Health status of refugees

and migrants in Turkey:

an evidence review of published scientific papers
Health status of refugees and
migrants in Turkey:
an evidence review of published scientific papers

By: Daniele Mipatrini, Matteo Dembech, Sarp Uner, Samer Jabbour, Altin Malaj, Toker
Erguder, Evis Kasapi, Pavel Ursu, Dorit Nitzan, Nedret Emiroglu
Abstract
After years of conflict in the Syrian Arab Republic, millions of people still need humanitarian
assistance. The numbers of civilian casualties continue rising, as millions of Syrians are exposed
daily to explosive hazards and escalating violence. Turkey is hosting 3.5 million refugees. In
addition to Syrians, there are over 350 000 refugees, mainly from Afghanistan, Iraq and the
Islamic Republic of Iran.
This report aims to synthetize the evidence available on the health status of refugees and
migrants and on Turkey’s health system performance in responding to the influx of refugees
and migrants.
Keywords
HEALTH STATUS
REFUGEE
MIGRANT
TURKEY
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About The Authors .................................................................................................................................. iv
Acknowledgements ................................................................................................................................ iv
Abbreviations ............................................................................................................................................. v
Executive Summary ................................................................................................................................. vi
Introduction ............................................................................................................................................. 10
Methods .................................................................................................................................................... 10
Results ........................................................................................................................................................ 11
Determinants Of Health .................................................................................................................... 13
Migration As A Determinant Of Health ..................................................................................... 14
Determinants Of Health Among Refugees And Migrants ................................................... 15
Health Status ........................................................................................................................................ 19
Communicable Diseases ............................................................................................................... 19
Mental Health ................................................................................................................................... 25
Other Health Issues ......................................................................................................................... 31
Injuries ................................................................................................................................................ 33
Reproductive Health ....................................................................................................................... 33
Pulmonary Pathology .................................................................................................................... 34
Cardiac Pathology ........................................................................................................................... 34
Inmates’ Health ................................................................................................................................. 34
Health Of Special Population Groups ............................................................................................ 35
Women’s Health ................................................................................................................................ 35
Child Health ....................................................................................................................................... 39
Health System Response ................................................................................................................... 43
Leadership And Governance, Legislation ................................................................................. 46
Health Workforce ............................................................................................................................. 46
Medical Products ............................................................................................................................. 47
Health Information .......................................................................................................................... 47
Health Financing .............................................................................................................................. 48
Service Delivery ................................................................................................................................ 48
Limitations And Strengths Of The Review ....................................................................................... 49
Conclusion ................................................................................................................................................ 50
References ................................................................................................................................................ 52
Figures
Fig. 1. Flowchart of included studies ................................................................................................. 12
Tables
Table 1. Studies on communicable diseases .................................................................................. 20
Table 2. Studies on mental health ...................................................................................................... 26
Table 3. Studies on other health issues ............................................................................................ 32
Table 4. Studies on women’s health ................................................................................ ................. 36
Table 5. Studies on child health .......................................................................................................... 40
Table 6. Studies on the Turkish health system response to refugees and migrants ......... 44
 ABOUT THE AUTHORS ABBREVIATIONS
4 4 2 3 4
Daniele Mipatrini , Matteo Dembech , Sarp Uner , Samer Jabbour , Altin Malaj , AGW Anogenital warts
4 1 4 1 1
Toker Erguder , Evis Kasapi , Pavel Ursu , Dorit Nitzan , Nedret Emiroglu anti-HBc Antibodies to hepatitis B core antigen
1
WHO Regional Office for Europe anti-HBs Antibodies to hepatitis B surface antigen
2
Hacettepe University, Ankara, Turkey anti-HCV Antibodies to hepatitis C virus
3
The Lancet–American University of Beirut Commission on Syria anti-HIV Antibodies to HIV
4 BSE Breast self-examination
WHO Country Office, Turkey
CA Community-acquired infections
CBCL Child Behavior Checklist for evaluation of emotional and
Peer reviewers
behavioural profile
Craig Hampton, World Health Organization
CBE Clinical breast examination
Istvan Szilard, WHO Collaborating Centre for Migration Health Training and
Research CI Confidence interval
CL Cutaneous leishmaniasis
DSM-IV-TR Diagnostic and Statistical Manual of Mental Disorders, 4th
Edition Text Revision
ACKNOWLEDGEMENTS
DSM-5 DSM, Fifth Edition
The WHO Health Emergencies team in Turkey would like to thank all ELISA Enzyme-linked immunosorbent assay
stakeholders who took part in the funding and development of its activities EMDR Eye Movement Desensitization and Reprocessing
throughout 2017. Special thanks go to the staff and management of WHO, the
GHQ-12 12-item General Health Questionnaire
United Nations, and nongovernmental organization, donor and government
partners who generously gave their time and efforts to improving the health HBsAg Surface antigen of hepatitis B virus
of refugees. Other contributors include Serap Şener, Bahadır Sucaklı, Murat ICUs Intensive care units
Şimşek, Mërkur Beqiri, Akfer Karaoğlan Kahiloğulları, Rocio Inigo Lopez and MDD Major depressive disorder
Nurtac Kavukcu from the WHO Country Office, Turkey.
NDM-1 New Delhi metallo-beta-lactamase 1
OR Odds ratio
Contact details PCR Polymerase chain reaction
Matteo Dembech, Reports Officer, WHO Country Office, Turkey (dembechm@who.int)
PEDS Pediatric Emotional Distress Scale
PTSD Post-traumatic stress disorder
SDQ Strengths and Difficulties Questionnaire
STIs Sexually transmitted infections
TB Tuberculosis
TRF Teacher’s Report Form for evaluation of emotional and
behavioural profile
YSR Youth Self Report for evaluation of emotional and behavioural
profile

iv v
 EXECUTIVE SUMMARY
After years of conflict in the Syrian Arab Republic, millions of people still need
humanitarian assistance. The numbers of civilian casualties continue rising, as
millions of Syrians are exposed daily to explosive hazards and escalating violence.
Turkey is hosting 3.5 million refugees. In addition to Syrians, there are over 350
000 refugees, mainly from Afghanistan, Iraq and the Islamic Republic of Iran. This
report aims to synthetize the evidence available on the health status of refugees
and migrants and on Turkey’s health system performance in responding to the
influx of refugees and migrants.
Determinants of Health
Studies highlighted the high prevalence of mental health conditions and poor
maternal and child health among refugees and migrants. Pre and post-migration
factors seemed to affect refugee and migrant health. Epidemiology of diseases,
the collapse of national health care service in the country of origin and the
traumatic events experienced during the war had an impact on health status.
The health service collapse in Syria lowered the vaccination rates among Syrian
children. Post-traumatic stress disorder (PTSD) and depression were associated
with traumatic events experienced in a war setting. Women refugees seemed
to be more exposed than men to PTSD and depression. In receiving countries,
living conditions in refugee camps and barriers to health service were important
determinants of health. Due to language barriers with Turkish health care
providers, Syrian patients reported difficulties meeting their personal needs and
correctly following treatment instructions.
Health Status
Several studies focused on communicable diseases. The prevalence of the surface
antigen of hepatitis B virus (HBsAg) was reported as 3% among 300 Syrians and
as 6.3% among a sample of non-Syrian asylum seekers; the highest prevalence of
HBsAg was found among asylum seekers from Somalia (9%).
The prevalence of antibodies to the hepatitis C virus, indicating previous contact
but not necessarily an active infection, was 2.3% among Syrian refugees and
4.5% among migrants from other origins.
No patients were found positive for HIV among 300 Syrians assessed.
Out of 89 Syrian women with vaginitis complaints, Trichomonas vaginalis
infection was detected in 19 (21.3%) by direct microscopy and in 32 (36%) by
Giemsa examination.
vi
Syrian refugees accounted for 66% of 263 cutaneous leishmaniasis cases in
Gaziantep Hospital and 69% of the 110 positive cases in Southeastern Anatolia.
Between 2013 and 2014, Syrian patients accounted for 89.4% of the 635 cases of
cutaneous leishmaniasis admitted to Gaziantep Hospital.
Among pulmonary tuberculosis patients in Hatay province, Syrians had a lower
rate of treatment success.
Out of 37 refugees included in a multicentre study, the most common community-
acquired infections were pneumonia (49%) and urinary infections (16.3%). While
the infections in refugees were similar to those in the Turkish population, they
seemed to have a higher mortality rate.
Vaccination coverage is lower among Syrian children than Turkish. In 2013, 74%
of Syrian children in camps were vaccinated against polio compared to 55% of
Syrian children living outside camps. Also, 72% of children living in camps and
59% of those living outside camps were vaccinated against measles. In 2017,
WHO conducted a massive vaccination campaign which improved vaccination
rates among Syrian refugees.
According to studies included in the evidence review, the majority of Syrian
refugees had at least one mental health condition. The prevalence of post-
traumatic stress disorder among Syrian refugees varied from 33.5% to 71%.
The prevalence of depression varied from 27.4% to 39.5% and reached 60%
among children. These data seemed to be disproportionate compared to the
international scientific literature on mental health among conflict-affected
populations.
Female gender, traumatic experiences (like death threats, torture, injury or loss of
family members and loved ones) and history of mental health problems were all
factors associated with the diagnosis of PTSD and depression.
Among 154 Syrians admitted to the emergency department in Istanbul for
musculoskeletal injuries, the sites more frequently involved were the lower
extremities, upper extremities, and axial skeleton. Blunt traumas, gunshot
wounds, falls from height and penetrant injuries were the most common
mechanism involved.
In Gaziantep, refugees accessed the emergency department more frequently
than the local population, particularly for head injuries, fractures, dislocations,
sprain of extremities and burns.
vii
 In total, 482 Syrian civilian war victims were admitted to an emergency Istanbul, the most common diagnoses were: diseases of the respiratory system
department in Hatay province between June 2011 and July 2012. The most (14.4%), diseases of the eye and adnexa (12.6%), and injury, poisoning, and certain
frequent trauma mechanism was gunshot (70%). Injuries were located mostly in other consequences of external causes (10.7%). Among 482 Syrian refugees
the extremity (31.7%). referred to the emergency department in Hatay province, 70% complained of
gunshots. The most frequent diagnoses were: extremity injury (n = 153), internal
disease (n = 93), chest injury (n = 44) and abdominal injury (n = 41).
Health Of Special Population Groups
Concerning women’s health, among 458 Syrian women interviewed in Şanliurfa,
47.7% had a history of pregnancy loss. Further research is needed to provide Turkey opened refugee health care centres staffed by Syrian health care
more data about obstetric outcomes in the Syrian refugee population. professionals who offer medical assistance to Syrian refugee patients in order
to address two main criticalities in the health care response to the inflow of
refugees: the overstretched health care facilities, and the linguistic and cultural
Concerning child health, Syrian refugee children appeared to be affected by barriers between Syrian patients and Turkish health care professionals.
preventable conditions such as malnutrition and anaemia. Among 104 Syrian
children referred to the Pediatric Clinic of Adiyaman University Hospital, weight
(19.2%), height (31.7%), head circumference (1.9%) and body mass index (6.7%)
were below the third percentile. Among 130 Syrian children admitted to the
paediatric nephrology department in Gaziantep from 2012 to 2015, two highly
prevalent conditions were described: congenital abnormalities of the kidney and
the urinary tract (26.2%) and chronic kidney disease (23.1%). A study conducted
in Ankara on 457 Syrian refugee infants found that neonatal morbidity and
mortality among Syrians seemed to be higher than that of Turkish infants (1.8% vs
0.04%). Further research is needed to provide more data about infant morbidity
in the Syrian refugee population.

