Health Status and Quality of Health Care Services of Congolese Refugees in Nakivale, Uganda

Physical and emotional wellness, as well as access to healthcare, are foundations for successful resettlement. Without feeling healthy, it is difficult to work, to go school, or take care of a family. Many factors can affect refugee health, including geographic origin and refugee camp conditions. Refugees may face a wide variety of acute or chronic health issues (Office of Refugee Resettlement, ORR Annual Report to Congress 2014; http://www.acf.hhs.gov). Resettlement of refugees in Uganda is usually supported by concerted efforts of UNHCR, Governments through the Office of the Prime Minister, OPM with support from host communities, local and international Non-Governmental Organizations. Due to resource constraints and local factors, immigrants are often subjected to poor living conditions which coupled with inadequacy inessential medical supplies might significantly affects quality of care and health service delivery and hence, rendering refugees to poor health status. This study was conducted from 2013-2014 to assess the determinants of health status of Congolese refugees living in Nakivale refugee settlement, in Isingiro districtSouth Western Uganda. A cross-sectional study design was used involving mixed techniques of both qualitative and quantitative KAP survey. The study focussed on Congolese refugee population in Nakivale Refugee settlement. 2401 key informants’ interviews and 8 focus group discussions respectively were conducted targeting service providers and beneficiaries/Congolese refugees in this case. The data was analysed using SPSS ver.20, 2011. Although majority (97%) of respondents sought medical services from established health facilities, findings confirm a high level of ill health prevalence among Congolese refugees in Nakivale camp, however, the difference in health services and perceived health status in camp versus the one in DRcongo is insignificant ( p=0.000) with respondents perceiving their health status as worse than when they were their own Country before the resettlement. Identified key challenges affecting access & uptake of available health services includes: language barrier; inadequate drugs; and the long distances to access health facilities. The health status of refugees could be improved by addressing the challenges related to language, drug supplies in addition to humanising conditions of shelter, providing appropriate waste disposal facilities while proving adequate food rations and clean & safe drinking water.


Introduction
Physical and emotional wellness, as well as access to healthcare, are foundations for successful resettlement.Without feeling healthy, it is difficult to work, to go school, or take care of a family.Many factors can affect refugee health, including geographic origin and refugee camp conditions.Refugees may face a wide variety of

Problem Statement
Nakivale refugees' settlement was formed in 1960 to host refugees who fled the Rwandan genocide of 1959.Today, the settlement hosts over 100,000 refugees and asylum seekers from Rwanda, Somalia, Burundi, DRC, Ethiopia, Eritrea, Kenyan and South Sudan (UNHCR, 2014).With such big numbers, like elsewhere in the world, challenges of resettlement become eminent.Some of the problems faced by refugees in Nakivale have been demonstrated by studies carried out by GTZ among the older Somali refugees, which found out that that traumatic experiences of refugees canlead to excessive consumption of alcohol, abuse of use drugs and substance aggravating incidences of violence such as rape, defilement of girls and exacerbate infections like STDs including HIV/AIDS (GTZ, 2005).In addition to violence, a large part of this settlement is located in a dry corridor where rains are below average, water supplies are inadequate and most refugees walk an average of 7km to access safe water or fetch water from Lake Nakivale.Lack of safe water and use of alternative unsafe water sources has led to the high prevalence of water borne diseases (UNHCR, 1994).There are only two health centres, Nakivale health centre III and Rubondo health centre II which serve a population of over 40,000 refugees and over 12,000 locals (UNCHR, 2009).This population is too high for the two facilities.It is likely that some refugees may have limited access to health services.
A short study conducted by GTZ on refugee health in Uganda based on health centre records with limited consultation with the service providers-the health workers and-the primary users, the refugees themselves.This approach indeed gives an indication of health problems the refugee experience but not the prevalence of diseases and the perceived health conditions or status of the refugees.Documented evidence on refugees' self-assessed health problems therefore remains scarce.This study investigated the self-perceived health status and utilization of health care service among the Congolese refugees in Nakivale in comparison with self-perceived health status in Congo.This approach is supported by the studies conducted by LaRue et al. (1979) which showed that self-perceived health status is an objective measure of health and predicts morbidity better than either medical records or physician generated data.Perceived health evaluation is also a significant predictor of morbidity even when physical health is controlled via the research design (Idler et al., 1995).

