The Health Needs of Syrian Refugees in Context of Social Determinants of Health: The Case of Turkey

Abstract

Aim:

This study aims to determine the health needs and access to health services among Syrian refugees.

Methods:

This cross-sectional study was carried out between March and September 2022 in a public setting that provides humanitarian aid in Istanbul Province. The sample included 150 participants who met the inclusion criteria. The data were collected through 20–30-minute face-to-face interviews using the Omaha System Problem Classification Scheme and the sociodemographic characteristics questionnaire. All data were transferred to IBM Statistical Package for the Social Sciences Statistics software, version 28.0, for analysis. Descriptive statistics and chi-square significance tests were performed.

Results:

The result of the analysis revealed that the health problems of Syrian refugees were mostly related to the physiological domain (13/39.3%), followed by the psychosocial domain (9/27.2%), health-related behaviors domain (7/21.2%), and environmental domain (4/12.1%).

Conclusion:

This study highlighted the fact that refugees continue to be vulnerable to social determinants of health. In this context, it is recommended to develop new policies to reduce poverty, increase access to health and other public services, and empower refugees.

Introduction

Social determinants of health (SDOH) have been defined as “the conditions in which people are born, grow, live, work, and age, as well as the broader set of forces and systems shaping the conditions of daily life” (Commission on Social Determinants, 2008). Migrants are more vulnerable to SDOH compared to host communities due to challenges such as employment, education, access to healthcare, legal status, poverty, exclusion, sociocultural norms, and language barriers (Davies et al., 2006; Torun et al., 2018).

Recent data provided by the United Nations High Commissioner for Refugees indicates that 89.3 million people worldwide have been forced to abandon their homes, of whom only about 27.1 million have refugee status (UNCHR, 2022b). Migration mobility has significant consequences not only for migrating communities but also for host countries. Migrant communities may consist of scientists, artists, or workers with knowledge, experience, and skills that impact the labor market in both high- and low-skilled occupations (OECD, 2014). While it is considered an opportunity for migrants to contribute to the development of host countries, it also carries disadvantages in terms of overburdening public provisions (Alshoubaki & Harris, 2019; Atar et al., 2022). On the other hand, displaced persons typically have poor health profiles due to their low socioeconomic status and carry a variety of migration-related problems, including injury, communicable and noncommunicable diseases, and psychological disorders. This migration mobility may lead to increased mortality and morbidity rates in host countries (Tuncay et al., 2022).

The Arab Spring, which started in the Middle East in 2011 and spread to Syria, became a historical turning point by causing millions of deaths, injuries, and extraordinary mass migrations (Karakoç Dora, 2020). Neighboring countries such as Lebanon, Jordan, Iraq, and Turkey have shouldered the burden of this humanitarian catastrophe for over 10 years by opening their doors to Syrian refugees seeking shelter (El Arnaout et al., 2019). Over 13 million Syrians live in Jordan, including 670,637 registered refugees, of which 129,822 are housed in camps. The remaining refugees sought resettlement in urban and rural areas. Social cohesion has been impaired due to internal migration mobility on the one hand and climate change and constant water scarcity on the other. Access to primary care for Syrians has been severely hampered by the impact of coronavirus disease 2019 (COVID-19) on Egypt’s and Iraq’s already subpar public health systems (UNICEF, 2022). Turkey is home to approximately 3.8 million forcibly displaced individuals, with the majority being Syrian nationals, totaling 3.6 million (UNCHR, 2022b). In the scope of the “Temporary Protection Regulation,” Syrian refugees are entitled to access most basic public services, such as health, education, and social assistance free of charge, although they may incur nominal fees for some medications. Unregistered refugees are limited to receiving basic healthcare only in emergency situations (Assi et al., 2019; Ekmekci, 2017; National Legislative Bodies, 2022). The COVID-19 pandemic has compounded the challenges faced by refugees in Turkey, causing job losses, difficulties in meeting basic needs, and barriers to accessing health services (Relief International, 2020). It is crucial to identify the up-to-date health needs of this vulnerable group and to develop new targeted interventions to address their well-being. The purpose of this research is to comprehensively determine the health needs of Syrian refugees.