Health System Response

Access to health care for Syrian refugees is guaranteed by a “Circular on Health
Services for the People under Temporary Protection” which also entitles Syrian
migrants to these services.

Syrian refugees overstretched the capacities of health facilities, especially at

the Turkish–Syrian border. This led to an increased workload for health care
professionals and increased patients’ waiting time. Difficulties have been reported
in communication between Syrian patients and Turkish health care professionals.

Little evidence was available concerning medical products and health

information. A paper reported problems in the reimbursement of pharmacists
who provide refugees with medications, which could challenge drugs provision
to Syrian refugees.

The estimated mean cost per admitted Syrian patient in Adana was 3723 Turkish
liras (US$ 919).

Studies reported information on the health service and on general reasons to

access the service by refugees and migrants. Among 251 Syrian refugees in

viii ix
 INTRODUCTION
The Syrian conflict continues to leave millions of people in need of humanitarian
assistance. Syrians are daily exposed to threats such as explosive devices and
violence. The conflict has overwhelmed the majority of health care facilities
and infrastructure in the country posing serious risks to people’s life and health.
Lack of clean water and sanitation and the dramatic fall in immunization rates
poses important risks for Syrian public health including a recent polio outbreak
(1). Turkey hosts the majority of Syrian refugees, which number more than
3.5 million (2). Only migrants from European countries are entitled to seek
asylum and to receive international protection as refugees in Turkey. However,
in response to the Syrian crisis, Turkey granted Syrian refugees temporary
protection with full access to the Turkish health care system (3). In addition
to Syrians, more than 350 000 refugees, mainly from Afghanistan, the Islamic
Republic of Iran and Iraq, live in Turkey (4).
4. Only papers published in peer-reviewed journals were considered eligible.
5. Only papers providing relevant information concerning the health of migrants
and refugees in Turkey or the health sector approach to this population were
included in the evidence review.
Two reviewers removed duplicates and screened the retrieved records first by
title and abstract and then by full text. Studies that clearly did not meet the
eligibility criteria were excluded. A third reviewer resolved disagreements. All
the references of the included papers were searched to identify papers not
found through the systematic database search.
The following pieces of information were collected from each paper and
included in the qualitative analysis: authors; year of publication; title of the
paper; journal of publication; study design; medical area; target population;
setting; and outcome. No quantitative synthesis of results has been conducted.

The massive influx of refugees poses important challenges to the Turkish RESULTS
national health care system, overstretching capacities at all levels. Refugees
and migrants may be exposed to particular health risks due to the conflict in The search yielded 392 papers, 265 from Medline and 127 from Scopus. Fig. 1
their country of origin, risky conditions during the migration process and living shows the flowchart of the process that led to the 53 papers included in the
conditions in receiving countries. Moreover, cultural and linguistic barriers may evidence review.
prevent refugees from using health care services (5).
The studies included focus mainly on Syrian refugees (41 papers) but also on
This review aims to collect and synthesize the available scientific evidence on international migrants and refugees from different origins (12 papers).
the health status of refugees and migrants living in Turkey. This work focuses
on the health of vulnerable groups, the social determinants of refugee and
migrant health, and the health system response. Evidence was collected for
Syrian refugees, as well as for international migrants.

METHODS

Two leading scientific databases – Medline and Scopus – were searched to

identify papers of interest on the health status of refugees and migrants living
in Turkey. The last search was performed on 20 September 2017.

The following eligibility criteria were used.

1. All types of papers which addressed one or more of the aims of the review
were considered despite the design of the study. Letters, commentaries and
editorials were also evaluated, as well as cross-sectional studies.
2. Only studies in English or Turkish published from 2000 on were considered.
3. Only papers considering refugees or international migrants in Turkey were
considered eligible.

10 11
 D E T E R M I N A N T S O F H E A LT H
DETERMINANTS
OF HEALTH
• Refugees and migrants seemed to experience poor health compared
to the Turkish population.
• Studies highlighted a high prevalence of mental health conditions
and poor maternal and child health.
• Women refugees seemed to be more exposed than men to PTSD
and depression.
• Pre and post-migration factors seemed to affect refugee and
migrant health.
• Epidemiology of diseases, the collapse of national health care
services in country of origin, and the traumatic events experienced
during the conflict impacted health status.
• In receiving countries, living conditions in camps and barriers to
health services were important determinants of health.

