Article Text
PDF
Abstract
Objective Conflict, forced migration and searching for safety in a foreign land are all experiences common to refugee children. They experience potentially traumatic events that are distinct from the general population, yet current adverse childhood experience (ACE) studies do not cover these events. Studies that do examine refugee children’s experiences typically focus on a single stage of migration or adversities from the community, offering insight into only a fraction of their realities. This study aimed to identify potentially traumatising and protective experiences subjectively perceived as influencing refugee children’s well-being from all stages of migration and all socio-ecological levels.
Design Qualitative study with thematic analysis of semi-structured individual and group interviews. Themes were organised within a socio-ecological model.
Setting Non-profit organisations, youth welfare facilities and societies that organise civic engagement for refugee families in the Rhine-Neckar region in Germany provided rooms where interviews could be conducted.
Participants Refugee parents and children who spoke one of the four most common languages of those seeking asylum in Germany in 2018 were included. This study excluded refugees who were not fleeing a conflict area. Forty-seven refugee parents and 11 children (aged 8–17 years) from Syria, Iraq, Palestine, Afghanistan and Eritrea participated.
Results Eight major themes emerged from interviews including six reflecting potentially negative experiences and two potentially protective themes. These themes evolved from experiences such as family dispersion, displacement, rigorous immigration and national policies, as well as constructive parenting and community support.
Conclusion It is increasingly important to identify these diverse experiences as the refugee population continues to grow, and the increased prevalence of poor health outcomes in refugee children continues to be widely documented. Identifying ACEs specifically relevant to refugee children could contribute to understanding potential pathways and could further serve as a starting point for tailored interventions.
- Child protection
- Community child health
- Child & adolescent psychiatry
- PUBLIC HEALTH
- QUALITATIVE RESEARCH
Data availability statement
Data are available upon reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
Statistics from Altmetric.com
- Child protection
- Community child health
- Child & adolescent psychiatry
- PUBLIC HEALTH
- QUALITATIVE RESEARCH
STRENGTHS AND LIMITATIONS OF THIS STUDY
Primary qualitative data were collected from both refugee parents and children in order for them to express their perspectives on experiences the children endured.
The languages selected for inclusion in the study covered more than 50% of the refugee seeking population, in Germany in 2018, allowing the representation of different ethnicities.
The necessary use of interpreters might have resulted in comments that were under-translated or misinterpreted.
Member checking for respondent validation was not possible.
Introduction
By the end of 2021, 89.3 million people were forcibly displaced due to multiple emergencies, of which 36.5 million (41%) were children.1 The humanitarian landscape is overwhelmed as new crises unfold such as the recent war in Ukraine, with approximately 8 million refugees fleeing the country.2 Refugees flee war, violence, conflict or persecution to find safety3 and typically go through three stages of migration commonly called pre-flight, flight and post-flight. Among refugees, psychological suffering may occur at each stage, caused by traumatic experiences in their home country and during flight, and/or by the stress of adapting to a new life/culture on arrival in the host country. Post-flight stressors, often unaddressed, can have an equal or greater effect than pre-flight stressors on refugee children’s psychological well-being.4 5
Research shows that undergoing potentially traumatic events in childhood—known as adverse childhood experiences (ACEs)—is a potential pathway to social, emotional and cognitive impairments leading to increased risk of unhealthy behaviours, violence, disease, disability and premature mortality.6 Previous ACE studies in the USA focused on adversities between the child and their family (abuse, neglect and household dysfunction)7 and to some extent the community (bullying, discrimination and neighbourhood crime).8 9 However, it is important to acknowledge that a range of factors on multiple levels influence a child’s health and development, as suggested by the socio-ecological model (SEM).10 In the SEM, the developing child is seen as being embedded in several milieus that affect their well-being, including family, community and society.11 Yet, not all studies consider such levels, often overlooking adversities associated with society (political climate or government policies). Furthermore, adversities relevant to the refugee population such as war, displacement or acculturation appear to be missing. These gaps highlight the need to acknowledge and explore the unique challenges refugee children face from all SEM levels.
