Pregnant women’s concern toward COVID-19 in Iraqi camps: differences between IDPs and refugees. A cross-sectional study

Abstract

Purpose

During the COVID-19 pandemic, there was growing concern about the health status of vulnerable groups living in camps. This study aims to investigate differences in the perception and concerns of pregnant women about the pandemic between two populations, i.e. internally displaced people (IDPs) and refugees. In fact, although the two categories are often conflated, the analysis of their respective profiles requires more careful attention. Particularly in Iraqi Kurdistan, these groups of migrants have specific characteristics that this study aims to highlight.

Design/methodology/approach

A cross-sectional study was conducted on a sample of 4,736 pregnant women living in camps in Iraqi Kurdistan. Participants were asked questions about the pandemic and self-perceived disadvantages of COVID-19.

Findings

IDP women were more concerned about COVID-19 infection [odds ratio (OR) = 2.59; CI: 2.29–2.92] and more afraid to visit health centers (OR = 3.79; CI: 3.36–4.28), with a reduction of health visits (OR = 0.76; CI: 0.68–0.86). The main self-perceived disadvantages were psychological pressure and concerns about changes in the services available in the camps. On the contrary, refugee women reported the lockdown as one of the most negative effects, together with their economic situation and unemployment.

Originality/value

Studies investigating the health status of vulnerable groups living in camps are generally underrepresented in global research. This study shows that the needs of IDPs and refugees are different, specific and contextual, even when the two groups appear to have similar backgrounds. Tailored interventions, according to the type of migrants hosted in camps, are needed, especially during a pandemic. Community volunteers can play a paramount role in supporting the continuity of health care for these vulnerable populations.

Citation

Alhanabadi, L.H.H., Moramarco, S., Basa, F.B., Pacchiarotti, L. and Emberti Gialloreti, L. (2025), "Pregnant women’s concern toward COVID-19 in Iraqi camps: differences between IDPs and refugees. A cross-sectional study", International Journal of Migration, Health and Social Care, Vol. 21 No. 1, pp. 161-175. https://doi.org/10.1108/IJMHSC-02-2024-0023

Introduction

In March 2020, the World Health Organization (WHO) declared the outbreak of the novel coronavirus SARS-CoV-2, the causative agent of COVID-19, a global pandemic. The consequences of the COVID-19 pandemic escalated due to several exacerbating factors, such as loneliness, insecurity, unemployment and lack of access to health services, with consequent psychological effects, especially when social determinants of health (e.g., poverty, inequality, stigma, the environment in which people live) coexist (Yadav et al., 2020). Therefore, concerns about the health status of vulnerable groups living in camps, such as refugees and internally displaced people (IDPs), grew exponentially due to the lack of adequate preparedness plans (Nott, 2020) and/or the failure to include these people in pandemic response plans (Saifee et al., 2021), especially in low- and middle-income settings. In particular, some of the WHO’s COVID-19 safety recommendations, such as confinement and social isolation, may have been difficult to implement or enforce in camps (Pati et al., 2021). On the contrary, their access to health services may have been limited, which could have excluded them not only from clinical management in the event of an outbreak but also from disruption of routine health services during an emergency. Specifically, in fragile and conflict-affected settings, the impact of the COVID-19 pandemic was compounded by multidimensional and overlapping challenges that further contributed to the vulnerability of these populations (Moya et al., 2021).

Despite this potentially devasting impact in camps, minimal attention has been paid to these settings globally (Raju and Ayeb-Karlsson, 2020). A previous study showed that people in camps are at increased risk of COVID-19, especially when high population density (40,000 people per square kilometer) and poor sanitation coexist (Kamal et al., 2020). In addition, widespread misinformation, disinformation and misconceptions may have exacerbated the spread and management of COVID-19 in camps due to low health literacy and adverse situations such as limited access to reliable sources of information (i.e. health services or health professionals) (Mistry et al., 2021).

Within such vulnerable groups, pregnant women may have been disproportionally at risk of facing barriers to accessing health services due to their need for routine health checkups. In addition, the psychosocial impact of the pandemic may have been exacerbated by preexisting vulnerabilities, with profound consequences for well-being beyond the pandemic, such as the negative effects on maternal mental health (Moya et al., 2021). To date, studies investigating this context are generally underrepresented in global research, so little is known about this issue, particularly in low- and middle-income settings (Lusambili et al., 2020).

