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

  • Salman Otoukesh1Email author,

    Affiliated with

    • Mona Mojtahedzadeh1,

      Affiliated with

      • Dean Sherzai2,

        Affiliated with

        • Arash Behazin3,

          Affiliated with

          • Shahrzad Bazargan-Hejazi4 and

            Affiliated with

            • Mohsen Bazargan5

              Affiliated with

              International Journal for Equity in HealthThe official journal of the International Society for Equity in Health201211:82

              DOI: 10.1186/1475-9276-11-82

              Received: 13 July 2012

              Accepted: 10 December 2012

              Published: 20 December 2012

              Abstract

              Introduction

              For nearly three decades, the two neighboring countries of Iran and Pakistan hosted millions of Afghans. Today, Afghans still represent the largest group of refugees in the world. This feature has greatly influenced provision of health care for this population. Due to a paucity of research on the health status of Afghan refugees in Iran, this study aim to make a vista on the pattern of different common diseases among Afghan refugees in Iran and use it as an index for performance evaluation of future health services to them.

              Methods

              This is a retrospective cross sectional study, in which we collected the demographic and medical data between 2005 and 2010 from referrals to the United Nations High Commissioner for Refugees (UNHCR) offices in Iran. We also considered a comparative review of the burden of disease estimates by the World Health Organization (WHO) for Afghanistan and Iran.

              Results

              Total numbers of referrals were 23,152 with 52.6% Female and 47.66% male. 29% were 0–14 years of age, 54% were 15–59, and 17% were 60+. The most common health referral for females and males (0–14) was perinatal diseases (15.16%, 15.2%, respectively). In the females (15–59) it was ophthalmic diseases (13.65%), and for males it was nephropathies (21.4%), and in both sexes (60+) age range it was ophthalmic diseases (21.3%, 19.9%, respectively). The largest ethnic group of afghan refugees in this study was Hazara (55%) followed by Tajik (14%), Fars (12%), Sadat (9%), and 10% others. Ophthalmic diseases were the major cause of referrals by Hazara, Tajik, Fars, and Sadat groups with 26%, 20%, 26%, and 27% respectively. Referrals by pashtun group were mostly for neoplasms (17%), among Uzbek group it was nephropathies (26%), and in Baluch group Hematopoietic disorders (25%).

              Conclusion

              These data indicate higher referral rate for women 15–59 years of old and people in 60+ with ophthalmic diseases, neoplasms, and nephropathies. Even given certain intrinsic limitations of such a study, we believe these unique findings are worth further explanation. This implies the need for public health researchers to pursue prospective studies in these areas.

              Keywords

              Refugee Health status Ethnicity

              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.

              Declarations

              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.

              Authors’ Affiliations

              (1)
              Department of Research, Charles R. Drew University of Medicine and science
              (2)
              Department of Neurology, Loma Linda University
              (3)
              UNHCR, Department of Field Unit
              (4)
              Department of Medical Education Program, Charles R. Drew University of Medicine and science
              (5)
              Department of Research, Charles R. Drew University of Medicine and science

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              © Otoukesh et al.; licensee BioMed Central Ltd. 2012

              This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://​creativecommons.​org/​licenses/​by/​2.​0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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