To date, qualitative research has concentrated on adult refugees’ experiences; for example, examining adult refugee mental health, coping mechanisms or social hardship.12 13 Of the studies that do discuss refugee children, many focus on a single migration phase (eg, war experiences pre-flight),14 a single aspect of the SEM (eg, refugee parenting behaviour)15 or on internally displaced refugees (different experiences arise when resettling abroad).16 While important, these studies offer insights into a fraction of what refugee children experience.
Equally important but similarly understudied is the identification of protective experiences that promote children’s development despite ACEs. The presence of healthy parents and nurturing environments, for example, are associated with fewer undesirable health outcomes.17 To reduce further adversity, promote the children’s developmental abilities (eg, resilience, discipline, stress-regulation and empathy) and encourage positive social, emotional and educational outcomes, refugee protective experiences must be identified.
In developing a clearer understanding of adversities refugee children encounter, and circumstances that could protect them, we must solicit the input of the individuals living these events. This study explores the perceptions of refugee parents and children experiencing conflict, migration and resettlement to uncover potentially negative and positive influences on the well-being of refugee children. In doing so, this study seeks to provide refugees with a voice, enabling a deeper understanding of sources of risk and resilience affecting refugee children’s health.
Methods
Patient and public involvement
The current study represents a component of a larger project entitled Beyond Refugee Adverse Childhood Experiences (BRACE). BRACE is a mixed-methods project with two aims; the first involves qualitative interviews with refugees to gain insight into the negative and positive experiences their children encountered at all migration stages. The goal was to identify experiences perceived to impact refugee children’s well-being and to inform item development for a questionnaire specific to their experiences. The second aim seeks to establish the psychometric properties of the resulting questionnaire (reported separately). Participants were not involved in the development of the research question, the design, recruitment or the conduct of our research. However, the qualitative component reported here was intended to ensure that the views and experiences of the study population were incorporated into the scientific questionnaire. Results will be disseminated via presentation at national and international conferences and sharing information through a short video on social media and the first author’s institutional website.
Setting and study population
Interviews for the current study involved refugees in the Rhine-Neckar region in Germany. As Germany hosted the largest number of refugees in Europe in 2015, it was a suitable location for this study.18 Recruitment was via convenience sampling through non-profit organisations, youth welfare facilities (eg, short-term placement homes for unaccompanied minors) and societies that organise civic engagement for refugee families. Five organisations granted access to locations where refugees lived/gathered. The target population included parents and children who were fleeing war and spoke Arabic, Farsi, Tigrinya or German, the official languages of most asylum seekers in Germany when the study began.19
To be included in the study, parents had to have at least one child under 18 years (as per the United Nations definition of a child20) and children had to be 6 years or older in order to participate individually and be able to comment meaningfully about their experiences.21 22 The study excluded asylum seekers who arrived to Germany prior to 2015 and/or were looking for better life opportunities (ie, not escaping armed conflict). This project follows the COREQ guidelines for reporting results (online supplemental appendix A).23
Supplemental material
Data collection
Participants were approached in person, introduced to the purpose of the study by the first author (SA, a female doctoral candidate with a master’s in public health) and invited to participate and ask questions; no relationship was established prior to study commencement. The interviews took place either in a room provided by an aforementioned organisation or in the participant’s home. Adults and children were interviewed separately and children spoke for themselves. SA, who speaks Arabic, English and intermediate German, conducted the interviews. Her theoretical training equipped her with key qualitative research skills and knowledge. When needed, she was supported by a female Farsi interpreter, a male Tigrinya interpreter or a female native German-speaking assistant. To offer support for participating children, a female child psychotherapist attended those interviews. The psychotherapist’s role was to ensure the child’s well-being during the interview, listening and intervening if necessary, and later having a general conversation with the children to check for any distress. She did not participate in data collection.
Participants were given the option to be interviewed either individually or in a group.24 The group could involve a participant and their spouse, siblings or other refugees depending on their preference. The aim of this approach was to decrease refusals/withdrawals. To build trust with participants and ensure their comfort to talk openly, the study team did not collect identifying data, thus future contact was not possible.25
Semi-structured interviews were undertaken between November 2018 and January 2020. An interview guide (online supplemental appendix B) developed by SA based on recent publications17 26 welcomed participants, explained the term ‘potentially traumatic experiences’, described the importance of their participation and reaffirmed their right to refuse answering questions and withdraw from the interview. For each migration stage, participants were asked to identify experiences they perceived as having a negative (potentially traumatising) or positive impact on a child’s well-being. Interview duration averaged 35 min (range: 15–75 min). When approached, a few persons declined to participate owing to a lack of time or interest. Among those participating, no interviews ended prematurely. Incentives were not provided. Data collection ended when no new experiences were addressed.
