Unintended Consequences of COVID-19 Public Health and Social Measures in Camps and Camp-Like Settings: A Systematic Review and Conceptual Analysis

Abstract

Objectives:

This study examines unintended consequences (UIC) of public health and social measures (PHSM) in camps and camp-like settings and assesses the pathways through which these UIC arise.

Methods:

We conducted a systematic review and conceptual analysis of UIC from PHSM aimed at preventing SARS-CoV-2 spread in these settings. PHSM were classified using the WHO taxonomy and the CONSEQUENT framework to analyse UIC pathways. The most frequent PHSM groups were: a) surveillance and response, b) social and physical distancing, and c) operational measures.

Results:

We identified 113 predominantly negative UIC impacting physical and mental health, healthcare access, economic stability, and social interactions. UIC occurred in both high- and low-income countries. Key mechanisms linking PHSM to UIC included mistrust, increased risk factors, lack of information, and uncertainty.

Conclusion:

This study reveals the complex interactions between PHSM and UIC and their broad mostly negative effects on marginalised populations. To reduce UIC in future health emergencies, they must be considered in pandemic planning with all stakeholders. Trust-building should be central in health interventions and PHSM design for more effective and equitable responses.

Systematic Review Registration:

https://www.crd.york.ac.uk/PROSPERO/view/CRD42022384673.

Introduction

Research on COVID-19 has predominantly examined the effects of both pharmacological interventions (e.g., vaccines) and public health and social measures on epidemiological and clinical outcomes such as virus transmission and COVID-19-related illness and death [1, 2]. Public health and social measures designed to contain the COVID-19 pandemic always come with consequences, some intended, some unintended. There is no unanimously defined concept of unintended consequences, and notions and understandings vary depending on disciplines and fields of practice [3]. In this paper, we draw on the understanding of Jabeen (2018), who draws upon sociological literature to define intended outcomes as the product of explicit and formal formally organised action and procedures to achieve a certain result, purpose or desired change. Any other results of an intervention, understood as formally organized social action, which are not part of the initial intention are understood as the ‘unintended outcomes’ [4]. Jabeen (2018) further proposes a typology of unintended consequences organised by four dimensions, which we use to organize our analysis: Unintended consequences can be positive, negative or neutral and anticipated or unanticipated [4]. A further way to classify them is the “Consequences of Public Health Interventions” (CONSEQUENT) framework which also links unintended consequences to their underlying mechanisms [5]. With potential unintended consequences of public health and social measures becoming a matter of concern, some studies have focussed on consequences for mental health and economic productivity in the general population [6, 7]. Others have examined such consequences in specific contexts, e.g., related to travel restrictions [8] or in schools [9]. However, little attention has been paid to potential unintended consequences of public health and social measures in camps and camp-like settings for refugees, asylum seekers and internally displaced persons (IDPs). For the purposes of this study, ‘camps’ refer to longer-term formal settlements for displaced populations, while ‘camp-like settings’ denote temporary reception (e.g., transit centre) or collective accommodation centres [10]. Against the backdrop of already severe negative psychological effects of quarantine such as post-traumatic stress symptoms, anger and other stressors across all settings [6], this neglect is concerning given the additional unique circumstances of camps and camp-like settings, which include crowded living conditions, shared sanitary facilities, communal eating spaces, limited access to information and social support, and restrictions on freedom of movement [11, 12]. Additionally, the responsibility for residents lies with the authorities, who may sometimes have restricted capabilities to take action [12]. These contextual factors significantly increase the likelihood that public health and social measures result in unintended consequences. Moreover, refugees, asylum seekers and IDPs typically have a high burden of mental [13, 14] and physical illness [15, 16], resulting from hardships in their countries of origin, dangerous migration journeys and precarious living conditions in host countries, rendering them particularly vulnerable to the adverse effects of public health and social measures.