An additional consideration must be made when considering different populations living in camps, whether they are IDPs or refugees. The international classification defines IDPs as those who remain within their national border, whereas refugees are those who cross an internationally recognized national border. Although the two categories are often lumped together due to their similarities and the fact that their protection is driven by similar root causes, the analysis of their respective profiles requires more careful attention, due to their distinct patterns and different needs (Ní Ghráinne, 2022). As previously explored, experiences of displacement and subsequent health needs are heterogeneous and multidimensional. The relationship between forced migrations and health is complex and can vary widely between countries of origin and host countries. IDPs are often considered more vulnerable than refugees; it has been shown that refugees, who are protected by international agencies, generally benefit from better access to food, shelter and health services than IDPs, who are sometimes more difficult to identify and reach, especially if they do not live in camps (Heudtlass et al., 2016).

Academic research on the two separate groups is scarce (Cantor et al., 2021). This reflects a paucity of health data and a wider gap in research on displaced persons in low- and middle-income countries compared to those in high-income countries (Morina et al., 2018).

In particular, to the best of our knowledge, the similarities and differences of these vulnerable and conflict-affected populations living in Iraqi camps have been largely unexplored, also due to the lack of systematic epidemiological statistical studies and the absence of demographic and health surveys used for public health planning in a country largely affected by complex and protracted humanitarian emergencies (Emberti Gialloreti et al., 2020). In addition, when talking about Iraqi Kurdistan, some differences could be drawn from the standard definitions and should therefore be taken into account: refugees are mainly Syrians with a Kurdish background; IDPs can have different life and social experiences with different sociopolitical histories. They may be either Yazidi minority or Arabic speakers with a different background from the host population. Therefore, it is necessary to properly consider and understand the local dynamics to draw the roadmap for providing health care to these specific displaced groups.

Aim of the research

After providing updated information on camps in the Kurdistan Region of Iraq (KRI) at the time of COVID-19, this study aimed to understand migrant pregnant women’s perception and concerns toward the pandemic and their impact on living conditions and access to services. Second, the present study attempts to draw different profiles for IDP and refugee women living in KRI camps, tracking the specific needs of two already fragile populations exposed to further health threats.

Materials and methods

Population

Iraq is a middle-income country that has endured several conflicts and sociopolitical tensions throughout decades, which have deeply impacted its asset. The KRI, in the north of the country, is an autonomous region within Iraq. Particularly, during the time in which the so-called Islamic State occupied several areas of the country, KRI enjoyed a better security environment. Therefore, thousands of people sought refuge there, even from neighboring countries. By the end of 2019, the UNHCR identified a total of 6,345,546 people of concern in the country, respectively, 1,414,632 IDPs since 2014 – in accordance with the International Organization of Migration (IOM) Displacement Tracking Matrix (DTM) (IOM, 2019) – and 4,596,450 returnees. In addition, Iraq hosted over 300,000 refugees and asylum seekers, mostly Syrians (over 245,000). The majority of IDPs and refugees were located in the KRI, where according to the UN Refugee Agency, UNHCR, 25% of the population was displaced (1.5 million people) (UNHCR, 2019). Out of the 26 formal camps in Iraq hosting 180,000 IDPs, 25 were in the KRI, where also the 99% of Syrian refugees resided (UNHCR, 2019). Therefore, the potential consequences of the COVID-19 pandemic for refugees and IDP populations in this area could have been clearly announced because the health-care system of the country was not adequate or prepared to contain the pandemic (Moramarco et al., 2020).

Setting

Just after the Ninewa province (54%), the highest proportion of the overall population of IDP households was found in Dohuk Province (29%) (OCHA, 2019). At the time of the study, there were 20 camps in the Dohuk governorate, 5 for refugees and 15 for IDPs. According to statistics from the Directorate of Migration and Crisis Response (DMCR) – a governmental office within the Ministry of Interior of KRI – in November 2021 the number of refugees living inside camps was still 52,164 (10,876 families), whereas the number of IDPs living in camps was 134,267 (26,433 families) [Directorate of Migration and Crisis Response (DMCR), 2021]. At the time of the data collection, the IDP camps mainly housed Yazidis, as most of the displaced people with an Arabic background had returned.