Study Objective(s)
The main objective was to determine the health status of Congolese refugees living in Nakivale Refugee camp with specific focus on perceived health status and the level of utilization of health care services compared with that in DRC.

Research Question
This study examined what common illnesses affecting Congolese refugees in Nakivale Camp?How does the self-perceived health status of respondents in the resettlement camp compare with their health status while in Congo?What type of health services are utilised by Congolese refugees in Nakivale camp and DRC?

Study Population
The target population comprised of Congolese refugees who arrived at the settlement camp between November 2008 and2013.All male and female refugee adults of 18 years and above were eligible for the study.

Study Design
The study employed a cross-sectional survey.Information on health status and health service utilization was gathered from systematically selected individuals of 18 years and above using the available UNHCR registration list for the Congolese refugees in Nakivale.A comparative study on illness and health service utilization amongst the refugees for two time frames, one before being a refugee and the other after acquiring refugee status was used.
The sample size, n was calculated using: Where, n = estimate of the sample size t = confidence interval (used 1.96 for 95%C.I) d = precision (0.02 was used) P = proportion of the target population with characteristics being measured (since prevalence was not known, 0.5 was used) and therefore Q is 1-P.
Selection criteria: Only individuals who were 18 years or above were eligible for the study.Using the official UNHCR registration for refugees in Nakivale camp, a systematic sampling technique was employed to select eligible respondents.

Data Collection
Data for the study was collected in June 2014.The translated study tools (i.e.questionnaires into local languages (Swahili, Lingala and French) were systematically administered to eligible and selected adults.Quantitative data was collected using structured questionnaires including perceived illnesses data collection form; health care service utilization questionnaire form; household health information access to health; and access to safe water form.Qualitative data was collected using Focus Group Discussions (FGD's).Members of focus groups were selected by the village leaders and they included camp leaders, village health teams (VHTs) and those providing health care services in Nakivale camp.
Upon consent, respondents were personally interviewed by trained enumerators.To optimize rapport, interviewers were matched to all respondents based on gender.The interviewers conducted the interview using a general standardized open-ended approaches.The initial domains in the tools included perceived health conditions of the refugee, health care access, health promotion, and the presence/absence of water sources for drinking respectively.

Data Analysis
The data analysed using Statistical Package for the Social Scientists SPSS Ver.2011.The results were summarized by running the analysis for the descriptive and Analytical statistics such as frequency, mean, standard deviation, standard error and the level of significance (p-value) ascertain used for interpretation and inference for the study.

Ethical Consideration
Permission to conduct the study was obtained from the Office of the Prime Minister (OPM) and the United Nation High Commission for Refugees (UNHCR).There was an informed consent obtained from respondents and confidentiality of the health information was guaranteed to be observed.In addition consent of those whose photographs appeared were sought.

Study Limitations
The major limitation to the data quality was social discomfort regarding disclosure of health conditions.Other www.ccsen minor lim simplistic

Inadequate food intake
Most of the respondent inadequate intake of food which often leads to body weakness and loss of weight as being one of the major health problems faced by the new Congolese refugees population in Nakivale settlement.

Mental health disorder (depression, nightmares, anxiety and suicidal tendencies)
The following health conditions, depression, night mare, anxiety and suicidal tendencies which can be characterized as mental health disorders are commonly perceived health problems by the majority of the refugees interviewed.These conditions can be expected given the hardship, violence and stress experienced by the refugees in the past and resulting from displacement from their home country.