The aims of this study are to synthesise the existing evidence of the unintended consequences of public health and social measures implemented in camps and camp-like settings to prevent the spread of SARS-CoV-2, to analyse the pathways linking public health and social measures to their unintended consequences using the CONSEQUENT framework, and to reflect on the applicability of existing frameworks for understanding and mitigating unintended consequences.

Methods

We performed a systematic review of the empirical literature on public health and social measures implemented in camps and camp-like settings for refugees, asylum seekers and IDPs in response to the COVID-19-pandemic. We used a conceptual analysis approach to explore and synthesise the unintended consequences of implemented public health and social measures in respective settings, guided by the “Consequences of Public Health Interventions” (CONSEQUENT) framework [5] to guide the classification of unintended consequences and the mechanisms through which they emerge. Methodologically, we built on a previous broad and comprehensive systematic review on COVID-19, displacement, and health [17] by developing a narrower set of inclusion and exclusion criteria (see below) to identify subsets of papers that report on public health and social measures and potential unintended consequences in camps and camp-like settings (first tier). A protocol containing details on how relevant literature was identified and extracted from the larger body of evidence of broader systematic reviews has been registered and published with PROSPERO: CRD42022384673 [18]. More recent literature was included using a search strategy specifically tailored to our research question, complementing the papers already identified within the previous systematic review (second tier).

Search Strategy

A two-tiered search strategy was applied. First, all included studies (12/2019 to 11/2021) of a previous review [17] on COVID-19 health and health-related outcomes, including clinical outcomes such as infections, hospitalisation, mortality but also mental health outcomes or wellbeing and social determinants that affect health, among refugees and other migrant populations worldwide were screened with narrower inclusion criteria (i.e., population, setting, exposure). Second, an update search (12/2021 to 02/2023) in the WHO COVID-19 Research Database (representing 24 bibliographic databases [19]) and The Cochrane Library was conducted, using a search string created along the PECO scheme (see Supplementary Tables S1, S2a,b). Websites of the International Organization for Migration (IOM), the European Centre for Disease Prevention and Control (ECDC) and the European Public Health Association (EUPHA) were searched for further grey literature articles.

Eligibility Criteria

We included empirical studies i) investigating refugees (including asylum seekers and IDPs) living in camps or camp-like settings such as reception and collective accommodation centres; and ii) reporting any type of public health and social measures based on the WHO taxonomy [20], such as individual measures, environmental, surveillance, response, or social and physical distancing measures; and iii) reporting any health-related outcomes (physical, mental, child, or maternal health, quality of life, social wellbeing) or social and economic outcomes. German, English and Spanish articles reporting empirical data using any research methodology were included from December 2019 until February 2023. Detailed inclusion and exclusion criteria are listed in the Supplementary Table S3.

Screening Process

Titles, abstracts, and full-texts were screened by two reviewers independently. Conflicts were resolved by discussion or a third reviewer. Subsequently, we applied a third screening step to distinguish between studies reporting intended vs. unintended consequences of public health and social measures. Intended consequences were defined as any impact that reduced SARS-CoV-2 transmission or infection. Only the studies reporting unintended consequences were synthesised. We used the Covidence software for the screening process [21].

Quality Appraisal

JBI checklists appropriate for the study design were used to assess the quality of the included studies [22]. For each study, the scores obtained from two independent ratings were averaged, and studies were grouped based on their scores and classified as high (100%–75% of full score), moderate (74%–50%), and low (<50%) quality studies. Rating discrepancies in case of considerably different scores (i.e., studies rated high by one reviewer and low by another) were resolved by discussion among the team. Questions marked “not applicable” were not included in the overall quality score to avoid artificially downgrading studies.

Data Extraction and Management

We extracted bibliographic information (author, year, title), results of the quality assessment, study characteristics (country of study (according to the world bank country classifications by income level [23]), study period, migrant population, sample size and study design/methodology) as well as information on public health and social measures (i.e., description, period of implementation, target of measure (general vs. camp-specific), and context of implementation). To systematically describe unintended consequences, we used the framework of Jabeen [4] to assess their knowability (anticipated/unanticipated), value (positive/negative/neutral), distribution of effects (some/whole population), and temporality (simultaneously/after some time) as well as the relationship of unintended consequences with health, economic, and social outcomes (direct/indirect).