Supplemental material
Data management and analysis
Each participating individual provided written consent for recording interviews, taking field notes and publishing the findings. Children under 16 years assented and required a guardian’s consent. All participants filled out a sociodemographic questionnaire that did not contain identifiers (ie, name or address). Recordings were transcribed by a professional transcription agency. Descriptors were removed for anonymity. An independent native German-speaking collaborator translated German transcripts into English, which were checked for content accuracy by SA. Transcripts in English and Arabic were imported into MAXQDA 2018 (VERBI Software GmbH) for qualitative data management.
The transcripts underwent reflexive thematic analysis as outlined by Braun and Clarke,27 which has been previously used in similar contexts.28 29 The steps for analysis were: (1) familiarisation with the data—SA listened to the audio recordings while reading the transcripts and highlighted potentially interesting items; (2) generating initial codes—SA developed and defined codes, resulting in a codebook that was used to assign codes to all transcripts in a descriptive manner (available on request). Using an online number generator, four transcripts were randomly selected for coding by a second independent individual to facilitate teamwork and stimulate discussion about the codes to generate themes. Determining inter-coder reliability was not a priority; however, no general discrepancies occurred in this double coded subsample. (3) Searching for themes—SA reviewed the coded data to identify areas of similarity and overlap and grouped similar codes into possible themes. (4) Reviewing potential themes—themes were reviewed and discussed within the research team to ensure that the themes were distinctive and coherent in relation to the data. (5) Defining and naming themes—To express the uniqueness of each theme, they were each named and given a thorough description.
The codes within each theme were then organised to reflect their level within the SEM. Codes with limited support (described by a few participants) were documented for future exploration. Member checking was not feasible as no contact data were collected.
Results
Thirty-six interviews with 58 participants were completed (table 1). Eleven children (six unaccompanied and five accompanied) with a mean age of 14.6 years (range: 8–17 years) and 47 parents, mean age of 35.4 years (range: 23–63 years) participated. Most participants were female (n=45), the majority spoke Arabic and came from Syria (n=31), Iraq (n=6) and Palestine (n=4), followed by participants who spoke Farsi from Afghanistan (n=13), and Tigrinya from Eritrea (n=4). Participants had limited educational attainment (n=39), and many were unemployed (n=41). At the time of the interview, participants had spent an average of 2 years in Germany (range: 1 week to 4.5 years). Despite differences in age groups, ethnicity and duration of stay in Germany, differences with regard to experiences they considered to affect their children seldom arose.
Participant distribution in interview groups
Experiences mentioned in interviews appeared to revolve around six negative themes: (1) experiencing disruption to daily life and structure, (2) exposure to/witnessing violence that brings about harm or destruction, (3) facing impediments that obstruct progress, (4) dealing with affliction, (5) feeling isolated, (6) feeling subjected to rejection; and two potentially protective themes: (1) feeling secure and stable, and (2) having connections. Experiences unique to refugee children were widely represented in the transcripts, not limited to the individual or family milieu, but also attributable to the community and society at all stages of migration. Table 2 defines these themes and lists which identified experiences are included within each theme and their SEM level.
Theme definitions and code organisation with respect to the SEM
To provide a comprehensive overview of the experiences showing their rooting in different socio-ecological contexts, the presentation of results follows the SEM structure. The perceived negative and protective experiences are summarised in figure 1 and figure 2, respectively. Below we report the themes (underlined) and respective refugee experiences (in italics). Representative quotations provided below for the respective themes reflect experiences mentioned by children themselves and by parents describing what they considered to affect their child(ren).
Six proposed themes and experiences* perceived as potentially negative (adapted from Dahlberg and Krug73). *Theme names have been shortened for better visualisation; experiences in bold were reported frequently by participants.
Two proposed themes and experiences* perceived as potentially protective (adapted from Dahlberg and Krug73). *Theme names have been shortened for better visualisation; experiences in bold were reported frequently by participants.
