees. Measuring refugee exposure to conflict at or near refugee camps, especially recurrent conflict, is important for the design and evaluation of refugee settlement and asylum policies, supporting refugee-host relationships, as well as refugee security and protection 3 . We used georeferenced datasets of 1,543 UNHCR refugee camps across Africa that were in operation between 1997 and 2020 ( UNHCR Geoservices, 2021 ) and conflict events recorded in the Armed Conflict Location and Event Database (ACLED) Project dataset ( Raleigh et al., 2010 ). With these data, we measured the count and proximity of conflict events around African refugee camps as well as the change in conflict event proximity after a camp's establishment. For comparison, we measured conflict proximity around non-refugee settlements from the Global Rural-Urban Mapping Project (GRUMP) Settlement Points dataset ( CIESIN et al., 2017 ), and stratified comparisons between UNHCR refugee camps and non-refugee GRUMP settlements by rural/urban settings, border proximity, and whether a conflict event was fatal. Our results offer the first systematic and spatially explicit assessment of the proximity and persistence of conflict events around refugee camps in Africa. Our findings have broad value for host countries and humanitarian actors who seek to protect refugees from conflict or develop more conflict-sensitive approaches to refugee settlement and planning.

Methods and Datasets

Study area and period.

We focus on refugee camps across the African continent because almost two-thirds of UNHCR refugee camps are in Africa and almost 30% of the world's refugees lived in Africa in 2020, more than any other continent 4 , and previous studies have recorded the highest levels of armed attacks on refugee camps in Africa ( Muggah and Mogire, 2006 ). The study is inclusive of the 47 African countries hosting UNHCR refugee camps in 2020. The 23-year study period of 1997–2020 saw widespread creation of refugee camps due to escalated frequency and duration of civil conflicts in many countries, resulting in forced displacement and asylum claims. The study period is also framed by the availability of ACLED conflict event data, described below, which were not available in Africa before 1997.

UNHCR Refugee Camps

There is no official, legal UNHCR definition of a refugee camp, though Jacobsen (2000) cites a 1958 UNREF document describing a refugee camp as “a group of dwellings of various descriptions … which, mainly because of the poor conditions of the dwellings but also for other reasons, are meant to provide temporary shelter.” In this study, we considered 1,543 refugee camp and settlement locations across Africa, which we collectively refer to as ‘camps’ for simplicity, established between 1966 and 2020 ( Figure 1A ). UNHCR data include the name and geographic coordinates of each camp (WGS84 coordinate reference system), as recorded in the field using GPS or through document analysis, as well as an establishment date for each camp, which is often just recorded as a year, and a closure date when applicable.

Figure 1 . Spatial distribution of (A) UNHCR refugee camps, (B) GRUMP settlements, and (C) ACLED conflict events per square decimal degree grid cell. Camps, settlements, and conflict events are aggregated here for purposes of visualization.

We subset the refugee camps data in two ways. First, to tease out potentially different conflict patterns around urban and rural camps, we subset refugee camps into rural and urban subgroups based on the GRUMP Urban Extend Grid. Second, we subset refugee camps based on their proximity to the nearest national border considering the potential importance of cross-border violence identified by Salehyan (2008) . Using Natural Earth administrative boundaries ( https://www.naturalearthdata.com ), we divided refugee camps into two subgroups: those greater than 50 km from a national border and those less than or equal to 50 km from a border.

GRUMP Settlements

As a complement to UNHCR refugee camps, the Global Rural-Urban Mapping Project settlement points dataset (GRUMP; CIESIN et al., 2017 ) was used to represent the geographic distribution of non-refugee settlements. The GRUMP dataset is global in scale and includes cities and towns with populations of at least 1,000 persons as of 2000. In Africa, GRUMP includes 4,396 geocoded settlement centroids ( Figure 1B ) with associated location names, classification as being urban or rural, and population estimates for 1990, 1995, and 2000 derived from a 30-arcsecond-resolution dataset primarily based on national census data. There has never been an explicit assessment of whether refugee camps are included in the GRUMP dataset but it is likely that most camps considered in this study are excluded since the vast majority were established after the GRUMP dataset was created. Because the majority of refugees live in urban settlements rather than refugee camps, it is likely that some GRUMP settlements are inhabited by urban refugees; however, there is are no continent-wide data available to characterize the presence, population, or arrival timing of urban refugees.

In order to avoid overlap between refugee camps and GRUMP settlements as much as possible, we removed any GRUMP settlement within 10 km of a UNHCR camp from the analysis. In total, 393 (9%) GRUMP settlements were within 10 km of UNHCR camps; these were predominantly urban (327 settlements vs. 66 rural settlements) and within 50 km of the nearest national border (283 settlements vs. 110 settlements farther than 50 km from a border). Working with the remaining 4,003 GRUMP settlements allowed us to define non-refugee hosting settlements more confidently and thus create a more reliable control for comparison with refugee camps. As above with ACLED data, we subset GRUMP settlements into urban/rural subgroups as well as by proximity to the nearest national border.

ACLED Conflict Event Data

The Armed Conflict Location and Event Data Project (ACLED) records geographically disaggregated conflict events across Africa, South Asia, Southeast Asia, and the Middle East ( Raleigh et al., 2010 ). ACLED is a human-reported conflict event dataset based on reports from people, generally journalists or human rights defenders, situated within a conflict ( Eck, 2012 ). ACLED was selected for this study because of its rigorous, standardized, and well-defined protocol for conflict event documentation, its broad temporal duration, and its geographically disaggregated record of conflict events. Though datasets devoted exclusively to conflict events perpetrated by and against refugees are available, such as POSVAR ( Gineste and Savun, 2019 ), they are not sufficiently geographically disaggregated for the goals of this study.

Between 1997 and 2020, ACLED recorded 229,071 geocoded conflict events across Africa ( Figure 1C ) with an increasing annual rate of conflict over most of the study period ( Figure 2 ). ACLED codes geoprecision on an ordinal scale where “1” indicates that an exact town or location is associated with the event; “2” indicates that a local region or neighborhood is associated with the event; or “3” where an event is coded to a provincial capital lacking any more detailed information ( Raleigh et al., 2010 ). We used ACLED events with all three geoprecision levels in this study; 77% of ACLED events had a geoprecision of 1, and 20% and 3% of events had a geoprecision of 2 or 3, respectively. In a comparative study, Eck (2012) found that geographic imprecision can lead to spatial inaccuracy, especially for events occurring in rural or otherwise remote locations where geographic coordinates were less likely to be reported. However, in our analysis, the inclusion of less precise event location data did not significantly change conflict event proximity or frequency measurements.

Figure 2 . Number of ACLED conflict events in Africa per year from 1997 to 2020, overlaid with the number of UNHCR refugee camps established per year.

ACLED also records the event date, the instigating group(s), the targeted group(s), an event type category (e.g., “Violence Against Civilians” or “Riots/Protests”), the number of resulting fatalities, and a notes field including a brief description of the event. 917 ACLED events include the word “refugee” in their descriptions, e.g., “Anuak attack Sudanese Dinka refugees” and “Eritrean refugees demonstrate against Eritrean regime” ( Raleigh et al., 2010 ). Of these, 305 events include the phrase “refugee camp” in their event descriptions, but surprisingly only 53% (162) of “refugee camp” events are within 10 km of UNHCR camps. The remainder of “refugee camp” conflict events tended to occur far from camp locations and were associated with protests in state capitals, government buildings, etc. advocating for policies related to treatment of refugees. Given these thematic limitations, ACLED event descriptions were only used to contextualize conflict, not to identify relevant conflict events for analysis.

ACLED's definition of a conflict event includes direct violence, such as armed clashes between militaries and extremist groups; cultural violence, such as politically motivated vandalism, destruction of crops, theft of livestock, etc.; and political protest, such as demonstrations and riots. We subset ACLED conflict events into two subgroups—fatal and non-fatal events—to account for the potentially different spatial relationships with refugee camps between fatal events that cause loss of life and non-fatal events that may still significantly impact refugees' health and economic security, and influence the securitization of refugee camps (e.g., Jacobsen, 2002 ; Halabi, 2004 ; Jabbar and Zaza, 2014 ).

Measuring Spatial Relationships Between Conflict Events and Refugee Camps

Nearby conflict event incidence.

For a given camp, we measured the count of ACLED events within 10 km of any refugee camp that took place during or after the year that the camp was established. We also calculated the proportion of camps with one or more conflict events within 10 km. A radial distance of 10 km was selected following Spröhnle et al. (2016) to estimate the range of movement by refugees outside of camps to access surrounding land resources. Even though the conflict events may not occur within a refugee camp, conflict proximity may nonetheless degrade refugee welfare or camp-based livelihoods or contribute to anti-refugee stigma that affects refugee-host relationships (e.g., Halabi, 2004 ). We measured similar counts of conflict events within 10 km for locations in the GRUMP dataset, however, we assumed that GRUMP settlements were populated for the entire study period (1997–2020) and thus compared them to all ACLED events, without regard to date. We measured the counts of fatal and non-fatal conflict events separately from each other and, as described above, made similar calculations for GRUMP settlements as well as for subsets of camps and settlements based on rural/urban designations and national border proximity.

Proximity of Nearest Conflict Event to Refugee Camps

We measured conflict-settlement proximity as the distance from each UNHCR refugee camp or GRUMP settlement to the nearest ACLED conflict event, and again only consider ACLED events that occurred in the same year as the camp's establishment or later. This analysis was repeated for GRUMP settlements, measuring the distance from each settlement to the nearest ACLED event, though we used the entire ACLED dataset (events from 1997–2020), assuming that GRUMP settlements were populated for the entire study period. As above, separate measurements were made based on fatal/non-fatal outcomes of conflict events as well as rural/urban and border proximity of refugee camps and GRUMP settlements.

Changes in Conflict Proximity Following Refugee Camp Establishment

As the above measures only consider conflict events after camp establishment, we also examined temporal relationships by assessing whether camp-conflict proximity changed in the years after a camp's establishment. We calculated the distance from each refugee camp to the nearest ACLED conflict event before and after a camp's establishment where the conflict event year was measured relative to the camp's establishment year, e.g., Year −3 and Year +3, representing three years before or after a given camp's establishment, respectively, regardless of the specific year when an individual camp was established; by using relative dating, changes in conflict event patterns could be compared across all camps established between 2000 and 2017. The before-camp-establishment distance was calculated as the average minimum distance of ACLED events to a given camp in Year −3 and Year −2, and the after-camp-establishment distance was calculated as the average of Year +2 and Year +3 minimum distances. The during-camp-establishment distance was also calculated using the average minimum distance of conflict events from each camp in Year −1, Year 0 (i.e., the year of camp creation), and Year +1; this three-year range was used to mitigate the effect of varying months of establishment between camps. As above, separate measurements were made based on fatal/non-fatal characteristics of conflicts as well as rural/urban and border proximity characteristics of camps and GRUMP settlements.

Conflict Event Incidence and Proximity

In total, we recorded 58,587 conflict events within 10 km of study refugee camps after camp establishment ( Table 1 ), amounting to an average of 38 conflict events per refugee camp. We found that 52% (809) of refugee camps had at least one conflict event within 10 km of the camp that took place after camp establishment and 36% (558) of refugee camps had at least one fatal conflict event within 10 km, though many conflict events involved multiple fatalities. For example, the description from the ACLED dataset for one high-fatality event was: “FNL [National Forces of Liberation, an ethnic Hutu rebel group in Burundi] raided a United Nations refugee camp and killed 189 Banyamulenge. FNL claimed the camp was a hideout for Burundi army soldiers and Congolese tribal militiamen. Most of the victims appeared to be women and children” ( Raleigh et al., 2010 ). Of the remaining 72% (42,466) of conflict events within 10 km of a refugee camp that were non-fatal, these were predominantly either non-violent protests, e.g., “Army sent to restore peace in Forchana refugee camp after riots and failed negotiations. 13 Sudanese, 2 Chadians and 1 Saudi arrested,” or non-violent but coercive actions by militant groups, e.g., “FDLR [Democratic Forces for the Liberation of Rwanda—an ethnic Hutu rebel group] recruiting fleeing Hutu refugees, working within DRC” ( Raleigh et al., 2010 ).

