Camps or Cities? Comparing Refugees' Self-Reported Health and Well-Being Outcomes in Sub-Saharan Africa

Background and Purpose: Refugees are increasingly migrating to urban areas, but little research has been conducted to compare outcomes of urban refugees with those based in camps. This study investigated differences in health-related quality of life for urban and camp-based refugees in sub-Saharan Africa, and examined associations of both the environment and the perceived environment on refugees’ self-reported outcomes. Specific research questions are: (1) Are there differences in self-reported quality of life between refugees in urban and camp-based environments? and (2) How do refugees’ urban or camp-based environments, and their assessments of their environments, each predict self-reported physical health?

Methods: This analytic cross-sectional study (N=430) used two domains from the World Health Organization’s Quality of Life scale (WHOQOL-BREF) to measure differences for urban vs. camp-based refugees. Data for urban refugees (N=334) were drawn from an administrative database used by an international agency that serves refugee populations in South Africa. Data for camp-based refugees (N=96) were collected via surveys conducted at two refugee camps in sub-Saharan Africa. Bivariate analyses examined differences between urban and camp-based refugees related to gender, region of origin, overall self-reported quality of life and satisfaction with health, and the domains of Physical Health and Environmental Well-Being. A hierarchical multiple regression approach was used to examine changes in coefficients and adjusted R² with the addition of the environment (urban vs. camp-based) and the perceived environment (Environmental Well-Being) to the model.

Results: Internal consistency for the WHOQOL-BREF Physical Health and Environmental Well-Being domains was adequate, with α=0.74 and α=0.75 respectively. Bivariate analyses showed that refugees in urban environments reported significantly higher satisfaction with overall health (p<0.001), physical health (p<0.001), and environmental well-being (p<0.001) than refugees placed in camps. In multivariate analyses, controlling for gender and region of origin, urban environments (vs. camps) were associated with better physical health for refugees (p<0.001; adj. R²=.075). A further model specified urban environments (p<.05) and self-reported Environmental Well-Being (p<.001; adj. R²=.346). Post hoc regression analyses with individual indicators of Environmental Well-Being revealed that refugees’ perceptions of their environment - particularly feeling safe in daily life (R²=0.226) and in the home environment (R²=0.202), and being satisfied with living conditions (R²=0.193) were each strongly associated with self-reported physical health.

Conclusions and Implications: Results suggest that refugees in urban areas may be faring better than their camp-based counterparts, but that refugees’ subjective assessments of their environments are the most important predictor of physical health irrespective of location. While refugees living in urban areas are more likely to report better physical health, refugees’ perceptions of the quality of their environments are more strongly associated with physical health than the urban location itself. Notably, in our post-hoc analyses, the strongest environmental indicators were related to feeling safe in living conditions. This finding is consistent with research that shows community-level violence, as well as perceptions of the violence in the community, to be significant predictors of individuals’ health outcomes. Further research should be conducted to compare outcomes for these populations using conventional health measures as well as subjective assessments.