Vulnerabilities of Arab refugees in primary health care: a scoping review

Lima Junior, Luiz Paulo de; Lima, Kayte Chaves Oliveira de; Bertolozzi, Maria Rita; França, Francisco Oscar de Siqueira

doi:10.11606/s1518-8787.2022056003691

Brasil

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Review • Rev. Saúde Pública 56 • 2022 • https://doi.org/10.11606/s1518-8787.2022056003691 linkcopy

Vulnerabilities of Arab refugees in primary health care: a scoping review

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

OBJECTIVE To map and analyze the vulnerabilities of Arab refugees in the context of primary health care.

METHOD Scoping review in which studies published in English, Spanish and Portuguese languages from 2011 onwards were reviewed. The following databases were surveyed: Cochrane, Scopus, Health System Evidence, MedLine-PubMed, CINAHL, Embase, Lilacs, Web of Science, SciELO, NYAM Grey Literature, BVS, Capes Thesis and Dissertation Database, Refworld and Journal of Refugee Studies. Data were analyzed in light of the concept of vulnerability.

RESULTS Of the 854 studies identified, 40 articles were held for analysis and extraction of vulnerability indicators in the individual, social and programmatic dimensions. Regarding the individual dimension, the main indicators identified were unemployment, unstable and overcrowded housing, lack of sanitation and access to water, mental disorders, communicable and chronic noncommunicable diseases, etc. In the programmatic dimension, were identified, mainly, health teams with work overload, lack of preparation to deal with cultural and linguistic barriers, and delays in providing care. In relation to the social dimension, lack of access to schools, to information about health programs in the host countries, and to rights, among others, were found.

CONCLUSION Vulnerabilities found highlight the disadvantage of refugees regarding health programs, services and system in host countries, in addition to highlighting the deep inequalities that affect this group. It is pointed out the need for programs and policies that promote actions, within the scope of primary health care, which recognize and respond to the health needs of refugees.

Refugees; Arabs; Health Services Needs and Demand; Primary Health Care; Health Vulnerability; Review

Author/year	Type of study	Objective of the study	Population of the study	Vulnerabilities identified

