2.7.1 Mapping the empirical context: A systematic review of factors contributing to risk and protection of refugee children`s mental health
In order to be able to embed this study in the wider empirical context, a systematic review of the current evidence on socio-ecological factors contributing to the mental health of refugee children and adolescents was conducted. The most comprehensive systematic reviews to date focusing on refugee
children living in high-income countries (Fazel et al., 2012) and in low- and middle-income countries (Reed et al., 2012) only considered studies that had been published until July 2010. During the past decade, however, there has been a dramatic surge in the number of forcibly displaced people in the world and a myriad of studies on refugee children`s mental health has been conducted, pointing to the need for a timely and comprehensive systematic review of the evidence. Recent reviews on this topic did not comprehensively meet this need as they were focused on specific settings of resettlement, e.g.
only high-income countries (Marley & Mauki, 2018; Reavell & Fazil, 2017), particular subgroups of refugee youth, e.g. unaccompanied refugee minors (El Baba & Colucci, 2018; Mitra & Hodes, 2019) and Syrian children (Yaylaci, 2018), specific disorders, e.g. PTSD and depression (Reavell & Fazil, 2017; Tam et al., 2017) , or specific factors of influence, e.g. placement type (O’Higgins et al., 2018) and acculturative stress (d’Abreu et al., 2019). Reviews that adopted a broader focus (Eruyar, Huemer, et al., 2018; Hodes & Vostanis, 2019) did not apply rigorous methods including systematic study selection criteria and quality appraisals of included studies. This systematic review claimed to fill these gaps by using rigorous selection and quality criteria and by not posing a limit on certain factors, samples or outcomes. While this heterogeneity precluded the use of meta-analytic techniques, such a broad focus was deemed essential to reflect the diversity of refugee children`s lived experiences.
Besides mapping the empirical context for the current study with refugee families, the central goal of the synthesis of the current evidence was to enable empirically grounded conclusions on which risk and protective factors shape the mental health and well-being of refugee children and should therefore be targeted by prevention and intervention approaches. Moreover, it aimed to point out limitations of current studies and make concrete recommendations for further research efforts. Consistent with the overall socio-ecological framework of this study and previous reviews (Fazel et al., 2012; Lustig et al., 2004; Reed et al., 2012), the systematic review classified factors according to their socio-ecological context (individual, family, community, society/culture) and the temporal stage in the refugee journey (pre-, peri- and post-migration).
2.7.2 The Burundian refugee crisis and the Tanzanian camps
The study focused on refugee families from Burundi who were living in refugee camps in neighboring Tanzania. Burundi is a small, landlocked country in the Great Lakes region in Eastern Africa. It is one of the most densely populated countries in the world, with an estimated 435 inhabitants per km2 in 2015, and it also one of the poorest countries, ranking 184th out of 188 countries in the Human Development Index of the United Nations (World Bank, 2018). Following Burundi`s independence from the Belgian colonialists in 1962, deeply rooted ethnic tensions between the Hutu and Tutsi groups were misused to gain and secure political power and erupted in several waves of extreme violence, for example in 1972, 1988 and a long-lasting civil war from 1993 until 2005 (Irankunda et al., 2017; Uvin, 2009). Due to these returning crises in Burundi`s younger history, a large part of the countries` population has been forced to flee and seek refuge in a neighboring country, particularly
Tanzania, Rwanda and the Democratic Republic of Congo, at least once, with phases of displacement and repatriation often taking turns (Uvin, 2009). It can be assumed that these atrocious traumas in Burundi`s younger history left their marks on the mental health of its citizens, which is supported by studies showing high rates of distress in samples of displaced and non-displaced Burundians (de Jong et al., 2000; Familiar et al., 2016; Yeomans et al., 2008). It also suggests that Burundi is a case in point for the importance of an intergenerational perspective in order to understand how the effects of trauma are transmitted from one generation to another (Berckmoes et al., 2017; Song et al., 2014).
