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01.12.2012 | Research | Ausgabe 1/2012 Open Access

International Journal for Equity in Health 1/2012

A retrospective study of demographic parameters and major health referrals among Afghan refugees in Iran

Zeitschrift:
International Journal for Equity in Health > Ausgabe 1/2012
Autoren:
Salman Otoukesh, Mona Mojtahedzadeh, Dean Sherzai, Arash Behazin, Shahrzad Bazargan-Hejazi, Mohsen Bazargan
Wichtige Hinweise

Electronic supplementary material

The online version of this article (doi:10.​1186/​1475-9276-11-82) contains supplementary material, which is available to authorized users.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

SO, MM, AB and D.SH were involved in the study from the design to the final manuscript. MM, MB and SH.B-H analyzed the data. AB drafted the first manuscript. SO, D.SH and MB reviewed the paper. All authors have read and approved the final manuscript.

Introduction

Afghanistan’s domestic upheaval in the 1970’s, followed by the Soviet occupation in 1979, resulted in a massive displacement of its population. After the Soviet withdrawal in 1989 and the removal of the communist regime in 1992, about three million Afghans returned from exile. However, neither the rise of the Taliban in 1994, nor their fall in 2001, mitigated the challenges facing the diaspora who fled the country in different waves, and have had to maintain their immigrant status.
Years of conflict have inflicted near fatal wounds upon the healthcare infrastructure throughout Afghanistan. According to the Ministry of Public Health (2009), the country has suffered a devastating decline during the past three decades, with human and socio-economic indicators hovering near the bottom of international indices[1]. For nearly three decades, the neighboring countries of Iran and Pakistan have hosted millions of Afghans. Afghans today in fact represent the largest group of refugees in the world[2]. The Afghan situation in Iran is characterized by a) prolonged exile, b) large numbers (1,019,700 Afghan refugees as of July 2011), c) residence in urban areas, d) the emergence of a second generation, and e) a significant social support system provided by the host country[35]. These factors have largely shaped and determined healthcare for this population.
There is, however, a paucity of data on the health status of Afghans in exile. Previous studies were limited in scope in regards to sampling, or in areas of coverage. One clinic for Afghan refugees in Pakistan reported that most referrals were for gastrointestinal tract disorders, followed by respiratory tract complaints[6]. One research project in Northern Pakistan focused on the prevalence and etiology of visual loss and eye diseases in a resident Afghan refugee community[7]. A number of other studies have addressed tuberculosis (TB) and the mental health problems of Afghan refugees in Iran[815], Pakistan[16, 17], the United States[1821] and the Netherlands[22, 23]. The scarcity of health data is also a challenge in Afghanistan. According to the Afghan Ministry of Public Health (2011), minimal data exists on the current health status of the population and on resource allocations in the health sector[24].
The World Health Organization (WHO) has stated that Afghanistan is a country where there is limited knowledge on most causes of mortality and morbidity[25]. Afghanistan’s non-communicable diseases (NCD) country profile, as reported by WHO (2011), reveals that mortality estimates have a high degree of uncertainty because they are not based on any national NCD mortality data. These estimates are based on a combination of country life tables, cause of death models, regional cause of death patterns, and WHO and UNAID program estimates for some major causes of death. These do not include NCDs, which are estimated to account for 29% of all deaths in the WHO report[26]. Due to a paucity of research on the health status of Afghan refugees in Iran, this study aims to illustrate patterns of common diseases among Afghan refugees in Iran, and to use these data as an index for evaluating the performance of future health services.

