Substance Abuse Amongst Refugee Youth: A Scoping Review

Identify and map health, economic, and social consequences of substance abuse, especially because the impacts of substance abuse can adversely and disproportionally affect refugee youth. This scoping review was conducted to exhibit gaps in the literature on the prevalence, risk factors, consequences, and interventions of substance abuse among refugee youth to provide a better understanding of the social determinants of this public health crisis. A systematic search for studies on EBSCOhost databases, MEDLINE, and Scopus retrieved 300 citations. Following a systematic screening, 10 studies met the inclusion criteria. The findings from the studies suggest the prevalence of substance abuse amongst refugee youth is exacerbated by several risk factors such as coping with pre- and post-migration experiences, accessibility and availability of substances, and socialisation with peers. Evidence shows that refugee youth suffer negative consequences because of substance abuse. However, they also show a lack of focus on interventions to mitigate the prevalence and negative consequences. Literature generally suggests that the presence of substance abuse amongst refugee youth leads to negative consequences. This finding is especially concerning given the lack of knowledge about mitigation strategies and the identification of several risk factors associated with substance abuse. Therefore, increased attention must be placed on substance abuse amongst refugee youth, especially noting the rising prevalence of global refugee migration.


Introduction
The volatile global geopolitical situation has caused numerous instances of mass migration [46]. A recent United Nations report estimates that 89.3 million people have been forcibly displaced worldwide because of war, conflict, and violence [53]. When refugees are relocated in a new country, they endure numerous hardships. Evidence suggests that some refugees use substances as a coping strategy when entering a new environment [19,21]. Although research on substance abuse is limited amongst refugees, high levels of substance abuse has been documented amongst these groups [22,33,39] and substance abuse issues are seen among refugees in many different parts of the world. Vasic et al. [55] for example, found that more than half of the young people living in two refugee camps in the Republic of Serbia regularly consume energy drinks, and use substances such as tobacco, alcohol, and marijuana. Cooley et al. [9] found that drug use behaviours amongst Karen youth, who are originally from Myanmar, were acquired during the "Americanization" of these children in Omaha schools. "Substance abuse" refers to the use of a drug/alcohol in amounts or by methods which are harmful to an individual or others [2]. These "substances" refer to alcohol and other drugs, though alcohol is the most common substance used by youth. As substance abuse becomes a growing concern among refugee youth, this scoping review attempts to map out the prevalence, risk factors, consequences, and strategies to mitigate substance abuse. Here, the umbrella term "substance abuse" is used interchangeably, although there are important conceptual and practical differences with terms such as "substance misuse", "substance use disorder", and "addiction".
Understanding the prevalence of substance abuse is a public health imperative for healthcare systems. Numerous studies have been conducted to ascertain the prevalence of substance abuse amongst youth [6, 9, 16, 18-21, 32, 42, 43, 55], however, evidence suggests there is only limited research aimed at at-risk youth such as refugee youth. With the evidence of substance abuse amongst refugees found in the literature [15,29], it is important to understand the prevalence of substance use amongst the millions of vulnerable refugee youths. This will assist policy and decision makers in developing and implementing culturally appropriate mitigating strategies.
It is critical to comprehend the factors that make young refugees susceptible to substance abuse. Literature suggests that refugees abuse substances as a coping mechanism of enduring hardship through displacement, followed by their subsequent journey and resettlement to hosting countries [19,21]. These hardships include post-traumatic stresses, language and communication difficulties, cultural barriers, discrimination, marginalisation, high unemployment, and abject poverty [19,21]. Furthermore, factors such as parental substance use, poor family relationships, peer pressure, ease of availability, and neighbourhood opportunities [25,31,56] can position refugee youth at greater risk of substance abuse. Hence, exploring the risk factors of substance abuse amongst refugee youth can enrich the literature on why they are at risk of such abuse.
Substance abuse is found to be associated with various health, economic, and social issues [33,35,39]. The negative implication of substance abuse amongst refugee youth can be concerning for several reasons. First, it leads to anti-social behaviours. Second, substance abuse can significantly increase the likelihood of psychological distress [26,30,36,49,52] Third, research shows that substance abuse is a leading cause of unintentional injury and premature mortality [22]. Fourth, substance abuse can lead to absenteeism at work, productivity loss, and, eventually, loss of employment [3,8]. Last, substance abuse can result in long-term antisocial behaviour, impaired memory, dysfunctional work, and poor school performance [28,44]. The negative consequences can be severe especially considering that refugee youth have already experienced numerous traumatic events. This cumulative effect could provide significant social and economic burden for the society.
The negative consequences of such abuse might be distressful if it is not prevented and managed in a timely manner. The most concerning issue could be that refugee youth might not know any prevention strategies to reduce the harm of substance abuse, as they are often unaware of the availability of any professional and counselling services in the host country. Prevention strategies play an important role in mitigating the negative consequences of substance abuse. Prevention strategies such as family functioning and social support, training programs and festivals, treatment options and counselling, and peer support might assist in mitigating the negative consequences of substance abuse [7,24,51]. Unmitigated substance dependence can even result in health, social, and economic burdens. Synthesising the issues related to substance abuse as they relate to a group, such as refugee youth, is also an important step in identifying their vulnerabilities to this phenomenon, the consequences they face, and the strategies they might use to mitigate risk factors.
Therefore, this scoping review synthesizes studies conducted on substance abuse amongst refugee youth. There are various definitions of youth; the current study refers to a young person as someone aged 12-24 [5]. The United Nations -without prejudice to any other definitions made by Member States-defines 'youth' as those persons between the ages of 15 and 24 [54]. This study expands the definition of refugee youth to include cultural and socioeconomic differences between countries and to capture the full breadth of refugee youth research. According to the Australian Institute of Health and Welfare, physical, intellectual, emotional, and social transformations occur between the ages of 12 and 24 (early, middle, and late adolescence) [1]. This age group is chosen because this is a period of a rapid brain development, and because substance abuse is associated with memory impairment [50]. Additionally, early substance abuse affects education progress [17], problems with the justice system [13] and unemployment [27]. Understanding substance abuse in this age group provides knowledge necessary to inform any intervention to mitigate such risk impacting refugee youth.
This scoping review is limited to peer reviewed articles on substance abuse among refugee youth published in English since 2000. The scoping review does not assess the quality of the research; rather it was conducted to provide a snapshot of the evidence available in the extant literature. An approach of scoping review is suited to this study as it investigates a complex area that has not been previously reviewed comprehensively (i.e., substance abuse amongst refugee youth) [4]. The study will contribute to knowledge by mapping out and visualizing the range of studies available in the literature.