Data Analysis and Presentation

After the extraction we classified the public health and social measures according to the WHO classification, and the unintended consequences according to the CONSEQUENT framework [5]. The framework categorises (unintended) consequences in multiple domains: health, health system, human and fundamental rights, acceptability and adherence, equity and equity-related, social and institutional, economic and resource-related, and ecological, whereas some consequences were not clearly assignable to single domains and therefore count into several domains, so that the percentages below exceed 100%. It also offers a set of potential mechanisms through which they emerge: bio-physiological mechanisms; (re-)action and behaviour change; perception, experience and assessment; available opportunities for (re-)action; environments and environmental exposure; social norms and practices; economic and market mechanisms; the functioning of systems and system components. Based on the frequency of measures identified, we split the public health and social measures into three main categories: a) surveillance and response measures in specific settings, including the protection of specific populations, b) social and physical distancing measures, and c) operational measures involving adaptations or closures of schools, health and social services, businesses, public spaces and administrative offices. We developed mosaic plots using the programming language R 4.3.2 to visualise the linkages between public health and social measures and unintended consequences (see Supplementary Chapter 4) and a diagram to visualise the cascading impacts of public health and social measures inspired by a framework of Carter et al. [24].

Patient and Public Involvement

As this study is based on published literature, patient and public involvement was not applicable.

Results

Eight studies were included from the first-tier search. The second-tier search yielded 1,745 records, of which 1,655 titles and abstracts were screened after duplicate removal. Of these, 163 full-text articles were assessed for eligibility, and 27 studies were ultimately included, resulting in a total of 35 included studies (see Figure 1). Almost all studies were of high or medium quality, except for three studies, which were assessed as being of low quality due to insufficient contextual and methodological information [25], significant methodological limitations [26], and inconsistencies across several categories in the respective JBI checklist [27] (see Supplementary Tables S4a–f).

FIGURE 1

Study Characteristics

The majority of the included studies were qualitative studies (n = 22; 62.9%), while ten (28.5%) were quantitative studies–comprising cross-sectional and cohort studies–and three (8.5%) were mixed-method studies (combining quantitative and qualitative research). In terms of migrant populations, 29 (82.9%) investigated refugees and asylum seekers, and three studies each (8.5%) examined IDPs and refugees in detention facilities. Geographically, the studies were conducted in 18 different countries, including five low-income countries (Burkina Faso, Mali, Rwanda, Somalia, Uganda), five low-middle-income countries (Bangladesh, Jordan, Kenya, Lebanon, Palestinian Territories (i.e., Westbank and Gaza)), and eight upper-middle and high-income countries (France, Germany, Greece, Iraq, Italy, Mexico, United Kingdom, and the United States) (see Table 1).

Overview of Public Health and Social Measures and Associated Unintended Consequences

We found public health and social measures related to different categories of the WHO taxonomy, namely, individual measures (such as using personal protective equipment (PPE) or mask wearing) [27–31], surveillance and response measures (i.e., detecting and isolating cases) [12, 28, 30, 32–38], social and physical distancing measures [12, 25, 26, 28–32, 34, 35, 37–56], and less frequently environmental and biological measures [46] (which are not part of this analysis). Social and physical distancing measures were the biggest group and the main focus of our analysis. This category contains various measures including domestic travel restrictions including stay-at-home orders and mobility restrictions, measures for special populations, measures for offices, businesses, institutions and operations, school closures, and the like.