Methods

This is a retrospective cross-sectional study that uses data collected from the UNHCR offices in Tehran and Mashhad. This database represents approximately 85% of Afghan refugees registered in Iran. These data were collected by two teams, each of which included at least three professional social workers and interviewers, one physician and one general purpose receptionist. These personnel, based in the UNHCR offices, held responsibility for extended areas in the central, northern and eastern parts of Iran.
Each case or patient approached UNHCR Offices for assistance, or were referred by hospitals, welfare, charity societies, or governmental and non-governmental organizations. Requests for assistance were screened and processed by the community and medical service teams through interviews conducted at home, in hospitals and in community visits. A report was recorded in the Community Integrated Social and Medical Assistance Program (CISAMAP) database by the interviewer after each case had given his or her consent. Records include all accepted and rejected cases for assistance, and are based on a list of referral causes (Additional file:1) to ensure reliable data entry. Medical assessment of each case rested solely with the CISAMAP physician.
Data extracted for this study is based on a sample of 23,167 registered Afghan refugees who were referred from 2005 to 2010, a six year period. Tables and graphs represent disaggregated data for age, gender and ethnicity of Afghan refugees for inter- and intra-group comparisons. This information was reviewed along with the Global Burden of Disease 2011 Report released by WHO. SPSS (version 18) was used initially for data analysis; tables and graphs were prepared in Microsoft Word 2010.

Findings

The total number of cases in this study was 23,152. Most referrals were for females (52.6%), followed by males (47.66%) The most frequent causes for referrals were for ophthalmic diseases (23.7%), neoplasm (13.3%), nephropathies (11%), ischemic heart diseases (10.4%), and perinatal disorders (9.2%) (Additional file:1). The Hazara represented the largest ethnic group of Afghan refugees (40.47%), followed by the Tajik (22%), Pashtun (8.8%), Sadat (6.6%), Fars (5.25%), Baluch (3.1%), and Uzbek (2.51%). By age, 38% of Afghan refugees in Iran are 0 – 14, 59% are 15 – 59, and 3% are 60+[27], with the percentage of referrals to UNHCR being 29%, 54%, and 17% for each of these groups, respectively. The highest referral rate was for females 60+ years of age (17%); for every 100 women age 60 and older, 17 received referrals. The rate for men in the same age group was 0.13 (Table 1).
Table 1
Referral rates
 
0-14
15-59
60+
Total
 
Male
Female
All
Male
Female
All
Male
Female
All
 
Total in the country
199397
186027
385424
329384
271050
600434
21748
13717
35465
1021323
Respective provinces
150026
139967
289993
247829
203938
451767
16363
10321
26684
768444
Referrals
3449
3261
6710
5503
7082
12585
2081
1776
3857
23152
Referral rates
0.02
0.02
0.02
0.02
0.03
0.03
0.13
0.17
0.14
0.03
Sources: Amayesh 2005 for total in the country and respective provinces (estimated) and UNHCR Database 2005–2010 for referral.

Cause of referrals for different age groups

Prenatal disorders (30%), ophthalmic diseases (21%), and congenital anomalies (15%) made up about 66% of referrals for patients 0–14 years of age. Ophthalmic diseases, nephropathies, neoplasm, and ischemic heart diseases were the most common cause of referrals for those 15–59 years of age (total 64%), at 20%, 16%, 16%, and 12% respectively. Ophthalmic diseases, ischemic heart disease, and neoplasm constituted 74% of referrals for those 60 or older, at 41%, 21%, and 12% respectively Table 2.
Table 2
Causes of referrals by age and gender distribution
Cause of referrals
0_14
15_59
60+
Total
 
F
M
All
F
M
All
F
M
All
 
Ophtalmic disease
Count
80
580
1385
1591
790
2508
822
769
1591
5484
%
24.70%
16.80%
20.60%
24.30%
14.40%
19.90%
46.30%
37.00%
41.20%
23.70%
Neoplasms
Count
267
327
594
1143
870
2013
164
312
476
3083
%
8.20%
9.50%
8.90%
16.10%
15.80%
16.00%
9.20%
15.005
12.30%
13.30%
Nephropathies
Count
105
128
233
859
1181
2040
87
188
275
2548
 