Aims and Objectives of the Scoping Review
The study aims to explore the evidence available in the extant literature on the prevalence, risk factors, consequences, and interventions of substance abuse amongst refugee youth. Three specific questions underpin this aim:

RQ1.
What is the prevalence of substance abuse amongst the refugee youth?; RQ2. What are the risk factors that increase the prospect of substance abuse amongst refugee youth?; and RQ3. What consequences do they experience and how could this substance abuse be mitigated?

Identifying Keywords and Search Strategy
This scoping review was conducted in accordance with the Joanna Briggs Institute (JBI) methodology for scoping review [4]. The Joanna Briggs Institute methodology systematically maps out the literature available on a particular topic, identifies the sources of gap, key concepts, and theories [4,12]. A protocol was developed before undertaking the scoping review. The protocol states the objectives, method, inclusion and exclusion criteria, source evidence, and search strategy. Furthermore, the protocol specifies what data is relevant and how said data will be tabulated. As such, the protocols for this scoping review were developed following the standards of Preferred Reporting Item for Systematic Review and Meta-Analysis (PRISMA-ScR) reporting guidelines [23,37,45]. The search strategy was developed and agreed upon by the reviewers as per the Joanna Briggs Institute methodology for scoping reviews (seen in Table 1

Inclusion Criteria
The inclusion criteria included the following:

