Elsevier

Social Science & Medicine

Volume 213, September 2018, Pages 199-219
Social Science & Medicine

Review article
A mixed methods systematic review of studies examining the relationship between housing and health for people from refugee and asylum seeking backgrounds

https://doi.org/10.1016/j.socscimed.2018.07.045Get rights and content

Highlights

  • Synthesis of studies on housing and health link for refugees and asylum seekers.

  • Limited research in either refugee camps or resettlement countries.

  • Evidence of the health impacts of housing problems, particularly in refugee camps.

  • Methodological limitations identified in the evidence base.

  • A range of potential public health interventions, but requires specific evaluation.

Abstract

Housing is an important social determinant of health and a key element of refugee integration into countries of resettlement. However, the way in which housing may affect mental and physical health for refugees and asylum seekers has not been systematically examined. This systematic review aimed to explore the effects of housing on health and wellbeing for this population, in order to identify key pathways for public health interventions. The review was undertaken following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Social Care Institute for Excellence (SCIE) guidelines. We identified publications through a search of Medline, PsychInfo, Scopus, Web of Science, Embase, CINAHL, Cohrane Library, Google, ProQuest, OpenGrey, MedNar and WHOLIS. Eligibility criteria included: publication in English between 1997 and 2017, with findings pertaining to the relationship between housing and health for refugees and/or asylum seekers. Out of 2371 items, 25 papers were included with a further five identified through reference lists. Eleven of the papers explored housing and health for those refugees and asylum seekers living within refugee camps, with 19 focusing on countries of resettlement. All studies identified housing issues for refugees and asylum seekers, with physical housing conditions particularly poor in refugee camps, and issues of affordability, suitability, insecure tenure and mobility as well as difficulties securing housing also highlighted in countries of resettlement. Consistent relationships were found between physical aspects of housing and physical and mental health, with other aspects of housing such as safety and overcrowding linked to mental health. There were a number of methodological issues with most of the studies, making it difficult to specify precise pathways. However, improvements to housing quality particularly in refugee camps, and targeted housing interventions more generally for refugees and asylum seekers would likely have an important public health benefit.

Introduction

People with refugee and asylumseeking backgrounds can face a range of risk factors for poorer health and wellbeing, including experiences of trauma, dislocation, and violence, with associated loss of family and community support (Fazel et al., 2005; Fozdar and Hartley, 2014; Hollifield et al., 2002; Taylor, 2004; Phillips, 2006; Silove and Ekblad, 2002). When building a new life, either temporarily within a refugee camp or longer term within countries of resettlement, there are several factors that are important for successful health outcomes, including housing.

Secure housing is an important social determinant of health (Marmot, 2005) and both a means and marker of successful integration for refugees and asylum seekers (Ager and Strang, 2004, 2008). However, there is evidence of a range of housing difficulties faced by refugees and asylum seekers (Bakker et al., 2016; Beer and Foley, 2003; Carter et al., 2009; Forrest et al., 2012; Phillips, 2006; Rose, 2001). While there is a growing body of research on the link between housing and health more generally, there is no current review of the impact of housing on the health of people from refugee and asylum seeking backgrounds (Forrest et al., 2012; Fozdar and Hartley, 2014). As such, this paper provides a systematic review of the literature concerning the relationship between housing and health and wellbeing for refugees and asylum seekers. It aims to synthesise the available evidence on the link between housing and health for refugees and asylum seekers, and to identify both research gaps and potential pathways for public health interventions.

Adequate housing is enshrined as a human right (OHCHR, 2018), with ‘adequate’ meaning more than just a physical shelter but “to have a home, a place which protects privacy, contributes to physical and psychological wellbeing and supports the development and social integration of its inhabitants” ((Bonnefoy et al., 2003) (pp 413)). Housing is also a key social determinant of health (that is, the set of conditions in which people are born and live, and which shape daily life (World Health Organization, 2017)), with a growing body of research linking housing to overall health and wellbeing (Baker et al., 2014; Bonnefoy, 2007; Braubach, 2011; Braubach et al., 2011; Evans et al., 2003; Gibson et al., 2011; Howden-Chapman, 2002; Shaw, 2004; Thomson et al., 2009). This evidence suggests that housing can influence all aspects of health and wellbeing to the extent that it is suitable, affordable, and offers secure tenure, and encompasses physical features of the housing itself as well as social and symbolic aspects such as a sense of safety, discrimination, identity and ontological security.

Housing can affect health and wellbeing through a range of pathways. For example, housing conditions such as mould, damp and unsafe water may directly influence health conditions (e.g., asthma or diarrheal illnesses), overcrowding can contribute to the spread of communicable diseases, housing difficulties can cause stress and anxiety, unaffordable housing costs can limit money available for health promoting resources, and housing issues can negatively affect access to other resources such as employment and education that are themselves social determinants of health (Acevedo-Garcia, 2000; Dunn, 2000; Evans et al., 2003; Howden-Chapman, 2002; Rosenberg et al., 1997; Shaw, 2004; Wanyeki et al., 2006). These effects are likely to be both direct and indirect (Howden-Chapman, 2002) and bi-directional where poor health, together with other social factors such as education, ethnicity, and socio-economic status, significantly impact on one's ability to secure appropriate housing (Baker et al., 2014; Mallett et al., 2011).