Table 1 . Summary of non-fatal (0 fatalities) and fatal (>0 fatalities) conflict event incidence within 10 km of UNHCR camp and GRUMP settlement locations and proximity to nearest conflict event.

In comparison, we measured 84,810 conflict events within 10 km of GRUMP settlements yielding 19 conflict events on average for GRUMP settlements, which is half of the average number of conflict events recorded within 10 km of refugee camps. A greater proportion (76%) of non-refugee GRUMP settlements saw at least one conflict event within 10 km compared to refugee camps (48%). However, note that all ACLED events from 1997 or later were considered for GRUMP settlements with the assumption that GRUMP settlements were settled before 1997, which likely leads to overestimates of actual conflict event incidence and proximity. While the relative proportions of non-fatal and fatal events near refugee camps (72 and 28%, respectively) and GRUMP settlements (75 and 25%, respectively) were very similar, GRUMP settlements also experienced higher rates of non-fatal (72%) and fatal (52%) conflict events within 10 km compared to refugee camps. These results show that refugee camps tend to have higher nearby conflict incidence on average (38 events per camp) compared to GRUMP settlements (19 events per settlement) but these conflict events were more localized at a smaller proportion of refugee camps (52%) compared to GRUMP settlements (76%). We also found that the median minimum distance of conflict events from refugee camps and non-refugee settlements was 9.0 km and 1.5 km, respectively, indicating that conflict events were more often much closer to non-refugee GRUMP settlements than refugee camps. Note that these median distances fall within the 10 km threshold used in measuring nearby conflict event incidence.

We also examined the potential difference in conflict incidence between urban and rural settings for UNHCR camps and compared to GRUMP settlements. UNHCR camps are by and large located in rural settings (82%) while GRUMP settlements tend to be urban (77%). Raleigh (2015) showed that conflict events in Africa became increasingly urbanized from 1997–2013, a similar time period as this study, and so we would expect a greater proportion of urban camps and settlements to have nearby conflict compared to those in rural settings. Indeed, we see that 94% of urban UNHCR camps had at least one conflict event within 10 km during the study period, which is markedly higher than the 82% of urban GRUMP settlements with nearby conflict ( Table 2 ). Meanwhile, 43% of rural UNHCR camps had nearby conflict compared to 56% of GRUMP settlements. We found that conflict events tended to be slightly closer to urban refugee camps (median: 1 km) than urban GRUMP settlements (median: 1.2 km) but farther from rural refugee camps (median: 11.9 km) than rural GRUMP settlements (median: 7.9 km). Urban refugee camps thus not only have higher conflict incidence compared to rural refugee camps and urban non-refugee settlements, conflict events also tend to be closer to urban refugee camps than other locations considered here.

Table 2 . Summary of conflict event incidence within 10 km of urban and rural UNHCR camp and GRUMP settlement locations and proximity to nearest conflict event.

We considered whether there was a difference in nearby conflict incidence for refugee camps within 50 km of the nearest national border and those that were farther away. Due to refugees so often seeking asylum across the nearest national border, 79% of UNHCR camps have been established within 50 km of national borders. Settling in refugee camps close to the national border is logistically pragmatic for asylum-seeking populations but being so close to a border often leaves refugees within reach of the violence that they fled (e.g., Jacobsen, 2000 ). Loescher and Milner (2005b) stated that geographical isolation, especially in border regions, contributed to the likelihood of cross-border attacks, however we did not find a large difference in conflict incidence for camps located within 50 km of a border (54%) compared to camps farther from a border (47%) ( Table 3 ). Moreover, conflict incidence was far higher for GRUMP settlements compared to refugee camps regardless of whether the settlement was near (79%) or farther (74%) from the nearest national border, and tended to be much closer as well.

Table 3 . Summary of conflict event incidence within 10 km of UNHCR camp and GRUMP settlement locations close to (within 50 km) and farther from (50 km or more) the nearest national border.

Changes in Conflict Proximity Following Camp Establishment

Above, we used the distance threshold of 10 km in measuring nearby conflict event incidence and also summarized distances between conflict events and camps and settlements. Here, we examined whether the proximity of conflict events to a given location changed in the years after refugee camp establishment for camps established between 2000 and 2017. We found that conflict encroached upon 52% of refugee camp locations after camp establishment, with an average movement of 11.2 km toward camps ( Table 4 ). Moreover, on average, all subsets of UNHCR camps (rural, urban, greater and less than 50 km from national borders) and ACLED events (zero fatalities and at least one fatality) experienced movement of conflict events toward refugee camps after their establishment. The largest movement toward camps was detected when comparing all UNHCR camps to ACLED events with at least one fatality. Fatal conflict events moved on average 23.6 km closer to UNHCR camps and 66% of camps experienced encroachment of fatal conflict events. UNHCR camps further than 50 km from a border experienced the next largest change in conflict proximity, with conflict events moving an average of 20.9 km closer in the after camp establishment period; this movement of conflict events toward refugee camps was detected in 49% of camps further than 50 km from a border. 53% of both rural UNHCR camps and camps less than 50 km from a border experienced encroachment of conflict events, though on average, conflict events only moved 11.5 km and 9.0 km closer, respectively. Conversely, 30% of urban UNHCR camps experienced no change in average distance of conflict events in the periods before and after camp creation.

Table 4 . Summary of change in conflict event proximity to UNHCR refugee camps after camp establishment (2000–2017).

This study shows that conflict events are frequently close to refugee camps and also that conflict tends to follow refugees after they settle in camps whether in rural or urban settings. Specifically, we found that 52% of refugee camps have had at least one conflict event within 10 km after establishment, that a greater percentage of refugee camps in urban settings or within 50 km of the nearest national border had nearby conflict compared to rural camps or those father from a national border, respectively, and that conflict around 52% of all refugee camps were closer (mean: 11.2 km) after camp establishment. Refugee camps in all contexts (i.e., urban and rural, near and farther from a national border) saw encroachment of conflict events toward the camp with camps in rural regions and those >50 km from a national border seeing the largest reduction in conflict proximity. The spatial precision afforded by measuring conflict incidence at the camp-level helps to illuminate security threats in refugee camps across Africa ( Savun and Gineste, 2019 ) and may also shed light on refugee concerns over land use and wage seeking movements beyond the camp ( Jacobsen, 2002 ).

Our Africa-wide results provide broader context for case study findings on conflict incidence at specific refugee camps such as Dadaab and Kakuma in Kenya ( Crisp, 2000 ; Loescher and Milner, 2005a ; Rawlence, 2016 ). Our results also echo country-level results reported in other scholarship, most notably Gineste and Savun's (2019) who compiled POSVAR, a dataset of violent conflict events between 1996 and 2015 either enacted by or against refugees, which is aggregated at the country-level. Globally, Gineste and Savun (2019) found that violence against refugees was much more prevalent than violence perpetrated by refugees, with ~50% of refugee-hosting countries experiencing violence against refugees and fewer than 20% experiencing violence enacted by refugees. Within Africa, they found similarly low levels of violence perpetrated by refugees. These findings align with our qualitative review of ACLED conflict event descriptions described above: of the 917 ACLED events that include the word “refugee” in their event description field, refugees were alternately described as targets of the conflict or as participants in non-violent protest but were not listed as instigators of any conflict events.

Refugee camps had nearly twice the number of conflict events compared to GRUMP settlements on average, but we found that urban refugee camps are the only subgroup of refugee camps considered in this study that show a higher percentage of nearby conflict event incidence at 94% compared to reference GRUMP settlements (82%). Conflict events tend to also be slightly closer to urban refugee camps (median: 1.0 km) compared to urban GRUMP settlements (median: 1.2 km). The frequency and proximity of conflict events around urban refugee camps is concerning since increasingly more refugees live in urban regions and, according to our results, are thus exposed to higher rates of nearby conflict compared to rural camps, which seem to offer a buffer from conflict according to our results.

Non-refugee GRUMP settlements tend to show higher conflict frequency and proximity than refugee camps, but there are several notable differences between UNHCR refugee camps and GRUMP settlements that impact this comparison. First, there are almost three times as many GRUMP settlements as refugee camps across the continent (4,003 GRUMP settlements vs 1,543 refugee camps), and this inevitably results in higher event counts around GRUMP settlements, especially because the annual rate of conflict also increased over the study period. Second, as of 2000, GRUMP settlements in Africa had an average population of 55,647, whereas, in 2016, African refugee camps had an average population of 4,342 ( UNHCR, 2017 ). The relatively large populations of cities and other urban areas contributes to the measurably high frequency with which cities and other urban areas were targets of conflict during civil wars (e.g., Beall, 2007 ; Raleigh and Hegre, 2009 ; Sampaio, 2016 ) and skews the distribution of conflict frequency around non-refugee settlements. Though population data for individual camps were not available, a population-normalized comparison of conflict around GRUMP settlements and UNHCR camps would have been valuable for understanding the effect of population density on conflict patterns. Third, this study could not account for the establishment year of GRUMP settlements and so GRUMP settlements were assumed settled by the start of the study in 1997. This assumption likely contributes to overestimation of conflict incidence at GRUMP settlements measured over the entire 1997–2020 study period.

Explanations for the variation in conflict patterns between refugee camps requires further investigation. This research cannot comment on why specific refugee communities or camps experience more or less conflict nor the various socio-spatial factors that contribute to conflict event likelihood (e.g., Fisk, 2016 ; Rüegger and Bohnet, 2018 ; Böhmelt et al., 2019 ). Such information would be helpful in identifying specific refugee camps at the greatest risk of localized conflict and in need of additional support. Similarly, this research did not examine the characteristics of conflict events in detail, such as the actors involved in fatal or non-fatal conflict events at refugee or non-refugee settlements, nor whether actors undertook cross-border attacks at refugee camps, for example. In the longer term, an improved understanding of why certain camps experienced more conflict could lead to preventative policies and guide camp planning to decrease the likelihood of conflict for camps that are yet to be established. Though ACLED data are recorded daily, this study did not examine the intra-annual timing of conflict events, which may have a bearing on the socioeconomic or food security costs of conflict events that occur at key moments during the agricultural harvest. Additionally, research examining the motivations that drive certain groups and state forces to target refugees and refugee camps would be welcome. Developing an inclusive conceptualization of the conditions and short- and long-term effects of frequent, nearby conflict on refugees living in camps would be extremely valuable for improving protections of refugees living in camps as well as holding perpetrators accountable.

As the population of refugees in Africa grows and refugee camps continue to proliferate, this study offers a new, spatially-explicit understanding of conflict surrounding refugee camps. This study is the first to describe and quantify this movement of conflict toward refugee camps, an important step in elucidating the relationship between refugee camps and conflict. In particular, this study shows that urban refugee camps are disproportionately exposed to conflict and conflict events encroach upon refugee camps following establishment. The threat of conflict at many refugee camps remains significant especially given the overarching vulnerability of refugees living in camps that are ill-equipped to protect refugees. The findings of this study underscore the need for greater support and protection of the growing refugee population settled in camps in rural and urban regions alike.

Data Availability Statement

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.

Author Contributions

FF and JV contributed to conception and design of the study. FF performed the spatial analysis. Both authors wrote the first draft of the manuscript, contributed to manuscript revision, read, and approved the submitted version.

This research was funded by the National Aeronautics and Space Administration (80NSSC18K0311).

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: refugees, conflict, Africa, spatial analysis, ACLED, refugee camps

Citation: Fein F and Van Den Hoek J (2022) Do Refugee Camps Offer a Refuge From Conflict? A Spatially Explicit Analysis of Conflict Incidence at 1,543 Refugee Camps Across Africa (1997–2020). Front. Hum. Dyn. 4:857250. doi: 10.3389/fhumd.2022.857250

Received: 18 January 2022; Accepted: 28 February 2022; Published: 28 March 2022.