Review Validation
All 300 identified citations were collated and uploaded to EndNote X9, with duplicates thereafter removed. Afterwards, 187 titles and abstracts were screened by two independent reviewers, with 167 articles being excluded as they did not meet the inclusion criteria (most of these articles did not address the issue of substance abuse amongst refugee youth). The remaining 20 articles were assessed by the same two reviewers for eligibility, and 10 articles excluded due to a lack of focus on substance abuse or refugee youth. Search Strategy (refugee? OR "asylum seeker" OR "asylum seekers" OR displaced) AND ("substance abuse" OR "substance use" OR "drug abuse" OR "drug addiction" OR "drug use") AND (youth? OR adolescent* OR "young people" OR teen* OR "young adult" OR "young adults") (refugee? OR "asylum seeker" OR "asylum seekers" OR displaced) AND ("substance abuse" OR "substance use" OR "drug abuse" OR "drug addiction" OR "drug use") AND (youth? OR adolescent* OR "young people" OR teen* OR "young adult" OR "young adults") (refugee? OR "asylum seeker" OR "asylum seekers" OR displaced) AND ("substance abuse" OR "substance use" OR "drug abuse" OR "drug addiction" OR "drug use") AND (youth? OR adolescent* OR "young people" OR teen* OR "young adult" OR "young adults")

3
The age range of 12-24 years chosen for this study varies with the age of the participants or non-availability of full-text articles. A search of the included sources' reference lists did not find any potential articles to include in this scoping review. The PRISMA diagram ( Fig. 1) was included to ensure transparency and completeness in the reporting of the scoping review [4,12].

Data Extraction
After the two phases of screening, selected data was extracted into a chart developed by the reviewers. Further information was recorded including study objective, key findings, authors, title, method,population, concept, context, types of evidence source, and future research. Finally, results were presented in a tabular form (shown in Table 2 below) in a manner that aligned with the objective of this scoping review [4].
The data extraction chart provides an overview of studies that met the inclusion criteria. Results from the charting table should include all data relevant to inform the objectives for the scoping review [4,38]. Within the 10 articles that met the inclusion criteria, 9 were peer-reviewed articles, and only one was a review, all were published between the year 2000 and 2021.

Descriptive Overview
Following the aim of the scoping review, we provide a succinct informative summary of the findings. The articles published in nine different journals mainly focused on prevalence, risk factors, intervention strategies, and the challenges of substance abuse amongst refugee youth.
For study location, most of the studies (7) were conducted in Australia (including a review article), one study in the USA, and two in the Middle East. No studies from Europe, South America, Asia, or Africa met the inclusion criteria. The participants in all ten articles were refugee youth, and most of them identified themselves as of African, Middle East, Venezuelan, and Asian origin.
In terms of methodology, four of the studies were conducted using different qualitative designs including participant engagement, thematic analysis, and exploratory method. Three studies were conducted using quantitative designs, namely a cross-sectional study based on a selfadministered questionnaire, a stratified 2-stage random sampling, and multistage area probability sampling. Two studies used a mixed-method design, while one study was a literature review article.

Prevalence of Substance Abuse Amongst Refugee Youth
Findings suggest that the prevalence of substance abuse amongst refugee youth is high. Most of the ten articles that met the inclusion criteria reported that refugee youth consume substances heavily and on a daily basis [18-21, 42, 43]. Other studies show a significant number of refugee youth try substances such as alcohol, which can lead to dependency on other substances. For example, one study reported that 19% of all surveyed refugee youth reported lifetime alcohol initiated substance use [47]. Furthermore, the findings showed substance abuse to be higher amongst      refugee youth compared to their non-refugee counterparts. Other studies conducted to compare substance abuse between refugee youth with urban and rural youth depicted significantly higher substance abuse amongst refugee youth from urban areas than their rural peers [11,16].