Research Questions

1. What are the health needs of Syrian refugees?

2. How is the refugees’ access to health and other public services?

3. Is there a significant relationship between age, gender, education level, duration of residence, and health problems?

Methods

Study Design

This is a cross-sectional study.

Sample

The sample for this study consisted of 150 Syrian refugees who applied for assistance at the foreigners and immigrants’ office of a municipality in Istanbul and voluntarily participated in the study between March and September 2022. Participants were recruited from the volunteers using a convenient sampling method and were included in the study if they met the following criteria: Syrian nationality, temporary protection status, proficiency in at least one of the Arabic or Turkish languages, age 18 or above, and registration in any province of Turkey.

Data Collection Tools

The Omaha System Problem Classification Scheme and a sociodemographic characteristics questionnaire were used as data collection tools. The Turkish reliability and validity of the Omaha System were established by Erdogan and Esin (2006), and it was used to assess the health problems of Syrian refugees in 2014 (Ardic et al., 2019). The sociodemographic characteristics questionnaire was prepared in accordance with the literature review and included information about age, gender, marital status, employment status, number of children, education level, chronic illness, number of people in the family, residence time in Istanbul, and type of residence. The Omaha Problem Classification Scheme is an appropriate tool, including a list of 42 problems and 335 signs and symptoms, to systematically assess individuals, families, and communities’ potential risks or actual problems in the domains of environmental, psychosocial, physiological, and health-related behaviors.

Data Collection

The research data were collected through 20–30-minute face-to-face interviews and observations by the researcher. During the interview, the researcher noted important points that could contribute to the study with the participants’ consent. The data were collected by a researcher who speaks the Arabic language.

Statistical Analysis

The data collected for this study underwent rigorous analysis utilizing the Statistical Package for the Social Sciences Statistics software, version 28.0 (IBM SPSS Corp.; Armonk, NY, USA). For numerical data pertaining to sociodemographic characteristics and health problems, mean and standard deviation were computed, while categorical data were expressed as percentages (%) through descriptive statistics.To ascertain the relationship between demographic features and health problems, a Chi-square significance test was employed, with a significance level set at p< .05.

Ethical Consideration

This study was conducted within the framework of the Declaration of Helsinki and with the permission of the Social Sciences Research Ethics Committee (Approval No: 2022.070.IRB3.023, Date: February 25, 2022). Participants were informed about the study, and verbal consent was obtained from individuals who volunteered to participate.

Results

Of the refugees participating in the study, 72% were women, and 87.3% were married. While the number of illiterate individuals was 13.3%, primary school accounted for 46.0%, secondary school for 22.0%, and the number of high school and higher graduates was only 18.7%. The average age of the participants was 40.8 ± 12.5. The number of children per capita was 3.84 ± 1.8, and the household size was 5.7 ± 2.08. The average residence time in Istanbul was 7 ± 2.03 years. 82% of the participants were unemployed, 18.8% of them had no income, and the average monthly income was $161 (3055 TL). Additionally, 54% had a chronic illness. All participants resided in apartments, and 60% of them resettled on the basement and ground floors, with 100% paying rent.

In this study, which aims to determine the health problems of Syrian immigrants, 33 problems and 190 signs and symptoms were identified in 150 individuals. Health problems were mostly related to the physiological domain (13/39.3%), followed by the psychosocial domain (9/27.2%), the health-related behaviors domain (7/21.2%), and the environmental domain (4/12.1%). According to the problem list, the priority needs of the participants were mostly related to income (97.3%), followed by communication with community resources (83.3%), nutrition (81.3%), housing (77.3%), healthcare supervision (74.0%), oral health (62.0%), mental health (55.3%), digestive issues (54.7%), and social contact (50%), respectively. Other frequently reported problems among Syrian migrants included sanitation, vision, urinary function, neuromusculoskeletal function, communicable/infectious conditions, and substance use (as shown in Table 1). Problems with signs and symptoms are shown in Table 1. Furthermore, education was found to be statistically associated with communication with community resources and social contact problems (Table 2).