Eye problems
Figure 2 shows a Congolese refugee girl with red eye infection.This could be attributed to the unhygienic conditions under these refugees live mostly arising from inadequate water for bathing and limited access to disinfectants fore washing hands and body.All these might have a drastic health effects on the refugees visual and skin health www.ccsen

Hearing p
The perce mentioned practices a into ear pa

Skin rash
Those inte Congolese cause irrita

Sexually tr
Generally, assessmen by the par believed to preventive

Stomach p
Stomach a diarrhoea,

Cough
Respirator given the cooking an under trees

Trauma af
Rape case one of the jobless life

Health Status by Gender
Table 4 shows the most common health complains of refugees by gender.Accordingly, findings indicate women had more health problems than men.The only health condition which affected men more were vision problems, scabies and ulcers.Upon categorization (Table 4), women dominated the most prevalent poor health conditions with 56.46% on average compared to the male.Considering this (Table 5).Further shows that there was a significant difference based on ones gander to have a health problem (p=0.00).

Health Status by Location
Table 6 shows perceived ailments as reported by respondents and their frequency by location whereas Table 7 shows categorized health conditions by location.Refugees perceived their health status to have been better while at home than in the camp.The perceived health condition by location is significant (p<0.05).There is week positive correlation between diseases and the camp (0.053).The results show that there is statistically significant relationship (p=0.000).Results indicate that on average more than 80% of perceived ill health occurred upon migration.

Health Care Service Utilization
Respondents sought healthcare from several alternatives ranging including designated health facilities, traditional healers, prayer groups and others, with the first option being by far the most common (Table 8).A similar pattern of health service seeking behaviour was practiced in the settlement and in Congo.The difference in the health seeking behaviour in the settlement and the one in Congo in terms of frequency distribution was at significant ( p=0.03; p <0.05).Most of the people interviewed had access to health facilities.A high (97%) proportion of households obtain health services from government and NGO health centres.Traditional healers were also found to provide a contribution (2.1%) to health services among the refugees.Notably, very few individuals reported seeking health services from prayer groups and others.Despite the high percentage of access to health services from formal health facilities, the results also showed that most centres have inadequate drugs and very few trained personnel.
Comparative analysis showed slightly higher (98%) of the respondents obtained health care service from designated health facilities in Congo compared to 97% in Nakivale, however in general, the pattern of utilization of health care services did not show significant differences.