12 13
 Migration As A Determinant Of Health
Several studies described inequalities in health status between refugees and migrants,
and the Turkish population. An analysis of 457 births in Ankara suggested that mortality
was higher among Syrian than Turkish newborn (6). Another study found no difference
among rates of low birth weight (>2500 g), oligohydramnios, stillbirth and fetal anomaly
between 300 Syrians and the control groups (7). Studies suggested a high prevalence
of kidney diseases (8), short stature, anaemia and malnutrition among Syrian refugee
children (9).
Refugees and migrants seemed to be more exposed to mental health threats than the
Turkish population. Several studies found high rates of PTSD and depression among
Syrian refugees and non-Syrian migrants . The prevalence of PTSD among Syrian refugees
varied from 33.5% to 71%; the prevalence of depression varied from 27.4% to 39.5% and
reached 60% among children (10–13).
Among Iraqi Yazidis displaced into Turkey, the rate of PTSD was 43% and that of
depression was 40% (14). The prevalence of PTSD and depression reported in these
studies were well above that reported by international researchers among conflict-
affected populations: a recent meta-analysis estimated the prevalence of PTSD among
conflict-affected populations at around 12.6% and the prevalence of major depression
at around 7.6% (15). A study conducted among 155 Afghan migrants suggested they
experience poor physical and mental health and high rates of psychological distress (16).
Refugee women seemed to be more exposed than Turkish women to sexually transmitted
infections (STIs). A study focusing on women’s health found a higher prevalence of
Trichomonas vaginalis among Syrian refugees than the Turkish population (17); in a
different study, of 458 Syrian women participating in a survey, 51% reported symptoms
of STIs (18). The same study reported that 48% of participants had a pregnancy loss, 50%
had iron deficiency, 46% had B12 deficiency and 11% had folic acid deficiency (18). A
migrant background seemed to be a risk factor for pregnancy in young women (aged
12–19 years) (7).
Among the general population, a study compared the rate of community-acquired
infections among Turkish and Syrian patients in intensive care units (ICUs) finding similar
rates of infections but higher mortality rates (59.5%) among Syrians (19). Several studies
reported a higher prevalence of cutaneous leishmaniasis (CL) among Syrian refugees
compared with the Turkish population. This could be due to the epidemiological profile
in the country of origin, the conditions during travel and the living conditions in Turkey
(20–23).
Finally, trauma seemed to be highly prevalent among Syrian refugees admitted to
emergency departments (24).
14
Determinants Of Health Among Refugees And Migrants
Several factors may affect the health status of refugees and migrants. Socio-demographic
factors play an important role, but the health of a migrant is also shaped by peculiar
experiences and situations in their place of origin, travel conditions during transit and
living conditions found in their eventual place of destination (25). For example, Syrian
refugees seemed to be more exposed than the Turkish population to some types of
communicable diseases due to these factors (26).
Gender And Socio-Demographic Factors
Ekmekci described the effects of a large migration flow on the social determinants of
Syrian refugees’ health, due to the sudden increase in population at the Turkish–Syrian
border. In particular, he emphasized critical protective factors such as education for
Syrian children; municipal services, such as garbage collection, city upkeep and a clean
water supply; cultural and social events; and employment and social security for Syrian
refugees. According to his work, difficulties accessing education, poor living conditions
due to overcrowded cities and poor working conditions could harm Syrians’ health. He
advocated for stronger legislation for refugees under temporary protection to ensure
their social protection and their opportunity to work (3).
Gender seemed to be a risk factor for psychiatric conditions. Among 781 Syrian refugees
residing in a camp, women were four times as likely as men to have PTSD and five times
as likely to be depressed (12). Among Iraqi Yazidis displaced into Turkey, more women
than men had PTSD and major depression. Among Iraqi migrants in Turkey, more women
than men with PTSD or depression reported having experienced or witnessed the death
of a spouse or child. Women with PTSD reported flashbacks, hypervigilance and intense
psychological distress due to reminders of trauma more frequently than men (14).
A study suggested that female gender may have a positive role on the likelihood of
accessing primary health care services. Among Afghani migrants in Turkey, female
gender was associated with a high probability of visiting primary care physicians and
outpatient specialists (16).
Educational level seemed to have no role on PTSD among Syrian refugees and Iraqi
Yazidi migrants in Turkey (10,14). Syrian women with a low educational level had a
higher probability of smoking during pregnancy (27).
Pre-Migration Factors
Conditions in countries of origin of refugees and migrants may affect their health. The
studies included in this evidence review focused in particular on the epidemiology of
diseases in the country of origin, the impact of war on national health care services and
on traumatic events experienced during the war in countries of origin.
Four studies reported a high rate of leishmaniasis among Syrian refugees, and these
could be in part attributed to the epidemiology of the disease in their country of origin
15
 (20–23). The impact of the war on the national health care system was described in a
paper focusing on the vaccination status of Syrian refugees. The Syrian war significantly
harmed the national health care system causing the fall of vaccination rates. Syrian
children refugees in Turkey showed lower rates of vaccination compared to Turkish
children. Demirtas & Ozden in 2015 reported that only 74% of children in camps and 55%
of children outside camps were vaccinated against polio, and 72% of children in camps
and 59% of children outside camps were vaccinated against measles (28).
Several studies described the traumatic events refugees and migrants experienced in
their countries of origin and the impact on their health. Among 311 Syrian children
interviewed in the Islahiye Refugee Camp in Gaziantep, 79% had experienced a war or
an armed conflict in their country of birth, 74% had experienced the death of someone
significant, around 60% experienced other very stressful life events that included feelings
of danger for themselves or for someone else and 60% saw someone get kicked or shot
(29). Among 781 Syrian refugees interviewed in a refugee camp in Turkey, the experience
of torture was associated with feelings of helplessness, hopelessness and powerlessness,
which may decrease their feelings of control and increase the risk of depression (12).
Non-Syrian migrants also experienced traumatic events: a total of 38 Yazidi children
and adolescents reported fear of persecution from the Daesh (also known as the Islamic
State in Iraq and the Levant), and hard physical and psychological conditions while
migrating to Turkey which effected their behaviour (30). Several children reported that
they had witnessed parents leaving their dead children behind while being on the run.
The majority of the assessed children (71%) reported sleep disruptions and disorders
including problems falling asleep, frequent awakenings and parasomnias such as
somnambulism and nightmares (30).
Association between traumatic events and mental health conditions were described
in particular for PTSD and depression. A study conducted among 352 Syrian refugees
suggested that the number of traumatic events experienced correlated with the
diagnosis of PTSD (10). Factors associated with the diagnosis of PTSD were previous life
threats (12), death, torture or life threats to someone close (12,14,31), having experienced
torture (31) having touched dead bodies (apart from funerals) (14), “having experienced/
witnessed a terrorist attack or torture, having been in a region that is affected by war,
and having experienced/witnessed an attack with a weapon” (14). Among Iraqi Yazidis,
depression in women was associated with: “having experienced or witnessed the death
of a spouse/child or a close friend or a family member and having witnessed and touched
dead bodies except at funerals”, and depression in men was associated with “having
experienced/witnessed death of a close friend or a family member (except spouse/child),
and having witnessed and touched dead bodies apart from funerals” (14). Having a loved
one who was tortured significantly increased the likelihood of depression (12).
Other pre-migration factors may have affected refugees’ health status. Having a previous
mental problem increased the risk of PTSD and depression (12).
In contrast, belonging to multiple groups before migration was related to a higher
likelihood of having preserved group memberships after migration and a sense of
16
social identity continuity, which predicted greater life satisfaction and lower levels of
depression (32).
Post-Migration Factors
The studies included in this review described living conditions in camps and barriers to
health services as potential post-migration determinants of health.
A study described an association between not being satisfied with life in the camp and
depression among Syrian refugees. Not being satisfied with conditions in the camp may
be related to difficulties in nutrition, shelter, education or safety during the settlement.
These difficulties may decrease hope for the future (12). On the other hand, being
satisfied with life in the camp and feeling safe were both associated with having no
probable depression (12). Iraqi refugees reported they did not feel safe in the camp (30).
The recent Syrian refugee flow to Turkey posed important challenges to the Turkish
health care sector. Some studies reported problems that Syrian patients have accessing
the Turkish health care services, while others highlighted the challenges faced by the
health sector due to the huge influx of Syrian refugees.
Language and communication barriers limited access to health care services. Both
nurses dealing with Syrian refugees and Syrian patients dealing with Turkish health
care professionals experienced communication problems due to language barriers
(33,34). Syrian patients reported difficulties meeting their personal needs and correctly
following treatment instructions (34). Compared with Turkish patients, Syrian patients
showed longer stays in and higher use of emergency departments (35). One study
conducted among 211 patients with pulmonary tuberculosis found that Syrians had
a lower probability of successful treatment and a higher probability of abandoning
treatment (26).
Among 150 Afghan migrants in Istanbul, only one third had access to a regular source
of health care. They were more likely to use nonprescription medications than visit
outpatient specialists, suggesting difficulties in accessing primary care. Access to health
care was affected by personal and social resources. Linguistic and discrimination-related
factors deterred the use of health services among the studied population (16).
Health care facilities at the Turkish–Syrian border faced difficulties due to the inflow
of refugees. Health care professionals reported increased workloads following Syrian
migration and increased waiting time for patients. Moreover, they highlighted the
insufficient intensive care capacity, and the lack of beds and medicines and blood (36).
At the Adiyaman University Training and Research Hospital in Turkey, Syrian refugees
increased the proportion of emergency department visits and the financial health care
burden. The majority of emergency department visits made by Syrian refugees were
classified as inappropriate by the authors of the study, probably reflecting a lack of
primary care service for these refugees (35).
17
 HEALTH STATUS
Communicable Diseases

• Among 300 Syrians, HBsAg (surface antigen of hepatitis B virus)

and anti-HBs (antibodies to hepatitis B surface antigen) were found
positive in 3% and 26.6% of patients respectively, while antibodies
to HCV (anti-HCV) were present in 2.3%. No patient tested positive
for anti-HIV.

H E A LT H S TAT U S
• Among 222 refugees crossing Turkey from different countries
of origins, HBsAg was positive in 6.4%, anti-HBs in 12.6%, anti-
HBc (antibodies to hepatitis B core antigen) in 0.4% and anti-HCV
(antibodies to hepatitis C virus) in 4.5% of asylum seekers. Asylum
seekers from Somalia had a higher prevalence of HBsAg (9%), and the
prevalence of anti-HCV was higher in those from Pakistan (5.5%).
• Out of 89 Syrian women with vaginitis complaints, Trichomonas
vaginalis infection was detected in 19 (21.3%) by direct microscopy
and in 32 (36%) by Giemsa stain.
• Syrian refugees accounted for 66% of the 263 positive CL cases in
Gaziantep Hospital and 69% of the 110 positive cases in southern
Anatolia. Between 2013 and 2014, Syrian patients accounted for
89.4% of the 635 cases of CL admitted to Gaziantep Hospital.
• Among pulmonary tuberculosis patients in Hatay province, Syrians
had a lower rate of treatment success.
• Out of 37 refugees included in a multicentre study, the most
common community-acquired infections were pneumonia (49%)
and urinary infections (16.3%). While the infections in refugees were
similar to those in the Turkish population, they seemed to have a
higher mortality rate.
• According to data from 2013, 74% of Syrian children in camps were
vaccinated against polio while only 55% of Syrian children living
outside camps were vaccinated. Also, 72% of children living in camps
and 59% of those living outside camps were vaccinated against
measles.

Table 1 provides an overview of studies on communicable diseases.