Across all these public health and social measures we identified 113 unintended consequences. 33.6% (n = 38) of unintended consequences related to health consequences including psychosocial health and wellbeing, and physical health and health behaviours. 23.0% (n = 26) referred to the health system, namely, to access to, utilisation of, and quality of health services, and acceptability and adherence to health services. Economic and resource-related unintended consequences accounted for 15.0% (n = 17), while 8.0% (n = 9) were related to human and fundamental rights, specifically autonomy, self-determination, and privacy. Finally, 28.3% (n = 32) of the unintended consequences were related to social and institutional factors, including the legal and political system, social cohesion and wellbeing, safety, security, and crime, conditions of daily living, and education and development. One unintended consequence referred to an ecological consequence in a low-middle income country due to the use of PPE [28]. Table 2 provides a detailed description of each unintended consequence, as noted in the primary studies.

Conceptual Linkage Between Public Health and Social Measures and Unintended Consequences

Figure 2 shows the distribution of unintended consequences by public health and social measures. The graph highlights that unintended physical health consequences were primarily reported in the context of individual measures (Figure 2a), particularly hand hygiene and the use of PPE (Figure 2b). Measures related to gatherings, businesses, and services were reported as having a significant impact on mental health, while social and physical distancing measures were primarily reported with respect to health system-related unintended consequences (Figure 2a). Two additional key findings become evident from the illustration. First, international travel restrictions are reported to have a significant impact on social and institutional outcomes, such as increased exposure to crime and delays in or failures of migration projects (Figure 2b). Second, detecting and isolation measures are the primary reported drivers of unintended consequences, particularly regarding human and fundamental rights as well as the acceptability and adherence to health services (Figure 2b).

FIGURE 2

Pathways Between Public Health and Social Measures and Unintended Consequences

This section integrates the three main public health and social measure categories (subsections Surveillance and Response Measures in Specific Settings, Social and Physical Distancing Measures, Operational Measures) with their associated unintended consequences. Figure 3 provides an overarching synthesis of the pathways through which public health and social measures give rise to unintended consequences across all three categories, distinguishing direct and indirect pathways (solid and dashed arrows) and highlights underlying mechanisms (blue squares) linking public health and social measures (yellow polygon) to unintended consequences (red shapes). Guided by this integrative framework, the following subsections examine each public health and social measure in detail. More detailed pathway diagrams for each public health and social measure group are provided in the Supplementary Figures S2a–c.

FIGURE 3

Surveillance and Response Measures in Specific Settings

Within the category of surveillance and response measures, the most frequently described public health and social measures were mass quarantine and isolation, as well as mandatory testing in closed settings such as refugee camps, reception centres or detention centres [12, 26, 28, 30, 32, 34, 35, 37, 38, 41–44, 46–48, 50]. We identified 38 unintended consequences attributable to this group of measures.

Direct unintended consequences resulting from this public health and social measure group included a deterioration in health outcomes–particularly mental health [32, 33, 36, 44, 48] – and an increased risk of SARS-CoV-2 infection [12, 26, 34, 44, 47]. Other immediate effects involved a reduction or even lack of autonomy [37, 42, 44, 48], as perceived by the asylum seekers and refugees residing in these facilities, as well as economic consequences and hardships [35, 37, 44, 48]. Health outcomes were further worsened by crowded living conditions which was triggered or amplified by mass quarantine. The sudden implementation of measures, along inadequate preparation and communication with the affected population, led to mistrust of institutions and authorities, which ultimately gave rise to conflicts and hunger strikes in some facilities [30, 37, 38, 41, 44]. The mobility restrictions imposed as part of the mass quarantine affected access to health services and prevented residents from seeking medical care outside the refugee camps [28, 30, 35]. In some cases, no health services were provided in camps and camp-like settings and aid organisations were denied access due to quarantine measures, leaving refugees without access to healthcare [28, 35].

Even when mechanisms were not explicitly analysed, many papers emphasised the contextual conditions under which public health and social measures were implemented and in which unintended consequences emerged. This underscores the importance of considering pre-existing restrictions in camp and camp-like settings–such as limited access to services, lack of internet access, insufficient communication and education, and geographically deprived locations–when assessing mechanisms and their effects.

