Association between distress and displacement settings: a cross-sectional survey among displaced Yazidis in northern Iraq

Worldwide, displaced populations are at a disproportionally high risk for trauma and mental illness such as post-traumatic stress disorder (PTSD), depression, and somatization before, during and after displacement [1‐6]. The built environment (i.e. man-made structures in which people live and work) plays an important role in displaced populations’ well-being [7‐12]. Research has identified camp conditions and post-displacement accommodations as important predictors of mental health [11, 13]. Exposure to violence and daily stressors, including those associated with the built environment and socioeconomic hardship, are associated with PTSD and poor mental health among these populations, suggesting that discontinuation of these stressors can be an important intervention to mitigate the consequences of trauma [4, 14, 15]. Separately, the relationship between cities, urban living and mental health has been well documented for the general population, but not for displaced populations [16‐18]. As displaced populations increasingly seek shelter in urban areas and the international community shifts away from establishing traditional camps for displaced populations, there is a need to better understand the implication of temporary settlement choices on mental health and explore how the built environment specifically can be conceptualized as an intervention to improve mental health and long-term outcomes [11].

The purpose of this study is to compare mental health outcomes and distress symptoms among internally displaced persons (IDPs) living in camps versus out of formal camp settlements in northern Iraq. Understanding and addressing mental health issues among this group is important; poor mental health can cause a myriad of downstream effects, including negatively impacting views on reconciliation and non-violence as a means to end conflict [19, 20].

This study focused specifically on Yazidis, an ethno-religious minority group from northwestern Iraq, which was victim to mass atrocities committed by the Islamic State (IS) [21]. On August 2014, IS attacked the city of Sinjar and its surrounding areas in Nineveh Governate where the Yazidi communities were primarily based. Although IS no longer occupies the Yazidi areas in the Nineveh Governorate (including Sinjar), about 230,000 Yazidis remain displaced in the Kurdistan region [22]. A study of Yazidi women and children, 16% of whom had survived enslavement, found that over 80% met clinical criteria for DSM-5 PTSD diagnosis [23].

At the time of this study, there were an estimated 1.6 million IDPs in Iraq, many of whom were targeted by ISIL in 2013 for their identity, including Sunni and Shi’a Muslims, Shabak, Turkmen, and Yazidis [24, 25]. More than two-thirds of displaced people in Iraq reside out of camps; the majority of IDPs residing out of camps live in rented accommodations, and a smaller percentage live with host families or in informal settlements (e.g. unoccupied buildings) [26‐28]. We hypothesized that while IDPs outside of formal camp settlements face several adverse factors [29], they also retain a higher level of control and quality of life, including social interactions, compared to camp-based IDPs, contributing to improved mental health.

Our study found a high prevalence of distress symptoms among Yazidi IDPs living in northern Iraq, with 69% of respondents meeting a distress symptom threshold that is highly predictive of PTSD. We also found that post-displacement settlement setting (in camp compared to out of camp) was significantly associated with higher distress symptom scores, with IDPs in camps predicted to have a 19% higher mean score compared to IDPs out of camps. Even though IDPs in camps had higher rates of exposure to violence, this difference in mean distress symptom scores remained significant even after controlling for exposure to violence, social cohesion, unemployment, and access to services.

Moreover, despite IDPs out of camps having a lower prevalence of distress symptoms, they reported worse access to many important services, including access to food, healthcare, and education. Our findings are consistent with a survey conducted in 2017 as part of the Mixed Migration Platform, which found that IDPs living in private accommodations had a more negative perception of access to services compared to their counterparts living in camps [29]. Difficulties in accessing basic services and a higher rate of respondents reporting being very dissatisfied with their housing reflect the challenges of the decentralized nature of safety net services for displaced persons in out of camp settings.

These findings raise several important questions. First, the association between lower distress scores and out of camp accommodation, even after controlling for exposure to violence, may suggest that post-displacement accommodation could be viewed as an intervention in itself to reduce the severity of post-trauma sequelae. While there is a growing body of research demonstrating the importance of the built environment and physical space in impacting well-being, this is still poorly studied among displaced populations [33, 34]. Our research lays the necessary foundation for investigating this question further. Second, we observed this association despite IDPs reporting poorer access to basic services and greater dissatisfaction with their housing in out of camp settings. This highlights the ongoing conflict between prioritizing access to basic services in a centralized setting such as a camp, while upholding the dignity, autonomy, resiliency, and privacy of displaced persons. It also may suggest the relative importance of factors related to self-efficacy, such as independence and dignity, on mental health and alleviating the sequelae of trauma. Finally, our findings highlight the challenge of reduced visibility for IDPs residing in non-camp settings and how it can impede their ability to receive assistance and services. In fact, the Internal Displacement Monitoring Centre (IDMC) reported that IDPs in gathered settings, such as camps, were twice as likely to receive assistance and protection from national authorities and humanitarian actors compared to those in dispersed settings [28, 35]. Exploring creative development solutions where support can be provided to IDPs who are not in formal camp settings without overburdening host communities will be a challenge, but could be effective in addressing any pre-existing structural issues faced by host communities. Such solutions could consequently facilitate and strengthen a greater link between humanitarian actors and vulnerable populations while also promoting development for the host communities.

Our findings also highlight an important issue within an ongoing discussion around collective trauma. Many have argued that traditional Western psychological models are inadequate in the international context, and instead argue for more trans-cultural and post-modern approaches to psychological care [36]. Western models have also been critiqued for their internalized problem discourse, putting the burden of trauma on the individual and absolving society from its collective responsibility. Such an internalized problem discourse fails to acknowledge the ways in which interventions aimed at improving the socioeconomic and living conditions may be a strategy for improving mental health. Our research provides an important groundwork for thinking about such strategies.

Our study has some limitations. First, while we did not find any demographic differences among Yazidi IDPs resettled in camps versus out of camps, we do not know whether the location of post-displacement resettlement is impacted by where they were resided within Nineveh governorate pre-displacement as we did not ascertain this information. In addition, we lacked information regarding the quality of housing, such as number of individuals sharing a unit and size of unit. Furthermore, though we had a holistic survey looking at exposure to violence, it is possible that we missed exposures or did not adequately assess severity of exposure, which could have differed by post-displacement accommodation. Furthermore, we did not have information regarding time from exposure to violence, which could have impacted distress scores and potentially differed between IDPs settled in camp versus out of camp.

Despite these limitations, our study lays important groundwork to begin investigating alternatives to camp-like settlements for displaced populations to improve their well-being and positive long-term outcomes. As the humanitarian community begins to shift towards new models of emergency and long-term housing, it will also be important to understand the potential and limitations of more decentralized models, and identify effective methods to maintain access to basic services while improving conditions for both displaced populations and host communities.