Reviewed by:

Copyright © 2022 Fein and Van Den Hoek. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Jamon Van Den Hoek, vandenhj@oregonstate.edu

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International refugee law is seen by many as constitutive for national refugee policy. Yet, as asylum has become politicized, many countries have adopted procedural and physical deterrence mechanisms to prevent refugees from accessing protection. The present article examines these policies, as well as the legal responses to them, as a critical case study for understanding the relationship between international law and refugee policy. Based on a theoretical triangulation of the dominant accounts of the interplay between international law and politics within liberal, realist and critical legal studies scholarship, it is argued that the two should rather be seen in a dialectic process of co-evolution. This speaks both to the continued power of international refugee law, but also to the instrumentalist approach of certain states trying to contest or circumvent their international legal commitments.

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Higher education for refugees: relevance, challenges, and open research questions

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Reflecting the increased public, political, and professional interest in higher education for refugees, research activity in this area has increased significantly in recent years. The growing body of literature provides new academic insights and crucial information for both policy and practice. This integrative literature review discusses 104 papers published between 2016 and 2019, contributing to the state of the research by offering a structured synopsis of the key themes and findings of this relatively new field. It first presents structural changes in the research literature, such as an increased focus on Germany and Turkey after the influx of asylum applications in 2015/16. It also outlines the high relevance of higher education for refugees, which is often discussed as the foundation of success in the host country. Further, the paper provides a synopsis of the personal, institutional, and structural challenges faced by refugees as they aim to realize their higher education goals, and an overview of structural challenges for institutions aiming to support them. In particular, the intersection of multiple challenges and the unaligned interests and needs of policymakers, higher education institutions, and refugees threaten the development of adequate support services. Finally, open questions and implications for further research are identified.

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Introduction

The United Nations High Commissioner for Refugees (UNHCR 2019 ) has reported “the highest levels of displacement on record,” with 70.8 million people worldwide having been displaced, including 25.9 million refugees. Notably, the UNHCR’s estimation of refugee enrolment in higher education institutions (HEIs) increased from 1% in 2019 to 6% in 2023. The UNHCR is striving to increase this number to 15% by 2030—the “15by30 target” (UNHCR 2023 ). This emphasizes the importance of targeted support programs (see also United Nations 2019 ).

Before 2016, studies on tertiary education for refugees were sparse and usually based on “primarily exploratory, qualitative investigations with (sometimes very) small case numbers” (Berg et al. 2018 , p. 82, translated from German). They highlighted some of the key challenges refugee students were facing in obtaining higher education, such as financial challenges (Stevenson and Willott 2007 ), the effect of traumatic experiences (Earnest et al. 2010 ), language proficiency (Shakya et al. 2010 ), interruptions and long breaks in their educational experiences (Morrice 2009 ), the lack of information (Stevenson and Willott 2007 ), and peer support in their communities (Joyce et al. 2010 ; Naidoo 2015 ). Along with growing social and practical interest, however, a growing body of academic literature has begun to investigate aspects of higher education for refugees.

Previous literature reviews have considered the state of research until early 2018 (Berg et al. 2018 ; Mangan and Winter 2017 ; Ramsay and Baker 2019 ), focused on specific groups, such as Syrian students in Germany (Ashour 2021 ) or women who experienced forced migration in resettlement contexts (Burke et al. 2023 ), or considered specific methods of teaching and learning, such as mobile learning applications for refugees (Drolia et al. 2020 , 2022 ). To provide a comprehensive overview of the rapid changes in the field over recent years and provide suggestions and implications for further research, this integrative review (Torraco 2016 ) focuses on the academic literature on higher education for refugees published between January 2016 and December 2019. In particular, the relevance of studying for refugees and the challenges faced by both students and higher education institutions have been identified as central themes in academic publications in this emerging field of research. While the challenges highlighted in previous studies persist, the greater density and diversity of studies offer a more in-depth look at the complex and interconnected difficulties that refugee students experience.

In order to reach UNHCR’s 15by30 target, it will be necessary to not only address individual challenges for refugee students but also structural and institutional issues that create obstacles to their ability to access higher education (Baker and Irwin 2019 ; Luu and Blanco 2019 ; Berg 2020 ). Synthesizing findings from the research field can provide guidance for this. This integrative review thus contributes to the state of the research by providing a synopsis of the key challenges faced by both refugees that aim to enter and succeed in higher education, and higher education institutions that aim to develop and implement targeted support programs.

Regarding the terminology, the terms “refugee” and “asylum seeker” cover a broad variety of living situations in diverse personal, structural, and national contexts. Considering the different definitions and sampling criteria used in the studies reviewed, I generally refer to “refugee students,” meaning students in higher education or preparatory programs who have experienced forced international migration (regarding internally displaced scholars, see Oleksiyenko et al. 2020 ).

This paper provides an integrative review (Torraco 2016 ) of the current literature on higher education for refugees. Because the body of literature has expanded rapidly since 2016, the narrow time frame is meant to survey recent developments in the field. This review is followed by a discussion of research gaps and a synthesis of open research questions and implications for further research. The following key questions structured the search and review process:

How has the field of research on higher education for refugees changed along with growing public and academic interest?

What are the central topics, results, and research questions that remain unaddressed?

How can further research build on and advance studies of higher education for refugees?

Literature research and selection criteria

The literature discussed in this review was identified and selected through several steps. The first step was to conduct a database search, which took place in May 2019. In addition to the large interdisciplinary database Scopus and the social science database GESIS, the following databases with an educational focus were searched: the Educational Resources Information Center (ERIC), Education Source, and peDOCS. Based on combinations of English and German keywords, the search was narrowed to focus on peer-reviewed articles that had been published in or after 2016. Table 1 provides an overview of all keyword combinations.

The second step was to conduct a similar search of additional databases, including Academia.edu, Google Scholar, and ResearchGate. Due to filter settings, this search was not limited to peer-reviewed articles. A final database search was conducted in January 2020.

For papers to be included in this review, they had to focus on study preparation or higher education for refugees. The first round of selection was based on the abstracts of the publications. I then excluded literature reviews on higher education for refugees and project reports. Ultimately, 104 journal articles, chapters, and books were included in this review. They will henceforth be referred to as “papers.” Table 2 provides a comprehensive overview of all the papers included. Furthermore, they are marked with asterisks in the reference list.

After the literature selection process, all papers were summarized to provide a preliminary overview of the material. During this step, I received crucial support from a group of students and Prof. Dr. Streitwieser, a fellow researcher in the field. The summaries were completed using a template I prepared, which included the following sections: topic, research question, location, relevance, methods, theoretical framework, and central findings. All summaries contained brief notes and selected quotations for all sections for which this was applicable.

I then familiarized myself with all papers and created a synoptic table to sort them according to their topic, method, sample, and regional focus. This “descriptive evaluation of each study” (Wright et al. 2007 , p. 26) allowed for a general comparison of the literature. I aimed to survey the main characteristics of and issues in this newly emerging field to identify implications for further research. Throughout the review process, I discussed the papers’ results and quality with students and fellow researchers.

All papers were sorted into descriptive categories, including their publication date, location, empirical method, sample, and main topics. Table 3 shows a notable increase in international publications from 2016 to 2019.

A comparison with previous literature reviews emphasizes this impression: Ramsay and Baker's ( 2019 ) discussion of 46 papers that were published between 1999 and early 2018 included 16 papers published in 2016–2018, in comparison to 30 papers published in the much longer period between 1999 and 2015. Berg et al. ( 2018 ) reviewed 34 empirical studies published between 1990 and early 2018. Seventeen of them were published in 2016–2018, in comparison to 17 papers published between 1990 and 2015.

International research before 2016 mostly focused on English-speaking countries, primarily Australia, Canada, the UK, and the USA (Berg et al. 2018 ). Table 4 shows that—even though Australia and the USA remain among those with the most academic inquiry and output on higher education for refugees—the general regional focus has shifted.

Before 2016, hardly any research had been conducted about refugee students in Germany. This has rapidly changed, with Germany now being the subject of the most country-specific studies in this review. This development seems to be closely related to the war in Syria, which caused a significant influx of new asylum applications in Germany, and the country’s rapid development of structural funding for refugee students. Parallel to this development, the publication numbers indicate increasing academic interest in refugee education in the countries neighbouring Syria, including Turkey and Jordan, and multi-country European studies.

The reviewed publications mainly focus on Europe, Australia, and North America (Canada and the USA). A few papers, however, also take Asian and African countries into account. Strikingly, the search produced no papers investigating the situation of refugee students in either South or Central American countries. In this context, it must be noted that the regional focus of the studies identified was surely influenced by the limitation of using only English and German keywords in my search. However, as many journals ask authors to provide English keywords even if they publish in a different language, one could assume that the search would produce multilingual results. Out of all the publications included, eight were published in German. Two were methodological, while six presented the results of empirical research (five studies conducted in Germany, and one in Austria).

Of the 104 papers included in this integrative review, 80 presented the results of empirical studies. The majority (59) were qualitative studies. Ten studies used mixed methods and nine were based on quantitative or standardized research designs. I was unable to classify the methods used in two of the empirical studies as qualitative, quantitative, or mixed methods due to their contradictory or partial methods sections. Often, the studies presented relatively small samples or case studies of individual support programs, including very small quantitative sample sizes.

There are several possible reasons why qualitative and small-sample studies were common. First, considering the rather small body of previous research, it stands to reason that research projects would either focus on or start with explorative studies to gather the first empirical evidence in the field. Second, programs for refugee students are often HEI-specific and not part of a coordinated national or international approach. Thus, even if all participants of a specific program are included, the sample size might still be limited. Third, identifying and reaching the target population outside of specific support programs poses serious difficulties for researchers. Finally, little quantitative information is available for further analysis because refugees are usually not identifiable in surveys and HEIs do not always provide specific information on them. As Streitwieser and Brück ( 2018 ) have pointed out, in the German context, no data is collected on the legal status of enrolled students.

Seven papers were categorized as conceptual, which I understand as drawing on or developing a theoretical framework to discuss a topic (Callahan 2010 ). Furthermore, seven papers were categorized as desk research. They provided policy overviews or project descriptions with no mention or description of empirical methods. Seven other papers presented descriptions and discussions of individual support programs. Finally, four papers introduced methodological implications or frameworks for research on and with refugee students.

Similar to previous publications (Berg et al. 2018 ), the main topics of most of the papers I reviewed were the situations and experiences of refugee students, institutional contexts, the challenges faced by and support available for refugee students, and the evaluation of these support programs. As the challenges faced by refugee students appear to be the leading topic in the field, I will discuss them in more detail below. Eight of the papers addressed higher education in refugee camps and six focused on online education. Finally, it should be noted that most of the research took the perspective of refugees into account. Of the 80 empirical studies, 60 either solely focused on (38) or included the perspectives of refugees (22) as part of mixed samples. This can be related to researchers’ strong demand to take forced migrants’ first-hand experiences into account (Baker et al. 2019 ; Berg et al 2019a , 2019b ; Reimer et al. 2019 ).

Similar to Ramsay and Baker's ( 2019 ) review of the literature published before early 2018, many of the papers discussed in this review can be placed in the broader field of education studies. In this area, the papers contributed to a wide range of topics such as the recognition of foreign degrees (Dunwoodie et al. 2020 ), program evaluation, academic culture (Baker and Irwin 2019 ), language proficiency (Nayton et al. 2019 ; Park 2019 ), internationalization (Streitwieser 2019 ; Berg 2018 ), equity, inclusion, and widening participation. These studies often focused on the perspectives of refugee students but also included higher education practitioners (Streitwieser et al. 2018a ), domestic and international fellow students (Ergin 2016 ; Grüttner 2019 ), teachers (Schröder et al. 2019 ), policymakers (Jungblut et al. 2018 ; Toker 2019 ), NGO members (Nayton et al. 2019 ), and policy analysts (Unangst 2019 ).

The relevance of support for refugee students

Academia, like freedom, is indivisible. It is enriched by diversity, and so long as some are excluded, all are restricted. How citizenship in the academic space is perceived and experienced is, therefore, a complex and urgent political concern. (Rowe et al. 2016 , p. 68)

Many authors insisted that there is a moral and social obligation to provide higher education opportunities for refugees (Abamosa et al. 2019 , p. 13; Lenette 2016 ) and referred to education as a human right (Naylor et al. 2019 ). They expected a number of benefits from providing this support on the social, institutional, and individual levels.