				Individual	Programmatic	Social
UNHCR/UNICEF ¹⁷ (2016)	Qualitative and quantitative mixed method semi-structured interview, survey and focal group.	Provide multi-sector view on the status of Syrian refugees in Lebanon.	23,000 Syrian refugees, 4,561 children younger than 5 years.
				93%: some degree of food insecurity (1.8 meals/day). Chronic (43%) and mental (12%) diseases. Children: 41% sick in the two weeks prior to the study. Symptoms: fever (31%), cough (25%) and diarrhea (15%). Overcrowded housing and no toilets (27%).		84% of children of 15 to 17 years old out of school. Causes: cost of education, child labor and marriage, cultural reasons, and cost of transportation. 70%: below poverty line ($3.84/day/person).
Hosten E. et al. ¹⁸ (2018)	Quantitative Retrospective Study.	Assess the prevalence of active and latent Tuberculosis (TB), risk factors for latent TB, and the performance of the Jordanian TB program.	76 Syrian refugees with TB (index cases). 481 contacts.	High prevalence of active and latent TB among contacts of TB patient. In contacts: prevalence of active and latent TB in children under 5 years old is 2 times higher than among adults.	Cure rate among index cases: 28.9%. Among women: 7.9%. Low adherence to treatment: 43.4%.
Truppa. C. et al. ¹⁹ (2019)	Quantitative Cross-sectional Survey.	Determine the impact of primary health care (PHC) on vulnerable populations. Identify barriers to the use of health services.	656 Syrian refugees in Lebanon.	Most common reasons for seeking care: Chronic noncommunicable diseases (40.6%): arthritis, musculoskeletal conditions, hypertension and diabetes; sexual and reproductive health conditions (28.6%). Communicable diseases affecting children (37.8%).	Most important barrier to using the services: lack of access to information about the services offered (54.2%). Low vaccination coverage. Low level of prenatal care and family planning. 80.9% had to pay additional amounts for health services in PHC.	-
Doocy. S; Lyles, E. ²⁰ (2017)	Quantitative Unidentified Survey Design.	Identify unmet needs and priorities for assistance in families undergoing displacement, and headed by women.	2,045 Syrian refugee families.	Families undergoing displacement and headed by women: most vulnerable. Food insecurity.
Ay, M. et al. ²¹ (2016)	Quantitative Cross-sectional Analytical Observational.	Identify health care service needs, accessibility to services, and barriers to access	196 Syrian refugees in Jordan.	56.6% sought PHC for acute illness in adults, and 53% in children. 36% reported chronic illnesses.	Discrimination by staff. Barriers to access: cost, long waiting hours, distance to health service, late appointments.	Lack of information about the provision of free of charge family planning services.
Al-Rousan, T. et al. ²² (2018)	Qualitative-quantitative. Mixed Methods.	Determine health needs from the perspective of refugees, health care team, and other stakeholders.	185 Syrian refugees in Jordan. 75 in the camp (41 men) 110 urban (65 women)	Respiratory illnesses associated with the desert climate of the camp. Chronic illnesses.	Shortage of transportation to reach the UBS. Shortage of female medical professionals for perinatal care. Overloaded health team.	Due to stigma, they don not report mental health care needs Poor housing conditions.
Cherri, Z. et al. ²³ (2017)	Qualitative Focal Group Interview thematic analysis.	Understanding needs, preferences, behaviors, and barriers to reproductive and sexual health.	108 Syrian refugee women (15 to 49 years old) in Lebanon.	High birth rate worsening socioeconomic condition. Early marriage (14 years) due to economic scarcity.	Cost reported as barrier to access. Lack of access to information on contraceptive methods.	42% did not use any contraceptive method. Forced migration reported as cause for non-use.
Doocy, S. et al. ²⁴ (2015)	Quantitative Cross-Sectional Study.	Characterize the prevalence of Noncommunicable Diseases.	9,580 Syrian refugees in Jordan (1,550 families) - 0 to over 60 years old	50% report a family member with a chronic noncommunicable disease.	Health policies that abrogate rights (in 2014: established payment of fees to obtain public health care).	Low access to education for heads of household. Lack of access to information regarding the supply of health services.
Gammoh, O.S. ²⁵ (2016)	Quantitative Cross-Sectional Study.	Describe complaints, diagnoses, and medication consumption.	375 Syrian refugees in Jordan, 0 to over 70 years old, 213 Women (56.8%). 162 Men (43.2%).	Infectious, chronic, cardiovascular (hypertension), musculoskeletal, gastrointestinal, respiratory, and skin diseases. Complaints: pain (throat, gastrointestinal), cough, shortness of breath, skin rash, fever, dizziness, weakness, anxiety symptoms, dental and vision problems.
Kakalou, E. et al. ²⁶ (2018)	Descriptive Quantitative Cross-Sectional Study.	Describe the morbidity profile of the refugee population in Europe in 2015-2016.	3,076 Syrians, 1,270 Iraqis.	Infectious diseases. Musculoskeletal, skin conditions, trauma/injury (caused by accident/violence). Cardiovascular, endocrine, respiratory, neurological, autoimmune, and congenital diseases Dental or oral cavity conditions. Women’s reproductive conditions, mental health, malnutrition, weakness, anemia, scabies and lice, substance abuse (psychotropic and alcohol).	50% of consultations with specialists were offered by NGOs (failure of the local health system to offer expert personnel).