Risk Factors for Substance Abuse Amongst Refugee Youth
Findings show that the prevalence of substance abuse amongst refugee youth is linked to several risk factors. First, refugee youth use substances to cope with negative pre-and postmigration experiences [19][20][21]47]. Researchers also reported a link between substance abuse and past traumatic experiences such as childhood trauma [11,19,21,42,42,43,43]. For instance, some researchers reported that refugee youth consumed substances to cope with problems, angers, and, worst of all, to satisfy an addiction [11,18,19,21,42,43]. Apart from the use of substances to cope with premigration experiences, it is revealed that substance abuse problems may arise to cope with post-migration experiences in their host countries [19,21,42,43]. Researchers demonstrated a link between refugee youth substance abuse and experience of post-migration risk factors such as potential cultural and linguistic barriers, loss of identity, family separation, intergenerational conflicts, disengagement from mainstream education and employment opportunities, lack of housing, and dependence on welfare [18,20,42,43]. Potential attempts to identify with two different cultures, while dealing with the post-migration stresses, are suggested to increase the risk of substance abuse amongst refugee youth [40]. Furthermore, the mismatch between refugee youths' education and employment opportunities in the post-COVID world is expected to grow. This indicates that post-migration issues make refugee youth ultimately susceptible to substance abuse.
Findings also revealed that the ease of access and availability of substances play a role in the prevalence of substance abuse amongst refugee youth. Exposure to substances leading to the formation of the belief that drug use will create the desired effect, such as an escape from negative feelings, which eventually lead to abuse [19,21]. Most refugee youth were unaccompanied, unemployed, disengaged from school, or were homeless [19-21, 42, 43]. These factors make them vulnerable and expose them to substance abuse [42,43]. Findings also showed that some refugee youth had limited exposure to substances or never used substances before resettlement, but would regularly use substances after settlement [20]. Similarly, some refugee youth claimed to hold negative attitudes toward substance use, but given the accessibility and availability, they could still be tempted to use them [19,21,42,43]. The ease of access and availability of substances thus make refugee youth vulnerable to substance abuse. Moreover, socialisation with peers emerged in this scoping review as one of the risk factors that increase the prevalence of substance abuse amongst refugee youth. Findings reported that refugee youth abuse substances as a mean to socialise with their peers [11,[18][19][20][21]. For example, researchers indicated that refugee youth reported the use of substances as a way of building social connection and experience [18][19][20][21]. They also reported refugee youths coming together every day to consume substances [18][19][20][21]. The summary of these findings is presented in Table 3 below.

Consequences of Substance Abuse Amongst Refugee Youth
Given the prevalence of substance abuse and driven by the series of risk factors, the findings showed refugee youth experience various negative consequences. Evidence indicates that refugee youth with substance abuse issues had poor previous interactions with law enforcement and justice systems, with most of them reported as having spent time in prison [11,[18][19][20][21]. For example, studies demonstrated that refugee youth who reported negative interaction with the police experienced substance abuse [18,19,21]. Furthermore, a study comparing police interaction between refugee youth with substance abuse and non-refugee youth found that the number of refugee youth in trouble with the police was significantly higher than other rural and urban youth [11].
Findings also indicated that refugee youth have poor relationships with their respective families and become socially disconnected because of substance abuse [19,21,42,43]. Other researchers reported that refugee youth with substance abuse become unemployed in the long-term, making them drop out of school and become involved in violence and anti-social activities [18].
Apart from social interactions, refugee youth with substance abuse issues reported poor health and suicide attempts [11,19,21,40]. Results showed refugee youth suffer substance use disorder and other mental health issues as a result of substance abuse [11,41,42,42,43,43]. For instance, some refugee youth are diagnosed with psychosis and report increased risk of suicide due to substance abuse [11]. Findings also demonstrate that substance abuse amongst refugee youth causes physical health problems, such as severe tooth decay and permanent damage to blood vessels [11,19,21]. Damage to the blood vessels can even cause other health issues such as stroke or even death [11].