In April 2015, Burundi plunged into the latest crisis, when the president Pierre Nkurunziza announced to stay in power for an illegitimate third term. Violence and atrocities committed by members of the ruling party, particularly its youth wing Imbonerakure, towards perceived opponents, including abductions, extrajudicial killings and torture, caused more than 400 000 Burundians to flee to neighbouring countries, making Burundi the 10th largest source country for refugees worldwide at the end of 2017 (Human Rights Watch, 2017; UNHCR, 2018b). Tanzania hosted the largest number of Burundian refugees with over 250 000 people as of October 2017, 58% of whom were children
(UNHCR, 2018a). The refugees were resettled in three refugee camps, Nyarugusu, Nduta and
Mtendeli, in the Kigoma region in Western Tanzania close to the border to Burundi. Nyarugusu camp was opened in 1996 to provide refuge for people fleeing the war in DRC and hosted 69 065 Burundian and 80 080 Congolese refugees as of October 2017 (UNHCR, 2017a), making it the third largest refugee camp in the world (International Federation of Red Cross and Red Crescent Societies, 2019).
Nduta and Mtendeli camps were reopened in 2015 to relieve the capacities of Nyarugusu and to manage the ongoing influx of refugees, hosting 120 043 and 47 296 Burundian refugees respectively at the end of 2017 (UNHCR, 2017a).
To better understand the overall context and climate in which Burundian refugees lived in the host environment after the latest flight wave, it is important to understand how Tanzania`s attitudes towards hosting refugees have changed over time. After Tanzania had become independent in 1961, the country`s first president Julius Nyerere pursued a welcoming “open door policy” towards refugees from neighbouring countries that was based on the values of humanism and pan-africanism and emphasized finding permanent and sustainable solutions to refugee crises (Chaulia, 2003). In 1998, however, the Tanzanian government passed a new Refugee Act as a response to the refugee crisis shaking the Great Lakes region in the 1990`s, now focusing on providing short-term relief for refugees in camps and restricting their rights to live, work and move outside the camps (Chaulia, 2003). This restrictive camp-oriented policy has been Tanzania`s status-quo ever since, even though in 2008, Tanzanian citizenship was offered to 200 000 Burundian refugees who had been living in Tanzania since 1972 (Kuch, 2017). The current government under president John Magufuli has taken a tough stance toward the Burundian refugees, urging them to return home to Burundi in July 2017 (The New Humanitarian, 2018). Early 2018, when this study was conducted, a constant fear among the refugees that the camps would be closed and that they would be forcefully repatriated to Burundi, where
violence and human rights violations were ongoing, was palpable. Apart from the political perspective, narratives of members of the host communities around Mtendeli and Nduta revealed that the locals have many concerns about the Burundian refugees, for example related to increased insecurity in the region, the loss of farmland to the camp areas and an increased risk of diseases (Felix Da Costa, 2018).
Burundians living in Nyarugusu, Nduta and Mtendeli have been facing extremely harsh living conditions. As of 2018, the Burundian refugee situation was the one which received least funding by international donors worldwide (Reliefweb, 2018), which affected all areas of life. For example, throughout 2017 the World Food Programme had to reduce monthly food rations given out to the refugees due to lack of funding up to only 62% of the required minimum intake (Felix Da Costa, 2018). As there are no alternative sources of cooking fuel, women and girls have to travel up to 15 kilometres per day outside of the camp to collect firewood, which additionally increases their already high risk of facing sexual gender-based violence (Al Jazeera, 2016). The lack of available resources is also keenly felt in inadequate shelters, overcrowded health centres and classrooms as well as reduced capacity to provide services to vulnerable groups such as unaccompanied children and victims of sexual violence (Reliefweb, 2018). The legal confinement to the camps including the prohibition to move and work outside the camps has been described as a “prisonlike” by their inhabitants (Deutsche Welle, 2018; Felix Da Costa, 2018). Although it is illegal for the refugees to leave the camps, they often do so due to the scarcity of food and lack of livelihoods inside the camps. This, however,
increases the risk of conflicts with host communities and exposes them to abuse and violence by police and locals (Felix Da Costa, 2018). Personal accounts of Burundians who left the Tanzanian camps to go to Uganda highlight the ongoing fear of insecurity also inside the refugee camps, indicating that due to the closeness to the Burundian border members of the Imbonerakure were able to enter the camps and continue to harass and attack people (Human Rights Watch, 2019).