Table 1 shows the characteristics of the camps in the Dohuk Governorate. The supplementary table reports specific information in terms of people hosted during the years of the pandemic and the presence of antenatal care services (ACS).

Study design

A cross-sectional study was carried out during the COVID-19 pandemic from June 2020 to March 2021, soon after the first case of COVID-19 was diagnosed in Iraq, i.e. March 2020. The study was conducted on the entire population of pregnant women living in camps where antenatal care services were provided (in Dohuk province).

During the pandemic, maternal and child health-care services (daily consultation and treatment) were available in all the Dohuk province’s camps, with three main services: antenatal/postnatal services, routine immunization and growth monitoring services for under-five children. Even during the lockdown, the primary health-care centers continued to provide all the main services despite facing more than usual logistics challenges due to a lack of required personal protective equipment (PPE), transportation of medical staff, medication allocations, unavailability of medications or laboratory tests, supplies in vaccines. Therefore, all pregnant women were reached by interviewers during visits to health centers, routine antenatal care services and/or family planning consultations.

Instruments

The investigation was made through an ad hoc questionnaire because no specific references were found at the time of the investigation. Therefore, questions were selected based on the field experience of the researchers in camps during the lockdown (since March 2020), with the mandate from the Directorate of Health of Dohuk as members of the Emergency Response to COVID-19 Outbreak committee, working specifically on health staff COVID-19 protection, preventive measures for the public, health staff education and cases notification, COVID-19 maternal infection, morbidity and mortality surveillance of suspected and confirmed COVID-19 pregnant cases.

The questionnaire was pilot-tested over the phone on ten pregnant women for finalizing it for readability and clarity and translated into Arabic and Kurdish.

Participants were interviewed by volunteers selected from the host population (28 in total, 2 from each camp, all females). First, volunteers were instructed in data collection tools and techniques through a full-day field training conducted by a PhD researcher, who visited each camp and accompanied the volunteers on the first day of the interview. In addition to specific explanations of the questionnaire, the training included tips on how to engage eligible participants, how to welcome them, how to maintain confidentiality and impartiality, how to obtain informed consent and how to ensure good communication skills and confidentiality. In the case of illiteracy or language barriers, volunteers were instructed to complete the questionnaire forms on behalf of the participants.

During data collection, COVID-19 safety precautions measures (i.e. use of face masks, social distancing and interviews conducted in open spaces or large rooms) were ensured.

Procedures

After an initial section covering sociodemographic information, the study’s outcome variables focused on concerns about COVID-19 and difficulties participants faced in accessing camp services during the pandemic, with a special focus on antenatal care. Specific topics included fear of infection, compliance with safety measures, access to services, changes in camp services, feelings and concerns about the pandemic. If participants reported fear of visiting the health center, they were asked to identify the main reason.

To measure the self-perceived main disadvantage of the pandemic, the general question “What was the worst thing that happened to you due to COVID-19?” was asked.

Ethical consideration

The ethical approval was obtained in June 2020 from the Ethics Committee of the General Directorate of Health of Dohuk – Iraq; Planning Directorate – Scientific Research Division (reference number 22062020-2). Written informed consent was signed by all the participants. At the time of data analysis, all the transcripts in the database were anonymized by deleting references to names and adding an ID number.

Statistical analysis

Information collected in questionnaires was at first input in an MS Excel sheet and then cleaned using the Statistical Package for Social Sciences (SPSS) version 26. The distribution of the variables was assessed through descriptive analysis performed using frequencies and percentages, means and standard deviations (SD). Data are reported as for total, then split by subgroups: IDPs and refugees. Comparisons between groups were examined by means of Pearson’s Chi-squared test. Effect size was determined by odd ratios (CI 95%). An alpha level of 0.05 was used for all statistical analyses.

Results

Out of all camps of Dohuk governorate, three (two for IDPs – Kabarto1, Mamilian – and one for refugee – Akre castle) were excluded from the survey because they did not provide ACS. Bersivi 1 (IDP camp) was not included in the survey because the health services were closed in 2020 due to COVID-19 pandemic. Due to the same reason, in Darkar camp (IDP camp) the health staff was not working when the current study was designed, but they resumed the work at the end of 2020. Essian camp (for IDPs) was excluded from the study because no volunteers to conduct the interview could be identified.