Sethi. S. et al. ²⁷ (2017)	Quantitative Unidentified Study Design.	Identify care gaps in noncommunicable diseases.	640 Syrians in Lebanon. 320 adults over 18 years of age. 300 children under 2 years of age.	Communicable and noncommunicable diseases.	Lack of transportation, lack of time to go to health facility and cost: reported as barrier in access.	Low education of mothers: 40.3% have no formal education. 20% with complete primary education
Aoun, A; Joundi, J; El Gerges, N. ²⁸ (2018)	Quantitative Cross-Sectional Study.	Examine the prevalence of eating disorders, and association with sociodemographic and clinical variables.	450 Syrians in Lebanon. 69 Men and 381 Women (18 to 45 years old).	Post-traumatic stress disorder, eating disorders, overweight and unemployment.	-	48% can only read and write in an elementary way.
Collins, D.R.J. ²⁹ (2017)	Qualitative-Quantitative Mixed Methods.	Determine the cardiovascular disease risk profile of the population.	2,907 Syrians in Jordan (18 to > 40 years old). 16 PHC team members.	Cardiovascular disease, dyslipidemia, diabetes and sedentary lifestyle.	Limited knowledge of health care team regarding protocols for cardiovascular disease.	Migration pattern impacted adherence to drug treatment.
Dogru, S; Doner, P. ³⁰ (2017)	Quantitative Retrospective and Descriptive.	Compare the frequency of new cases of pulmonary tuberculosis, and successful treatment.	33 Syrian refugees with Tuberculosis in Turkey.	Tuberculosis affects younger age groups among Syrians compared to the local population.	TB treatment goals were not met Lower cure rate among Syrians.
Doocy. S. et al. ³¹ (2016)	Quantitative Cross-sectional	Assess health status, unmet needs, and health service delivery.	1,376 families/8,257 Syrians in Lebanon (0 to > 60 years old).	Hypertension, cardiovascular disease, diabetes, chronic respiratory disease, and arthritis.	Need to pay for health services in PHC.
Segal, S. P. et al. ³² (2018)	Quantitative Cross-sectional Structured Interview Survey.	Assess the mental health status of Syrian and Palestinian refugees. Determine the prevalence of mental illness.	161 Palestinians, 47 Syrians and 46 Lebanese in Shatila camp in Lebanon.	High prevalence (52%) of mental disorders (10 times higher than local population).	Need to strengthen the mental health program in PHC.	High rate of people without schooling: up to 3 times more than the local population. Difficulties in access to justice, laws that restrict fundamental rights. Low access to the local economy. Live an average of 17 years in the camps. Lack of basic sanitation. Overcrowded camps. Insufficient housing.
Heenan, R.C. et al. ³³ (2019)	Quantitative Retrospective Study.	Review health conditions of Syrian and Iraqi refugee children in the context of screening at arrival in Australia.	128 children (7 months to 16 years).	Vitamin D deficit (63%), growth/nutrition deficits, neurological/metabolic disorders, related to learning/behavioral mental health, latent tuberculosis, developmental delay.	The most omitted screening tests were for tuberculosis (only 7.1% completed screening). Delayed vaccination schedule in children. Difficulty in access to tuberculin skin testing/PPD in PHC.	25% of children with difficulty in accessing education even after 3 months in the host country. Pre-arrival adversities: exposure to trauma, concern about parents’ mental health, concern about other families abroad, separation from a family member
Doocy, S. et al. ³⁴ (2017)	Qualitative-Quantitative Mixed Method Longitudinal Cohort Study.	Evaluate the effectiveness of treatment guidelines and a mobile health app (mHealth) on quality of care and health outcomes	793 Syrian Refugees in Lebanon with Type 2 Diabetes and Hypertension.	Uncontrolled diabetes (57.9%).	Team having difficulty in interacting with patient. Low percentage of patients who received lifestyle health counseling. Divergences between electronic data and written medical records.
Elliot. J.A. et al. ³⁵ (2018)	Quantitative Cross-Sectional Study.	Determine associations between patient factors, self-management, diabetes education and support.	292 Syrian Refugees in Lebanon (>18 to 84 years old) with Diabetes.	Diabetes (diagnosed in 30% of patients after the conflict in Syria). Long fasting (Ramadan) associated with insulin use.		Low educational level. Inability to recognize and respond to hypoglycemia (34%).
Javanbakht. A. et al. ³⁶ (2018)	Quantitative Cross-Sectional Study.	Determine the prevalence of mental disorders.	157 Syrians in the United States (18 to 65 years old).	Post-traumatic Stress Disorder (PTSD) (32.2%), anxiety (40.3%), and depression (47.7%), mainly after forced migration.
Torun. P. et al. ³⁷ (2018)	Qualitative-Quantitative Mixed Method.	Assess health needs of urban refugees in Istanbul.	111 families/8,901 Syrian refugees in Turkey.	Symptomatology compatible with sexually transmitted infection, chronic, pulmonary, cardiac, gastrointestinal, neurological, renal, psychiatric, musculoskeletal diseases, hypertension.	Pregnant women (60%) with difficulties in access due to language barrier, waiting time, queues, tense environments, and negative attitudes of the staff.	High rate of children dropping out of school due to migration (55%). Lack of aid for education and rent. 49.6% did not know about the right to free access to health care. Inadequate working conditions.
Lyles E. et al. ³⁸ (2018)	Quantitative Unidentified Design Survey.	Characterize access to and utilization of health services in Lebanon.	2,062 Syrian refugee families in Lebanon.	Communicable, and chronic noncommunicable diseases, injuries, skin diseases, pregnancy complications, gynecological, gastrointestinal, and eye problems.	Greater difficulty in access to medicines than local population.