On a social level, higher education is a crucial enabler of the integration of refugees (Marcu 2018 , p. 18). Furthermore, Rasheed and Munoz referred to it as a method of “peacebuilding” ( 2016 , p. 172), and Avery and Said ( 2017 ) argued that it helped prevent radicalization. In the long term, educated refugees were understood to be important actors who could “support their communities in exile and contribute to the future development of their home countries” (Avery and Said 2017 , p. 107).

On an institutional level, refugees were sometimes understood to support the internationalization of HEIs (Abamosa et al. 2019 ; Berg 2018 ; Streitwieser 2019 ) and enrich their cultural diversity (Theuerl 2016 , p. 178; Unger-Ullmann 2017 , p. 5). By orienting themselves to the needs of refugee students, newly implemented support programs were seen to provide a chance for HEIs to “re-assess the ways in which students can engage and how they can give value to the skills brought by the prospective students” (Sontag 2018 , p. 542).

On an individual level, higher education was described as empowering refugees (Crea 2016 , p. 19), supporting their sense of belonging, psychological well-being (Al-Rousan et al. 2018 ; Bajwa et al. 2019 ; Grüttner 2019 ), and self-esteem (Bajwa et al. 2018 , p. 120), and helping them overcome trauma (Maringe et al. 2017 ). Finally, participation in higher education programs can be seen as “an act of resistance itself” (Villegas and Aberman 2019 , p. 79), which allows refugee students to defy stereotypes and negative ascriptions (Harvey and Mallman 2019 , p. 663f.).

Refugee students were found to be highly motivated to participate in higher education. They were often described as expecting their situations to improve (Schneider 2018 ) and seeing higher education as a facilitator of positive individual development and a social participation, as a chance give back to their communities (Crea 2016 , p. 19), or repay the support they received in their host countries (Hirsch and Maylea 2016 , p. 23).

Overall, researchers have claimed that higher education can potentially "yield better settlement outcomes for refugees to increase social cohesion and, more importantly, help redress some of the personal and social disadvantages and the detrimental public discourse" (Lenette 2016 , p. 2). By providing trustworthy environments and spaces for exchange (Villegas and Aberman 2019 , p. 77) and thereby “humanising” (Fleay et al., 2019 , p. 187) refugees, HEIs can support refugees in building agency, developing critical thinking, and reflecting on their own positions, thereby counteracting social exclusion and marginalization (Avery and Said 2017 ; Bajwa et al. 2018 ; Fleay et al. 2019 ; Lenette 2016 ).

Challenges for refugee students

Similar to publications before 2016, the main research interests of the reviewed studies included challenges for refugee students.

The main challenges identified throughout the papers included language proficiency (Akbasli and Mavi 2019 , p. 10; Harvey and Mallman 2019 ; Park 2019 ), the accessibility of information (Baker et al. 2017 ), finances (AbduRazak et al. 2019 , p. 176; Baker et al. 2017 ; Sheikh et al. 2019 , p. 15), housing in stressful environments and/or remote areas (Akbasli and Mavi 2019 ; Schammann and Younso 2017 , p. 13), difficulties with the acknowledgement of credentials, and issues of mental health. Furthermore, family obligations (Perry and Mallozzi 2017 , p. 511), social isolation, discrimination, acculturation to a new learning environment, legal issues, disrupted educational experiences, and institutional settings inhibited refugees’ access to and success in higher education.

Some authors also argued that cultural differences slowed social and academic integration (Karipek 2017 , p. 125; Tamrat and Habtemariam 2019 , p. 134). In this context, gendered expectations caused additional hurdles, especially for women (Crea and Sparnon 2017 , p. 17; Perry and Mallozzi 2017 , p. 496). Even though many of the challenges discussed have been pointed out in previous studies (Berg et al 2018 ), the great number of new studies creates a more nuanced understanding of the situation of refugee students. It also allows the analysis to avoid exclusively focusing on deficits and include the capabilities and strengths of refugee students.

Several studies investigated the mental health and well-being of refugee students. Mental health challenges stem from both pre- and post-migration phases (Jack et al. 2019 , p. 62) or unclear prospects (Crea 2016 , p. 19), and can result in a lack of stability, increased vulnerability, and inhibited academic performance (Erdoğan and Erdoğan 2018 , p. 275; Sheikh et al. 2019 , 9; 14). Mental health issues and the various time-consuming challenges that prevent quick integration and participation in the host country created a feeling of lost time (Baker et al. 2019b, p. 11). This can frustrate and potentially demoralize refugee students. Furthermore, the non-acknowledgement of their previous knowledge and education (Baker and Irwin 2019 ; Jack et al. 2019 ; Sheikh et al. 2019 ), on the one hand, and social isolation and discrimination, on the other hand (Harvey and Mallman 2019 ; Molla 2019 ; Villegas and Aberman 2019 ), caused the feeling of low self-esteem (Park 2019 , p. 7; Tamrat and Habtemariam 2019 , p. 134). Based on quantitative survey data, Grüttner ( 2019 ) showed that.

mechanisms of social exclusion can hamper learning and study preparation success and thereby threaten the academic careers of international students and integration strategies of refugee students. Personal resources of resilience like resilient coping can strengthen feelings of belonging against the backdrop of perceived xenophobia. (p. 42)

The intersectional challenges faced by refugee students do not only limit their access to traditional higher education. Six of the reviewed papers specifically dealt with online courses for refugee students (Brunton et al. 2017 ; Crea and Sparnon 2017 ; Halkic and Arnold 2019 ; Muñoz et al. 2018 ; Reinhardt et al. 2018 ; Zlatkin-Troitschanskaia et al. 2018 ). Generally, online courses were seen as a potential solution for learners due to being cheaper, more flexible, and independent from the availability of local tertiary education (Crea and Sparnon 2017 ; Muñoz et al. 2018 ). However, the studies showed low completion rates (Halkic and Arnold 2019 ) and pointed out that the challenges of accessing higher education in general (e.g., language barriers, finances, housing, time management) also impacted refugee students’ ability to participate in online education (Brunton et al. 2017 , p. 17f.; Halkic and Arnold 2019 , p. 17).

Finally, the “diversity of the target groups” (Halkic and Arnold 2019 , p. 17) caused difficulties in creating online education offers that fit the diverse backgrounds and needs of the population (Reinhardt et al. 2018 , p. 217f.; Zlatkin-Troitschanskaia et al. 2018 , p. 171). Therefore, online courses were, rather, seen as a helpful tool to “form realistic expectations about higher education study” (Brunton et al. 2017 , p. 17) and potentially “improve prospective flexible learners’ preparation for higher education study through the provision of active developmental supports, early in the study life cycle” (Halkic and Arnold 2019 , p. 17). However, to foster long-lasting solutions, individual, institutional, and structural challenges need to be addressed and overcome.

Institutional challenges for refugee students

Recent studies have also increasingly investigated institutional settings that add to refugees’ challenges in entering and obtaining higher education in three ways.

First, challenges in entering and obtaining higher education are enhanced by unclear or absent higher education policies for refugees. This places the responsibility on individual institutions (Villegas and Aberman 2019 , p. 73) and creates a confusing situation. Furthermore, in some cases, refugee policies were “focused primarily on workforce development and career training, rather than on the academic track of post-secondary education” (Luu and Blanco 2019 , p. 9).

Second, repressive asylum policies and the multisector entanglement of higher education, welfare, legal, and asylum policies create challenges for refugees because “these areas need to be taken into account simultaneously, but what is more challenging is that they are often not well in tune with one another” (Schammann and Younso 2017 ; Sontag 2019 , p. 72; Détourbe and Goastellec 2018 ; Klaus 2020 ).

Third, HEIs’ unawareness or ignorance of refugees can result in unfitting institutional contexts. This includes the “[a]voidance of the notion of refugees” (Maringe et al. 2017 , p. 6) and the “[a]bsence of a culture of care and support [in an] academic environment [that] is built around notions of the survival of the fittest” (ibid.). Institutional rules and regulations about university transition are based on assumptions about students, cultural capital, language proficiency (Park 2019 , p. 8), aspirations, linear life courses, and knowledge of academic practices and education systems (Baker and Irwin 2019 ; Stevenson and Baker 2018 , p. 96f.). This results in institutional environments that do not consider and therefore do not or cannot adequately address the backgrounds, experiences, and needs of refugee students.

To give an example, some HEIs offer refugees guest access to their classes. This is meant to provide them with insight into academic practices and language. However, studies have found that refugee students have little interest in programs without official degrees (Crea and Sparnon 2017 , p. 15; Schammann and Younso 2017 ). Klaus ( 2020 , p. 136) described this as a quick solution, not a serious endeavor to fully include refugee students in academic life.

Challenges for institutions

Even though research on members of HEIs, including students and staff, has found that they generally have a robust motivation to support refugees, some studies have argued that HEIs themselves face structural challenges when trying to provide such support. They often lack trained staff and have difficulties finding enough specialists (Maringe et al. 2017 ), such as competent language teachers, instructors with intercultural training (Crea and Sparnon 2017 ), or qualified providers of psychological support (Steinhilber 2019 ), to address the complex and diverse needs of refugee students (Schröder et al. 2019 , p. 72). Additionally, some papers described faculty members’ insecurities about how to address students who have experienced forced migration or deal with practical questions (e.g., determining the validity of documents; Schammann and Younso 2017 , p. 12; Toker 2019 ; Lenette 2016 ).

The lack of information and guidelines is closely linked to political frameworks and the availability of policy solutions. Considering the situation in the USA, Luu and Blanco ( 2019 ) stated that “[t]he perspective on refugees espoused by the Trump Administration is symptomatic of a larger discourse that vilifies and dehumanises refugees” (p. 4). Political discourse and policy frameworks are of great importance to HEIs that aim to support refugee students because they determine the existence and availability of official guidelines, target group-specific policies (Abamosa et al. 2019 , p. 4), policy solutions or suggestions about topics such as the acknowledgement of documents, and—last but not least—public funding. Public and non-profit HEIs, especially, have difficulty fully funding their programs, which makes public funding a crucial factor (Nayton et al. 2019 ).

Discussion and research implications

The amount of research and literature on tertiary education for refugees has grown massively, especially since 2016. In this review, I have discussed 104 papers, including 80 empirical studies, that were published between January 2016 and December 2019.

As in literature published before 2016, there is a primary focus on the challenges faced by refugee students and the majority of the papers are qualitative case studies or conceptual papers, emphasizing the importance of higher education opportunities for refugees (Shakya et al. 2010 ; Earnest et al. 2010 ; Joyce et al. 2010 ; Stevenson and Willott 2007 ). Nonetheless, a new focus on formal study preparation (Schröder et al. 2019 ), a slight increase in quantitative and mixed methods approaches, and the appearance of studies on new countries and regions all indicate the increasing importance of this research field and create a more nuanced picture.

It can be assumed that due to the narrow time frame considered, many of the studies were conducted simultaneously. In combination with the little previously published literature on the topic, this results in a somewhat repetitive body of work, with many studies focusing on challenges for refugee students. In the following section, I will summarize some potential open questions and research topics to further differentiate and substantiate this newly growing field.

Multi-level and multi-perspective studies

I recommend enhancing the growing methodological and theoretical diversity to create insights into various aspects, cases, and perspectives. This would include moving beyond (single) case studies and emphasizing comparative, multi-perspective, and multi-level studies. On the one hand, such research could investigate the premises and conditions of successful preparation for, access to, and participation in higher education for refugee students and identify expedient support strategies for various contexts that fit the needs and lived experiences of refugee students. Furthermore, such research could look into the broad activities of individual HEI staff members, students, or volunteers (Webb et al. 2019 ; Resch et al. 2021 ; Sevenson and Willott, 2007 ). It could develop strategies to understand the value of the knowledge they have obtained and preserve it, while also considering ways to formalize this support so it does not need to be offered on private time (Berg et al. 2022 ). On the other hand, it could enhance the understanding of the diverse living situations of refugees and the institutional contexts that shape them, thus broadening education research.