The total sample included pregnant women hosted in four refugees and ten IDP camps within the Dohuk province, all providing antenatal care services, even during the lockdown when the services were ongoing inside the camps, without exceptions.

Figure 1 is showing the camps location, whereas Figure 2 is showing the study population flowchart.

The total population of pregnant women living in camps was reached. Only 53 women (1.1%) did not complete the interview for medical reasons (e.g. feeling weak or ill), with no differences between camps (range between 0.8% and 1.4%). No refusals were reported. Data from a total of 4,736 respondents were analyzed. Overall, 47.1% (n = 2,229) were living in refugee camps, and 52.9% (n = 2,507) in IDP camps. The two categories were homogenous in terms of sociodemographic characteristics.

As summarized in Table 2, the majority of the women were in their 20s (46.3%; 45.0% for refugees and 47.5% for IDPs, respectively) and their 30s (38.2%; 39.0% for refugees and 37.5% for IDPs, respectively). Nearly the total of the sample was married (99.9%) with a mean number of 2.3 children in both groups. No data on educational level were provided while all of them were housewives.

As shown in Table 3, more than half of the overall sample reported being concerned (63.9%) about COVID-19 infection, with more than 80% of the responders accepting to about the main reason behind it, the main reported reason was fear of getting infected (40.9%).

Women perceived even a change in the health service during the pandemic (40.2%), coupled with perceived changes in other services (37.7%).

In addition, Table 3 compares answers about concerns related to COVID-19 of the two groups, i.e. IDPs vs refugees. Pregnant IDP women showed to be more concerned about COVID-19 infection than refugee women (74.2% vs 52.5%), despite reporting lower compliance to preventive measures (74.9% vs 87.8%). In addition, IDPs declared to be more afraid of visiting health centers (65.9% vs 34.0%), therefore, having reduced health visits more the refugees (63.4% vs 57.3%). They also perceived more a change in health services (45.0% vs 34.8%).

Contrariwise, refugees showed less concern for their health and their families’ safety (42.0% vs 49.9%) and also they perceived less changes in other services either than health services (35.4% vs 39.8%). All these differences were statistically significant (Table 3).

In terms of effect size, the largest differences between the two subgroups (IDPs vs refugees) were fear of visiting health centers [odds ratio (OR) = 3.79; CI: 3.36–4.28] and fear of COVID-19 infection (OR = 2.59; CI: 2.29–2.92), with a reduction in health visits (OR = 0.76; C I:0.68–0.86).

Pregnant women were also asked to indicate the worst self-perceived negative effect of the COVID-19 pandemic. As shown in Table 4, lockdown (including restrictions in traveling and movement, as well as school closures) was indicated as the main downside by the total sample (39.4%), with refugees reporting to be more affected (46.9% vs 32.7%). The second main concern was the psychological pressure, perceived by 15.8% of the overall sample, with IDPs feeling more constrained (18.7% vs 12.5%). When deeply investigating the reasons behind these conditions, isolation from family and friends, social distancing, stress and fear were the main factors identified. In addition, overall 10.9% of respondents expressed concerns surrounding the economic situation and unemployment (8.6%), with more concerns expressed by refugees (13.7% vs 8.4% and 10.3% vs.7.2%, respectively). Fear of COVID-19 infection itself was declared by 8.6% of women, mainly IDPs (10.5% vs 6.6%). The answer “Other” (8.9%) included changes in available services within the camps due also to COVID-19 countermeasures and was reported mainly by IDP women (14.2% vs 2.6%). When investigating which services were meant, the main perceived changes were in health services (39.3% of the respondents), followed by residential services (20.5%) and hygiene services (20.4%). The perception of a disruption in dry food distribution and lack or delay in general support was perceived by the 12.2% and 7.6% of the women, respectively.

Discussion

In the current study, we aimed to investigate the perceived difficulties of pregnant women living in Iraqi camps due to COVID-19 and how the pandemic has affected their access to services in the camps, particularly health care services (antenatal care).