Interventions
The studies show a lack of targeted, culturally appropriate intervention strategies for treating substance abuse among refugee youth despite the revelation of the substantial negative consequences. Findings show that although some refugee youths are aware of the possible risk of substance abuse, there remains a lack of knowledge of appropriate strategies that could assist them to avert the potential risk [11,20,[41][42][43]. Among the ten articles, one indicated that refugee youth attended counselling, residential detoxification programmes, and self-imposed physical isolation to mitigate the negative consequences of substance abuse [19,21]. Surprisingly, results even showed that some refugee youth intentionally commit a crime to go to jail as the only way to stop substance abuse [19,21].

Discussion
This study mapped out the available literature on the prevalence, risk factors, consequences, and strategies to prevent substance abuse amongst the refugee youth to better understand the phenomenon. Evidence herein suggests that substance abuse is a prevalent phenomenon amongst refugee youth. The prevalence of substance abuse is concerning because consequences can be dire to an already disadvantaged group. For instance, research shows that some refugee youth consume substances on a daily basis. Consumption of substances can greatly affect their education, work, and physical health.
Furthermore, findings show that several risk factors exacerbated substance abuse among refugee youth. The factors investigated that were found to be linked with substance abuse among refugee youth include the availability of substances, the ease of accessing said substances, the need to cope with pre and post-migration stress and trauma, and social/peer pressure.
Given the complexity of these experiences, results indicate that refugee youth that are confronted with pre-migration and post-migration experiences could resort to substance use as a coping mechanism, which increases the risk of substance abuse. The use of substances to cope with post-traumatic stresses and pre-migration experiences coincides with the Acculturative Stress Model, which implies that resettling in a new country may be stressful and can contribute to substance abuse as a coping mechanism [40]. Coping strategies were also found to be largely associated with substance abuse [34]. Therefore, complex pre-migration and post-migration risk factors increase the prospect of substance abuse amongst refugee youth Table 4.
Researchers also examined and found that the ease of access and availability of substances may entice refugee youth to substance abuse. These youths acknowledged that the availability of the substance lured them to usage, even though they knew the risks associated with them. For refugee youth, the ease of access to substances can be attributed to different societal norms [34] and parenting styles [14]. Those from more authoritarian societies who resettle in western communities can exploit the norms of that country, thus catalysing substance abuse.
Similarly, socialising with peers has been found as a risk factor that increases the prospect of substance abuse among refugee youth [32]. Researchers reported that refugee youth consume substances to feel high and to "have fun" [19,21], while some initiated substance uses as a social experience [19,21]. The use of substances to socialize with peers increases the prospect of substance abuse among refugee youth.
Findings indicate that refugee youth suffer negative consequences because of substance abuse [19,21]. The consequences the refugee youth experience because of substance abuse is comprised of health, economic, and social aspects. Evidence demonstrates that refugee youth with substance  Intervention use [11] Substance use was significantly higher among refugee teenagers than among urban and rural teenagers. More refugee teenagers agreed that it is easy to gain access to alcohol (47.9%) from refugee camps. The refugee teenagers (25.4%) More refugee teenagers had drunk alcohol and smoked tobacco to feel high, to have fun, cope with friends, run from problems, get rid of anger, and satisfy an addiction No weaning strategy use [19,21] Refugee youth gathered in public spaces to consume alcohol on a daily or near-daily basis to cope Refugee youth abuse substances to cope with trauma, to cope with boredom and frustration, and as a social experience Self-isolation and counselling to reduce substance abuse [18] Refugee youth consume substances with most reporting daily or near daily Risk factors experience included family separation, disengagement from education and employment, and period of homeless No intervention mentioned [40] Young people of refugee backgrounds are at risk of developing substance use disorder Potential cultural and linguistic barriers put young, resettled refugees at a disadvantage when seeking help for their problems No intervention mentioned [42,43] Interviews with refugee youth revealed how the interrelated nature of risk factors may place young people from refugee backgrounds at heightened risk of experiencing substance abuse Refugee youth experience substance as a result of lack of service provision, social disconnection, housing/homelessness, and employment/education [41] Refugee at risk of substance abuse Risk factors linked to substance abuse are potential cultural and linguistic barriers No intervention mentioned [47] In the US refugee youth report lifetime alcohol initiation and past-month use. Half (52%) of all refugee youth surveyed-and three out of five (63%) ages 15 to 17report having initiated alcohol use No intervention mentioned [16] Among youth aged 20-24 years, 22.4% of males and 11.6% of females reported trying alcohol; 10.5% of males and 4.3% of females reported trying drugs. While smoking is of particular concern Prevention outreach for all behaviours directed at subgroups and areas identified as the highest risk. In addition to close access to drugs or alcohol from Israel abuse have poor interaction with the police and justice system, and most reported spending time in prison [20]. They also experience poor relationships with family and become socially disconnected. Other researchers reported that refugee youth become unemployed over the long-term, drop out of school, and are involved in violence [19,21,42,43]. There are also reports of mental and physical issues such as suicide and death [42,43]. The findings reinforced the previous research, which linked the phenomenon with social, health, and economic challenges [3,8,19,21]. The negative consequences are also exacerbated by a lack of knowledge in seeking professional assistance. The evidence of negative consequences amongst refugee youth has proven that substance abuse can have serious implications for an already vulnerable group such as refugee youths.
Much of the concern surrounding this issue relates to how substance abuse amongst refugee youth can be mitigated. Findings indicate that refugee youth lack significant knowledge of prevention strategies that could help them to reduce substance abuse. Only one study identified that refugee youth attended counselling or residential detoxification programmes, along with self-imposed physical isolation. However, substance abuse harm reduction strategies such as family functioning and social support, training programs and festivals, and media are not mentioned in the findings. Some substance-free strategies, which can also assist in mitigating substance abuse such as sports and exercise, are likewise not mentioned in the findings [10,48]. Understanding such prevention strategies can assist refugee youth in reducing the prevalence and negative consequences of substance abuse.
This scoping review highlighted additional opportunities for future research. Most of the articles suggest future studies that will include different genders in studies as researchers indicate a lack of gender parity and studies that focus on traditional cultural beliefs. More importantly, scholars recommend research on early detection and prevention strategies to mitigate the risk of substance abuse amongst refugee youth.