Author/year	Type of study	Objective of the study	Population of the study	Vulnerabilities identified

				Individual	Programmatic	Social
Al Baz, M. Law, M. R. Saadeh, R. ³⁹ (2018)	Quantitative Cross-Sectional Study.	Study knowledge, attitudes and behaviors about antibiotic use.	250 Palestinians in Jordan. Mean: 32 years 205 women and 45 men over 18 years.	47% use of self-medication with antibiotics; Unemployment; Income below the national average.	Waiting hours in the health service.	-
Khader. A. et al. ⁴⁰ (2014)	Quantitative Cohort.	Report the complications of diabetes in a cohort of refugees.	119 diabetic Palestinians in Jordan aged 0 to > 60 years.	Diabetes, obesity, sedentary lifestyle, cardiovascular disease. 57% had additional risk of obesity (BMI > 30).	Progressive loss in treatment follow-up (p < 0.001) Progressive reduction in proportion of patients attending clinic each year (p < 0.001)	-
Riccardo, Flavia; Khader, Ali; Sabatinelli, Guido ⁴¹ (2011)	Quantitative Cross-Sectional Study.	Analyze trends in infant mortality, among Palestinian refugees (1995-2005).	14,202 children in Jordan, Lebanon, Syria, Gaza Strip and West Bank.	Infant mortality rate higher than local population. Low Birth Weight/ Prematurity. Congenital malformation associated with early pregnancy and consanguineous marriage. Respiratory infections.	Poor access to health care: main condition for neonatal death. Fragmented care, highly privatized health system.	-
Khader. A. et al. ⁴² (2014)	Quantitative Cohort.	Determine the outcomes of diabetes mellitus (DM) treatment.	2,246 Palestinians in Jordan aged 0 to > 60 years with DM.	81%: Diabetes + SAH. 58%: DM controlled.	Difficulty of staff to maintain treatment follow-up.
Al Kasseh, A. S. M. et al. ⁴³ (2013)	Quantitative Retrospective case control.	Determine the risk factors for gestational diabetes in refugee women.	189 Palestinian Women in the Gaza Strip. 18 to 36 years/Median age 34.1 years.	Risk factors for Gestational Diabetes: history of spontaneous abortion (more than 1) (p < 0.0001); Weight before pregnancy (p < 0.001); Family history of DM (p < 0.001); History of stillbirth (p = 0.002); Weight in pregnancy (p < 0.001).	Weakness of preventive policies in the postpartum period.	Low educational level was a factor associated (p < 0.001) with Gestational Diabetes.
Saadeh. R. et al. ⁴⁴ (2015)	Quantitative Unidentified Study Design.	Describe trends in use of antihypertensive drugs.	244,169 Palestinians in Jordan > 40 years.	Increase in prevalence of hypertension from 2008 to 2012.	Increase in program spending on antihypertensives drugs.
Khader. A. et al. ⁴⁵ (2014)	Quantitative Cohort.	Determine characteristics of refugees and the Hypertension program.	18,881 Palestinians in Jordan > 60 years old, with Hypertension	Hypertension, diabetes, obesity, congestive heart disease, sedentary lifestyle, acute myocardial infarction, stroke, and blindness.
Abouteir. A. et al. ⁴⁶ (2011)	Quantitative Prospective Case Control.	Investigate the relationship between diarrhea frequency and potential risk factors, including access to water.	3,338 Palestinians in the Gaza Strip. 266 patients with diarrhea, aged 0 to > 40 years.	Respiratory infection and diarrhea. Factors associated with diarrhea (p < 0.05): Socioeconomic status, poverty, unemployment, lack of access to public water, pets, poor sanitation.	Prescribed drug therapy does not follow WHO recommendations.
Alameddine. M. et al. ⁴⁷ (2019)	Qualitative Semi-structured Interview Thematic Analysis.	Understand the resilience of health systems.	61 Palestinians in Lebanon and Jordan; 37 in refugee camp/24 outside the camp;	PTSD, violence against women, depression.	Overloaded health care team, and high absenteeism rate. Stress in the work environment.
Khader. A. et al. ⁴⁸ (2012)	Quantitative Cohort.	Recording, monitoring and reporting chronic diseases.	4,130 Palestinians in Jordan with Hypertension from 0 to > 60 years.	Diabetes, cardiovascular disease, and hypertension.	Failure to measure blood pressure and blood glucose tests.
Bastin. P. et al. ⁴⁹ (2013)	Quantitative Cohort.	Identify mental diseases.	1,107 Palestinians, Iraqis and Lebanese - 18 to > 60 years.	28%: depression 15.6%: anxiety 11.5%: Psychoses.		Lack of access to education associated with mental health issues.
Khader. A. et al. ⁵⁰ (2012)	Quantitative Cohort.	Assess the quality of services for refugees with diabetes.	2,851 Palestinians in Jordan with Diabetes from 0 to > 60 years.	Diabetes, blindness, stroke, cardiovascular disease, and amputations.	Failure to maintain treatment adherence after 12-month period. Failure of the health care team to follow protocols.
Saleh. S. et al. ⁵¹ (2018)	Quantitative Randomized Controlled Clinical Trial.	Evaluate the effect of low-cost mobile health tools on accessibility to health services.	2,359 Palestinians in Lebanon 1,433 interventions 926 controls 40 to > 71 years old with DM and SAH.	Diabetes and hypertension.	The program showed weaknesses: maintaining annual eye checkup in patients with diabetes and hypertension, and in promoting smoking cessation. SMS did not generate clear intervention effect on the use of PHC services.
Khader. A. et al. ⁵² (2013)	Quantitative Cohort.	Report the number and characteristics of new refugees with DM.	12. 550 Palestinians in Jordan with Diabetes from 0 to > 60 years.	Type I and II diabetes, hypertension, smoking, sedentary lifestyle, obesity. Complications of diabetes: acute myocardial infarction, end-stage renal disease.