It is already known that during the pandemic, both IDP and refugee populations had limited access to health services and/or other services such as human assistance in the form of food, water and shelter (Mangrio et al., 2022; Ozer et al., 2022; Mumin et al., 2022; El Arab et al., 2023).

In general, pregnant women have been found to be overwhelmingly distressed by the COVID-19 outbreak and perceived vulnerability due to pregnancy (Yassa et al., 2020). Looking specifically at women living in camps, the sudden deterioration of living conditions due to the overlapping crises may have influenced women’s attitudes toward fertility behavior and pregnancy (Mourtada and Melnikas, 2022). Previous findings noted that, among others things, concerns about contracting disease prevented Afghan refugee women in Iran from seeking pregnancy support (Lebni et al., 2022), while Lusambili et al. reported a delay in seeking care among Kenyan refugee pregnant women, as well as an overall decrease in the use of maternal health services (Lusambili et al., 2020).

In the current study, although primary health-care centers continued to provide all essential antenatal care services in the camps during the lockdown, nearly 40% of pregnant women reported that they had reduced the uptake of health services during the COVID-19 pandemic, in part due to fear of infection, in part due to lockdown and in part due to perceived disruption of services. For those who answered “yes” to the question “Are you concerned about COVID-19?”, our findings are consistent with a study conducted among adult Rohingya refugees in Bangladesh, which reported that 61.5% of them were strongly concerned (Mistry et al., 2021).

Although we did not specifically investigate the reasons behind it, we can assume that concerns may have been raised due to fears of being more susceptible to infection due to pregnancy, transmitting the virus to the fetus or later during breastfeeding, as reported for Syrian refugee pregnant/mothers in Jordan (Hamadneh et al., 2021).

As one of the main objective of this study was to draw different profiles between IDP and refugee pregnant women living in KRI camps, the responses were analyzed separately to explore the specific needs of the two groups. Despite having similar sociodemographic characteristics, the responses revealed significant differences between the two populations. All of these differences between the two subgroups were statistically significant.

IDPs were more afraid of visiting health centers, they were more concerned about COVID-19 infection, but reported less adherence to preventive measures. A previous study conducted in Rohingya refugee camps to identify the reasons for poor practice of COVID-19 preventive measures reported religion, local context, community trust and interaction with aid workers, communication methods, equity between men and women and social inclusion as some of the key areas (Halder et al., 2023). Following the findings of Halder and colleagues, we can speculate that some of these reasons may be similar; Yazidis in KRI have experienced persistent genocide, marginalization and oppression over the years due to their minority status; Yazidis women could be considered even more vulnerable than other IDPs as they have been exposed to recurrent traumatic experiences related to specific attack and violence, being held captive, sold, enslaved and sexually abused. Global evidence on high rates of post-traumatic stress disorder and suicide among female survivors of conflict-related sexual violence is particularly applicable to the context of the Yazidi female population (Lobanov-Rostovsky and Kiss, 2022). In particular, the risk of depressive symptoms among internally displaced pregnant Yazidi women living in camps (Sulaymaniyah Province) was found to be higher than the general Kurdish-speaking population, even before COVID-19 outbreak (Seidi et al., 2022).

This consideration should be taken into account when observing that, when asked about the main self-perceived negative COVID-19 effect, in our study IDP women seem to be more affected by psychological pressure compared to refugee women. Previous studies have found that IDPs, especially if they are female, have worse mental health outcomes than refugees overall, although with differences between contexts (Cantor et al., 2021). Moya et al. provided evidence of worsening maternal mental health associated with the COVID-19 pandemic in IDP women living in camps in fragile and conflict-affected settings (Moya et al., 2021). In addition, Lobanov-Rostovsky and Kiss found that COVID-19 worsened the mental health of Yazidi survivors (Lobanov-Rostovsky and Kiss, 2022). These findings were corroborated by a study that examined the effect of COVID-19 on the mental health of a small sample of Yazidis in a camp near Dohuk, where the likelihood of mental health problems increased compared to the already difficult situation before the crisis, especially in women (Kizilhan and Noll-Hussong, 2020).