Conclusion
This scoping review provides a snapshot of studies on refugee youth substance abuse. The review highlights the need to explore the state of substance abuse amongst refugee youth as several pre-migration and post-migration risk factors exacerbate the vulnerability of this group. Their experiences and level of vulnerability to substance abuse require further investigation. Findings demonstrated a gap in research on mitigation strategies to reduce the prevalence and negative consequences of substance abuse. These results highlight the importance of understanding harm reduction as they demonstrate how refugee youth suffer numerous negative consequences and do not know the best strategies to overcome the substance abuse. Understanding and mitigating the substance abuse risk factors can lead to a reduction in the number of negative consequences. More importantly, understanding issues affecting refugee youth can assist them to resettle in a new country and avoid the risks associated with substance use and abuse.
The study's conclusion that there are insufficient interventions to mitigate the prevalence and negative effects is alarming. It appears that policymakers are focusing on the crisis's consequences rather than its fundamental causes. Prevention, treatment, and rehabilitation should be the focal points of such mitigation strategies. Evidence suggests the efficacy of cognitive behavioural therapies; however, given the social determinants of the risk factors as identified in this study, the design of such interventions should take into account certain socio-demographic and cultural factors. A comprehensive approach comprising of lifestyle modifications, medical care, detoxification support, psychotherapy, and so on should be considered, as opposed to a series of discrete interventions.
It would be significant for succeeding research to be conducted in a swath of countries to fully understand the extent, risk factors, and consequences of substance abuse amongst refugee youth. There are many barriers that prevent refugee youth from receiving and/or seeking substance abuse treatment. It is therefore important for policymakers, service providers, and other stakeholders to engage with the refugee youth and co-design need-based, culturally appropriate intervention strategies.
Funding Open Access funding enabled and organized by CAUL and its Member Institutions

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There are no human subjects in this article; hence, informed consent is not applicable.

Competing Interest The authors declare no competing interests.
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