18 19
20 21
 Viral Infections
One paper (37) addressed the prevalence of hepatitis B, C and HIV among Syrian
refugees undergoing surgery in a training and research hospital department in 2015.
The study retrospectively evaluated the prevalence of positivity (through enzyme-linked
immunosorbent assay (ELISA) tests) for HBsAg, anti-HBs, anti-HCV and anti-HIV in 300
Syrian refugees. HBsAg and anti-HBs were found positive in 3% and 26.6% of patients
respectively, while anti-HCV was present in 2.3%. No patient tested positive for anti-HIV.
Another paper (41) investigated the prevalence of hepatitis B and C among asylum
seekers crossing Turkey in June 2008. The study evaluated the positivity to HBsAg, anti-
HBs, anti-HBc total and anti-HCV, by ELISA method, in 222 asylum seeker (54.9% from
Somalia, 16.3% from Pakistan, and 10.4% from the West Bank and Gaza Strip and 18.4%
from other countries). HBsAg was positive in 6.4%, anti-HBs in 12.6%, anti-HBc total in
0.4% and anti-HCV in 4.5% of asylum seekers. Asylum seekers from Somalia had a higher
prevalence of HBsAg (9%), and the prevalence of anti-HCV was higher in those from
Pakistan (5.5%).
Trichomonas Vaginalis
One paper (17) addressed the frequency of Trichomonas vaginalis among female Syrian
refugees in Urfa province. The study evaluated 89 patients who had vaginitis complaints
and agreed to a gynaecological examination; Trichomonas vaginalis infection was
detected in 19 (21.3%) by direct microscopy and in 32 (36%) by Giemsa staining of
the samples taken during the examination. The prevalence of Trichomonas vaginalis
detected in female Syrian refugees was higher than the prevalence (3–13%) in the Turkish
population but was close to the prevalence (40%) of groups with risky behaviours. The
authors mentioned that health screening studies and health education about safe sex
for Syrian refugees would be useful in the prevention of sexually transmitted diseases.
Couteneous Leishmaniasis
Four papers (20–23) related to CL among refugees from Syria. The first one (23) evaluated
563 patients with suspected CL in the state hospital of Gaziantep city, located near the
Syrian border, between January 2009 and July 2015. All patients were evaluated through
parasitological examination, and 34 patients were also tested for CL by polymerase chain
reaction (PCR). In total, 263 patients were diagnosed with CL. Of the patients with CL,
66% were Syrians, while only 33% were Turkish. Leishmaniosis tropica was detected
the most in the PCR analysis (90% of PCR positive patients). Syrian CL cases peaked in
2013, with 76 cases of CL, and then gradually decreased to three cases in 2015. The study
authors claimed that more attention should be paid to vector control in the area of
study. The second one (21) evaluated 110 patients with CL admitted to the Department
of Dermatology at Kahramanmaras Sutcu Imam University Faculty of Medicine between
January 2011 and June 2014. The cases were evaluated regarding demography and
clinical features of the lesions, and 69% of the cases were Syrian refugees. The prevalence
was significantly higher in the 0–20-year-old age group. The authors claimed that the
living conditions of refugees should be improved, together with the control of vector-
borne disease and treatment of infected patients, to prevent the spread of CL.
22
The third one (22) evaluated 436 patients (341 were Syrian refugees) admitted between
1 January 2010 and 19 March 2013 to the state hospital in a district in south-eastern
Turkey. All patients were evaluated through parasitological examination, with a dramatic
increase of CL cases observed after the Syrian civil war. Only 15 patients were Turkish
while 62 Syrian cases were diagnosed in just three months (2013). According to the
authors, leishmaniasis became an important threat to the health of the region.
The fourth study (20) evaluated the epidemiological characteristics of 635 CL patients
admitted for one year, as of 1 April 2013, to the Leishmaniasis Diagnosis and Treatment
Centre in Gaziantep. Of these patients, 67 (10.6%) were Turkish, while 568 (89.4%) were
Syrian. The majority of cases occurred in patients aged 0–9 and 10–19 years (respectively
39.5% and 26.5% of the total number of cases). The authors claimed that regular health
screening programmes should be conducted for CL, and that vulnerable communities
should be informed and educated.
Pulmonary Tuberculosis
One paper (26) addressed the frequency and treatment of pulmonary tuberculosis (TB)
among Syrian refugees and Turkish patients in the Hatay province. The study evaluated
178 patients (84.4% Turkish and 15.6% Syrians) who completed the treatment between
2010 and 2013. The authors found no differences between Turkish and Syrian patients
regarding contact history, presence, and results of smear and drug sensitivity. However,
they found that loss to follow-up was higher among refugees (30.3% vs 3.9%, P<0.001).
Also, Syrian patients were younger (32.27 ± 16.06 vs 44.68 ± 19.47, P=0.001) and had a
lower rate of treatment success (63.6% vs 88.8%, P<0.001). The authors claimed that a
new national TB control programme focused on the refugee population was needed.
Community-Acquired Infections
A multicentre study (19) addressed the impact of community-acquired (CA) infections in
Intensive Care Units (ICUs) by refugees in 10 centres. Thirty-seven refugees accessed the
Intensive Care Units (ICUs) for CA infection between 2010 and 2015. The most common
CA infections were pneumonia (49%) and urinary infections (16.3%). Death was observed
in 22 patients (59.5%). In five cases, the CA infection was considered directly responsible
for the deaths, but only partially responsible in nine cases. The authors concluded that,
while the CA infections carried by refugees were similar to those of the host population,
they seemed to have a higher mortality rate, likely due to the high frequency of patients
with trauma history (21 patients) and the severity of illness (average Acute Physiology
and Chronic Health Evaluation (APACHE II) score was 23). They called for more studies on
this topic to better address the health needs of this population.
Review
Two narrative reviews (38,39) addressed various communicable diseases affecting
refugees. One paper (39) focused on the situation in various countries, including Turkey,
particularly affected by the phenomenon of refugees following the war in Syria. The
authors claim that refugees pose important challenges to host countries in terms of
control of TB, CL, measles, polio, hepatitis and other communicable diseases. With the
23
 support of international organizations, international networks could help control the
spread of diseases across countries. The second paper (38) focused on the impact of re-
emerging infectious diseases in Turkey, following the settlement of Syrian refugees. They
reported that the Syrian conflict led to the re-emerging of some infections in Turkey, i.e.
measles, TB, CL and poliomyelitis.

Case Studies
Two papers (40,43) reported the isolation of multiresistant organisms in two Syrian
refugees: the NDM-1-producing Acinetobacter baumannii ST85 and Neisseria HEALTH STATUS
Mental Health
meningitidis B. The authors of both papers pointed out the need for active surveillance
and control measures.

Intervention Programme
One paper (42) focused on a community-based public health intervention on TB among
irregular migrants in Turkey. The intervention took place in Istanbul between July 2005

and April 2008. Two social entrepreneurs and the Istanbul Anti-TB Association developed
the programme. The Association provided confidential screening and treatment of
irregular immigrants. Moreover, nongovernmental aid and support organizations,
capable of reaching irregular immigrants and providing non-medical support (such as
food, clothing and housing), joined the programme. The programme conducted house
visits to irregular immigrants; encouraged them to be screened and provided them
with educational materials on TB in seven different languages. The programme and the
involvement of community leaders ensured follow-up with the engaged patients. The
authors claimed that involving non-health care stakeholders and establishing trust with
immigrants were key actions for realizing successful community-based programmes.
Vaccination And Immunization Coverage
According to Demirtas & Ozden (2015) (28) who reported the results of a field survey
conducted in 2013 (44), 74% of Syrian children in camps were vaccinated against polio
compared to 55% of Syrian children living outside camps. It showed that 72% of children
living in camps and 59% of those living outside camps were vaccinated for measles. In
the editorial, the authors emphasized the importance of strengthening disease control
and preventative health services for both the Turkish population and Syrian refugees.
In 2017, WHO organized a massive vaccination campaign aimed at increasing the
proportion of vaccinated Syrian children (45–47).
H E A LT H S TAT U S
• Prevalence of PTSD among Syrian refugees varied from 33.5% to
71%.
• Prevalence of depression varied from 27.4% to 39.5% and reached
60% among children.
• These data seemed to be disproportionate compared to the
international scientific literature on conflict-affected people.
• Factors apparently associated with both diagnoses were female
gender, the experience of traumatic events (e.g. death threats, torture,
death or injury of family members and loved ones) and previous
mental health problems.
• A study reported interesting results concerning the use of Eye
Movement Desensitization and Reprocessing (EMDR) in reducing
PTSD and depression symptoms among Syrian refugees living in
camps.
Eleven papers investigating mental health were retrieved (Table 2). The
majority (eight papers) focused on Syrian refugees (10–13,29,32,48,49),
while two papers addressed the Iraqi Yazidi refugees (14,30) and
another one investigated a mixed population of asylum seekers in
Istanbul (31).

24 25
 Syrian Refugees
Several papers focused on the prevalence and potential predictors of mental health
disorders, such as PTSD, major depressive disorder (MDD) and anxiety, among Syrian
refugees (10–13). Alpak et al. focused on PTSD (10). Their cross-sectional study involved
352 adult Syrian refugees randomly selected from a group living in a tent city in
Gaziantep in 2013. Data were collected through a socio-demographic form, a stressful
life events screening questionnaire and diagnostic psychiatric interviews. PTSD was
diagnosed according to the criteria of DSM-IV-TR (American Psychiatric Association
2000). The prevalence of PTSD was found to be 33.5%. Positive correlations were found
between PTSD and the number of traumatic events experienced (P=0.002), female
gender (P<0.001) and either personal (P=0.012) or family (P=0.021) history of any
psychiatric disorder. Through the binary logistic regression analysis, the probability of
being diagnosed with PTSD among refugees with the aforementioned risk factors was
71%.