According to our findings, IDPs perceived more disruption in health services, as well as other services, despite their continuity in all camps. A previous study of IDPs in KRI found that lack of access to medical care in case of illness was a significant predictor of mental health symptoms (Rofo et al., 2023). Conversely, we can speculate that the preexisting psychological pressure may have influenced the perception of lack of health services, as it is already a sensitive issue. However, we should keep in mind that Rofo and colleagues considered Christian IDPs who did not live in camps. Therefore, these differences should be taken into account before drawing conclusions. Further research is needed to confirm this hypothesis.

On the contrary, refugee women were less concerned about COVID-19 infection as such, were more compliant with preventive measures and visited health centers more than IDP women. When asked about the main negative effects of the pandemic, they were more concerned about the lockdown measures, economic situation and unemployment than their counterparts. These conditions may have been caused by an increased sense of disconnection from friends and relatives, limited access to virtual communication and closed borders, possibly due to the restrictions as well as their fragile economic conditions, as previously found by Lebni and colleagues (Lebni et al., 2022) and by Noh and colleagues, who reported refugees struggling with economic difficulties, limited livelihoods and lack of access to services (Noh et al., 2022). The pandemic may have exacerbated the economic challenges refugees faced on a daily basis, as the lockdown prevented them from earning an income, especially since many refugees lacked stable employment opportunities (El Arab et al., 2023).

Previous studies have highlighted that resettled refugee women often face barriers to care related to language and cultural differences with providers (Stirling Cameron et al., 2021; El Arab et al., 2023). This condition does not apply to our sample, as most refugees in Iraqi Kurdistan are Syrians and Kurdish asylum seekers from Iran and Türkiye, who share the same language as the host population.

We did not find other studies comparing these two specific populations of migrants in KRI with their peculiar characteristics. We identified one study conducted in Iraq that compared two vulnerable groups, i.e. IDPs and returnees living in their households; however, the study did not specifically address pregnant women (Noh et al., 2022). Conversely, a recent study conducted generally among women of reproductive age living in camps (Erbil Governorate) found that language, cultural factors, lack of supportive persons, transportation and COVID-19 restriction were the main barriers to seeking maternal health care; however, the study included a small group of pregnant women and specific differences between the two groups (i.e. IDPs and refugees) were not analyzed (Mirkhan et al., 2024). Therefore, the current study opens the floor to the need for a deeper investigation of the differences and specific needs between these two populations living in camps, especially in Iraqi Kurdistan where these groups have peculiar characteristics.

Implications for public health and humanitarian sectors

By quoting WHO, during an epidemic “people, efforts and medical supplies all shift to respond to the emergency. This may lead to the neglect of routine essential health services. People with health problems unrelated to the epidemic find it harder to get access to health care services” (WHO, 2023). Thus, the outbreak poses yet another challenge that risks overshadowing the preexisting humanitarian needs of the most vulnerable people, such as pregnant women, who are an inherently vulnerable group, even more when they are migrants living in camps. In fact, these communities may experience a unique set of personal, social and physical barriers to accessing health services, which may affect their motivation to seek routine health care.

Due to the lack of research in this area, it is imperative to conduct specific local investigations to provide the basis for designing evidence-based strategies to support public health and humanitarian actors. The present study has direct relevance to efforts to provide adequate health care to marginalized populations living in camps in a middle-income region. Our findings suggest that perceptions of routine health services utilization significantly reduced during the COVID-19 outbreak, even though maternal health services in the camps were never suspended. Internal factors may include mental and psychological pressure, difficulty in trusting local health personnel and the health system, feelings of discrimination and cultural and/or religious barriers. A better understanding of specific needs and disparities between different groups of migrants (including personal experience, exposure to historical trauma, beliefs and perceptions) could enable primary care providers and public health policymakers to develop tailored and cost-effective community-based approaches to securing, strengthening and increasing access to health care for marginalized populations.