It is important to acknowledge that there are likely differences in the experiences of housing for refugees and asylum seekers, and these two groups of people are heterogeneous. Asylum seekers are defined as people who are outside their country of origin and seeking formal protection, but have not had their claims to refugee status assessed, while refugees are defined as people who meet the criteria for refugee status as defined by either the United Nations High Commissioner for Refugees (UNHCR), or particular criteria outlined by specific countries (UNHCR, 2017). Within the terms “asylum seeker” and “refugee”, there remains large amounts of variability, and thus it is acknowledged that these terms are potentially problematic in subsuming complex and diverse identities and lived experiences into single categories.

In relation to housing and accommodation specifically, people with refugee or asylum-seeking backgrounds will likely have differing experiences based on both their status in relation to their refugee claims, as well as the country they are currently residing in. Most obviously, refugees living in middle or high income resettlement countries such as Australia, New Zealand, Canada, the United States (US) or the United Kingdom (UK) will live in the community and be required to access private or public accommodation as per the practices and structures in that country (although some countries, such as Australia, do provide temporary accommodation to newly arrived refugees for a short period of time). On the other hand, asylum seekers living in resettlement countries will be subject to a range of different practices depending on the country. For example, in countries such as Australia and the UK, deterrence-related policies are adopted such that access to support services and publicly funded housing is restricted in order to reduce the perceived attractiveness of those destinations for asylum seekers (Bakker et al., 2016). In these instances, asylum seekers may have to access private housing while having their ability to work or receive welfare restricted. Correspondingly, the experiences of housing and accommodation in resettlement countries are likely to differ broadly based upon the status of a person as either a refugee or asylum seeker.

For refugees and asylum seekers living in resettlement countries, current research indicates that new arrivals face a range of barriers to accessing suitable housing or accommodation (Forrest et al., 2012; Phillips, 2006; Refugee Council of Australia, 2013; Rose, 2001). Specifically, research from Australia and the UK has highlighted challenges to accessing private rental accommodation including availability, lack of references, and affordability, with other forms of accommodation often out of reach (Bakker et al., 2016; Beer and Foley, 2003; Forrest et al., 2012; Phillips, 2006; Rose, 2001; Ziersch et al., 2017c). Similarly, research has found evidence of discrimination towards refugees and asylum seekers in resettlement countries, further impacting the ability to access housing (Forrest et al., 2012). Other issues identified in the literature include overcrowding, language barriers, and unfamiliarity with housing stock and locations (Forrest et al., 2012; Fozdar and Hartley, 2013). The studies reviewed below provide further evidence of these challenges. Housing difficulties have also been linked to other areas of refugee integration or resettlement. For example, Phillimore and Goodson's (2008) summary of several studies they conducted with respect to refugee integration found that housing affected a range of other areas of integration including undertaking education and forming social connections.

Large numbers of refugees or asylum seekers (an estimated four million people in 2015, (UNHCR, 2016)) live in refugee camps in (usually) low to middle-income countries, and are thus faced with a very different set of housing conditions. Such conditions may include little protection and inadequate infrastructure such as water and proper sewerage (Alnsour and Meaton, 2014; Rueff and Viaro, 2009). Previous research with both refugees and children of refugees living in refugee camps has found that lack of housing or shelter is experienced as a significant traumatic event (Sabin et al., 2003).

While these issues surrounding the housing situation for refugees and asylum seekers are well known, and there is emerging evidence of the impacts on health, this has not been systematically examined. As such, this paper aimed to provide a comprehensive systematic review of the literature concerning the relationship between housing and health and wellbeing for people with refugee or asylum seeker backgrounds, including all study designs, and across the range of housing outcomes (that is, resettlement in a developed or developing country, or refugee camp). In addition, the paper aimed to identify gaps in the literature and potential public health interventions.

Section snippets

Methods

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was drawn upon in the collection and analysis of articles, as well as qualitative data synthesis and analysis processes from the Social Care Institute for Excellence (SCIE) Systematic Research Review Guidelines (Moher et al., 2009; Rutter et al., 2010). Specific details are provided below.

Results

From the 2371 results generated from the search and reference list check, 30 publications that met the inclusion criteria were identified (see Fig. 1 for full search results and flow chart for selection). Full texts were obtained for all articles. The main reasons for excluding articles were consideration of internally displaced populations or migrants rather than asylum seekers or refugees, and not exploring the relationship between housing and health, but rather focusing on these two as

Discussion

Overall, the review found significant housing issues experienced by refugees in both refugee camps and resettlement countries. These issues were associated with worse mental and physical health outcomes, supporting a broad literature highlighting housing as an important social determinant of health (Baker et al., 2014; Bonnefoy, 2007; Braubach, 2011; Braubach et al., 2011; Evans et al., 2003; Gibson et al., 2011; Howden-Chapman, 2002; Shaw, 2004; Thomson et al., 2009). In particular, the

Conclusion

Housing has been identified as a key social determinant in a range of previous research, and our review indicates that this is also the case for people from refugee and asylum seeking backgrounds. Housing – whether in resettlement countries or refugee camps – was typically found across studies to impact on mental and physical health and wellbeing in terms of housing condition and quality, availability, overcrowding, discrimination, tenure security and mobility, and safety. However, there is an

Acknowledgments

This review was not directly funded, but was conducted by the authors who were funded through an Australian Research Council grant and fellowship (LP130100782, FT120100150). We gratefully acknowledge the contribution of the two anonymous reviewers.

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