Chung et al. focused on PTSD too. They examined the interrelationship between trauma
centrality, self-efficacy, PTSD and psychiatric co-morbidity among 792 adult Syrian
refugees living in Turkey (in a camp and community near the borders with Syria) (11).
Participants were asked to fulfil a demographic form, the Harvard Trauma Questionnaire,
the General Health Questionnaire-28, the Centrality of Event Scale and the Generalized
Self-Efficacy Scale. PTSD prevalence, based on the DSM-IV diagnostic criteria, was found
to be 52%. Trauma centrality was positively correlated with PTSD (P<0.05), psychiatric
co-morbidity (P<0.01) and self-efficacy (P<0.001). Self-efficacy was negatively correlated
with PTSD only (P<0.001). Gender did not moderate the mediational effect of self-
efficacy on the path between trauma centrality and distress outcomes.

Acarturk et al. focused on both PTSD and depression (12). In 2013, they interviewed
781 adult Syrian refugees randomly selected from Kilis Refugee Camp, to collect socio-
demographic variables and information about pre-migration personal and family mental
health, war and migration trauma and camp life. The Impact of Event Scale-Revised
was used to measure PTSD and the Beck Depression Inventory to measure depression.
The study reveals high rates of probable PTSD and depression among Syrian refugees.
Probable PTSD prevalence was 83.4%, with predictors being female (odds ratio (OR) 4.1),
previous mental health problems (OR 4.5), death threat (OR 3.0) and injury of a loved one
(OR 1.8). Probable depression prevalence was 37.4%, with predictors being female (OR
5.1), previous mental health problems (OR 2.9), having a loved one who was tortured (OR
1.7) and not being satisfied living in a camp (OR 1.7).

Ozer et al. (29) also showed a high prevalence of depression and PTSD among Syrian
refugee children. They investigated the frequency of war-related traumatic events and
mental health problems among 311 children attending school at the Islahiye Refugee
Camp in Gaziantep in 2012. The study employed mixed methods of surveys and drawings.
Children were asked to complete the Stressful Life Events Screening Questionnaire, the
Social Provisions Scale, the Children’s Revised Impact of Events Scale, the Children’s
Depression Inventory and a Psychosomatic Problems questionnaire; moreover they were
asked to draw a “Person” and pictures of “War” and “Peace”. Additional demographic and
health information was collected from parents through a questionnaire.
26 27

Two hundred eighty-eight children provided full data. Regarding traumatic events,
50% of the children were exposed to six or more traumatic events; 74% experienced
the death of somebody they cared strongly about, and 58% experienced events where
they felt their lives were in danger. The mental health problems associated with the war
experiences were very serious as 60% had symptoms of depression, 45% of PTSD, 65%
reported psychosomatic symptoms and 22% included aggressive emotional indicators
in their drawings. Of course, many children suffered from two or more of these mental
health problems. On the positive side, 71% of girls and 61% of boys had strong close
relationships they trusted for help and support (29).
Marwa focused on PTSD, depression and anxiety (13). This cross-sectional survey was
conducted in 2012 in four Syrian refugee camps located in southern Turkey. Three
hundred adult refugees selected through a snowball sampling method were asked to
complete a survey including demographic data, Impact of Event Scale-Revised, and
the Hospital Anxiety and Depression Scale. There were 95 complete surveys returned
(31.6%), revealing high levels of psychological disturbance among Syrian refugees.
Anxiety within the refugees was pathological in 50 (52.6%) and borderline in 18 (18.9%),
whereas depression was pathological in 26 (27.4%) and borderline in 37 (37.9%). PTSD
was present in 58 (61.1%) survey subjects. Anxiety was strongly associated with PTSD
(P<0.001), while PTSD and depression did not bear significant difference. Anxiety,
depression and PTSD were not significantly associated with age, gender or marital status.
Another paper by Acarturk et al. focused on the treatment of PTSD and depression,
particularly EMDR (48). They performed a single-blind, open-label randomized control
trial aimed at examining the effect of EMDR to reduce PTSD and depression symptoms
compared to a wait-list condition. The study was conducted in 2013 in Kilis Refugee Camp
and involved 29 adult Syrian refugees with PTSD symptoms who were randomly allocated
to either EMDR sessions (n = 15) or wait-list control (n = 14). The efficacy of treatment was
assessed through two self-reported instruments: the Impact of Event Scale-Revised for
PTSD symptoms and the Beck Depression Inventory for depression symptoms. Results
showed that EMDR might be effective in reducing PTSD and depression symptoms
among Syrian refugees located in a camp. In fact, at post-treatment, the EMDR group
had significantly lower trauma scores (confidence interval (CI): 0.92–2.64) and a lower
depression score (CI: 0.35–1.92) compared with the wait-list group.
One paper by Smeekes et al. examined the importance of multiple group memberships
and social identity continuity for mental health and psychological well-being (32). They
conducted a survey study among 361 adult Syrian refugees living in Istanbul and Antep
in 2015. Measures collected through questionnaires were: belonging to multiple groups
before migration; continuity group memberships after migration; life satisfaction; mental
health; and demographic data. Results indicated that belonging to multiple groups
before migration was related to a higher likelihood of having a sense of social identity
continuity after migration (P<0.001), which, in turn, predicted greater life satisfaction
(P<0.001) and lower levels of depression (P<0.05).
28
Finally, Cartwright et al. tested the feasibility of assessing the mental health of children
displaced in and near refugee camps on the Turkish–Syrian border (Qah Refugee Camp
and Bab-Al-Salam Refugee Camp in northern Syria, and Reyhanli camp in southern
Turkey) using parent-reported questionnaires (49). In 2013, 144 caregivers of children
recruited from primary schools in and near the refugee camps, with the support of a
nongovernmental organization, were invited to complete the Pediatric Emotional
Distress Scale (PEDS) and the Strengths and Difficulties Questionnaire (SDQ). Results
demonstrated the feasibility of this approach as 106 caregivers completed the
questionnaires yielding a good return rate of 74%. The PEDS appeared to perform better
than the SDQ in this context as they were completed by 77.4% of caregivers vs the 57.5%
that completed the SDQ. Moreover, results indicated high levels of emotional problems
(PEDS: 49% of children met the clinical cut-off for being anxious/withdrawn and 62% for
being fearfully rated; SDQ: 45% met the clinical cut-off for emotional symptoms) and
behavioural problems (more than a third had clinical levels of behavioural problems on
both scales) among displaced children.
These data seemed to be disproportionate compared to the international scientific
literature on mental health among conflict-affected populations (15).
Iraqi Yazidi Refugees
Two papers analysed the psychiatric symptoms and disorders of Iraqi Yazidi refugees
displaced into Turkey as a result of the attacks by Daesh (also known as the Islamic State
in Iraq and the Levant) terrorists in 2014 (14,30). Ceri et al. retrospectively reviewed the
psychiatric assessments of 38 children and adolescents interviewed in 2014 upon their
arrival at the refugee camps of Cizre, Silopi and Diyarbakir (30). The analysis showed that,
although they had not witnessed violent acts, all children and adolescents exhibited
psychiatric problems and disorders: 50% had one, and 50% had more than one. The most
common symptoms were sleeping problems (71% of children), impaired social inclusion
(39.4%) and somatic complaints (36.8%). The predominant psychiatric diagnoses, mainly
assigned according to DSM-5 criteria, were MDD (36.8%), conversion disorders (28.9%),
adaptation disorder (21.8%), acute (18.4%) and posttraumatic stress (10.5%) disorders
and nonorganic enuresis (18.4%).
Tekin et al. focused, instead, on 238 adults randomly selected from the Cizre camp in
2015 (14). Prevalence and gender-based differences in the symptomatology of PTSD and
depression were evaluated using the Structured Clinical Interview for DSM-IV and the
Stressful Life Events Screening Questionnaire. Of the participants, 42.9% met the criteria
for PTSD, 39.5% for MDD and 26.4% for both disorders. More women than men suffered
from PTSD and MDD. Also, more affected women than men reported being exposed to
war-related events such as the death of a spouse or a child. Regarding PTSD symptoms,
women reported flashbacks, hypervigilance and intense psychological distress due to
reminders of trauma more frequently than men; men reported feelings of detachment
or estrangement from others more frequently than women. Regarding depressive
symptoms, more women than men reported feelings of guilt or worthlessness.
29
 Asylum Seekers In Istanbul
Tufan et al. investigated the mental health of a mixed population of adult asylum seekers
and refugees receiving mental health services from a nongovernmental refugee support
programme in Istanbul between 2005 and 2007 (31). They retrospectively evaluated the
records of 57 adults assessed through the DSM-IV-TR criteria and the Stressful Life Events
Screening Questionnaire. In terms of nationalities, the most common groups were
Iranians (34.3%), Ethiopians (14.9%) and Congolese (10.4%). PTSD and MDD were found
to be the most common diagnoses (both diagnosed in 55.2% of participants). The most
common criteria of PTSD were problems in concentration and social isolation (97.3% for

HEALTH STATUS
both). Traumatic events found to be associated with a diagnosis of PTSD were suffering
torture (P=0.005) and losing a significant other due to violence (P=0.003).