Individual influences
The first SEM level focuses on the individual, characterising their traits and biological/biographical aspects that affect their well-being. Dealing with affliction was the only negative theme at this level. Many respondents commented on afflictions in the form of unfavourable psychological and physical health conditions of their child, giving examples of breathing poisonous gases during the war causing their child to develop asthma. Other parents reported that children had skin infections caused by poor housing conditions or somatic symptoms (eg, stomach pain) from continuous stress. A few noted afflictions such as changes in their child’s development and behaviour:
They no longer have the courage or the desire. [S/he] – who was not able to stop playing in the street – no longer did. They no longer desired to play in the street. [S/he] started saying here maybe someone can die, here is such … I mean their childhood is over. - Palestinian parent
A positive individual influence pertaining to the theme feeling secure and stable was valuing education. Many children stated that learning was important as a pathway towards a better future. For both children and parents, this was an indication of good emotional well-being.
Family influences
The SEM’s family level, concerned with how a child’s well-being is affected by family interactions, connections, structures and norms, was evident in all identified themes. Within the theme experiencing disruption to daily life and structure, several participants mentioned that family bereavement (death of a loved one) was causing emotional suffering, in addition to instability and change in the family structure. Others perceived family dispersion as disruptive and potentially harmful for the child’s mental well-being since family members were scattered in different countries. Reasons reported for dispersion included: a family member being at greater risk than other members (eg, forced military recruitment) or high financial costs for travelling as a family. Some parents reported sending a child to safety in Europe with the assumption that family reunification applications for minors would be accepted faster, only realising that this was disruptive to the child’s emotional well-being. Only a few participants recalled disruptive events such as divorce, parent arrest and a missing parent (whereabouts unknown).
Concerning the theme exposure to/witnessing violence that brings about harm or destruction, only participants from one family mentioned physical abuse on the familial level.
Strong support existed for the theme facing impediments that obstruct progress, especially in the form of economic hardship. Many described losing their jobs and homes as detrimental to a child’s physical and mental well-being as it threatened access to basic necessities and an escape to safety.
A few participants shared dealing with familial afflictions in the form of poor parental mental/physical health and parental drug use. The majority described parent’s distress, recognising that their worry and fear was reflected in their children, which may impact the child’s emotional health:
The children only were afraid due to that stress that we had, [the parents]. - Afghan parent
Regarding feeling isolated, two participants thought that orphaned children and unaccompanied minors would sense this as they lacked family support and were deprived of emotional stimulation, perceived to hinder their emotional development. Similarly, some participants described how children might feel subjected to rejection by citing physical neglect, in which a guardian failed to take care of their child, and sometimes abandoned them. They described attachment and social difficulties as resulting psychological consequences.
It appeared that participants supported family experiences regarding feeling secure and stable as potentially protective to mental health. A few participants mentioned presence of parents and financial stability as examples. They explained how the presence of parents is important for setting boundaries for children and protecting them from danger. Others described financial stability as a way to access nutritious foods, safe housing and other essentials that help children thrive. Many also viewed constructive parenting as important for their child’s emotional well-being. Constructive parenting was described as either masking reality or explaining the current circumstances, depending on the child’s age. Others described it as modelling strength by encouraging patience, hope and gratitude:
I mean, when we lived in the tent and in the caravans, in the camps… I tell them it is ok, this is a small phase and we will be patient. And we acclimatised and we got to know other people - Syrian parent
A few participants also mentioned the theme having connections when referring to presence of parents. They perceived it as crucial for children to live under one roof with parents to build a healthy relationship through their daily interactions.
Community influences
Community influences were also evident in many of the themes. Experiencing disruption to daily life and structure was perceived to have occurred due to displacement. Nearly all respondents recalled several forced relocations, missing the opportunity to build bonds with others or establish roots. This was described as a potentially harmful experience influencing children’s mental well-being:
We have only been from camp to camp…we have been in camps for [several] years. From [country 1] to…we went to [country 2]…they rejected us. The situation was very bad. I mean I have my [child], this little one, [s/he] is [an infant], [s/he] is psychologically unbalanced. I mean [s/he] doesn’t know the meaning of a home. - Syrian parent
Almost all participants, except those under 13 years, mentioned experiences at the community level related to exposure to/witnessing violence that brings about harm or destruction. A few participants mentioned sexual abuse, however, the majority expressed concerns for destruction, bombings, killing, fighting which they mostly faced in their home countries as well as extortion, exploitation, fraud, kidnapping, human trafficking and physical harm mainly encountered during flight:
The [foreign] guards caught us and beat us. They hit…you see my [child]? [S/he] was [an infant] when we left. The [foreign] guards hit [him/her], the situation is really… [shaky voice, crying] - Syrian parent
Dangerous and long travel routes were examples of facing impediments that obstruct progress, with one unaccompanied minor taking 4 years to arrive to Germany. Some impediments mentioned included crossing the sea on an overcrowded dinghy, suffocating in the back of an overloaded box truck or travelling through conflict zones and/or deserts. In each case, these situations were perceived as life threating and emotionally damaging to the child.