Social and Physical Distancing Measures

The main measures reported in the category of social and physical distancing measures included closure or ban of public transport [25, 51], stay-at-home orders [25, 39, 47, 56, 57], general lockdown measures (often not further specified) [25, 29, 30, 40, 45, 49, 51, 53, 55], and border closures [46]. In Figure 3, we divided these measures into two groups: national lockdown measures (including national stay-at-home orders and public transport bans) and international border closures. The latter, which was reported only once, directly impacted and delayed asylum applications. This, in turn, generated uncertainty as a mechanism indirectly contributing to a deterioration in health [46].

In camps and camp-like settings, lockdown measures contributed to negative health outcomes, such as food insecurity [53], deteriorating mental health [45, 49, 51], and an increased risk of infection [30]. They also reduced access to healthcare [25, 29, 51] and caused significant economic impacts, including job and income loss [29, 35, 55], and decreased resources and support [30, 53], including food supply [46]. In such settings, stay-at-home orders had additional social and institutional consequences, such as a heightened risk of gender-based and domestic violence, neglect, abuse, and exploitation of children [25, 56]. These lockdown-induced effects were driven by increased exposure to unstable living conditions and the emergence in risky behaviours, both of which exacerbated health problems. In addition, the measures contributed to heightened mistrust, which in turn led to greater perceived discrimination and stigmatisation at both institutional and interpersonal levels [30, 47].

Operational Measures

Unintended consequences resulting from public health and social measures classified as operational measures encompassed adaptations and closures of five key sectors: schools and education, health and social services, businesses, public spaces, and administrative offices. For analytical purposes, we grouped these measures into two categories: adaptations to health and social service provision, and closures of businesses, administrative offices, schools, and public spaces. A total of 37 negative unintended consequences were reported in association with operational measures, the majority of which stemmed from changes in health and social services. Several studies described altered healthcare accessibility and utilisation [25, 29–31, 52], resulting from complete services closures [25, 30, 35, 57], reduced personnel [31], shortened operating hours [31], or transitions to online and telehealth services [29, 42]. One study reported that frequent changes in the availability of health services due to pandemic management protocols generated uncertainty regarding service availability, which in turn led to lower utilisation, even when services remained available in principle [29]. (Indirect) Health consequences of reduced service utilisation included higher mental health burden, increased risky sexual behaviours, and greater substance use [12, 30, 35, 56, 57]. Several studies also described non-health-related effects of adaptations to health and social service provision. For example, in crowded living conditions, telehealth services violated privacy, and cut-backs in financial and in-kind assistance from aid organisations’ exacerbated resource shortages, such as food supply [25, 29, 30, 32, 42, 47, 48, 52, 54].

The second group of operational public health and social measures–closures of businesses, administration, schools, and public spaces–caused unintended consequences at multiple levels. Business closures caused a direct loss of livelihoods, pushing migrants further into precarity, while changes to administrative operations substantially reduced or completely halted the processing of asylum claims. Studies reported direct effects on social and legal systems, which faced substantial delays and/or were unable to accept new claims [25, 30, 32, 48], as well as indirect effects on the integration of refugees and asylum seekers and on their psychosocial health and wellbeing [30, 42]. The closure of schools had direct effects on the education of camp residents. Concurrent closures of public spaces further impaired access to the internet, which is typically unavailable within camps [29, 42]. This limited access disrupted refugees’ social networks and their ability to obtain reliable information, a mechanism that negatively affected trust in pandemic measures and public authorities. Additionally, one study reported that school closures altered daily practices and behaviours of the camp residents, leading to riskier behaviours and delinquency [35]. These changes subsequently contributed to increased sexual violence, higher risk of sexually transmitted infections, and unwanted pregnancies [35].