Beyond the deficit discourse

As Ramsay and Baker ( 2019 ) argue in their literature review, research on refugee students should “go beyond a lens of issues and problems” (p. 57). Similar points are made in the discussion sections of many of the reviewed papers. Still, relatively few works investigated the capital and knowledge refugees bring, which should be valued and thematized (Harvey and Mallman 2019 ; Shapiro 2018 ). Studies in this area could include the benefits HEI expect from supporting refugee students but should also critically investigate the norms, limits, and adaptability of academic culture (Baker and Irwin 2019 ), as well as ways to create agency for refugees (Grüttner et al. 2018 ).

Teaching and learning strategies

Several studies mention the use of unfamiliar teaching and learning styles as a challenge faced by refugee students. However, the studies reviewed do not further investigate the learning strategies that refugee students use. As Parkhouse et al. ( 2019 ) have pointed out, well-prepared teachers can be crucial for the success of students from marginalized communities. Higher education staff members, including counsellors and teachers, often show little diversity and are insufficiently qualified to deal with intercultural issues (Schammann and Younso 2017 ). Further research that aims to provide a more detailed understanding of refugees as academic learners (Ives and Castillo-Montoya, 2020) and teaching styles in intercultural higher education could have valuable strategical and practical implications, along the lines of Warriner et al. ( 2019 ) conceptual approach to teaching academic English in schools.

Organisational responses and contexts

Many studies around higher education for refugees investigate the experiences of refugee students (Bajwa et al. 2017 ; Joyce et al. 2010 ) or introduce, investigate, or evaluate case studies about higher education programs (Bacher et al., 2020 ; Naidoo 2015 ). However, very few apply organizational theory to understand institutional reactions and frameworks that shape the higher education system and, more specifically, programs for refugees (one exception is Webb et al. 2019 ). A closer investigation of institutional rationale, decision-making processes, and potential organizational changes could clarify the exact context of higher education for refugees. This could also include a more detailed investigation of concepts, aspects, and strategies related to integration and participation and how well they meet the needs of refugee students. Unangst and Crea ( 2020 ) introduced an approach to bridge the contrast between subjective identities and generalized support programs: Intersectional programmes could consider a variety of intersectional identity markers to offer a range of supports. Additionally, as not all endeavours to support refugee students originate from HEIs, it seems important to investigate all relevant public and private institutions, their actions, and their objectives. This could present interesting overlaps with studies of civic engagement.

The impact of the Covid-19 pandemic

As the world adapts to the “new normal,” it becomes increasingly clear that the Covid-19 pandemic not only affected all aspects of everyday life, including higher education, but also exacerbated the situation of at-risk populations globally. Further research will need to consider and measure the impact of the pandemic, including its consequences for refugee education. In different contexts, different outcomes can be expected, from backlash to questions of survival to a shift towards online education. The outcomes for (student) mobility, migration, social security, the organization of higher education, and many other factors that influence refugee (higher) education have yet to be determined.

Data availability

The data that support the findings of this study were used under license for the current study, and so are not publicly available. All data are cited in the paper and can be accessed via their respective publishers.

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Acknowledgements

I especially want to thank Dr. Bernhard Streitwieser. He strongly supported the conceptualization of this paper and actively participated in the research and analysis of the discussed literature. I thank Renny Osuna and Olivia Laska for both their literature research and summaries. Further, I thank Thierry Adrien, Jen Bhiro, Lexus Bivins, Alexandra Croteau, Lydia Delamatta, Michelle Fleuriot, Jisun Jeong, Hailey Klein, Samira Sariolghalam, Kelber Tozini, Siyu Wan and Sebastian Zühl for their summaries.

Open Access funding enabled and organized by Projekt DEAL. The article is based on research funded by the German Federal Ministry of Education and Research [01PX16015].

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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  

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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.

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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

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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

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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.

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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.

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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.

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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

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• Published: 13 December 2023

Inclusive education of refugee students with disabilities in higher education: a comparative case study

• Maha Al-Hendawi   ORCID: orcid.org/0000-0001-9280-9357 1 &
• Ali M. Alodat 1 , 2  

Humanities and Social Sciences Communications volume  10 , Article number:  942 ( 2023 ) Cite this article

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• Social policy

The United Nations Sustainable Development Goal 4 (SDG-4) calls for the establishment of an inclusive education system for all students. As conflicts, persecution, and natural disasters continue to displace millions globally, the duration of refugee situations has become increasingly extended. The complexities of exile have further entangled the human rights issue, making it essential for affected individuals to seek sanctuary in other countries. These crises not only uproot families but also disrupt livelihoods and educational systems. Consequently, the onus has been on international laws and policies to promote and protect inclusive education as a human right for students with disabilities. In this study, using mixed methods, we first conducted interviews with two Syrian students with disabilities at Yarmouk University in Jordan and Qatar University in Qatar. Thematic analysis of these interviews yielded three primary themes: equity in educational opportunities, services provided, and challenges facing inclusive education. Following the interviews, we conducted a document analysis to evaluate the educational policies at both institutions. We used the 4-A framework for this evaluation, emphasizing that educational systems should be Available, Accessible, Acceptable, and Adaptable. The analysis indicated significant disparities in how closely each institution adheres to the principles of the 4-A framework. The findings indicate that inconsistencies in policy implementation, unequal access to financial aid, and difficulties in career planning are influenced by cultural, social, political, and economic factors.

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Introduction.

The ongoing global refugee crisis has led to the displacement of an estimated 100 million individuals by the end of 2022 (UNHCR, 2021 ). In particular, ~32.5 million of these displaced individuals are housed in refugee camps, primarily in South Asia, the Middle East, and Africa (INEE, 2019 ). This issue extends beyond a humanitarian crisis, representing a severe underutilization of human capital with lasting social and economic implications.

In a broader context, education serves as a vital pathway for social mobility and the effective integration of refugees into their host societies (Dryden-Peterson, 2016 , 2017 ). However, a multitude of barriers, including social stigma, discriminatory policies, and institutional constraints, restrict refugees’ access to quality higher education (Alodat et al., 2021 ; Crea and McFarland, 2015 ; Crock et al., 2017 ; Dryden-Peterson and Giles, 2012 ). For refugees with disabilities (RwDs), the challenges are further compounded, manifesting as a unique set of multilayered barriers associated with their intersectional identities (Alodat et al., 2021 ; Crock et al., 2017 ; Muhaidat et al., 2020 ; Wray and Houghton, 2018 ). Studies indicate that globally, only approximately 1% of refugees can access higher education, and the rates are even lower for refugee students with disabilities due to additional barriers posed by their disability and displacement (Alodat et al., 2021 ; Crock et al., 2017 ). They are subjected to societal prejudices and educational marginalization because of their refugee status (Johnson, 2012 ; McGreal, 2017 ; Muhaidat et al., 2020 ; Nicolai et al., 2017 ) and simultaneously face an additional layer of challenges, including environmental inaccessibility and policy exclusion (Muhaidat et al., 2020 ; Wray and Houghton, 2018 ). The cumulative effect of these intersecting barriers leads to systematic exclusion from higher educational opportunities, thereby perpetuating intergenerational poverty cycles and the loss of economic productivity (INEE, 2019 ).

The importance of inclusive education is underscored by its centrality in Sustainable Development Goal 4 (SDG-4) and is anchored in human rights frameworks such as the Convention on the Rights of Persons with Disabilities (CRPD) (Al-Hendawi et al., 2023 ; Johnson, 2012 ; McGreal, 2017 ; Nicolai et al., 2017 ). While Article 24 of the CRPD mandates the provision of inclusive education for all persons with disabilities, its implementation often falls short because of inadequacies in existing legal and policy frameworks (Beco, 2021 ). While the UN’s Sustainable Development Goal 4 aims for universal access to education, including refugees, complex prolonged displacement requires comprehensive policies beyond short-term fixes to facilitate social advancement and accommodate disabilities acquired through conflict (Al-Hendawi et al., 2023 ; Bell, 2013 ; Dryden-Peterson, 2016 , 2017 ).

As such, the right to education does not necessarily equate to meaningful participation in either host or origin societies, especially given the possibility of indefinite exile. Indeed, the gap between normative ideals and actual policy implementation restricts refugees’ ability to fully exercise their rights to education, employment, and civic participation (Dryden-Peterson, 2016 ). This dissonance leads to a limited capacity for refugees to apply for their educational credentials in host countries, often due to restrictions on employment and political engagement. Effective refugee education necessitates a comprehensive, long-term strategy that includes elements, such as language instruction tailored to learners, certifications that are widely recognized, policies and services that facilitate integration, quality teacher recruitment and training, trauma-informed support, and sustainable solutions for protracted displacement scenarios (Dryden-Peterson, 2017 ). Fiscal constraints further highlight the need for flexible educational systems capable of serving all refugees, including those with disabilities (SwDs) (Lourens, 2015 ). Therefore, integrated planning and policymaking are crucial for refugees to effectively leverage their education and skills.

Research on inclusive higher education (HE) highlights the distinct challenges faced by refugee students with disabilities (RSwDs) (Kromydas, 2017 ). However, the policies lack accommodation guidelines for this group, and while inclusive education originated at the primary/secondary levels, refugee education access has increased its HE importance (Dryden-Peterson and Giles, 2012 ; Moriña, 2016 ). Studies show that young refugees encounter substantially higher education barriers (Crea and McFarland, 2015 ), which intensify RSwDs (Alodat et al., 2021 ; Crock et al., 2017 ). Multilayered factors such as nationality, socioeconomics, trauma, and disability contribute to the low rates (Muhaidat et al., 2020 ; Wray and Houghton, 2018 ). Coordinated efforts across governments, organizations, and institutions are needed for the inclusion and active participation of RSwDs in HE to foster independence, reduce stigma, and boost self-esteem.

In geopolitical contexts, such as the Syrian conflict, which has displaced over six million people since 2011 (Aydin and Kaya, 2019 ; Yazgan et al., 2015 ), challenges for students with disabilities (SwDs) have deepened. In conflict zones, these students face restricted curriculum access, limited assessment options, and exclusion from financial and social resources (Mutanga, 2017 ; Shevlin et al., 2004 ; Swart and Greyling, 2011 ); of note, such issues are less prevalent in stable countries (Yssel et al., 2016 ). Host countries, burdened with essential service provision, often neglect human capital represented by Refugees with Disabilities (RwDs). This neglect leads to inefficient resource allocation with economic implications: both lost productivity and increased social welfare costs create a cycle of poverty and dependency. Current literature and policies generally treat refugees and disabilities as separate categories, rarely investigating their intersection (Alodat et al., 2021 ; Bell, 2013 ; Crock et al., 2017 ; Lourens, 2015 ). This leaves a policy gap for those with intersecting identities (Kromydas, 2017 ). Thus, targeted research and policies are needed to better understand RSwDs in HE patients. This need is amplified by a notable research gap in RwDs, especially in the Syrian context.

In this study, we explore the intersecting challenges faced by Syrian students with disabilities in higher education settings in Jordan and Qatar. Employing a mixed-methods methodology, the research integrates in-depth case studies with an evaluation of university inclusion policies. The aim is to pinpoint shortcomings and formulate actionable recommendations to bolster accessibility and support services. Anchored in a human rights framework, this study attempts a holistic assessment by synthesizing insights from policy analysis, scholarly literature, and direct student experiences, thereby contributing practical solutions to advance inclusivity in higher education.

Theoretical framework

Applying a human rights-based approach to education requires the development of a comprehensive model that encompasses all aspects of the education system (Klees and Thapliyal, 2007 ; Schaeffer, 2008 ). The 4-A framework, which was first introduced in the Right to Education Primer 3 , contains four essential markers: availability, accessibility, acceptability, and adaptability, and requires inclusive educational contexts to show them. The 4-A framework further provides clarity and specificity for addressing the right to education, particularly for marginalized populations such as PwDs, as it outlines governments’ obligations to guarantee and realize that right (Al-Hendawi et al., 2023 ; Tomasevski, 2004 ). Although the framework was not developed specifically for PwDs, it has been used to evaluate the provided guidelines and inclusive policies in states and institutions (Murungi, 2013 ). Internationally, this framework has been used to analyze legislation and policy on primary education for children with disabilities (Maxwell and Granlund, 2011 ); however, as argued earlier, the extension of inclusive education to HE infers that the four markers are equally important to this sector as well as to their governing policies.