%
3.205
3.70%
3.505
12.10%
21.50%
16.20%
4.90%
9.00%
7.10%
11.00%
Ischemic Heart Disease
Count
17
17
34
768
794
1562
389
412
801
2397
%
0.50%
0.50%
0.50%
10.80%
14.40%
12.40%
21.90%
19.80%
20.80%
10.40%
Perinatal disease
Count
1017
1020
2037
57
36
93
2
0
2
2132
%
31.20%
29.60%
30.40%
0.80%
0.70%
0.70%
0.10%
0.00%
0.10%
9.20%
Congenital anomalies
Count
485
531
1016
80
66
146
0
0
0
1162
%
14.90%
15.40%
15.10%
1.10%
1.20%
1.20%
0.00%
0.00%
0.00%
5.00%
Appendicitis
Count
86
119
205
370
461
831
6
7
13
1049
%
2.60%
3.50%
3.10%
5.20%
8.40
6.60%
0.30%
0.30%
0.30%
4.50%
Labor complications
Count
4
2
6
754
5
759
1
0
1
766
%
0.10%
0.10%
0.10%
10.60
0.10%
6.00
0.10%
0.00%
0.00%
3.30%
Deafness
Count
117
93
210
199
139
338
50
98
148
696
%
3.60%
2.70%
3.10%
2.80%
2.50%
2.70%
2.805
4.70%
3.80%
3.00%
Liver, Billiary, Pancreas disease
Count
14
20
34
381
134
515
72
72
144
693
%
0.40%
0.60%
0.50%
5.40%
2.40%
4.10%
4.10%
3.50%
3.70%
3.00%
Urinary disorders
Count
43
59
102
201
251
452
29
62
91
645
%
1.30%
1.70%
1.50%
2.80%
4.60%
3.60%
1.60%
3.00%
2.40%
2.80%
Neurologic disorder
Count
144
190
334
81
144
225
37
40
77
636
%
4.40%
5.505
5.00%
1.10%
2.60%
1.80%
2.10%
1.90%
2.00%
2.70%
Fractures
Count
30
77
107
91
372
463
25
37
62
632
%
0.90%
2.20%
1.60%
1.30%
6.80%
3.70%
1.40%
1.80%
1.60%
2.70
Hematologic diseases
Count
96
265
361
117
137
254
3
6
9
624
%
2.90%
7.70%
5.40%
1.70%
2.50%
2.00%
0.20%
0.30%
0.20%
2.70%
TB (all forms
Count
31
21
52
263
123
386
89
78
167
605
%
1.00%
0.605
0.80%
3.70%
2.20%
3.10%
5.00%
3.70%
4.30%
2.60%
Total
%
3261
3449
6710
7082
5503
12585
1776
2081
3857
23152
  
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%

Cause of referrals by gender

In our study, 12,126 females (52.34%) and 11,041 males (47.66%) received referrals. Although more females received referrals than males, they shared the most common causes, including ophthalmic diseases (9.2% vs. 14.4%), neoplasm (6.5% vs. 6.8%), nephropathies (6.4% vs. 4.5%), and ischemic heart disease (5.2% vs. 5%).

Cause of referrals by ethnicity

By ethnicity, the Hazara received the highest number of referrals (55%), followed by the Tajik at 14%, Fars at 11%, Sadat at 8%, Pashtun at 2%, and Uzbek at 1%. Ophthalmic diseases were the major cause of referrals with the Hazara, Tajik, Fars and Sadat at 26%, 20%, 26%, and 27% respectively. The disproportionate frequency of referrals among the Pashtun for neoplasmic disease (17%) is noteworthy, as with nephropathies among the Uzbek at 26%, and hematopoietic disorders (25%) for the Baluch Table 3.
Table 3
Cause of referrals by ethnicity distribution
Disease
BALOCH
FARS
HAZARA
PASHTUN
SADAT
TAJIKA
UZBEK
OTHERS
NOT INDICATED
TOTAL
Ophtalmic disease
Count
7
682
3310
58
490
635
17
157
129
5485
%
9.2
26.2
25.9
10.2
27.3
19.6
12.4
11.8
21.3
23.7
Neoplasma
Count
16
290
1646
99
172
493
17
242
109
3084
%
21.1
11.1
12.9
17.3
9.6
15.2
12.4
18.1
18
13.3
Nephropathies
Count
6
158
1461
61
219
371
35
188
49
2548
%
1.9
6.1
11.4
10.7
12.2
11.4
25.5
14.1
8.1
11
Ischemic Heart Disease
Count
5
437
1150
51
165
375
4
146
64
2397
%
6.6
16.8
9
8.9
9.2
11.6
2.9
10.9
10.5
10.3
Perinatal disease
Count
1
203
1140
72
188
305
10
134
85
2138
%
1.3
7.8
8.9
12.6
10.5
9.4
7.3
10
14
9.2
Congenital anomalies
Count
4
38
644
52
86
182
19
95
48
1168
%
5.3
1.5
5
9.1
4.8
5.6
13.9
7.1
7.9
5
Appendicitis
Count
1
206
534
10
74
162
0
45
17
1049
%
1.3
7.94
4.2
1.8
4.1
5
 