Nature of Unintended Consequences

While the pathway analysis primarily focused on unintended consequences with negative effects, we also identified reports of unintended consequences of a different nature. For example, Akhtar et al. reported that a lockdown in the Azraq refugee camp in Jordan was associated with a decrease in symptom severity among residents with post-traumatic stress disorder [40]. Another study described positive unintended outcomes among Rohingya refugees in Bangladesh, where supervision visits implemented for quality control of public health and social measures and mandatory testing of visitors and staff entering healthcare facilities increased trust in authorities and healthcare providers within the community [28]. In addition, Rohingya refugee women living in Cox’s Bazar, Bangladesh, identified new income-generating opportunities through the production of producing face masks, driven by the mandatory mask-wearing requirements as part of individual-level public health and social measures and shortages of available PPE [29]. Finally, at a detention centre in California, several measures–including suspension of visitations, overcrowding of medical wards, and the imposition of mass quarantine in specific units–let to a hunger strike among detainees [41]. While the value of this unintended consequence is debatable, it illustrates that detainees were able to politically organise despite differences in language, culture, and nationality, as well as the threat of penalties.

Discussion

In this study, we explored the unintended consequences of public health and social measures implemented during the COVID-19 pandemic on refugees, asylum seekers, and IDPs living in camps and camp-like settings. The public health and social measures identified included surveillance and response measures, social and physical distancing measures, and operational measures, such as closure or changes to schools, health and social services, businesses, and public spaces. Across the included studies, we identified 113 unintended consequences affecting residents of camps and camp-like settings, covering outcomes related to health, health system functioning, economic resources, human rights, and social and institutional factors. Health-related consequences–particularly impacts on mental health and access to healthcare–were the most frequent, followed by economic effects and changes in social interactions. Overall, our findings highlight the complex interplay between public health and social measures and unintended consequences: all identified categories of measures were associated with direct and indirect negative effects on health outcomes, primarily mental health and infection risk, as well as on socio-economic conditions, including job and income loss, food insecurity, and precarious working conditions.

Despite the predominance of negative unintended consequences reported in the existing literature, some positive unintended consequences–including greater trust in the authorities and new economic opportunities–have also been described. Given that many public health and social measures amplified mistrust, and thus, contributed to negative health-related outcomes such as increased discrimination, stigmatisation, and reduced utilisation of health services, it is important to examine how, in other cases, public health and social measures unintendedly built trust; for example, through follow-up on the implementation of measures in a collaborative and non-fear-inducing manner [28]. Leveraging such positive effects can help strengthen trust in health services and authorities, both in preparation for and in response to future pandemics and health emergencies.

Positioning of Findings Within the Literature

Our results extend the existing literature on public health and social measures in two important ways. First, while studies in the general population, specific settings or populations in vulnerable situations often focus on single measures or single outcome domains [6–9, 58] – most commonly mental health or access to services–we show that public health and social measures in camps and camp-like settings lead to interconnected and cascading unintended consequences [35, 53] across multiple domains, including health, economic stability, human rights, and social and institutional factors. Second, unlike previous reviews [58] that examined specific public health and social measures or specific population groups, our study considers all public health and social measures and explicitly traces the pathways and mechanisms through which these measures result in unintended consequences in highly constrained living environments such as camps and camp-like settings.

Added Value of Used Frameworks

By applying the CONSEQUENT framework [5], we were able to move beyond a descriptive listing of unintended consequences and systematically identify the mechanisms and pathways through which public health and social measures affect residents of camps and camp-like settings. As mentioned previously, we observed that trust played a central role in shaping pathways and mechanisms, highlighting its crucial role as a foundation of health systems [59], particularly during health emergencies. The framework identifies five “root mechanisms” that should be considered when planning and implementing public health and social measures. These mechanisms call for counteracting actions: taking context into account, ensuring stakeholder buy-in and participation, acting on reliable evidence, addressing root causes, and strategically allocating scarce resources [5].