This study examines the lived experiences of two Syrian RSwDs in HE settings in Jordan and Qatar and analyzes their universities’ policy provisions regarding inclusive education. The internationally recognized 4-A framework serves as the theoretical framework and functions as the basis for the development of a methodological tool. The next section offers an overview of the conditions for Syrian students with disabilities in higher education in Qatar and Jordan. This is followed by a discussion of inclusive education and the 4-A framework. The methodology of our study is then outlined, leading to the results and a brief discussion. The study concludes with an examination of its limitations and implications.

Study contexts

Syrian refugees with disabilities.

The Syrian crisis resulted in the most tragic refugee movement in the 21st century, as millions of Syrians fled to neighboring countries where they have been living as internally displaced people (IDP) (Salameh et al., 2020 ). RwDs are expected to face compounded difficulties owing to the extra assistance needed because of their impairments. This was in addition to social, legal, and economic issues caused by refugee status (Fig. 1 ). The Disability Prevalence and Impact-IDP Report estimated that the number of PwDs among refugees and the IDP exceeded 12 million (UNHCR, 2020 ). Regarding Syrian refugees, a systematic review of the literature showed that these RwDs were the most vulnerable population (Alodat et al., 2021 ), with ~20% of those exiled in Jordan and Lebanon identified as disabled (Crock et al., 2015 , 2017 ; Rohwerder, 2018 ). Furthermore, in Jordan and Turkey, lack of accessibility, financial ability, inclusive education, vocational training, policies, and psychosocial programs have been cited as obstacles to the education of RwDs (Alodat et al., 2021 ; Muhaidat et al., 2020 ; Yamamoto and Matsuo, 2017 ).

This figure illustrates the multifaceted challenges faced by Syrian refugee students with disabilities. A (Disability): showcases the barriers related to assistive technologies, the physical environment, social factors, and attitudinal barriers that these students encounter. B (Refugee Status): details the factors including residency status, funding/scholarships, legal status, and social integration that impact these students. C : highlights the interplay of residency status, funding/scholarships, social integration, assistive technologies, the physical environment, and attitudinal barriers, demonstrating how these elements compound to create a unique set of challenges for Syrian refugee students with disabilities. Symbols used: Arrows in all directions between ( A ) and ( B ): These arrows represent the dynamic and interconnected nature of the barriers related to refugee status and disability. Arrows from ( A ) and ( B ) towards ( C ): These arrows indicate the cumulative effect of the challenges highlighted in ( A ) and ( B ) on the overall situation of Syrian refugee students with disabilities.

Jordan is located in southwest Asia and is a diverse cultural nation ruled through civil and Bedouin laws, with a modest economy (Patai, 1958 ). Although not a signatory to the 1951 Refugee Convention, Jordan hosted more than 670,000 Syrian refugees, accounting for approximately 10% of its population (Achilli, 2015 , 2014 ). This hosting of refugees has made Jordan the second-largest host for Syrian refugees worldwide (UNHCR, 2022 ). Undertaken in collaboration with donor countries, Jordan provides protection, housing, health care, employment, social services, and education to Syrian refugees despite challenging economic circumstances (Alodat and Gentry, 2022 ). The 2015 Jordanian census indicated a total of 1,265,514 Syrians, most of whom had migrated in the previous five years, and 953,289 who were officially classified as refugees.

The HEI in Jordan began in a teacher’s house in 1958. Jordan boasts 10 public universities, 17 private universities, and 51 community colleges (Education and Education 2022 ). While over 30% of college-aged Jordanian citizens enroll in HE, only 8% of Syrian refugees in Jordan pursue tertiary studies. This enrollment gap underscores the significant barriers that limit Syrian refugee participation. Notably, the statistics on Syrian refugees who attend these HEIs vary, with some reports indicating a mere 8% (Fund, 2019 ), while others indicate as much as 14% (WANA, 2018 ), as a significant proportion of refugees live in urban areas or informal settlements with more access than residents in rural places (Saleh et al., 2018 ). While these are available to all refugees, refugee SwDs, in particular, have limited financial ability to pay HE costs, despite having access to a limited number of scholarships. While there is a perception of underrepresentation of Syrian RSwDs in HEIs (Kathleen Fincham, 2020 ), the lack of concrete statistics, alongside supporting narratives to explain the low uptake of opportunities, show why research is warranted to evaluate the provision of inclusive education.

Qatar is an Arab Gulf state with a strong economy that is primarily dependent on the production and export of oil and gas (Al-Hendawi et al., 2017 ). Like most other Arab nations, Qatar did not sign the 1951 Refugee Convention (AlMarri, 2019 ; Hitman, 2019 ). However, since the beginning of the Syrian crisis in 2011, Qatar hosted a limited number of Syrian refugees based on geographical, political, and administrative factors (Ghadbian, 2021 ). Early statistics indicated that the number of registered refugees and asylum seekers in Qatar was 322 (UNHCR, 2013 ). However, based on statistics collected from visitors’ visas, later studies approximate that number to have increased to 60,000, which is ~2.2% of the Qatari population (AlMarri, 2019 ). The State of Qatar has made significant contributions to the support of Syrian refugees in host countries through substantial financial and material grants that have expanded the areas of housing, health, education, and employment (UNHCR, 2022 ). It is pertinent to note the distinct residency status of Syrians residing in Qatar, a substantial number of whom are on visitor or work visas instead of possessing formal refugee status. This variation in residency status notably affects the range of services extended to Syrian students, as they are not recognized as refugees.

Currently, 32 Qatari HEIs provide more than 366 educational programs for nearly 39,000 students (Education and Education, 2022 ). As part of the country’s assistance to Syrian refugees in HE, the Qatar Foundation has provided educational scholarships to refugee students in host countries, such as Lebanon (Yavcan and El-Ghali, 2017 ). Although specific information for Syrian RwDs in Qatari HE is limited and there are no statistics or studies that accurately show their numbers and the type or quality of services provided to them, the ‘Quest’ initiative, launched in 2016, supports Syrian students in HE by providing education and training for Syrian refugees dispersed throughout Syria, Jordan, Lebanon and Turkey (QF, 2022 ).

Accessing HE is a major challenge for refugees in host communities (Dryden-Peterson and Giles, 2012 ). RSwDs are especially vulnerable, facing compound barriers related to forced displacement and disability status (Calvot and Merat, 2014 ; Crock et al., 2017 ). Their enrollment in higher education institutions (HEIs) is strikingly lower than the national average. For example, only 8% of Syrian refugees attend tertiary education in Jordan, 6% in Lebanon, and 1% in Turkey, compared to the overall national enrollment rates of over 30% in these countries (K. Fincham, 2020 ). This profound disparity underscores systemic exclusion, which limits RSwD participation. In host countries, critical barriers include a lack of financial resources, university capacity, and supporting legislation (Kamyab, 2017 ). In these countries, the lack of financial resources, university capacity, and legislation are among the most critical barriers that limit the enrollment of Syrian refugees in HE (Kamyab, 2017 ). With only a few studies having examined refugee students’ access to HE in host countries (Moriña, 2022 ; Unangst and Crea, 2020 ) and even fewer having analyzed educational policies and how they have impacted the experiences of Syrian RSwDs in HE, it is the case that, for Arab countries, the lack of statistical data on foreign nationals makes it difficult to assess the percentage of Syrian refugee students in HE (Hitman, 2019 ).

Inclusive education in Arab states

Inclusive education is a system that accommodates SwDs in primary, secondary, and postsecondary settings (Moriña, 2022 ). The advocacy for the extension of SwDs in HE has been met with some success (Taneja-Johansson, 2021 ). However, for refugees and RwDs, HE still presents barriers and obstacles, such as negative attitudes, professional insufficiency, difficulty in access, and lack of resources and support (Sharma et al., 2018 ). Among Arab nations, there is no unified policy on special education. While Arab societies have been described as diverse and are made up of numerous social differentiation systems based on ethnic, linguistic, sectarian, family, tribal, regional, socioeconomic, and national identities (Al-Hendawi et al., 2023 ; Mounzer and Stenhoff, 2022 ), this in turn results in each country adopting its own system, ranging from segregation to varying degrees of inclusion (Weber and City, 2012 ). With the increasing number of refugees and asylum seekers, which now include SwDs, these countries must develop plans for inclusive education practices and transitional services (Al-Hassan and Gardner, 2016 ); in other words, the incorporation of inclusive education policies within educational institutions (Block et al., 2014 ). The UNHCR, despite a significant deficit, as the United Nations Children’s Fund indicated a lack of inclusive educational practices for Syrian refugee students in host countries (Culbertson and Constant, 2015 ), recommends that all states incorporate refugees, stateless children, and adolescents into their education provision wherever feasible.

Study purpose and design

This study utilizes a qualitative mixed-methods approach to elucidate how geopolitical, cultural, and economic contexts across Arab countries influence inclusion in HE for Syrian refugee students with disabilities (RwDs). This study provides macro, meso-, and microlevel perspectives (Bartlett and Vavrus, 2017 ), as outlined below.

Micro-level: Semi-structured interviews were conducted with two selected Syrian students with disabilities.

Macro-level: Content analysis was used to evaluate educational policies at Yarmouk and Qatar Universities.

Meso-level: A literature review contextualized the cases within broader inclusive education discussions.

We analyzed all the data using the 4-A framework of inclusive education (availability, accessibility, acceptability, and adaptability). This multilevel analysis aimed at addressing the following research questions:

What are Syrian RwDs’ experiences regarding inclusive education practices at Yarmouk and Qatar Universities?

To what extent do the Yarmouk and Qatar University policies align with inclusive education principles for RwDs?

Setting and participants

This study was conducted at two Arab universities, Yarmouk University (YU) in Jordan and Qatar University (QU) in Qatar. Two Syrian RSwDs were purposefully selected to provide diverse perspectives relevant to the research questions. The students were enrolled in different country contexts (Jordan vs. Qatar), had different types of disabilities (visual vs. physical), came from varying socioeconomic backgrounds (high vs. low income), and were at different stages of their university studies (3rd vs. 4th year). Selecting information-rich cases with maximum variation in these criteria aimed at achieving depth and richness of understanding regarding inclusive education issues from diverse angles. The participants included Sana, a 3rd-year student at QU with visual impairment and a high-income background, and Mohammad, a 4th-year student at YU with a physical disability and a low-income background. Pseudonyms are used to ensure confidentiality. Both students provided informed consent, as approved by the university ethics board. The institutional review boards of both universities approved this study. Informed consent was provided by the participants for the full process.

Educational policies

Educational policies on SwDs were hosted on the official websites of both universities. The authors reviewed the YU’s regulations: Student Admission System, Yarmouk University Law, Department of SwDs Services, and Strategic Plan. The authors also reviewed the QU’s regulations: Inclusion and Special Needs Support Center, Bylaws/Policy Portal, and the Strategic Plan.

Researcher roles and reflexivity

The study was conducted by a two-person research team. Author 1 led the participant recruitment, data collection through interviews and the analysis of transcripts. Author 2 collected and analyzed institutional policies from universities. The researchers collaboratively developed a coding scheme for policy analysis based on the 4-A inclusive education framework. They also worked together to code the policies, interpret the findings, and integrate the interviews and policy data. The researchers acknowledged that their professional experience in education may introduce certain biases. To mitigate bias, the researchers maintained reflexive journals and memos throughout the data collection and analysis to bracket any preconceived notions. Member checking of the interview transcripts with participants was also conducted to ensure that their perspectives were accurately represented.

Establishing trustworthiness

Several strategies were employed to enhance the credibility, dependability, confirmability, and transferability of this study. Credibility was established through member checking of the transcripts by participants and through triangulation of the interview and policy data sources. Dependability was achieved by creating a detailed audit trail outlining the research activities and processes. Confirmability was supported by researcher reflexivity, bracketing, and journal maintenance. Finally, transferability was enabled through a thick description of the university context and purposeful selection of information-rich cases to achieve maximum variation in participant perspectives. The comprehensive audit trail provides transparency to the rigorous qualitative procedures followed to ensure trustworthy findings that authentically represent participants’ perspectives and institutional policy contexts.