Evidence suggests that close collaboration with affected communities ensures effective solutions (Wolff et al., 2017). Engaging volunteers – members with shared life experiences and similar cultural and linguistic backgrounds – is a relatively simple solution and essential strategy for providing tailored, culturally appropriate and participatory approaches that build trust among migrant communities. Peer involvement can bridge healing support, overcome cultural and linguistic barriers, mediate between cultural beliefs and service acceptability and strengthen relationships between health-care providers and beneficiaries. Peers can also support in humanazing health and social services since, as their participatory approach can support inclusive and acceptable communication. When specifically addressing people’s health, educational campaigns based on culturally appropriate information should include bidirectional communication and dialogue to ensure proper access to health services during a pandemic in migrant contexts (Mahon, 2022). In addition, accessible information should take into account differences in literacy levels, which can be overcome through face-to-face support. Therefore, training and education with a focus on communication skills should be considered as an integral part of the peer role. Our study recalls the need to prioritize community involvement as an essential investment to be included in long-term strategic plans in camps. This is essential to be prepared in case of future pandemics and public health crises and/or other emergencies and then to mitigate their effects.

On the contrary, specific training for health-care providers should include developing a better understanding of the communities they serve to find ways to connect with them. For example, this is particularly important when delivering COVID-19 vaccinations to inform an effective vaccine campaign. Given that COVID-19 vaccines had not yet been introduced at the time of this study, future research analyzing vaccine uptake and coverage in these camps could provide more detailed information about these vulnerable populations.

Strength and limitations

The current study has several strengths since, to the best of our knowledge, it is one of the first studies investigating concerns about COVID-19 among pregnant women living in Iraqi camps (either IDPs and refugees) and their self-perceived barriers to accessing routine health services during the pandemic. With its large sample, this study adds to a very small international literature exploring the difficulties of people living in camps in accessing health services during the COVID-19 pandemic. In addition, it proposes a new approach of considering IDPs and refugees as two different context-related populations with their own specific needs.

However, the study has several limitations. It was cross-sectional and therefore causality cannot be established. We acknowledge that some information that could have been helpful in better distinguishing between the two groups was not collected during the interview (e.g. educational level). In addition, data were collected using self-report information, which may have been subject to recall bias and misunderstanding of the questions. Third, although we conducted a thorough literature review to identify potential misconceptions, no standardized questionnaire was found, so we may have overlooked some potential misunderstandings of questions or worded them in a way that may have biased responses.

Finally, the paucity of scientific research in this context, together with the lack of an integrated system for epidemiological surveillance in Iraq, has impeded us from providing comparisons of data between the two populations of migrants and the host population. Further investigations are required to better understand health outcomes and causal pathways between these groups.

Conclusion

Understanding the health of pregnant women living in camps and how they are affected in the context of the pandemic is critical for developing and implementing strategies and interventions that can assist in the delivery of health services. Our findings show that needs for IDP and refugee women are diverse, specific and contextual and require tailored interventions to ensure continuity of care in camps, especially during a pandemic. Therefore, in a new era of migrations where most conflicts are within national borders and involve different ethnic groups, we recall the need to enrich the classical international definitions (IDPs vs refugees) with contextual considerations, taking into account the fact that sometimes sharing the same nationality does not mean being less vulnerable than foreign populations.

Our study aims at enhancing guidelines for health and humanitarian interventions for migrants living in camps to promote health coverage and access to services. We recall the importance of collaborative and intersectional partnerships between health professionals, academics and the volunteers themselves. Along with the provision of adequate health care, we support the implementation of community‐based, sustainable and context-sensitive approaches, including peer training and education.

Furthermore, the gaps in essential information in this study call for the development of integrated epidemiological surveillance systems to ensure a deeper knowledge of health data for all populations living in Iraq (Emberti Gialloreti et al., 2020). Therefore, investment in epidemiological surveillance is essential, especially in war-torn countries (Gialloreti et al., 2020). A better understanding of health data will help to adapt policy and programming responses to the specific context of displacement and to identify potential interventions to improve uptake of services during a new pandemic.

Figures

Figure 1

Camps map in the Dohuk Governatorate, subdivided by province

Figure 2

Study’s flowchart

Table 1

Number of people that are hosted in Dohuk camps

Type of camp	Name of the IDP camps	Name of the refugee camps	Number of people that can be hosted
Four IDPs and one refugee camps	Darkar, Dawoudia, Mamilian, Shekhan	Akre castle	<5,000 people
Four IDPs and three refugees camps	Bajed kandala, Bersive1, Bersivi2, Mamrashan	Gawelan Domiz2, Bardarash	5,000–10,000
Six IDPs	Khanki, Essian, Kabarto1, Kabarto2, Rawanga, Shariya		10,000–15,000
One IDP and one refugee camps	Chamishko	Domiz1	>15,000

