Psychosocial and health impacts on refugees caused by living in overcrowded camps and by the Covid-19 pandemic: disease profiles and barriers in access to health care - a mixed method cross sectional convergent study in Moria refugee camp Lesbos, Gre

The aim of this research project is to assess psychosocial and health impacts on refugees caused by living in overcrowded camps and the Covid-19 pandemic and to explore and identify current physical and mental health problems and barriers to adequate healthcare for refugees in camp Moria (Lesbos). Since Moria is one of the largest and most overcrowded camps in Greece there is an urgent need to assess the current situation so as to tailor public health measures that meet local needs. In contrast to previous studies, which mainly investigated disease profiles from the healthcare provider view, we would like to examine different stakeholder`s viewpoints, particularly refugees themselves. We believe this approach enables us to receive comprehensive and diverse answers to our study objectives, that would otherwise remain hidden. Despite the general knowledge about the prevalence of communicable diseases in refugee camps, little is known about their origin (imported/transmitted within the camp) nor about the prevalence of Covid-19, especially in large, overcrowded camps. Furthermore, past research mainly focused on lack of medical staff or communication barriers in access to healthcare, but there is no information regarding which type of diagnostic tools and therapies are lacking in order to provide adequate healthcare services. Assessing all of this lacking information, is crucial for giving guidance to different stakeholders on implementing needed public health measures to prevent the spread of disease, protect the health of the community and improve patient outcomes. This in turn can also provide a relief for limited medical resources. Furthermore, the identification of stress and resilience factors of refugees can help to reduce stress during the stay in refugee camps and to strengthen their resilience and thus health. We hope that the findings of this research will not only benefit refugees staying at Moria, but might be transferred to other refugee camps worldwide, giving them guidance on the type of public health measures and research studies needed. This mixed method study consists of three phases with specific objectives in each phase. Phase 1:- To assess disease profiles of refugees: type and frequency of communicable and non-communicable diseases.- To identify barriers to medical care: communication, availability of medical staff & resources, frequencies in which available diagnostic and therapeutic options were sufficient or insufficient to diagnose or treat the patient. Identification of resources, diagnostic tools and medication, which are most urgently needed.Phase 2:- To examine, which laboratory tests are available at the hospital in Mytilene and which were frequently used to diagnose communicable diseases in 2020. To assess the frequency and results of testing for SARS-CoV-2 among refugees at the hospital in Mytilene since February 2020.Phase 3:- To examine the psychosocial impact of the Covid19 pandemic and of the stay in Moria camp. - To assess the perceived level of physical and mental health by the refugees during the stay in the camp in general and during the pandemic.- To assess symptoms of anxiety, depression and stress.- To identify current needs, stress factors and barriers in access to healthcare.- To identify factors affecting the development of psychological distress and resilience.- To identify most frequently used coping strategies.- To analyse associations between psychological coping methods, exposure to social media, physical and mental health background, demographic and psychological variable Outcomes.Methods:We plan to conduct a mixed methods cross sectional convergent study design, which will allow us to investigate upon the study objectives from different stakeholder`s viewpoints. Phase one will concentrate on the treating physicians viewpoint by examining medical consultations carried out by NGO`s during the medical field work in Moria camp. Phase two focuses on laboratory resources of the local, public hospital in Mytilene, which is run by the government and ministry of health. The third phase will provide insights into the perceptions of physical and mental well-being of refugees in Moria camp by conducting a survey among them. Phase 1: We will screen, during a period of three weeks, all medical consultations of the three different healthcare providers in Moria camp (one with mainly GP services of general and chronic diseases, one with children and mental health care services and one with emergency care services). Screening will take place one full week per health care provider and will be carried out by a physician, who attends and only documents the medical consultations and, after each consultation, assesses a short one minute questionnaire survey (open and closed questions) with the treating doctor about the working diagnosis of each case, diagnostic certainty and diagnostic and therapeutic resources. Phase 2: Screening of laboratory records of refugees for the execution and results of SARS-CoV-2 tests at the hospital in Mytilene between February and October 2020. Additionally we will conduct a short questionnaire survey with staff of the Mytilene hospital laboratory concerning the availability and frequency of the application of test methods to detect different communicable diseases in 2020. Phase 3: We will conduct a survey with refugees, who live in Moria. The Survey will be available in different languages and will be programmed on to tablets, which will be handed over to the participant to fill out the survey with assistance by trained study assistants. Participants will be recruited during the waiting time for medical consultations in case the patient does not have a very urgent problem and at central places in Moria camp (e.g. at central cloth washing stations). Furthermore, there will also be postings in the camp, on which a link to the survey can be seen in the respective language, so that refugees can fill out the questionnaire online independently. These methods are chosen in order to provide a sample of refugees from the camp, as representative as possible.Expected Outcomes:We expect to increase the knowledge about current disease profiles of refugees in Moria and about the prevalence of locally transmitted diseases, where we anticipate the prevalence of communicable diseases to be higher than shown in previous studies among different refugee populations, as Moria is an overcrowded camp and because of the worldwide Covid-19 pandemic. Furthermore, we expect to identify current barriers in access to adequate healthcare, where we anticipate the lack of personal, diagnostic and therapeutic resources be high. Thereby a regional action plan will be developed to address locally existing barriers and health problems. Additionally, we expect to receive an overview about the perceived level of physical and mental health by refugees and to identify stress factors and actual needs during the stay in the camp in general and during the pandemic. Furthermore we anticipate to identify regional mental health problems and high levels of psychological distress of refugees caused by living in an overcrowded camp or by the pandemic and to identify the underlying factors and most frequently used coping strategies. We will gain knowledge upon the actual psychosocial impact of the Covid19 pandemic and of the stay in a large, overcrowded camp and upon the underlying factors and associations. This enables us to create an action plan with priorities, which need to be addressed to improve the mental well-being and examples of projects/ public health measures to address these priorities.This research will provide, in the Greek context, evidence that will underpin better selection and development of adequate public health measures, leading ultimately to an improve in access to adequate health care services and a better prepared medical and public health workforce, thus improving refugee`s health status.