Procedure and data analysis

The second author interviewed Sana by telephone and interviewed Mohammad in a face-to-face session in the YU library conference room using the same open-ended questions (see Appendix) that were developed specifically for this study. The first interview lasted 93 min, and the second 134 min (227 min in total). The authors transcribed the interview data into 75 pages, after which an inductive analysis procedure was applied (Paul, 2015 ). First, the authors independently coded the data using descriptive words and phrases. Second, the authors discussed the initial codes until they agreed on the final codes. Finally, the authors discovered the patterns, organized similar codes into categories, and identified the themes. The authors conducted and transcribed the interviews in Arabic, and translated the data into English. The translation was checked by a faculty member in the English Department at YU (Halai, 2015 ).

Analysis of educational policies

In the interim, the second author collected data on policies from the websites of the two universities. Both authors developed a coding scheme to analyze educational policies based on the 4-A framework (Tomasevski, 2004 ; Tomaševski, 1999 , 2001 ). The coding scheme included the following markers: availability, accessibility, acceptability, and adaptability. The indicators (which comprised the coding system’s themes) were operationally established within the context of HE. Availability implies unrestricted access by universities to RwDs (Crea et al., 2022 ). This unrestricted access required the establishment of disability and refugee units within the institution since they play an important role in the unrestricted inclusion of RSwDs (Anati and Ain, 2012 ). Equality and inclusiveness are cornerstones of accessibility . By reducing existing structural and cultural hurdles that may limit the ability of SwDs to obtain admittance, institutions must go further and adopt a proactive approach to remove obstacles that hinder their acceptance of RSwDs (Sepúlveda Carmona, 2017 ). With universities, by establishing specific programs to integrate the perspectives of disabled refugee students, because the voices of SwDs are rarely heard in inclusive practices (Hayes and Bulat, 2017 ), this acceptability indicates a desire to interact with RwDs and represents the institution’s acceptance and acknowledgment of these students as members of the university community (K. Fincham, 2020 ). To benefit all students, adaptability requires institutions to use universal design principles that incorporate the flexibility of the curriculum, teaching methods, and assessment possibilities (Ramaahlo et al., 2018 ; Tomasevski, 2004 ).

The phases of data analysis were complex. First, a coding system was constructed using inclusive education indicators and markers, which served as the system’s themes for policy assessment. The establishment of the coding system was followed by consensus coding. The authors read the synthesized documents, marked the data within the coding scheme, extracted codes and identified themes (Braun and Clarke, 2006 ). The authors independently reviewed the data-collection policies and coded the data using a coding scheme. Both authors collaboratively discussed codes to create the final coding formulation. If a disagreement about the coding occurred, both authors discussed the issue until an agreement was reached, and sought advice from a colleague when necessary (Wicks, 2017 ). Rigor was ensured by meticulously outlining the analytical procedures (Braun and Clarke, 2006 ).

Interview findings

Based on the students’ discussions of their perspectives on education as refugees, three main themes emerged: equity, services, and challenges (Fig. 2 ).

This figure organizes the themes and subthemes identified from interviews conducted with Syrian refugee students with disabilities. Theme 1 (Equity): covers aspects related to residency status, admission processes, and financial resources, highlighting the equity challenges faced by these students. Theme 2 (Services): focuses on the accessibility and support services available or required for these students, emphasizing the gaps and needs in this area. Theme 3 (Challenges): details the administrative obstacles and concerns regarding future careers, shedding light on the practical hurdles these students encounter.

Equity in HE

The first theme identified three subcategories: residency status, admission, and financial resources.

Residency status

Legal residency status, which indicates official permission to live in the host country, was among the most critical impediments. As refugees, complying with arduous procedures to maintain residency authorization was challenging. Mohammad shared,

“As a refugee student, many papers are needed by the university, like a UNHCR card, Ministry of Interior approval, and medical reports.”

Mohammad’s experiences differed from Sana’s, who held a unique status (temporary residency visa) tied to her father’s employment rather than refugee status. She stated, “I registered as a student with a disability at the university; this does not require anything refugee-related because I have residency.”

Mohammad and his family were initially required to live in a refugee camp in Jordan. However, Jordanian law also permits camp refugees to transfer and live outside the camp under special conditions, as was Mohammad’s case after high school. He explained:

Before 2019, we were in the Zaatari camp. When I finished high school, my father submitted a request to live in Irbid to be closer to the university, and at the end of 2019, we moved here.

Both participants had similar experiences regarding university admission, and there were no specific requirements because they were refugee SwDs. Both participants indicated that the admission procedures were similar to those of national students and that there was no special consideration for their refugee status or disability. Sana said, ‘I completed high school in Qatar and registered at the university based on my grades in [high] school. There was no special treatment because I am a refugee student or have a disability’. Mohammad explained that Jordan’s admission system was all-inclusive and subject to the same criteria for all students. He said:

When I completed high school, I submitted a request to the Unified Admission Committee in Jordan and put 20 options for the universities I wanted to study. Based on my grades, the committee chose the university from my options that matched my grades.

Financial resources

Participants mentioned fairness related to financial resources, and this fairness varied based on the nation, its rules, accessible financial resources, and students’ experiences in obtaining stable funding that would allow them to enroll in inclusive educational colleges. Mohammad recounted his negative experiences accessing a financial source that would enable him to join YU:

The money issue was my biggest obstacle when joining the university. I was a year late to enter the university because I did not have tuition fees, and no scholarships were available to support my studies from any party. After a year, I received a grant from a European institution and was able to enter the university. Without this scholarship, I would not have been able to continue my studies because it is expensive.

As a refugee, Mohammad felt he could not benefit from the available national scholarships: ‘I could not get the 90% tuition discount provided by the Higher Council for the Rights of Persons with Disabilities because these grants are available for Jordanians only’. Sana also complained about the high cost of studying at QU and her hope to benefit from some type of bursary/scholarship. ‘Tuition fees are expensive, and there are some scholarships within the university and fee reductions for outstanding students.’ However, Sana implied that the economic situation in Qatar allowed her family to afford the study costs. She said, ‘My father is a doctor with a good salary, so my father, thank God, can bear the costs of my studies at the university, and I do not need to apply for grants permanently.’

Service was a critical aspect of both Syrian RSwDs’ experiences with Arab HEIs. Two main categories related to this theme emerged: accessibility and support services.

Accessibility

Participants referred to their experiences with university services that enabled them to meet learning requirements, while simultaneously highlighting varying experiences. They were based on the type of disability related to the accessibility of services needed. Sana said, ‘As a student with a visual impairment, I need many services to complete my university education. I can read and write, but I need to enlarge the font on paper and screens. The university provides these services.’ Regarding the physical environment, Sana expressed no need for services to move around the university, because she was self-dependent. ‘As for transportation, I do not ask the university for any services because I can move on my own and with complete freedom.’

Mohammad, on the other hand, explained that he faced some difficulties moving around at YU, where environmental services were an essential requirement for him. Mohammad explained:

Not all university facilities suit me as a student using a wheelchair. Some colleges have broken elevators; some are small and do not accommodate me [the chair]. Some roads in the university do not have ramps, so I find it difficult to move from one place to another without assistance.

He clarified that, although the university provided these services to some students, he personally did not need a modified curriculum or assistive technology. ‘I do not want to increase the time in the exam or reduce the syllabus. I can succeed without specialized services.’

Support services

In addition to academic support services, with university policies showing some contradictions in the provision of support services, participants expressed the need for psychological, emotional, and social support services. Mohammad explained—[At YU] ‘There are courses in the university at the refugee center for psychosocial services’. Mohammad also expressed the importance of these services for Syrian SwDs and the need for these types of services—’I have benefited from the psychological and social rehabilitation services provided at the university. SwD have psychological pressures and social problems, and these services are useful’.

Mohammad also indicated that his university colleagues and faculty members were friendly and provided positive emotional support. Mohammad elaborated, ‘People at the university are good with me. I have friends at the university, and the doctors help me if I need anything’.

Conversely, Sana clarified that there were no specialized services for refugees at QU and that the support services provided to her were similar to those offered to other students. In addition to academic support services, Sana listed the availability of counseling services, but she had never requested this service. She stated, ‘No, there is nothing for refugee students at the university. Services are available at the Disability Center for all students. She added, ‘I only need font augmentation services in lectures and exams’. Regarding emotional support, Sana indicated that her relationships with peers and faculty were amicable. She said, ‘My relationship, praise be to God, is excellent with everyone, and I have no problems'.

The final emergent theme was the challenges faced by Syrian RSwDs in the Arab HEIs. The refugee students with disabilities faced multilayered administrative obstacles related to their intersectional identities. As refugees, they struggled with language barriers and unfamiliar university systems. Their disabilities made independently navigating campus offices to complete registration paperwork challenging. Financial instability as refugees meant grant paperwork was critical yet difficult. Communication difficulties stemming from their impairments also hindered their ability to explain administrative needs. In essence, being refugees with disabilities converged to complicate administrative processes like paperwork, finances, transportation, and communication in unique ways. Two main categories related to this theme are identified: administrative obstacles and future careers.

Administrative obstacles

While administrative procedures, such as registration and financial aid, impact all students, these processes pose particular challenges for RSwDs due to their multifaceted identities. As refugees, language barriers, and unfamiliarity with the new university system complicated administrative tasks. Their disabilities also presented obstacles to navigating different campus offices independently to complete paperwork. Financial precariousness as refugees made grant paperwork critical yet difficult. Communication difficulties stemming from visual and physical impairments have also hindered their needs. Sana confessed that with electronic registration and fee collection services, her challenges were minimal, but small problems might arise related to scheduling conflicts with courses and previous commitments. Sana said:

Registration at the university is easy. All students register online using `My Banner’, but there is a problem if a course is not available and there is a need for an alternative course, then I must visit the academic adviser, who will assign another course, and this takes time and effort.

Mohammad also faced difficulties with course registration, withdrawals, and obtaining department stamps for his grant due to accessibility and communication issues. Mohammad said, ‘Although the registration is electronic, there is a routine in some cases, especially withdrawal and addition courses, which requires going to the faculty and registration department. This is difficult for me’. Mohammad described, ‘The most difficult thing for me is when the issue is in the financial department because I have a grant, and I have to get the department’s stamp on the grant paper’.

These perspectives highlight how the intersection of refugee status and disability multilaterally disadvantaged them in terms of administrative barriers related to paperwork, finances, transportation, and communication. Strengthening administrative accommodation and support is vital for increasing the inclusion of these uniquely disadvantaged students.

Future career

Syrian SwDs’ perceptions of their professional future were uncertain because of their status as RwDs. Although some Arab universities provide career services within the principles of inclusive education, planning a professional future is one of the biggest challenges. Mohammad said, ‘I do not know what will happen when I graduate. I am studying hard, but I have a fear of the future’. He added, ‘You know, I feel frustrated when I see Jordanian graduate students without disabilities suffer from unemployment. The university provides nothing on this matter, and we, as refugees or individuals with disabilities, do not have any help in finding a job. I lose hope when I see Jordanian SwDs, who have a priority in employment in Jordan, do not work’.

Sana also shared her concerns about her future career due to her disabilities. She said, ‘I think there are job opportunities in Qatar, but I am afraid that my opportunities will be few because of my disability’. She denied knowledge of any programs or services provided by QU regarding the university’s provision of vocational training or employment.

Policy analysis findings

Policy analysis coding procedures were conducted to compare educational policies on the inclusive education of RSwDs in YU and QU based on the 4-A framework (Tomasevski, 2004 ; Tomaševski, 1999 , 2001 ). The authors extracted 15 codes from the universities’ educational policies. Table 1 shows the distribution of codes using the four inclusive education themes.