Other Health Issues

H E A LT H S TAT U S
• Among 154 Syrians admitted to emergency departments in Istanbul
for musculoskeletal injuries, the sites most frequently involved were the
lower extremities, upper extremities and axial skeleton. Blunt traumas,
gunshot wounds, falls from height and penetrant injuries were the
most common mechanisms involved.
• In Gaziantep, refugees accessed the emergency department more
frequently than the local population, particularly for head injuries,
fractures, dislocations, sprain of extremities and burns.
• Four hundred eighty-two Syrian civilian war victims were admitted to
an emergency department in Hatay province between June 2011 and
July 2012. The most frequent trauma mechanism was gunshots (70%).
Injuries were located mostly in the extremity (31.7%).

Eight papers addressed various health issues on refugees and

migrants, i.e. injuries (24,50,56), reproductive health (51), general
health needs (52), pulmonary pathology (53), cardiac pathology
(54) and inmates’ health (55) (Table 3).

30 31
 Injuries
Two cross-sectional studies dealing with injuries were retrieved. Both papers focused
on Syrian refugees admitted to emergency departments with musculoskeletal system
injuries. The first one (50) investigated retrospectively 154 Syrian civil war victims
admitted to emergency departments between 2012 and 2014 who underwent a
surgical operation. The sites most frequently involved were the lower extremities, upper
extremities and axial skeleton. Blunt traumas, gunshot wounds, falls from height and
penetrant injuries were the most common mechanisms involved. The cost treatment of
a patient with fall from height was significantly higher than that of the patients with
another trauma mechanism.

The second one (24) took place in a state hospital in Gaziantep province that serves
two refugee camps. Both refugees and the local population referred to this centre in
2015 were evaluated for demography and trauma mechanism. The refugees accessed
the emergency department more frequently than the local population (638/10 000 vs
323/10 000, P<0.05), particularly for head injuries (120.9/10 000 vs 42.6/10000, P<0.05),
fractures, dislocations and sprain of extremities (235/10 000 vs 18.5/10 000, P<0.05) and
burns (110.3/10 000 vs 69/10 000, P<0.05). Conversely, the refugees showed a lower
prevalence of motor vehicle accidents (20.9/10 000 vs 42.3/10 000, P<0.05) and of
physical assaults (16.5/10 000 vs 98.3/10 000, P<0.05). Also, the refugees were younger
than the local population (<18 years 58% vs 33.3%, P<0.05) and more often females (33%
vs 29.1%, P<0.05).

The authors claim that the high rate of burns together with the lower age of refugees
is indicative of a major defect in basic health care inside refugee camps. In conclusion,
the authors think that low living standards, lack of adequate childcare and hygiene,
somatization of psychological disorders, and a possible underlying relationship between
PTSD and physical violence can explain the higher rate of access to the emergency
department of Syrian refugees compared to the Turkish population.

One paper (56) focused on 482 Syrian civil war victims admitted to an emergency
department in Hatay province between June 2011 and July 2012. Most of the victims
were male (88.8%) with a mean age of 30.8 ± 17.2 years. The most frequent trauma
mechanism was gunshots (70%). Injuries were located mostly in the extremity (31.7%).
Also, 71.8% of patients were admitted to the hospital. Overall, of the 482 patients, 94.6%
were discharged, 4.6% died and 0.8% were transferred. The mean length of hospital stay
was 10.1 days. Head and neck injuries were the most expensive to cure.

Reproductive Health
The paper from Tas et al. (51) focused on the assessment of psychosexual dysfunctions in
Syrian refugees due to anogenital warts (AGW). This cross-sectional study investigated
the psychological consequences of AGW in 100 refugees at the dermatology, family
medicine and psychiatry clinics of Health Sciences University, Bagcilar Research and
Training Hospital, between September 2012 and April 2014. Overall, the investigators
found that the AGWs did not have a significant influence on the psychosexual life and
mood changes in the patients. Also, 83% of patients had no awareness of their disease.
32 33
 The authors claim that the unchanged sexual behaviour is indeed due to the lack of
knowledge about the disease, often misperceived as nevi, pimples, wounds or other

H E A LT H O F S P E C I A L P O P U L AT I O N G R O U P S
dermatological scars.

Pulmonary Pathology
The paper from Soydan et al. focused on pathological pulmonary alteration detected
trough computerized tomography (CT) in asylum seekers (53). This cross-sectional study
investigated 1149 patients that were referred to the Capa Medical Faculty at Istanbul
University or Haydarpasa Numune State Hospital between March 2013 and February
2015 for respiratory symptoms and abnormal chest X-ray findings. Chronic changes were
the most detected alteration (17.2%), followed by signs suggestive of infections (3.4%)
and by nodular/mass lesions (1.4%). In addition, 1% of the patients showed findings
suggestive of TB. In the multivariate analysis, the age group of 55–64-year-olds was
an independent risk factor for chronic changes and lesions suggestive of malignancy
(OR 2.4, CI: 1.6–3.8; OR 10.2, CI: 2.3–46.5; respectively). The authors conclude that active HEALTH OF SPECIAL
screening programmes should be activated to perform TB surveillance upon arrival of
refugees and that the age group 55–64 years could benefit from active screening for POPULATION GROUPS
pulmonary malignancy.
Women’s Health
Cardiac Pathology
One study focused on the outcome of Syrian refugees undergoing coronary bypass
surgery (54). This cross-sectional study investigated 53 Syrian refugees at Şanlıurfa
Mehmet Akif İnan Training and Research Hospital between 2012 and 2014. During the
postoperative period, 9.4% of patients had atrial fibrillation, and 5.4% had a stroke. The • Among 458 Syrian women interviewed in Şanliurfa, 29.6% of women
mortality rate that was considered acceptable by the authors was 5.7%. The authors gave birth before 18 years of age, and 47.7% had a history of pregnancy
claim that, despite the challenging condition, therapy for chronic heart diseases should loss. Unmet need for contraception affected 56.9% of women, and
be offered to refugees. 50.8% reported having symptoms of STIs.
• According to a case-control study, Syrian women had poor antenatal
care compared to Turkish women, but no difference was found in
Inmates’ Health adverse perinatal outcomes.
One paper, by Keten et al, investigated the respect of the Istanbul Protocol during medical • Further research is needed to provide more data about obstetric
examination and detention of undocumented immigrants (55). The Istanbul Protocol is outcomes in the Syrian refugee population.
a set of international guidelines for documentation of torture and its consequences.
In this cross-sectional study, they evaluated 100 records of medico legal examinations
performed in Van-Çaldıran Government Hospital between 1 January and 31 December
2009. The paper showed that none of the forensic evaluations were performed following Table 4 provides an overview of studies on women’s health.
the Istanbul Protocol, given the absence of an interpreter during the examination, of
informed consent and of psychological examination. They claim that the information
retrieved from the records was insufficient to exclude cases of torture or maltreatment
and that the Istanbul Protocol should be incorporated into the curricula of undergraduate
and graduate education programmes.

34 35
 One paper, by Simsek et al, addressed the status of women’s health among Syrian
refugees living outside camps, in terms of sociodemographic characteristics,
reproductive behaviour, mental symptoms, malnutrition and STIs (18). The study was
conducted in Şanliurfa between March and April 2015. In total, 458 women aged 18–49
years participated in the study. It found that 79% of women reported their overall health
as good, while 17.2% reported having an illness. Also, 93.4% reported nutrition as a
primary issue. Regarding matrimonial status, 55.8% had a consanguineous marriage, and
51.3% married before 18 years of age. Moreover, 29.6% of women gave birth before 18
years of age, and 47.7% had a history of pregnancy loss. Unmet need for contraception
affected 56.9% of women, and 50.8% reported having symptoms of STIs. With regard
to nutritional status, 50% of women had an iron deficiency, 45.6% had a vitamin B12
deficiency and 10.5% had a folic acid deficiency. Also, 89.7% of women reported at least
two mental symptoms.

The results of the multivariate analysis showed that: less education and shorter length of
stay in Turkey were associated with early marriage. Early marriage and having the desired
number of children were associated with the use of contraception. A higher number of
household members, working husbands and longer length of staying in Turkey were
negatively associated with the number of desired children. The lack of social support, the
inability to speak Turkish and B12 deficiency were associated with having two or more
mental symptoms. The authors claim that there is an urgent need for improving primary
health care, which should include nutrition, reproductive health and integrated mental
health services.

Maternal Health
One case-control study compared clinical characteristics and pregnancy outcomes
between Syrian refugee women and Turkish non-refugee woman between 2013 and
2016 at a maternity center in Istanbul (7). Demographic data and obstetrical history
were collected from 300 Syrian refugees and 300 control patients. Only singleton
pregnancies were considered. Compared to control patients, Syrian patients showed
younger maternal age (25.2 vs 28.1, P<0.001) and a higher percentage of adolescents
(14.3% vs 5.3%, P<0.001). They also had poor antenatal care (41.3% of refugee patients
had no antenatal care vs 7.7% of control patients, P<0.001) but no difference was found
in adverse perinatal outcomes. Pre-term birth rates showed no difference between the
groups; however, post-term birth rates were significantly higher in the control group
(12.4% vs 4.3%, P<0.001). The authors call for larger multicentre studies to provide more
data about obstetric outcomes in this population.