3.4
2.8
4.5
Labor complications
Count
0
116
432
4
49
137
1
20
7
766
%
 
4.5
3.4
0.7
2.7
4.2
0.7
1.5
1.2
3.3
Deafness
Count
1
137
384
2
70
83
0
15
4
696
%
1.3
5.3
3
0.4
3.9
2.6
 
1.1
0.7
3
Liver, Billiary, Pancreas disease
Count
8
15
423
34
62
84
8
30
29
693
%
10.5
0.6
3.3
6
3.5
2.6
5.8
2.2
4.8
3
Urinary disorders
Count
3
136
321
13
51
90
0
24
7
645
%
3.9
5.2
2.5
2.3
2.8
2.8
 
1.8
1.2
2.8
Neurologic disorder
Count
2
143
317
6
53
78
1
30
6
636
%
2.6
5.5
2.5
1.1
3
2.4
0.7
2.2
1
2.7
Fracture
Count
3
18
399
20
43
81
14
37
17
632
%
3.9
0.7
3.1
3.5
2.4
2.5
10.2
2.8
2.8
2.7
Hematologic diseases
Count
19
10
213
63
35
108
5
155
17
625
%
25
0.4
1.
11
1.9
3.3
3.6
11.6
2.8
2.7
TB (all forms
Count
0
15
426
26
39
57
6
17
19
605
%
 
0.6
3.3
4.6
2.2
1.8
4.4
1.3
3.1
2.6
Total
%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
Source: UNHCR Database 2005-2010.

Discussion

The tremendous uncertainty that surrounds the health status of millions of refugees in exile underscores the need for health referral data for this population. Currently, the worldwide occurrence of non-communicable disease is 43%, but is expected to increase to 60% and cause 73% of all deaths by 2020. Most of this will occur through epidemics in developing countries such as Iran, especially among refugee populations[2831].

Age and gender

Afghanistan is in the early stages of demographic transition, which will become more evident by 2025[28, 32]. The percentage of the population 65 years of age and older will increase from 2.1% in 2000 to 2.9% in 2025[32]. Older residents are more likely to be affected by NCDs, and it is expected that disease rates will rise commensurate with aging[32].
The most common cause of referrals among 0–14 year olds was perinatal disorders, which are documented as communicable diseases in Afghanistan and Iran. In this age group, referral rates for males and females are identical. Better health status, along with greater access to health services in Iran, are thought to have resulted in reduced referral rate for refugees in this age group, compared to similar populations in Afghanistan. However, because medical costs are higher for refugees compared with citizens in Iran, limitations may eventually restrict access.
Those15-59 years of age had 54% of referrals and constitute the largest number of Afghan refugees. Ophthalmic diseases were the most common cause of referrals. Because this age group represents the bulk of the workforce in the diaspora, the impact of these diseases is clear. Referral rates in this group were higher for females. This can be attributed to the role of women as the head of the household, as well as to the documented reluctance of men to seek medical care due to the high cost[33].
In our study, only 17% of referrals were by refugees aged 60+. The most common condition was ophthalmic, followed by cardiovascular disease. Referral rates were higher for women in this age group, which may be attributed to two factors. Afghan women in Iran have been traditionally involved in handicraft, which has been associated with greater occurrences of ophthalmic diseases[34, 35]. In refugee settings, men are also seen to use health care services less frequently than women[33].
Chronic diseases such as heart disease and stroke are prevalent among elderly populations, including refugees[36, 37]. However, the reduced number of chronic cases in our population may be attributed to factors such as a) language barriers and incorrect interpretation and translation services[38], b) cultural and structural barriers[39], and c) the lack of access for preventative care and treatment[40].