Availability

The availability theme refers to the presence of educational programs for SwDs (Maulida, 2019 ). First, YU had a specialized center for refugees called ‘ The Refugees, Displaced Persons, and Forced Migration Studies Center ,’ unlike QU. Furthermore, the analysis showed YU’s and QU’s commitment to accepting SwDs without discrimination. For example, in the YU Admission Law No. 4, Item 4 stated: ‘The university is committed to providing justice in accepting SwDs.’ In the law establishing the Inclusion and Special Needs Support Center No. 24 of 2022, QU also stated, ‘QU is committed to providing a diverse and supportive academic and work environment for PwDs, based on the principle of equal opportunities.’

Under this theme, both universities had units or centers that provided services for SwDs. However, there was no specific mention of Syrian RSwDs on these centers/units’ websites, considering that these students were part of the SwDs at the university. This supports, in part, students’ claims regarding the all-inclusive approach to HE. Interestingly, the YU website showed the availability of a specialized psychosocial service program for Syrian refugee students, which helped refugees overcome crises and consisted of counseling, rehabilitation, and checks on mental health and well-being (Weissbecker et al., 2019 ). The findings indicated that there was no specialized assessment for SwDs in either university, but both universities relied on evaluating SwDs to register. Conversely, the results showed that student advocacy services do not exist as independent services, but are affiliated with service centers for SwDs.

Accessibility refers to the provision of physical and programmatic services that minimize the impact of disabilities and support the inclusion of PwDs in a specific context (Lister et al., 2022 ). An analysis of educational policies revealed the degree of commitment of the two universities in providing accessibility services to SwDs. Regarding the physical environment, the results showed that QU’s educational policies stated the accessibility, such as ‘accessible classrooms, comfortable chairs, and adapted laboratories,’ of services to individuals with disabilities. For YU, and not meaning that these services do not exist, but rather that university educational policies do not impose these services within the legislative context, researchers did not find any explicit items in educational policies regarding these services.

However, the findings revealed access to the academic services provided to SwDs at both universities. For example, QU requires faculty members to offer extra time for exams and to adjust curricula as part of the university’s existing accessibility services. In comparison, in their educational policies, YU provided academic services such as sign language translation, sighted writers, and modification of educational content.

Regarding assistive technology, the findings showed that both universities used assistive technology as an accessible service for SwDs. QU used various assistive technologies, such as printed text readers, writing font amplifiers, speaking software, Braille printers, audiobooks, and electronic libraries. Both YU and QU provided services in the classroom such as printed books in Braille, audiobooks, font amplifiers, sound amplifiers, and digital libraries. SwDs are integral to the university and should also benefit from these universities’ services, although the accessibility of services is not allocated to Syrian SwDs within the legislation.

Acceptability

Acceptability refers to accepting SwDs in an inclusive environment in terms of respect, rights, and participation (Tomaševski, 2001 ). The findings indicate that universities accept Syrian RSwDs in the university environment by providing all means of academic and social participation on an equal basis to students with or without disabilities. YU policies refer to the freedom of SwDs to participate in academic and social life at university. YU is committed to providing students with space for their academic and educational choices. For example, the second paragraph of the university’s philosophy states, ‘The university pays great attention to quality of education. Therefore, it adopts a system of semesters and credit hours to give students more freedom to choose what suits their needs and desires.’ Regarding social participation, the Department of Students with Disabilities Services states the importance of social involvement for SwDs with respect to integrating them into the student community by organizing cultural, sports, and artistic activities.

Similarly, the QU policies indicated an interest in students’ academic and social participation at the university by offering various services. The inclusion and special needs support center provides services such as additional lessons in coordination with learning centers, working with faculty members to provide academic support to students, motivating students to participate in student clubs, and conducting courses to develop the professional and social skills of students.

Adaptability

Adaptability refers to methods that meet the needs of students in classrooms, such as the Universal Design for Learning (UDL), financial resources, and employment (Shabeer et al., 2020 ). The findings show the complete absence of the adaptability principle as a pillar of inclusive education services for RSwDs at YU. There was a lack of financial aid resources, such as scholarships and tuition discounts, for Syrian SwDs at YU; however, these resources were available to Jordanian SwDs. For Syrian refugee students in general, and SwDs in particular, YU depended on donors and foreign projects to provide scholarships and tuition discounts for those students. Regarding the application of the UDL framework, there were no specific instructions in the educational legislation related to the university’s adoption of the framework in designing the educational environment for SwDs. In accordance with the findings of the policy analysis, the university also did not adopt any programs aimed at employing SwDs after graduating from the university, such as vocational training, job fairs, or employment programs.

On the other hand, the policy analysis findings at QU show the university’s interest in the adaptability principle by providing various programs and services for its students. For example, the university offers a wide range of financial aid programs for SwDs in the form of monthly financial aid, full or partial payment of tuition fees funded by the university, exemption from transportation fees, full or partial payment of university housing fees funded by the university, and emergency assistance. Regarding the application of UDL principles, university policies imposed a comprehensive system for students, faculty members, and university employees to implement UDL principles. For example, the university provides instructions for multiple means of presenting information (what we learn), multiple means of expression and performance (how we learn), and multiple means of participation and engagement (why we learn). Finally, with the example of the inclusion and special needs support center holding courses to develop students’ professional skills, programs to assist students in obtaining jobs, and coordination with local community institutions to provide employment opportunities to SwDs, the university was interested in employing SwDs postgraduation by providing training programs, job opportunities, and follow-up plans.

This study employed a mixed-methods approach involving case interviews and content analysis of university policies and documents to critically examine the status of inclusive education in two major Arab universities: YU in Jordan and QU in Qatar. The focus was on the experiences of Syrian RSwDs. The findings highlight a stark gap between policy pronouncements and the lived experiences of these students on campus. Notably, while both universities commit to inclusivity, the experiences of RSwDs differ from those of institutional promises.

The interviews presented three central themes—inequity, services, and challenges—that resonate with earlier findings (Hornby and Kauffman, 2021 ; Taneja-Johansson and Singal, 2021 ). The document analysis reflects universities’ explicit commitment to inclusivity. Inclusive educational practices differed among universities. Disparities in scholarship availability significantly impact equitable access, as financial barriers are multilayered for RwDs. The Qatar University’s alignment of services and legislation is enabled by resources. The availability of scholarships can better support their integration (Alodat et al., 2021 ). These findings on service provision corroborate previous research showing that efforts must be comprehensive to uphold RwD rights for inclusion in higher education (Alodat and Almomanİ, 2019 ; Alodat et al., 2021 ; Alodat and Gentry, 2022 ; Muhaidat et al., 2020 ).

RSwDs face distinct challenges stemming from their intersectional identity. As reported by Mohammed and Sana, RSwDs encounter multilayered barriers related to both refugee status and disability that converge to exacerbate disadvantages and complicate educational access (Morrice, 2021 ). Their narratives revealed how RSwDs must navigate exclusions based on nationality, legal standing, trauma, communication needs, and inaccessibility. This highlights the necessity for tailored research and policies addressing the complex identities of RSwDs compared with domestic or non-disabled students.

Regarding disability services, neither Sana nor Mohammed received targeted support, although they perceived provision differences based on university resources (Alodat and Gentry, 2022 ). Mohammed highlighted mobility restrictions from inadequate infrastructure. Interviews revealed that Syrian RSwDs experience insufficient disability services despite university commitments on paper (Alodat et al., 2021 ; Muhaidat et al., 2020 ). Mohammed described extensive residency paperwork needed for Jordanian university enrollment, evidencing bureaucratic obstacles. He noted scholarship obstacles and demonstrated the economic barriers. Their narratives substantiate the barriers to HE participation faced by RSwDs in light of their multifaceted identities and statuses.

Essentially, these results reveal a critical disconnect between the principles of adaptability in HE, as discussed in modern inclusive education frameworks such as UDL, and real-world programs designed to prepare SwDs for life after graduation. This is particularly true for RSwDs in Syria. As stated above, although QU follows legislative guidelines for inclusive education and offers UDL-based programs and career services, it still overlooks the specific experiences and career expectations of Syrian SwDs in Qatar. For instance, Sana was apprehensive about her professional future despite a strong Qatari economy, whereas Mohammad felt that his future was entangled in administrative complexities at YU.

This study also sheds light on the existing challenges of inclusive education in Arab universities, offering insights into the barriers faced by RSwDs. Inclusion practices varied between the QU and YU, with significant disparities in scholarship opportunities affecting educational quality and equity. The interviews indicated that QU’s legislative framework for accessibility aligned with students’ experiences, supported by the institution’s economic capacity, which is consistent with prior research (Simadi and Alqaryouti, 2017 ). While support services were lacking in Qatari institutions, Jordanian universities have recognized the importance of psychological and emotional support for Syrian students (Alodat et al., 2021 ).

Policy and institutional changes are essential for improving inclusive education in Syrian RSwDs. At the policy level, residency and legal procedures for Syrian refugees must be streamlined for equal educational opportunities. In addition, partnerships between governments can help meet the educational needs of Syrian RSwDs. Institutionally, simplifying admission requirements can ease entry barriers, particularly for refugee camps. Boosting disability accommodation and services is also vital. Collaborative efforts between universities, government bodies, and donors can facilitate resource mobilization and outreach, thereby informing refugees about educational opportunities.

Educational strategies should include the formulation of individualized education programs that detail the specific support for each SwD. The integration of assistive technologies such as screen readers and speech-to-text software is crucial for facilitating learning and communication. Making learning materials accessible to all, including those with visual, hearing, or cognitive impairments, promotes an equitable educational environment. These interventions can significantly enhance the inclusivity and accessibility of education for SwDs, aligning them with the principles of justice and inclusive education.

Limitations

This study had several limitations. The comparative case study method was limited to two participants, who constituted high- and low-income earners in their respective host states. Therefore, in addition to the study’s inability to be generalized, it is not transferable to other RSwDs in different jurisdictions. Second, the analysis of educational policies on the two universities’ websites did consider the host country’s legislative policies regarding the issue in HE; therefore, there is some bias in reporting. Furthermore, while our study offers crucial insights into barriers to inclusive HE for RSwDs, follow-up research should include more Syrian SwDs to build on the findings and elements of national policies. Furthermore, the use of thematic analysis could have also introduced some biases despite our efforts to control for these through peer debriefing; thus, there is the possibility that the ideas and concerns of the researchers may have influenced the data analysis. However, in-person interviews do not differ from telephone and online interviews in terms of the substantive coding approach; in other words, they do not capture body movements and facial expressions, so it is important to note that the difference in interview modalities may have influenced the degree to which participants felt comfortable sharing sensitive information. Bearing in mind that age, gender, and academic status can impact student experience, future research in this area with larger or more diverse samples would allow for further consideration of specific measures to improve inclusive HE for RSwDs. Here, we see that reflection in the context of HE experiences may evolve, social change occurs quickly, and it is crucial to include present systems in the construction of future frameworks to ensure that they reflect the current reality.

Conclusions

This comparative case study revealed gaps between inclusive education policies and practices experienced by Syrian RwDs in HE. Financial barriers have emerged as multilayered for RwDs. Expanded need-based scholarship and grant programs can improve availability and participation. Streamlining disability and refugee registration processes through centralized systems may ease the administrative burdens related to paperwork requirements.

Enhancing campus infrastructure and transportation through accessibility audits, upgrades, and assistive technologies are advised to reduce physical barriers. Providing academic accommodations tailored to disability types, such as assistive software, note-takers, and interpreters, could boost academic success.

Dedicated career counseling and mentoring services tailored to the legal and social constraints facing RwDs would help to navigate future education and employment goals. Socioemotional counseling and facilitated peer support groups may help foster belonging and address trauma.

Future research should longitudinally examine HE access, accommodations, and outcomes among RwDs to evaluate their long-term impacts on well-being, social inclusion, and human capital. Exploring faculty preparedness and attitudes can help to identify professional development needs. Rights-based inclusion approaches warrant investigation of their capacity to build social capital and leadership.

Data availability

Data are not publicly available due to ethical restrictions, as they contain information that could compromise the privacy of research participants.

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Al-Hendawi, M., Alodat, A.M. Inclusive education of refugee students with disabilities in higher education: a comparative case study. Humanit Soc Sci Commun 10 , 942 (2023). https://doi.org/10.1057/s41599-023-02410-6

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