Using Jabeen’s framework [4] to classify unintended consequences proved challenging, as relevant information in primary studies were often unavailable, and in most cases, the unintended consequences were not clearly described, appearing instead as incidental findings within the result sections. Applying the CONSEQUENT framework as an analytical lens to identify unintended consequences and underlying mechanisms provided valuable insights into the ways public health and social measures impacted residents of camps and camp-like settings. The framework enabled a clear distinction between direct and indirect effects of measures and helped classify the mechanisms linking public health and social measures to unintended consequences. We found that the most impactful mechanisms were those that restricted refugees’ agency and self-efficacy. Understanding and considering these mechanisms and pathways–including restricted agency and self-efficacy of camp residents, mistrust, and contextual constraints–can help explain how public health and social measures lead to unintended consequences in camps and camp-like settings. This knowledge can guide the development and planning of countermeasures, ensuring that negative unintended consequences will be avoided from the outset or addressed promptly if they emerge. Public health and social measures are complex interventions implemented within complex systems and therefore require appropriate, non-linear solutions and careful planning with the engagement of all relevant stakeholders. Simple, one-size-fits-all approaches are insufficient, particularly when multiple forms of marginalisation intersect.

Challenges and Limitations

We encountered several challenges in applying existing frameworks to our study. For example, public health and social measures were often not reported in detail, and national or regional lockdown measures, in particular, were rarely specified, which may affect the comparability and generalisability across studies. While some studies described public health and social measures–such as the detention of infected individuals or measures of spatial separation in crowded accommodations–their unintended consequences were often not analysed or supported with data. In most cases, unintended consequences were only reported “incidentally” in the discussion sections of primary studies. Only thirteen out of 35 included studies explicitly aimed to analyse unintended consequences [29, 30, 34, 35, 38, 41–43, 47, 49, 52, 53, 57], and none applied a clear concept or an a priori definition of unintended consequences. Future research should prioritise transparent reporting and systematic evaluation of public health and social measures to strengthen the evidence base for decision-making and to better anticipate unintended consequences, fostering more effective and equitable public health responses in refugee reception and accommodation centres.

The heterogeneity of studies conducted in camps and camp-like settings for refugees, asylum seekers, and IDPs across both high-income and low-income countries limited their direct comparability. Nevertheless, despite these differences, the settings–regardless of the country of study–share common contextual factors such as overcrowding and limited access to social and material resources, which shape living conditions. In addition, camps are often located in remote areas, restricting access to essential services such as healthcare and education. Accordingly, we assume that the outcomes and mechanisms identified in this study are likely to be similar across collective (refugee) accommodations in different countries, as well as in other institutionalised settings that limit the residents’ agency.

Conclusion

By combining a comprehensive assessment of public health and social measures with a conceptual analysis based on existing frameworks, this study advances current understanding of how pandemic measures affect displaced populations living in camps and camp-like settings. Overall, there is substantial evidence of unintended consequences of public health and social measures–in particular social and physical distancing measures, such as lockdowns–that negatively impact the mental health of refugees, asylum seekers, and IDPs in these settings, both directly and indirectly. These unintended consequences are closely linked to interruptions of social support and networks, precarious economic conditions, and increases in risky behaviours, such as substance use. Limited access to health services further exacerbates these impacts. Negative consequences were observed across both high- and low-income countries. Nevertheless, the evidence remains incomplete, as unintended consequences of public health and social measures were often not the primary focus of studies and were frequently reported only incidentally.

From a practical perspective, it is essential to systematically consider unintended consequence of public health and social measures in emergency preparedness plans and to develop and implement pre-emptive measures to mitigate them, particularly in camps and camp-like settings such as reception and collective accommodation centres for refugees. Given that mistrust and uncertainty emerged as key mechanisms driving negative unintended consequences, public health and social measures must incorporate trust-building strategies into health interventions both before and during emergencies. Trust and trust-building should be integral to the design of public health and social measures, rather than optional components considered only during implementation. Future planning of control measures should explicitly account for root mechanisms and involve all relevant stakeholders across disciplines to ensure interventions are effective, equitable, and context-sensitive.

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