Summary of research findings
In this review, we identified eight studies examining associations of micro- and meso-environments’ characteristics with refugee children’s PA. Firstly, all but one of the studies were qualitative, and most of them were conducted in the last five years (75%). The empirical research on associations between the built environment and refugee children’s physical activity is in its infancy. Secondly, qualitative studies suggest that both micro- and meso-environments are relevant to refugee children’s PA. These include available indoor spaces (micro) and accessible formal and informal spaces for PA and safety (meso). One quantitative study found that installing a formal play area in undeveloped greenspace resulted in greater use of that area for PA by refugee children [37]. There was only one study reporting on a low- and middle-income country (LMIC) setting in which children stayed in a temporary refugee camp. All other studies reported on refugee facilities (non-camps) within high-income countries (HICs). Our review shows that studies in LMICs are greatly under-represented, since the majority (68%) of refugees reside in low- and middle-income countries [43].
Refugee children vs non-refugee children
The authors found that built environmental barriers and facilitators to physical activity for refugee children, i.e., access to physical activity facilities and neighbourhood safety, were similar to those identified for non-refugee children’s PA in earlier reviews. However, the findings do not necessarily mean that refugee and non-refugee children are equal in their access to physical activity facilities. Future research needs to compare refugee and non-refugee children in terms of how active they are, where they engage in physical activity, and how accessible activity spaces are. Such research would highlight the disparities in PA levels and opportunities between refugee and non-refugee children. With regard to safety concerns, they are often about road safety or local crime for non-refugee children [20]. However, refugee children need to adapt to new, unfamiliar environments when they come to their host country. Since they may have escaped from war situations or have experienced military occupation [41], they may be more cautious and sensitive about safety issues than non-refugees [40]. Such concerns by their parents are particularly salient, as where children can play typically dictated by their parents [14]. Future research needs to pay particular attention to how refugee children and parents perceive danger in surrounding environments and to what extent it is different from non-refugee children and parents. This review did not find studies that examined the role of macro-environment in refugee children’s PA, although it was found to be related to non-refugee children’s PA [19]. Considering that the location of refugee accommodation is a matter for the discretion of local authorities, future research on this topic is needed to inform where best to build refugee facilities to enhance refugee children’s activity, health and safety.
Micro- and meso- environments
It was reported that refugee children have limited access to neighbourhood places for their play [14]. In such a situation where meso environments are not conducive to children’s physical activity, micro-environments (refugee accommodation and its immediate vicinity) are likely to play an important role in refugee children’s PA in both camps and non-camp settings. However, existing studies on micro-environments do not seem to suggest that refugee facilities provide adequate opportunities for children’s PA. One study reported that being physically active indoors at home is not practical due to noise and space issues [38]. The other study found that passageways, stairwells and basement areas within apartment blocks were utilised as makeshift exercise spaces for occupants [40]. However, they may not be totally safe for children to play. It is recommended that additional spaces suitable for children to be active should be provided in/around their accommodations.
In meso-environments within HICs, one study argued that free access to outdoor space and parks are particularly important for refugee children since their financial situation would not allow them to participate in organised sports and other fee-based activities [14]. However, local parks are not always a safe place to play in deprived areas [44], which are often chosen as a site for refugee accommodation [11]. Given that safety may be a particular concern, research needs to identify what measures can be implemented to ensure parks are safe for refugee children to play. Natural surveillance, in which actions and behaviour in a park can be observed by “eyes on the street”, seems like an important principle [14]. Future studies from HICs can examine other park features (e.g., size, features, distance) that encourage refugee children’s active park use. Only one study was conducted in an LMIC setting [41]. It illustrated that refugee children without access to safe and suitable spaces for PA (e.g., parks) had to use space such as roads, streets and other open spaces despite dangers from military confrontation. Further studies should focus on settings in LMICs to identify PA barriers and facilitators in diverse contexts.