Ethnicity

The Hazara, Tajik, Fars and Sadat ethnic groups incurred the most referrals for ophthalmic diseases, probably as a result of their trade and livelihood, e.g. construction workers, handicraft jobs[34, 35]. The number of referrals for smaller groups such as the Pashtun and Baluch may not be truly representative, as they reside mainly in the south and southeast of Iran, and data for these populations may be incomplete.
Afghan refugees are uniquely distributed in neighboring countries for several reasons. With the communist takeover of 1978, their migration has been heterogeneous in regards to race and religion. History, culture and religious differences have had a significant impact on where Afghans have settled. Pashtuns have more often migrated to Pakistan because of ethnic, linguistic and religious similarities. Nearly 40 million Pakistanis in the region bordering Afghanistan are of Pashtun origin, speak Pashtu and are Sunni Muslims, germane to their Afghan refugee counterparts. The Hazara are mostly Shiite, speak Farsi, and live mainly in the northern and northeastern regions of Afghanistan. This religious and linguistic proximity draws them disproportionately to Iran (55% vs. 40.47% of all refugees)[41].

Limitations

The retrospective analysis of data from UNHCR offices in Iran limits our choice of variables, and may be inferior to a prospective, active data collection research paradigm. Most retrospective studies rely on the accuracy of data records, and/or the recollection of individuals. Similarly, our study has relied on the accuracy of data entry by interviewers. Moreover, inconsistencies in record keeping between UNHCR offices did not allow comprehensive data to be compiled for the entire country of Iran. Referral rates were calculated assuming equal access to referrals by all Afghan refugees, and on the homogeneous distribution of age groups in the country.
There are more than 2 million unregistered foreigners in Iran, mostly Afghan and Iraqi nationals, who were not included in this study[3]. This report also does not consider communicable, diarrheal and parasitic diseases which are prevalent in Afghanistan and are considered a major part of the healthcare burden in Iran[42]. These conditions may be mitigated by access to safe drinking water and vaccination, and allocation of resources to costly in-patient treatment and care.

Conclusions

Our study is unique in that it provides a comprehensive look into perhaps the largest diaspora of Afghans. Important findings include that, for those 0–14 years of age, prenatal disease was the most common cause in seeking healthcare, whereas those 15–59 and > 60 years of age were referred primarily for ophthalmic diseases, neoplasms, and nephropathies. We also highlight differences in disease proclivity by ethnicity, which may facilitate better access and effective treatment. Despite the intrinsic limitations inherent in such a study, these findings promise to provide insight into providing improved access and care for this beleaguered population.

Acknowledgement

We are immensely grateful to the CISAMAP team in AOR/Tehran (Sanaz Kahestan, Ladan Moshari, Shima Balout, Parisa Masjedi, Shima Heidari, and Yalda Saidi), without whose help and support this work would not have been possible.
Dr. M. Bazargan’s research activity was partially supported by the Charles R. Drew University of Medicine and Science, AXIS program, Grant# U54MD007598 from the National Institute of Health-NIMHD.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

SO, MM, AB and D.SH were involved in the study from the design to the final manuscript. MM, MB and SH.B-H analyzed the data. AB drafted the first manuscript. SO, D.SH and MB reviewed the paper. All authors have read and approved the final manuscript.
Zusatzmaterial
Additional file 1:Appendix1. Cause of referrals. (DOCX 28 KB)
12939_2012_328_MOESM1_ESM.docx
Authors’ original file for figure 1
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Authors’ original file for figure 2
12939_2012_328_MOESM3_ESM.docx
Authors’ original file for figure 3
12939_2012_328_MOESM4_ESM.docx
Authors’ original file for figure 4
12939_2012_328_MOESM5_ESM.docx
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