Children also dealt with afflictions such as inadequate shelter, considered to cause physical and mental suffering for the child because they were living in a tent/container, in overcrowded places under unhygienic conditions or were homeless:
We lived [several] years in a camp in [country]… If it’s raining …it would pour on us. When the weather is getting hot the tents burn, because of the electricity … the tents were on fire. - Iraqi child
Furthermore, both parents and children mentioned feeling isolated. A few described no community support and loss of network, which were described as emotionally straining. However, children mostly described missing in-person interactions and were yearning for their relatives. Multiple participants described how cultural differences were stressful for children due to multiple views, attitudes, languages and traditions that seem to elicit feelings of isolation for children trying to balance different cultures:
There are huge differences between the way we raise our kids and our culture and between the way [Germans] raise their kids and their culture. Of course this will make us suffer. Our kids want to integrate. - Syrian parent
There was also strong support for the theme feeling subjected to rejection in various forms, including discrimination at the community-level:
They didn't want to see so many Syrian people in [country]. And that’s why we can't do so many things. For example, this year, when I changed my school, we can't talk to the [foreign] students. So they think we just have to have a Syrian school. We are separated. And you just think that, we are not normal. - Syrian child
While the quotation above represents an example of discrimination during flight, many also described discrimination pre-flight (eg, due to their ethnicity or religion). A few mentioned post-flight prejudice (eg, unfriendly behaviour and name calling). Bullying and rejecting own cultural customs (eg, arranged/child marriage) were also mentioned by a few participants. A child subjected to any of these situations was perceived to suffer from emotional distress.
Protective community influences were also reported. Strong support for feeling secure and stable appeared in reference to community support, existing in different forms. Participants shared stories of community members providing them with practical (protection/transportation), informational (guidance) and emotional (care and compassion) support as examples of security. Likewise, remarks about stability were made when participants described receiving material (food/clothing) and practical (accommodation/translations) support. These different forms of support occurred at all stages of migration. Participants shared instances of neighbours opening their doors after losing their homes in bombings, strangers helping carry their belongings during flight, emotional support from strangers in times of hopelessness and practical support from Germans for daily tasks. The examples were numerous and were believed to reduce distress and anxiety for the child.
Lastly, a common theme revolved around the value of having connections with Germans, relatives nearby, people from their original culture and forming true friendships:
I had a '[sibling]' to be honest and we were well-suited to be on this path because [s/he] helped me and I helped [him/her] and so on…[S/he] was a good friend. And that was good, because it touched your heart so much. One does not think, one does not feel lonely in such situation…We were mutually healing for each other, so to speak. - Afghan child
Only a few participants mentioned connections that maintained ties to the child’s original culture and fitting in at school. Regardless of the type of connection, participants believed that such interactions were beneficial for the child’s emotional well-being.
Societal influences
Societal influences also played a role with regard to the theme experiencing disruption to daily life and structure. More than half of the children and parents commented on disruption in education describing how an insecure political climate pre-flight forced school closures, and how problematic policies in transit countries prevented children from getting a proper education. Participants complained that educational disruption could potentially influence children’s academic, social and emotional well-being negatively.