Table 1.

Identified Health Problems with Signs/Symptoms Using the Omaha Problem Classification Scheme (N=150)

Domain	Problem	n	%	Signs and Symptoms	n	%
	*Income	146	97.3	Low/no income	125	83.3
				Buying only necessities	21	14
				Difficulty buying necessities	125	83.3
Environmental domain	*Sanitation	65	43.3	Dirty living area	39	26
				Inability to store and dispose of food	14	9.3
				Presence of insects/rodents	52	34.7
				Foul odors	29	19.3
				Inability to supply water	9	6
				Inadequate sewer system	17	11.3
				Insufficient laundry conditions	8	5.3
				Infection and contamination agents	40	26.7
	*Residence	116	77.3	Structurally unsound	78	52
				Inadequate heating/cooling	56	37.3
				Inadequate/crowded living space	67	44.7
				Other	59	39.3
	Neighborhood/workplace safety	23	15.3
Psychosocial domain	*Communication with community resources	125	83.3	Unfamiliar with options/procedures for obtaining services	81	54
				Difficulty understanding the roles/regulations of service providers	34	22.7
				Unable to communicate concerns to provider	107	71.3
				Dissatisfaction with services	47	31.3
				Language barrier	107	71.3
				Cultural barriers	78	52
				Educational barriers	91	60.7
				Transportation barriers	9	6
				Limited access to care/services/goods	82	54.7
	*Social contact	75	50	Uses healthcare providers for social contact	15	10
				Limited social contact	75	50
	Role change	11	7.3
	Interpersonal relationship	39	26
	*Mental health	83	55.3
	Spirituality	31	20
	Grief	10	6.7
	Caretaking/parenting	35	23.3
	Abuse	32	21.3
Physiological domain	Hearing	11	7.3
	*Vision	70	46.7
	*Oral health	93	62	Missing/broken/malformed teeth	87	58
				Caries	83	55.3
				Sensitivity to hot or cold	11	7.3
	Pain	25	16.7
	Skin	15	10
	Neuromusculoskeletal function	51	34
	Respiration	15	10
	Circulation	28	18.7
	*Digestion–hydration	82	54.7	Nausea/vomiting	9	6
				Indigestion	18	12
				Reflux	43	28.7
				Anemia	45	30.0
				Anorexia	9	6
	Bowel function	36	24
	Urinary function	49	32.7
	Reproductive function	27	18
	Communicable/infectious condition	51	34
Health-related behaviors domain	*Nutrition	122	81.3	Overweight	47	31.3
				Exceeds established standards for daily caloric/fluid intake	17	11.3
				Unbalanced diet	108	72.0
				Does not follow recommended nutrition plan	28	18.7
				Insufficient food intake/preparation	108	72
				Hyperglycemia	12	8
	Sleep and rest patterns	46	30.7
	Personal care	43	28.7
	Substance use	63	42
	Family planning	40	26.7
	*Healthcare supervision	111	74	Fails to obtain routine/preventive healthcare	107	71.3
				Fails to seek care for symptoms requiring treatment/evaluation	55	36.7
				Fails to return as requested to healthcare provider	6	4
				Inability to coordinate multiple appointments/treatment plans	7	4.7
	Medication regimen	27	18

Note: *Mostly reported health problems.

Table 2.