36 37
 H E A LT H O F S P E C I A L P O P U L AT I O N G R O U P S
HEALTH OF SPECIAL
POPULATION GROUPS
Child Health
• Syrian refugee children appear to be affected by preventable
conditions such as malnutrition and anaemia.
• Among 104 Syrian children referred to the Pediatric Clinic of Adiyaman
University Hospital, weight (19.2%), height (31.7%), head circumference
(1.9%) and body mass index (6.7%) were below the third percentile.
• A study of 130 Syrian children admitted to a paediatric nephrology
department in Gaziantep from 2012 to 2015 identified two highly
prevalent conditions: congenital abnormalities of the kidney and the
urinary tract (26.2%) and chronic kidney disease (23.1%).
• A study conducted in Ankara on 457 Syrian refugee infants found that
neonatal morbidity and mortality among Syrians seemed to be higher
than that of Turkish infants (1.8% vs 0.04%).
• Further research is needed to provide more data about infant
morbidity in the Syrian refugee population.

Table 5 provides an overview of studies on child health.

38 39
 Three studies analysing the medical records of Syrian refugee children were retrieved
(6,8,9). Bucak et al. observed two main preventable conditions affecting their health
status: malnutrition and anaemia (9). Their retrospective study involved 104 Syrian
patients referred to the Pediatric Clinic of Adiyaman University Hospital in 2015. Results
showed that weight (19.2%), height (31.7%), head circumference (1.9%) and body mass
index (6.7%) were below the third percentile. All patients with body weight below
the third percentile had chronic malnutrition. Half of the patients for whom results
of complete blood count were available had anaemia, mainly due to iron deficiency
(62.8%) and vitamin B12 deficiency (14.2%).

Kara et al. studied the kidney disease profile of 130 Syrian refugee children admitted
to the Department of Pediatric Nephrology of the University of Gaziantep from 2012
to 2015 (8). Their analysis identified two highly prevalent conditions: congenital
abnormalities of the kidney and the urinary tract (26.2% of children, mainly bladder
abnormalities, vesicoureteral reflux and ureteropelvic junction obstruction) and chronic
kidney disease (23.1% of children, mainly due to the neurogenic bladder or to unknown
causes).

Finally, Büyüktiryaki et al. focused on neonatal outcomes (6). Morbidity among 457
Syrian refugee infants delivered in a tertiary hospital in Ankara between 2013 and 2014
appeared to be higher than that of local infants; their overall mortality rate was 1.8%
while the Turkish mortality rate was 0.04%. Further research is needed to provide more
data about infant morbidity in the Syrian refugee population.

40 41
 HEALTH SYSTEM
RESPONSE

H E A LT H S Y S T E M R E S P O N S E
• Leadership and governance, legislation: access to health care for Syrian
refugees is guaranteed by a “Circular on Health Services for the People
under Temporary Protection” which entitles Syrian migrants to health
care service.
• Health workforce: Syrian refugees overstretched the health facilities
capacities, especially at the Turkish–Syrian border. This led to an increased
workload for health care professionals and increased patients’ waiting
time. Difficulties have been reported in communication between Syrian
patients and Turkish health care professionals.
• Medical products: A paper reported problems in the reimbursement
for pharmacists who provide refugees with medications which could
challenge drugs provision to Syrian refugees.
• Health information: No studies addressed this topic.
• Health financing: The estimated mean cost per admitted Syrian patient
in Adana was 3723 Turkish liras (US$ 919).
• Service delivery: Among 251 Syrian refugees in Istanbul, the most
common diagnoses were: diseases of the respiratory system (14.4%),
diseases of the eye and adnexa (12.6%), and injury, poisoning and certain
other consequences of external causes (10.7%). Among 482 Syrian
refugees referred to the emergency department in Hatay province, 70%
complained of gunshots. The most frequent diagnoses were: extremity
injury (n = 153), internal disease (n = 93), chest injury (n = 44) and
abdominal injury (n = 41). Refugee health care centres staffed with Syrian
health care professionals offering medical assistance to Syrian patients
should address two problems: the overstretched health care facilities,
and the linguistic and cultural barriers between Syrian patients and
Turkish health care professionals.

Table 6 provides an overview of studies on the health system

response to refugees and migrants in Turkey.