Societal exposure to/witnessing violence that brings about harm or destruction was also addressed by many. Participants gave examples about surviving in the midst of political insecurity, forced military recruitment, systematic violation of human rights, police/soldier brutality and militarisation:
The soldier came home, put me and my mother in jail…to put pressure on my father…and this fear of what they did to us, until today I always have a nightmare…that was a very difficult time, what I have experienced. And so for my health it has hurt terribly until today. I cannot find peace out of this fear. - Eritrean child
Participants also prominently mentioned facing impediments that obstruct progress from the societal level. Newly arrived and long-term refugee families had similar experiences, except for the frequency of mentioning immigration policies. Refugees living less than one year in Germany saw immigration policies as an obstacle complicating family reunification, including travel restrictions and lengthy processing times for asylum applications:
You [the government] are doing something good, for example, for the children, you are bringing [his/her parents] for [him/her], but what about [his/her] siblings? Are they not from the rest of [his/her] family? And they are minors… I mean the [child] has been waiting for [his/her parents] and family for three and a half years. - Palestinian parent
Participants identified national policies as an impediment, with countries closing borders leading to detention of refugees. The Europe-wide fingerprinting scheme was also described to impede refugees’ efforts to choose their resettlement country obliging them to return to the first European country where their fingerprints were taken. A few interviewees recalled impediments such as lack of job opportunities in transit countries due to difficulties in obtaining work permits. Some also mentioned difficulties in obtaining medical care in refugee camps due to extremely long waiting times and limited personnel/resources. Participants described these impediments as emotionally damaging for their child, as it would cause them to lose hope, and in the latter case physically suffer.
There was also a significant focus on feeling subjected to rejection, specifically from refugees who had recently arrived to Germany. In their point of view, refusal of asylum, revocation of refugee status or forced repatriation were all stressful thoughts that were troubling refugee children.
Experiences with regard to feeling secure and stable on the societal level were also reported by participants in the form of a non-violent environment with basic human rights and social security (eg, child allowance, health insurance, habitual residence). Such aids were perceived to inherently benefit and provide security and thus emotional stability for children.
Discussion
Our analysis revealed that refugee children encounter various experiences on multiple levels of the SEM throughout all stages of migration. Refugee ACEs revolved around six themes, whereas protective experiences revolved around two. The study identified experiences specific to refugees that, to our knowledge, have not been reported previously in ACE research. Below, frequently reported experiences are discussed in relation to previous studies followed by implications for future research and potential interventions.
Family influences
Family influences were the initial foundation for ACE research among the general population.7 Our study confirms that many ACEs reported in previous literature (parent arrest, divorce, family death, parental neglect, physical abuse and parental mental health7) were also perceived as relevant for refugee children. However, other experiences were more prominent.
Participants associated economic hardship (eg, currency depreciation and long-term parental unemployment) with refugee children’s struggles, causing difficulties in affording necessities and safe refuge. Economic hardship has previously been shown to affect school performance and increase early marriage or child labour rates30 and to have a negative impact on the emotional well-being of parents and thus their children.15
In this study, refugees frequently commented on experiencing dispersion of family, previously recognised as causing anxiety in children due to uncertainty regarding their parent’s whereabouts.31 Additionally without parents’ physical presence (whether due to dispersion, death or neglect), children tend to have behavioural problems, low academic achievement and motivation, and lack of self-esteem.32
These negative influences, whether anxiety or behavioural problems, could be buffered by potentially protective experiences, such as those in figure 2. It is important to recognise that protective and adverse events were not mere opposites but parts of a continuum.33 For instance, constructive parenting is not simply parental presence (the opposite of absence); it is a way of guiding the child’s behaviour by comprehending their needs. Through constructive parenting, parents actively try to provide their children with security and stability.34
Community influences
The majority of the events recounted by participants were from the community level of the SEM, which includes the child’s environment and their relationships with relatives, friends, teachers, neighbours and strangers. The UNHCR defines shelter as ‘a habitable covered living space that provides a secure and healthy living environment with privacy and dignity (…) comfort and emotional support’.35 However, the participants’ descriptions of their shelter did not align with this definition, and inadequate shelter was perceived as a potential adversity altering community life. This is in line with previous findings, with inadequate shelter described as bearing potential physical and mental health risks for refugee children, such as the spread of diseases due to overcrowding and stress/anxiety resulting from living in an insecure environment.36
Cultural differences including language difficulties were described as a community-level adversity leading to acculturative stress among refugees in this study, which is in line with previous findings.37 In this study, refugee children were more likely to express difficulties with cultural differences than their parents, possibly due to increased exposure to the host culture through school enrolment37 and limited social interaction of their parents, of which the majority were homemakers.