Comparison of Health and Health Service Delivery
Table 9 compared respondents' satisfaction with health service delivery in Congo and Uganda.According to the Congolese interviewed, health care in Congo was by far better than the one received in Camp.However, the difference in service delivery is very weak and insignificant association (p=0.000).
www.ccsen  or were held captive in Congo.All respondents had some of sort of multiple self-perceived ailments.The most commonly mentioned complaints being general body pain (20.7%), nutrition disorders (19.4), psychological torture (18.6), poor skin conditions (10.9) and reproductive health related concerns (7.05%).The general body pain experienced by refugees could be attributed due to fatigue from the long distances travelled between their displacement sites and Nakivale refugee settlements.Moreover, these long journeys are made while carrying huge baggage and some basic necessities.
Self-perceived undernourishment and related disorders were also highly recorded.This could have arisen from change in food habits following forced migration.Although Doocy et al. (2011) commended feeding programs for reduction in the incidence and prevalence of malnutrition, the diets provided in such programs may not suit the original taste and food preferences of the refugees.Also whether the food rations provide by humanitarian agencies during resettlements meets the nutritional requirements of migrant remains to be investigated.
Psychological problems characterized by nightmares, anxiety, depression, aggression or suicidal tendencies among others could have arisen from traumatic experiences like loss of dear ones and witness of violence.According to Onyut et al. (2009) and Kolassa et al. (2010), mental health consequences remain long after conflict and worsen with additional exposure.
Reproductive health are big concerns and greatly contribute to perceived ill health.Such concerns included bleeding, UTIs, STIs and incidences of rape.At individual level, rape occurred more in DRC than in the Nakivale camp, this is could be attributed to high incidences of lawlessness in conflict areas.Smith-Khan et al. (2015) confirmed a high incidence of sexual violence despite formal obligations to uphold rights of refugees and propose conceptualization of justice for disadvantaged groups through the lens of international law.Women continue to remain a more vulnerable group given the cultural context in most developing countries.According to a study by Peterman et al. (2011) approximately 1.69 to 1.80 million women had been raped in their lifetime and 3.07 to 3.37 million women had experienced sexual partner violence in Kinshasa.Culture and protracted political unrest could further expose particularly women to incidences of sexual and domestic violence.
More than 90% of all nutrition and sanitary related health concerns arose from the camps, possibly due to food shortages and difficulty in accessing clean and safe water supplies.This is congruent with studies of Anderson (1999) according to whom long term displacement raises new health needs.However, individual responses in this study found a higher prevalence of sexual violence and rape in DR Congo compared to Nakivale.Frequent incidences of rape and sexual violence in DR Congo have previously been reported by Wakabi (2008) and Johnson et al. (2010) Respondents who sought health care services from several alternatives ranging including designated health facilities, traditional healers, prayer groups and others with no marked differences before and after migration.Majority of Congolese refugees interviewed had access to a health facility.This is could be attributed to the continuous health promotion activities by health partners including the UN agencies, national and International NGOs, government on the importance of timely health seeking for skilled care from trained health workers.Although majority obtained services from a designate health facility, health services in DR Congo was consistently ranked better in Nakivale, with very weak significance level ( p=0.000).
Health care service access constrained by language barrier, poor infrastructure and inadequate drugs at designated health centres.Similar studies which highlighted language barrier as an impediment for access to health services were carried out in the west Nile region of Uganda.Findings indicated that Sudanese refugees did not seek health services from proper health centres where most of the health workers did not speak Sudanese native languages.It was also revealed that provision of translators at health service points did not improve access to health care due to potential loss of confidentiality.In cases where patients had to communicate through translators, they either concealed their actual sickness or sought health services from traditional healers (Makerere Health Dept., 2007).It is likely that patients who are confronted with language barrier might seek health services from alternative, in this case traditional healers, house of prayers or witch doctors.In similar studies (Mudzingwa, 2011) found that the diverse inhabitants of Nakivale lacked of a common language which could create mistrust, tension, animosity and proposed that Swahili be promoted a common language.
In similar studies by Whelan and Blogg (2007) which investigated views of refugees on reproductive health services, poor perceived health of refugees was attributed to ill equipped health care units characterized by inadequate drugs (antibiotics), low staff numbers and high staff turnover.Poor infrastructure also mentioned in this study continues to remain a major service delivery impediment in most developing countries

Recommendations
This investigation confirms high prevalence of ill health among Congolese refugees in Nakivale.The most predominant complaints included general body pain (20.7%), nutrition disorders (19.4), psychological torture (18.6), poor skin conditions (10.9) and reproductive health related concerns (7.05%).Based on these findings, the study recommended integrated community based health delivery & system strengthening activities to increase access of preventive medicine to the refugee population; training and employing ethnic community members in health promotion and health service delivery as well as creating platforms to learn the most commonly spoken language for community harmony; there is need to identify and design mechanisms in which key hindrances to health seeking behaviour are addressed; there is need to create new services such as mobile clinics to address the health needs of the refugees population; and finally clean and adequate water provision should be priority of those in charge of the refugee's welfare.

Conclusions
Post conflict refugee populations relocated to another third world country have a higher prevalence of diseases than when there were in their own country but the level of significance in difference in quality of perceived health care on health status in camp compared with while in their home of origin is very weak or actually insignificant ( p=0.000).To manage this level of self-perceived ailments, common health access barriers like language, drug inadequacies and long distances traversed to the health care facilities which often had a negative effect on the utilization of health care services should be addressed.The health of Congolese refugees could further be improved by humanising conditions of shelter, providing adequate toilet facilities, clean water, and adequate nutritious food.Immediate and urgent establishment of psychosocial support services will also go a long way in reducing post-traumatic stress and disintegrating violence patterns.

Figure
Figure 2. R Figure

Table 3 .
Grouped Summary of self-perceived ailments net.org/jfrRed eye infecti problems eived preferenc d.Some of th and lack of ade ain was also co

Table 4 .
Categorized health complains of refugees by gender

Table 6 .
Health status comparison by location

Table 8 .
Health care facilities utilised in Congo and Nakivale