42 43
44 45
 Leadership and Governance Legislation
Several conventions and protocols can be considered a written international consensus
concerning refugees’ social rights (the 1951 United Nations Convention Relating to the
Status of Refugee and its additional Protocols, the Organisation of African Unity Refugee
Convention Governing the Specific Aspects of Refugee Problems in Africa, the Cartagena
Declaration on Refugees in Latin America, and the Charter of Fundamental Rights of the
European Union). However, none of those documents or agreements address the right to
health and the social determinants of health for refugees (3).
Turkey has a geographical reservation to implement the Convention: it can entitle refugee
status only to migrants from Europe. However, the Law on Foreigners and International
Protection introduced a “temporary protection” for Syrian immigrants. Access to health
care for Syrian refugees is guaranteed by a “Circular on Health Services for the People under
Temporary Protection” which also entitles Syrian migrants to health care services. However,
according to Ekmekci (3), the status of temporary protection does not give Syrian migrants
the same rights as refugees. International legislation does not recognize this status, and
the Turkish Parliament could pass legislation to abolish it.
The official registration of migrants is crucial to ensure their full access to health care. As of
September 2013, Syrian refugees were granted free access to health care, thanks to article
27 of the temporary regulation protection (59). Syrians can also purchase their medicine
with an 80% discount similar to Turkish patients covered by social security.
In order to diminish the burden of Syrian refugees on Turkish hospitals and community
health centres, around 50 refugee health centres have been established (3). In November
2014, a collaborative initiative was launched to enable Syrian health professionals to work
in refugee health centres with the aim of reducing linguistic and cultural barriers for Syrian
patients. Syrian doctors and nurses in Turkey receive training courses to adapt to the
Turkish health system, and after verification of their credentials and certification, they are
hired by the Turkish Ministry of Health (58).
Health Workforce
Semi-structured interviews administered to 10 nurses involved in health care for refugees
in Kilis provide information on their thoughts and feelings (33). Nurses reported difficulties
in communication due to language barriers. Moreover, they referred to problems
concerning gender and privacy. Male nurses encountered problems communicating with
female Syrian patients and vice-versa. Practices such as urethral catheterization were
largely unacceptable for Syrian patients. Nurses reported differences in attitudes between
Syrian and Turkish patients toward daily behaviours in hospitals and death. Finally, nurses
reported feeling compassion and empathy, especially for children and female patients.
Savas et al. in 2015 conducted a survey among 210 health care professionals in Hatay
province investigating changes that occurred in Hatay hospital after the start of the
Syrian conflict (36). It showed that 86% of doctors and nurses participating reported an
46
increased workload, 67% worked more hours per day and 53% reported increased patient
accesses to their department. According to 72% of health care professionals interviewed,
the patients’ waiting time increased. The majority of health care professionals indicated
that Syrian patients had more complications and showed a higher need for patient care,
inpatient treatment and intensive care compared to Turkish patients. The majority also
thought that the number of health care workers (92%), the number of hospital beds (68%)
and the capacity of intensive care (76%) were insufficient for refugees’ needs.
In contrast, Syrian refugees expressed difficulties dealing with Turkish nurses. Sevinc et
al. in 2016 interviewed 30 Syrian patients undergoing treatment in internal medicine.
Refugees experienced difficulties in communication due to linguistic barriers, and
difficulties in meeting their personal needs and correctly following treatment instructions
(34). Difficulties in implementing treatment were mainly due to bureaucratic and financial
issues. Another issue highlighted was the need for psychosocial support. Patients are often
alone in a foreign country with difficulties communicating with their relatives in Syria, and
this was reported as the main stress factor for refugees participating in the study. However,
refugees felt gratitude toward nurses and Turkey.
Civaner et al. (2017) dealt with the ethics of disasters, including massive migration flows, for
health care personnel (57). The interview conducted among 31 health care professionals
who have been involved in disasters, revealed their concerns about the ethics of disaster
management and relief. The main criticalities pinpointed were: insufficient guidelines and
education for health care professionals, the unpreparedness of the health sector, public
authorities’ defensive attitude towards information, the media mindset raising a violation
of personhood rights and loss of information credibility. Moreover, resource allocation,
politicians’ interventions to control it and the instrumental use of disasters by relief
organization stakeholders who devalue the concepts of “helping” and “solidarity” were
concrete concerns for survey respondents.
Medical Products
Sözen Şahne et al. in 2015 described the pharmacy service for migrants (61). Drugs have
been provided to refugees, especially those living in camps, since the beginning of the
Syrian crisis, thanks to protocols signed by related governorships, pharmacy chambers,
provincial health directorates, and disaster and emergency directorates. In September
2015, a circular of the Prime Minister of Turkey regulated the medicines provision to Syrian
refugees at 20% of market cost. The paper reported problems in the reimbursement for
pharmacists which could challenge the provision of drugs to Syrian refugees.
Health Information
No studies focused on health information, an important field requiring further
development.
Health Financing
Since 2016, within the framework of the European Union–Turkey Statement, the European
Union has provided Turkey with 3 billion euros for 2016 and 2017 (65). Gulacti et al. analysed
the medical records of the Emergency Department of Adiyaman hospital retrospectively
47
 for the year 2015, and estimated the total cost of Syrians’ visits to emergency departments,
including discharged and admitted patients, as US$ 773 374.60 of which US$ 153 405 was
for discharged patients and US$ 619 969 was for admitted patients (35). Tahirbegolli et al.
(2016) estimated the costs per admission of 251 Syrian refugees hospitalized in Istanbul
as US$ 48/per patient. The total cost of hospital admissions was US$ 12 031 in a six-month
period (60). Ozdogan et al. estimated the mean cost per admitted Syrian patient in Adana
as 3723 Turkish liras (US$ 919) (62).
Service Delivery
According to the Turkish Ministry of Health, more than 7 million outpatient examinations
and 300 000 hospital admissions of Syrian patients were registered between 2011 and
2015, including 25 000 wounded patients, more than 220 000 surgical operations and
around 60 000 childbirths (38). According to the Ministry of Health, 30–40% of the capacity
of hospitals on the Turkish–Syrian border were devoted to Syrian refugees (3). Gulacti et al.
(2017) analysed the numbers and costs of the admissions to the Emergency Department
of Adiyaman University in 2010 and in 2015. They found an 8% increase in emergency
department accesses in 2015 compared to 2010 mainly due to Syrian patients (35). In 2015,
9842 Syrians visited the emergency department, of which more than 55% were female
and the majority lived outside refugee camps. Only 12.4% were admitted to the hospital
while 87% were discharged. The most common reason for emergency department visits
were: upper respiratory tract infections, myalgia, abdominal and pelvic pain, urinary tract
infection and chest pain.
A cross-sectional study reported the discharge diagnoses of 251 Syrian refugees in a
Turkish university hospital in Istanbul in 2015 (60). The most common diagnoses were:
diseases of the respiratory system (14.4%); diseases of the eye and adnexa (12.6%) and
injury, poisoning and certain other consequences of external causes (10.7%). Ozdogan et
al. reported data from Adana Numune Training and Research Hospital which is located
close to the Turkish–Syrian border. In two years (from June 2012 to July 2014), around
234 000 Syrian patients were admitted to the Hospital. Of these, 2842 were hospitalized,
and 1812 had surgical procedures. According to the study, the need for health assistance
among Syrians overstretched the ward’s capacity (62). During the same period, 280 Syrian
patients were hospitalized in intensive care, 80 of which in surgical intensive care. Among
these the most common injury was a gunshot wound. The mean length of stay was 12 days.
The study showed that 75% developed complications and 55% died (62). In another study,
1355 Syrian civilians were referred to the Mustafa Kemal University Faculty of Medicine
in Hatay between June 2011 and July 2012 (56). Karakuş et al. retrospectively analysed
the records of those (n = 482) referred to the emergency department. Seventy per cent
complained about gunshot injury while the frequent diagnoses were: extremity injury (n =
153), internal disease (n = 93), chest injury (n = 44) and abdominal injury (n = 41).
Yaman et al. focused on the assessment of the general health needs of refugees (52). This
cross-sectional study investigated 212 refugees that accessed a private family practice
centre in Ankara between September 1997 and March 1998. The refugees came mostly
from Iraq (64%), the Islamic Republic of Iran (22%) and the West Bank and Gaza Strip (6%).
Infections (43%) were the most common diagnoses. Upper respiratory tract infections and
48
acute sinusitis were more frequent in the 19–35-year-old group, while musculoskeletal
problems were more common in the 36–50-year-old group. Female patients had a higher
diagnosis of PTSD compared to male patients (17% vs 9%).
Health Care In Refugee Camps
In 2012, Salhool et al. reported the results of an evaluation of health care services at
refugee camps in Turkey (64). When Sahlool wrote the report, only 22 000 Syrian refugees
were living in Turkey, in nine sites located in Hatay, Gaziantep and Kilis. The report was
overall positive but raised some concerns regarding the total number of daily visits per
clinician, which may have exceeded the recommended number, the language barriers,
the delay in dispensing medication, the abuse of the health system by refugees, the lack
of important specialties or services such as rehabilitation and child psychology, and the
lack of refugees’ awareness of psychological trauma. In 2012, Alghothani et al. published
the results of a survey conducted among 18 medical doctors participating in a mission in
refugee camps in Turkey (63). According to the doctors interviewed, the most common
diseases were acute conditions such as upper respiratory infections, conjunctivitis,
hepatitis A, gastroenteritis and skin rashes, as well as complications of chronic conditions
such as diabetes, hypertension, chronic obstructive pulmonary disease, asthma, arthritis,
gastroesophageal reflux and exacerbated chronic back pain. Participants identified the
lack of proper facilities and medical supplies and equipment as the main limiting factors.
Nearly half would prefer to have had a better pre-mission preparation.
Afghan Migrants
Among 155 Afghans participating in a survey in Istanbul, Alemi et al. (2017) (16)
investigated factors enabling and limiting contacts with health care services, in particular,
the use of non-prescription medicines, use of prescription medication, and encounters
with general practitioners and outpatient specialists. Predictors of encounters with general
practitioners were female gender, higher income and higher severity of asylum difficulties.
Higher income was also a predictor for outpatient specialists encounters, together with
family presence in Turkey. Presence of family in Turkey, higher income and having regular
access to a health care provider significantly increased the use of prescribed medicines
while no factors were associated with the use of non-prescription medications.
Limitations And Strengths Of The Review
The aim of this review was wide and challenging. For this reason, a broad approach was
adopted, including studies with different designs and targeting different populations.
These factors have to be taken into account while reading the review.
The study design and the target population are described for each piece of information
to allow the reader to understand and critically interpret the results. Nevertheless, the
discussion did not address the strengths and weaknesses of the various epidemiological
studies examined. Despite the effort to be as inclusive as possible, important gaps were
found in the scientific literature. Noncommunicable diseases and occupational health, as
well as behavioural risk factors for noncommunicable diseases, are not addressed.
49

Moreover, the health system analysis framework revealed a lack of evidence concerning
health information and health products.
A major limitation of this report is that the investigative articles are limited in their ability
to represent both refugees and the Turkish population. However, this work provides an
overview of the social determinants of health, health status and health systems in the field
of refugee and migrant health in Turkey.
CONCLUSION
This review highlights important facts on refugee health which could affect health sector
policies and strategies.
mediators should support the work of health care professionals both in community care
and in hospital settings in regions with a high presence of Syrian refugees.
The evidence collected supports the need to strengthen primary care settings and
psychosocial support for refugees and migrants, as well as public health interventions such
as tuberculosis control programmes. Inappropriate visits to the emergency department by
Syrian refugees prove the strong need for community care for this population. Refugee
health care centres with Syrian health care workers assisting Syrian refugees may represent
an innovative solution to responding to their health needs and reducing the inappropriate
referral to hospitals. Long-term strategies to ensure the sustainability of refugee health care
centres should be designed taking into account workforce, infrastructures, medications
and strong information services. However, long-term strategies to potentiate hospitals at
the Turkish–Syrian should be taken into account.

The analysis of the current evidence on health status highlights the priorities for future
policy. Mental health is a field of particular concern. Syrian refugees, but also migrants
from different origins, experienced war and traumatic events with consequences on their
mental conditions. Screening for psychological distress and psychosocial support should
be offered to refugees and migrants. Vaccination rates among Syrian children were low, and
vaccination strategies should be implemented. Maternal and child health care for refugees
should be prioritized; refugees, in fact, show poor neonatal and child outcomes. Finally,
living conditions, water and sanitation may represent a priority too; the high prevalence of
CL among Syrian refugees suggests a low level of attention to these aspects.

This review also highlights the need to strengthen evidence. Noncommunicable diseases,
occupational health and women’s health are not or only marginally addressed by papers
included in this review. For instance, further research is needed to provide more data
about obstetric outcomes and infant morbidity in the Syrian refugee population, possibly
through large multicentre studies. Nevertheless, additional information on some of these
topics might be hidden in grey literature. One example is the WHO STEPwise approach
to surveillance (STEPS) survey for Syrian refugees on noncommunicable diseases, not
retrieved in the present review, which was limited to traditional scientific databases (66).
Alternative sources of evidence should be considered in future reviews.

Moreover, no data were available on health information, medication and health financing.
The need to structurally fill these gaps is a priority for the Turkish health sector. Research
and in-hospital and community-based national monitoring systems may significantly
improve knowledge of this field and provide a solid background for policy. With around 3.5
million Syrian refugees in Turkey, having reliable and updated data on their health status
is important to shape policy.

An important challenge for the Turkish health sector is reducing barriers for refugees and
migrants accessing the health service. Linguistic and cultural barriers may seriously limit
health service accessibility and the effectiveness of treatments. This criticality highlights the
need to strengthen services specifically targeting refugees’ needs. Interpreters and cultural

50 51
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55
The WHO Regional
Office for Europe

The World Health Organization (WHO)

is a specialized agency of the United
Nations created in 1948 with the primary
responsibility for international health matters
and public health. The WHO Regional Office
for Europe is one of six regional offices
throughout the world, each with its own
programme geared to the particular health
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Lithuania Regional Office for Europe
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Tel: +45 45 33 70 00 Fax: +45 45 33 70 01
Email: eucontact@who.int
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