Association Between Demographic Characteristics and Health Problems of Syrian Refugees (N=150)

Problem	Education Level		Yes	No	Total	Chi-Square	df	Sig.
Communication with community resources	Low (0–eighth grade)	Observed Count	107	15	122	8.993	1	.009*
		Expected Count	101.7	20.3	122
	High (≥ ninth grade)	Observed Count	18	10	28
		Expected Count	23.3	4.7	28
	Total		125	25	150
Social contact	Low (0–eighth grade)	Observed Count	66	56	122	4.391	1	.036*
		Expected Count	61	61	122
	High (≥ ninth grade)	Observed Count	9	19	28
		Expected Count	14	14	28
	Total		75	75	150

*p <.05

Discussion

The health of individuals is affected by multiple layers of social determinants, including biological factors like age and gender, lifestyle choices, social and community impact, living/working circumstances, and broad socioeconomic, cultural, and environmental factors (Davies et al., 2006). In the context of SDOH, the findings of our study illustrated that Syrian refugees live in poverty and maintain their lives with no or low income and high unemployment levels. Workers were mostly employed in temporary, low-skilled, and risky jobs such as construction, industry, apparel, or collecting recyclable items. They were working for low wages and without social security. Difficulties in finding a job and a lack of consistent income severely limit refugee households’ ability to cover their necessities, including food (Doctors of the World, 2019). Most refugees with low or no income reported having difficulty paying rent and meeting their food, electricity, and natural gas needs, and they were in debt to survive. According to a study conducted in Jordan, only 51% of Syrians work in a salaried job, and 90% have debt. 32% of the refugees borrow money from their neighbors and other relatives to pay their rent, 26% to buy food, and 20% to pay for health expenses (UNCHR, 2022a). Likewise, the “Vulnerability Assessment of Syrian Refugees” report conducted in Lebanon showed that despite the increase in international aid, 88% of Syrian refugees were living below the survival minimum expenditure and had difficulties meeting their basic needs (UNCHR, 2021). Furthermore, participants in our study stated that poverty pushed children to drop out of school and work when the men, traditionally the breadwinners of the household, could not earn their livelihood. In a study conducted with 308 Syrian refugee children in the province of Elazig, it was determined that 341% of the children were employed (Aytaç & Kılınç, 2021). Studies showed that the factors that trigger Syrian child labor are poverty, parental unemployment, the desire to support the family, and the large number of members in the family. Child workers are likely to be physically, emotionally, sexually, or economically abused due to cheap labor (Harunoğulları, 2016). Local governments need to develop mechanisms to address and handle this issue, particularly since being a refugee could increase this risk.

Participants shared that they live with their relatives or friends in old buildings with high humidity (data reported as “others”) and live under inadequate heating conditions. A similar report in Lebanon highlighted that 57% of the refugees live in houses that are overcrowded, below humanitarian standards, and in danger of collapse (UNCHR, 2021). In the report of the Ministry of Health in 2018, it was stated that while 54.1% of the Syrian refugees were heating with wood or coal and 134% were using electric heaters, only 38% were not using heating. In addition, 72.6% of the participants in the study met their drinking water needs from tap water, 16.6% from carboys, and 52% from purification devices (Republic of Turkey Ministry of Health, 2018). The present study illustrated that the number of participants who have difficulty accessing water is too low while they have difficulty accessing heating.

Despite all the advancements in the healthcare system, our findings showed that refugees have difficulty accessing services due to a language barrier. The largest group that frequently encountered a language barrier was women. Women were culturally responsible for housekeeping and childcare, and their lack of inclusion in business life had a negative impact on both their social relationships and language acquisition processes. Women who were not able to speak Turkish sustained their lives by receiving translation support from their own children. While the acquisition of a second language by refugee children supports their access to services, limited awareness of the health system and a lack of education complicate matters. As a result, many refugees have trouble communicating with Turkish healthcare professionals, government representatives, and host communities (Zhang & Worthington, 2021). Participants stated that they were paying for private translation services due to not being able to explain their health issues or understand the referral/medication/treatment process. In the previous study, it was found that only 94% of Syrian women and 10.1% of men were able to read and understand issues such as patient rights and responsibilities (Mipatrini et al., 2019). The Turkish government has been attempting to overcome the Turkish–Arabic language barrier by employing Syrian healthcare professionals at migrant health centers and interpreters in public hospitals, but there is still a lack of interpreters (Assi et al., 2019). In contrast to the study of Mipatrini et al. (2019), which found that 57.0% of participants could access family health center services, every participant in our study reported being able to access primary healthcare services. However, 83.3% reported having trouble accessing secondary/tertiary health services and other resources. It could be said that migrant health centers contribute to the increase in Syrian refugees’ access to primary health services. Moreover, the Arabic language sets a barrier between refugees and host communities in terms of interaction. Previous research also revealed that although immigrants are willing to communicate with locals, the negative effects of the language barrier persist, and being educated and fluent in a language makes immigrants feel safer (World Food Programme, 2020).