Earlier studies with refugees from Africa, Eastern Europe and Asia have highlighted the significance of discrimination in resettlement countries.14 15 38 39 However, in this study, discrimination was more commonly experienced in participants’ home countries and during migration due to historical conflicts (eg, intolerance faced by Kurdish people in Iraq, Syria and Turkey40). Discrimination has been shown to have a negative impact on children’s mental and physical health, including reduced aspirations, lower self-esteem and affecting their feeling of belonging.41
This study supports the adverse impact of displacement, which participants described as being caused by countless relocations disrupting community life. Prolonged periods of displacement have been linked to poorer mental health and development outcomes.42 Regular routines that contribute to language skills, academic success and emotional growth43 are disrupted by displacement. Displacement is also associated with prolonged uncertainty, impeded access to education and healthcare, lack of job opportunities and delayed arrival to a safe/secure environment, all of which can affect children’s health and well-being.44 Slow resettlement efforts (less than one per cent of the 20.7 million refugees of concern to UNHCR in 2020 were resettled45) further prolong displacement, exposing refugees to the aforementioned consequences for extended periods. Moreover, refugees may be forced to take longer, dangerous routes, potentially exposing them to traumatic events that can lead to further psychological and physical health consequences.31
The majority of adult participants in the study described community violence as the primary reason for their flight, mentioning the various forms presented in figure 1, suggesting its universal significance. Previous studies have linked such violence to negative health outcomes including mental distress, depression, anxiety and post-traumatic stress disorder.41 Notably, children under 13 did not describe community violence, possibly due to age-related limitations in recall or lack of personal exposure.
While child refugees are vulnerable to various adversities, this study supports previous descriptions of community support and resulting connections playing a protective role. Community support has been reported to promote resilience by aiding refugees with their needs.46 Establishing connections with relatives or other refugees can help maintain ties to original culture,47 while connections with people from the host community allow for sociocultural adaptation.38 Attending school and participating in leisure activities like football can provide opportunities for social integration and well-being.48 49
Societal influences
The final level of the SEM includes societal influences such as political climate, societal norms and policies. Our participants repeatedly reported on the negative impact of disruption of education. Despite efforts to offer schooling to refugee children, accessibility depends more on the migration/asylum phase than on the child’s educational needs50 leaving many children without education. A child’s critical thinking, confidence and stability are hindered by this disruption, consequently affecting their well-being.51
Additionally, the perceived negative effects of militarisation reported previously52 were strongly supported in our study, yet its negative impact is rarely discussed in other research.53 Continuous blockades, interrogations and unwarranted raids of homes cause children to constantly feel in danger52 and prompt further disruptions (eg, disrupting education). Furthermore, societal violence can trigger community violence, affecting children’s health and diminishing trust in police and soldiers.
Concerns about immigration rejection and immigration policies were frequently mentioned. The former can cause children to feel rejected by society and live in constant fear and anxiety of another rejection or deportation.39 The latter increases the duration of uncertainty, insecurity and distress.14 54 55 Moreover, national policies and negotiations related to immigration are often discussed without considering their potential impact on refugee children. Policies such as the Dublin regulation56 and the European Union-Turkey deal,57 which aim to aid the humanitarian crisis, were described by some refugees in this study as forms of rejection as they sometimes led to transfers, detentions and travel restrictions.