Formal vs informal spaces for refugee children’s PA
The quantitative study reviewed highlights the importance of formal activity space quality [37]. It found that children’s energy expenditure in park areas increased from 2010 to 2012, after an undeveloped green space park had been transformed into a recreational park with subdivided functional activity zones. It suggests the importance of a high-quality park with suitable facilities and amenities rather than the mere presence of a park. Identifying design attributes of parks relevant to refugee children’s PA is informative for design and management of refugee-related facilities.
Qualitative studies reviewed reported the importance of informal space for refugee children to engage in physical activity [14, 42, 44]. However, this may be a reflection of lack of opportunities for them to take part in sports and exercise. Given that it can be difficult to organise sports in refugee settings, it is important that there is at least informal space such as open spaces where children can be active with friends during leisure time. It is thus conceivable that diverse opportunities (both formal and informal spaces) are important for refugee children’s PA. Considering that participation in sports activities involves not only physical activity but also social interactions, providing refugee children with such opportunities is likely to have multiple benefits [39]. Future studies can assess the effect and feasibility of sports and other activity programs targeting refugee children and investigate their benefits.
Camp and non-camp settings
The included studies were conducted in different refugee accommodation settings: a refugee camp in an LMIC [41], non-camp settings including designated refugee accommodations located in HICs [14, 15, 37, 39, 40] and community-accommodations specific to their culture in their host countries [38, 42]. It is difficult to compare these settings due to the small number of studies. However, they are likely to differ in terms of the provision of spaces for children. Thus, it could be postulated that environmental correlates of PA may be different for camp and non-camp settings. Further studies should identify environmental attributes related to children’s PA in these diverse contexts, and investigate whether similar environmental attributes may be relevant or there are unique environmental correlates in specific settings.
Measurement issues for physical activity and built environment
There was no objective measurement of PA in the studies identified. It is evident that self-report measures contain errors and bias in capturing physical activity [45]. Future research needs to employ devices such as accelerometers to measure refugee children’s PA. Furthermore, there was little objective measurement of the built environment in the studies reviewed. The quantitative study by King et al. (2015) provided the pre- and post-construction satellite images, which show the presence of some PA facilities after renovation [37]. The qualitative studies included in this review used self-report measures of the built environment, but these were, by their nature, descriptive and subjective. It is important that further studies employ objectively derived (GIS or audit) measures or validated self-report measures of relevant built environmental attributes. Future studies should learn from existing studies targeting non-refugee children, as they have developed a range of methods to assess the built environment [46]. Particular attention may be given to specific attributes of PA spaces (distance, size, accessibility and features) and safety (perceived safety by parents and by children, objective measures such as crime statistics).
Gender and cultural differences
Previous studies have shown that refugee girls and boys are likely to play differently [47,48,49] and have different preferences for places where they would like to play [15, 39, 50]. There was only one study investigating gender differences in this review [37]. It found that more girls participating in vigorous physical activity were observed after park renovation. This seems to suggest that girls may require well-designed places for play, while the presence of open space (without facilities/amenities) may be sufficed for boy’s PA. There were studies examining refugee children from diverse cultural backgrounds [15, 37,38,39,40, 42], but they did not examine whether there were between-culture differences in environmental correlates of PA. Further studies need to investigate gender-specific and culture-specific associations between refugee children’s PA and environmental attributes.
Limitations of the review
There are a few limitations in this review. The inclusion of only peer-reviewed English-language articles may have excluded studies that were conducted in non-English speaking countries with relevant information. For example, much research on refugee children in Germany is reported in German [10, 51]. This review focused on the built environment of places where refugee children lived. However, there may be policies and regulations (e.g., organised PA program) [38, 42] within refugee accommodations, which may be strong determinants of how active children can be. Future reviews may need to consider how policy and environmental factors may be related (independently and jointly) to children’s PA. Finally, we conducted a narrative review, reflecting a small number of studies identified and an early stage of research on this topic. It is expected that more fruitful literature reviews will be conducted in future in light of an increasing interest in refugee’s health and well-being in international contexts.