Author/year	Type of study	Objective of the study	Population of the study	Vulnerabilities identified

				Individual	Programmatic	Social
Worabo, H.J. et al. ⁵³ (2016)	Qualitative In-depth focal group Phenomenological Analysis	Understand newly arrived refugees’ perceptions of the US healthcare system.	10 Iraqis (> 18 years old) in the US; 7 Men.	Infectious diseases, malnutrition, and mental health problems. Reluctance to adhere to latent TB treatment because they had no symptoms, and did not feel sick.	Language barriers caused abandonment of treatment. Lack of interpreter-translator. Team does not listen to complaints. Long wait for a consultation at the PHC.	They do not look for PHC because they cannot afford a translator, and due to the high cost of health services.
Goosen. S. et al. ⁵⁴ (2014)	Descriptive Population Quantitative Study.	Map the prevalence and incidence of diabetes.	9,436 Iraqis in the Netherlands. 1,169 Syrians. Age Group: 20 to 79 years old.	Diabetes: twice as prevalent among refugees compared to the local population
Van Loenen. T. et al. ⁵⁵ (2018)	Qualitative Semi-structured Interview / Thematic Analysis.	Understand refugees’ health needs, barriers to access, and desires regarding PHC.	39 Syrians, 12 Iraqis in Greece, Slovenia, Croatia, Hungary, Netherlands, Italy, Austria.		Lack of mental health service provision in PHC. Lack of healthcare continuity. Difficulties in finding medical care at the busiest borders.
Kvittingen. A. et al. ⁵⁶ (2018)	Qualitative In-depth Interview.	Understand the experiences of Syrian and Iraqi refugees, and their migration aspirations.	62 refugees in Jordan: 32 Iraqis and 30 Syrians.	Lack of formal employment. None of the respondents were able to obtain legal residency.	Policies of revoking free access to public health and education, and limiting access to international humanitarian assistance.	50.0% of respondents had concrete plans to leave the country due to restrictions and lack of opportunities.
Doocy. S; Burnham G. ⁵⁷ (2011)	Quantitative Unidentified Design.	Provide information on family economy and livelihoods of Iraqi refugees in urban area of Syria.	800 families of Iraqis in Syria.	Overcrowding of accommodations. Only 12% with stable work; heavy work; child labor; long work hours/week; underpayment or no payment for work done.	Unawareness about access to family planning services.	Poverty related to low educational status.

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