Societal influences perceived as protective for refugee children include open borders, fast resolution of asylum applications and a safe and stable society including social security. Open borders enable safe passage without detention, while quick resolution of asylum applications reduces stress, facilitates resettlement and school enrolment, all beneficial for the child’s well-being.58 Additionally, social security enables refugee children to live with dignity as full, equal members of society,59 potentially contributing to their stability and sense of belonging.60
Strengths and limitations
This qualitative study explores refugee children’s experiences at all stages of migration in different socio-ecological contexts and uncovers experiences not described in previous ACE work. Employment of interpreters enabled access to refugees from various ethnic backgrounds, revealing salient themes across cultures. Qualitative methods including semi-structured interviews, audio recording, professional transcription, computer software to organise codes, duplicate coding and thematic extraction via team discussions aimed to ensure study rigour. Interviewing refugee children about their own experiences added their own perceptions and voices. Using both group and individual interviews, as done is this study, has the potential to increase knowledge of a phenomenon61: Group interviews offer opportunities to obtain a sense of the range of mutual views62 while individual interviews provide more in-depth information.63
Despite these strengths, a few limitations exist including restraints in generalisability as common in qualitative research. However, the distribution of participants’ origins approximates the distribution of nationalities of refugees in Germany; Arabic speaking refugees made up the highest percentage (36%) of asylum seekers in Germany19 as well as in our study. Furthermore, the necessary use of interpreters may have resulted in under-translated statements. The research team addressed this by employing bilingual interpreters with experience in interviewing refugees and coached them prior to the interviews regarding methods to avoid under-translation/rephrasing or self-interpretation. Absence of member checking might have also contributed to misinterpretation. However, recommendations exist to either avoid member checking or implement it with caution with marginalised or traumatised participants64 as re-engagement with the topic might cause re-traumatisation.65 Future research with refugees from other backgrounds or in different settings such as internally displaced people or refugees resettling in low-income countries may provide further insights and enhance generalisability.
Implications for future research and practice
Our data highlighted the need for parenting programmes in all refugee contexts to alleviate parental stress and encourage constructive parenting. Parenting programmes have previously shown successful outcomes in low-income and middle-income refugee settings, with a positive impact on child development.66 Our data further supports the approach of government assistance with housing, healthcare and minimum living expenses.59 Implementing such policies, along with cash-based interventions,67 in refugee-receiving countries could help improve refugee children’s livelihoods. Furthermore, due to lack of a better strategy, refugee camps have become permanent settlements,68 an experience frequently reported in this study by participants struggling with inadequate shelter. Modifying emergency responses into more durable long-term solutions by quickly relocating refugees to more private/suitable accommodation is considered a strategy adequate for protracted crises offering better educational and future opportunities.69 As participants and previous literature have described, children’s well-being is also greatly impacted by national and immigration policies, as they can lead to children being detained or hinder family reunification resulting in several health consequences.70 Policies need to be re-evaluated to guarantee the unalienable rights outlined by the Convention on the Rights of the Child (CRC) including keeping families together (Article 9), ensuring contact with parents across countries (Article 10) and averting child detention (Article 37).20
Conclusion
Refugee children clearly face multiple and ongoing challenges, yet numerous gaps in our understanding of the refugee child experience exist. Refugee children’s encounters differ greatly from the general or even immigrant populations. Given the continued growth in the refugee population and previous research highlighting an increased prevalence of mental and physical health disorders among children associated with ACEs, it is increasingly important to understand the adversities affecting the well-being of refugee children and experiences that may be protective. Identifying and analysing their needs through qualitative research can add valuable insights to build a groundwork for future research and interventions but also for policy development. This study adds new concepts to consider when examining ACEs in refugee children such as family dispersion, displacement, immigration and national policies. In addition, participants described constructive parenting, attaining basic human rights and having opportunities to build connections as potential protective experiences. Today, screening and measurement tools to identify individuals that could benefit the most from targeted interventions are missing.71 We anticipate that integration of insights from this study into our future work in the BRACE project will help fill this gap.
Data availability statement
Data are available upon reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by the Medical Ethics Committee of the Medical Faculty Mannheim, Heidelberg University (approval no 2018-610N-MA). Prior to their inclusion in the study, participants and children's legal guardians were required to provide written informed consent. Additionally, in cases involving minors, children were requested to provide their assent.
Acknowledgments
We gratefully thank all parents and children who shared their experiences with us, as well as the organisations for enabling access to the study population and the interpreters for their assistance in making this research possible. We also thank David Litaker, MD, PhD (Center for Preventive Medicine and Digital Health, Medical Faculty Mannheim, Heidelberg University) for his valuable recommendations throughout the writing process.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors JF, JL, MS and SA contributed substantially to the conception of the study; SA was responsible for data collection and analysis; MS and SA interpreted the data; SA drafted the work and MS, JF and JL revised it. SA is the author acting as guarantor. All authors approved the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Funding The Deutsche Forschungsgemeinschaft (DFG-GRK2350) supported this research. For the publication fee we acknowledge financial support by Deutsche Forschungsgemeinschaft within the funding programme „Open Access Publikationskosten“ as well as by Heidelberg University.This work is part of the first author's dissertation project.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.