Source:

Table by authors

Table 2

Sociodemographic characteristics

Variable	Total = 4,736 N. (%)	Refugees = 2,229 N. (%)	IDPs = 2,507 N. (%)
Age (mean ± SD)	29.1 ± 6.5	28.5 ± 6.2	29.7 ± 6.8
<20	297 (6.3)	107 (4.8)	190 (7.6)
20–29	2,194 (46.3)	1,003 (45.0)	1,191 (47.5)
30–39	1,811 (38.2)	870 (39.0)	941 (37.5)
≥40	434 (9.2)	249 (11.2)	185 (7.4)
Number of children (mean ± SD)	2.3 ± 1.6	2.3 ± 1.5	2.3 ± 1.6
None	873 (18.4)	412 (18.5)	457 (18.2)
1–3	2,648 (55.9)	1,164 (52.2)	1,484 (59.2)
>3	1,215 (25.7)	653 (30.3)	566 (42.6)
Marital status
Married	4,732 (99.9)	2,227 (99.9)	2,505 (99.9)
Widow	4 (0.1)	2 (0.1)	2 (0.1)
Month of interview
June–August 2020	148 (3.1)	87 (3.9)	61 (2.4)
September–November 2020	1,048 (22.1)	410 (18.4)	639 (25.5)
December 2020 to March 2021	3,540 (74.8)	1,732 (77.7)	1,807 (72.1)

Source:

Table by authors

Table 3

Concerns about COVID-19 by subgroups

Questions	Total = 4,736 N. (%)	Refugees = 2,229 N. (%)	IDPs = 2,507 N. (%)	p-Valuea
Are you concerned about COVID-19?
Yes	3,027 (63.9)	1,170 (52.5)	1,857 (74.2)	<0.001
No	963 (36.1)	626 (47.5)	337 (25.8)
Do you support preventive measures?
Yes	3,836 (81.0)	1,958 (87.8)	1,878 (74.9)	<0.001
No	346 (19.0)	50 (12.2)	296 (25.1)
Do you feel you and your family are safe?
Yes	2,550 (53.9)	1,294 (58.0)	1,256 (50.1)	<0.001
No	909 (46.1)	267 (42.0)	642 (49.9)
Do the COVID-19 measures affect your freedom of movement?
Yes	3,126 (66.0)	1,446 (64.9)	1,680 (67.0)	=0.034
No	805 (34.0)	432 (35.1)	373 (33.0)
Are you afraid to visit the health center?
Yes	2,411 (50.9)	759 (34.0)	1,652 (65.9)	<0.001
No	1,757 (49.1)	902 (66.0)	855 (34.1)
Do you visit the health center as before?
Yes	1,871 (39.5)	953 (42.7)	918 (36.6)	<0.001
No	2,250 (60.5)	661 (57.3)	1,589 (63.4)
Do the health services differ during the pandemic?
Yes	1,904 (40.2)	776 (34.8)	1,128 (45.0)	<0.001
No	1,369 (59.8)	840 (65.2)	529 (55.0)
Have other services (other than health) changed?
Yes	1,787 (37.7)	789 (35.4)	998 (39.8)	<0.001
No	1,330 (62.3)	761 (64.6)	569 (60.2)

Note:

^aχ² test

Source: Table by authors

Table 4

Self-perceived COVID-19 main downsides

What was the worst thing that happened to you due to COVID-19?
Question	Total = 4,736 N. (%)	Refugees = 2,229 N. (%)	IDPs = 2,507 N. (%)	p-Valuea
Lockdown countermeasures	1,865 (39.4)	1,045 (46.9)	820 (32.7)	<0.001
Psychological pressure	748 (15.8)	279 (12.5)	469 (18.7)
Economic situation	517 (10.9)	306 (13.7)	211 (8.4)
Unemployment	409 (8.6)	229 (10.3)	180 (7.2)
COVID-19 infection itself	411 (8.6)	148 (6.6)	263 (10.5)
Other	415 (8.9)	59 (2.6)	356 (14.2)
Nothing	371 (7.8)	163 (7.4)	208 (8.3)

Note:

^aχ² test

Source: Table by authors

Supplementary material

The supplementary material for this article can be found online.