Social determinants of health include not only physical factors but also interpersonal factors that affect mental health. Although the mental health of asylum seekers is closely related to traumatic events prior to migration, the long-term financial inadequacies, uncertainties, discrimination, and social exclusion they face post-migration also have a negative impact on their health (Hynie, 2018). Mental health problems reported in this study were associated with sadness due to social isolation, being away from relatives, low socioeconomic conditions, fear of being deported to Syria, as well as feeling insecure. Similar to our results, Acarturk et al. (2021) reported the prevalence of anxiety at 36.1% and depression at 34.7%, and the associated factors were being female, economic condition, unmet social support, safety, and law (Acarturk et al., 2021). A systematic review on mental health among refugees highlights the high rates of mental disorders among Syrian refugees, as well as the need for additional research to identify the specific needs of refugees during the post-resettlement period (de Lima Sá et al., 2022).

Another significant finding in this study was the “healthcare supervision” problem. Most participants were not aware of preventive health services or early diagnosis and did not receive any consultancy service from migrant health centers regarding mammography, pap smear tests, and so on. Others stated that they did not apply to the health center even for existing health problems and that they felt the need to receive health services only in emergencies. They emphasized that problems such as vision or hearing were not important enough to apply to the hospital. These statements show the difference in the level of cultural perception of health. Our findings were consistent with the literature. The previous study stated that only 43% of women were aware of pap smears, 48% were aware of mammography screening, and 71.9% of women did not receive antenatal care during pregnancy (Mipatrini et al., 2019).

Study Limitations

This study has some limitations. First, the cultural and language differences between the participants and the researcher may have influenced the participants’ responses. It is possible that participants may have had difficulty fully expressing their experiences. Second, it is important to acknowledge that the financial support provided in the public setting where the study was conducted could introduce potential bias. Participants may have exaggerated their living conditions in a negative way to receive more assistance or ensure the continuation of support. This potential bias should be considered when interpreting the results and may limit the generalizability of the findings.

Conclusion and Recommendations

This study revealed that Syrian refugees were living on low incomes and continue to face difficulties in meeting their basic needs, such as nutrition, shelter, and sanitation. To address these issues and mitigate associated risks while also reducing poverty, we recommend the creation of new job opportunities with state-supported employment for qualified refugees, along with the provision of vocational training for unskilled refugees. Communication problems with community resources and challenges in social interactions were common among Syrian refugees, and these issues were closely related to educational levels. The language barrier was cited by the refugees as the reason for the problems in communicating with community resources. Thus, we suggest an increase in language courses to help alleviate this language barrier. In addition to physiological health concerns, it was also determined that mental well-being was low. Culturally sensitive mental health support programs could be implemented to enhance the psychological well-being of the refugees. Another remarkable result of this study was the insufficient access to health services and healthcare supervision due to a lack of awareness about preventive health services. To tackle this gap, we recommend the organization of awareness campaigns through primary healthcare services.

In conclusion, this study highlights the need for intervention programs such as economic empowerment, language education support, access to health services, health education, and psychosocial support. Policymakers may contribute to the improvement of the quality of life and well-being of this vulnerable population by developing new policies and supporting programs not to leave anyone behind. This study showed that the Omaha Problem Classification List offers an opportunity for public health nurses to assess the health needs of migrants in an inclusive and facilitating manner, even within institutions beyond health centers.

Data Availability

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to their containing information that could compromise research participant privacy and consent.

Funding Statement

The authors declared that this study has received no financial support.