ABSTRACT

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

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

INTRODUCTION

In 2019 it was estimated that 275 million people migrated outside the borders of their own countries, meaning that 3.5% of the world’s population were international migrants. That figure number has tripled in the last 45 years ¹1. International Organization for Migration . World Migration Report 2020 . Geneva (CH) : IOM ; 2019 [ cited 2020 Oct 21 ]. Part I, Data and information on migration and migrants; Chapter 2, Migration and migrants: a global overview ; p. 19 - 52 . Available from: https://publications.iom.int/system/files/pdf/wmr_2020.pdf
https://publications.iom.int/system/file... . Currently, there are about 79.5 million people in forced displacement and, of these, 26 million are refugees ²2. United Nations High Commissioner for Refugees . Global trends: forced displacement in 2019 . Geneva (CH) : UNHCR ; 2020 [ cited 2020 Oct 21 ]. Available from: https://www.unhcr.org/statistics/unhcrstats/5ee200e37/unhcr-global-trends-2019.html
https://www.unhcr.org/statistics/unhcrst... , i.e., people who “are out of their home country because of well-founded fear of persecution related to armed conflict, race, religion, nationality, membership of a particular social group or political opinion, or serious and widespread violation of human rights” ³3. Alto Comissariado das Nações Unidas para Refugiados . Protegendo refugiados no Brasil e no mundo . São Paulo, SP : ACNUR ; 2016 [ cited 2020 Oct 3 ]. Available from: https://www.acnur.org/portugues/
https://www.acnur.org/portugues/... .

In 2011, due to the so-called Arab Spring and the armed conflict in Syria, the Arab world became the epicenter of the refugee issue. Syria now has the largest forcibly displaced population in the world. Of its population of 13.5 million in 2019, 6.7 million of them are refugees. Iraq has about 3.3 million people in this situation, and Palestine, 5.5 million ²2. United Nations High Commissioner for Refugees . Global trends: forced displacement in 2019 . Geneva (CH) : UNHCR ; 2020 [ cited 2020 Oct 21 ]. Available from: https://www.unhcr.org/statistics/unhcrstats/5ee200e37/unhcr-global-trends-2019.html
https://www.unhcr.org/statistics/unhcrst... . Lebanon has the highest concentration of refugees in the world in relation to the general population (156/1,000) ⁴4. United Nations High Commissioner for Refugees . Global trends: forced displacement in 2018 . Geneva : UNHCR ; 2019 [ cited 2020 Oct 21 ]. Available from: https://www.unhcr.org/5d08d7ee7.pdf
https://www.unhcr.org/5d08d7ee7.pdf... , which worsens health conditions in the country, noting that most refugees come from Syria ⁵5. United Nations High Commissioner for Refugees . Global trends: forced displacement in 2016 . Geneva (CH) : UNHCR ; 2017 [ cited 2020 Oct 12 ]. Available from: https://www.unhcr.org/statistics/unhcrstats/5943e8a34/global-trends-forced-displacement-2016.html
https://www.unhcr.org/statistics/unhcrst... .

Global refugee trends also echo in Brazil. Since the beginning of the conflict in Syria, 3,772 people have requested refuge in the country ⁹9. Ministério da Justiça (BR) , Comitê Nacional para Refugiados . Sistema de Refúgio Brasileiro: desafios e perspectivas. Refúgio em números . Brasília, DF : CONARE ; 2017 [ cited 2020 Oct 20 ]. Available from: https://www.acnur.org/fileadmin/Documentos/portugues/Estatisticas/Sistema_de_Refugio_brasileiro_-_Refugio_em_numeros_-_05_05_2016.pdf
https://www.acnur.org/fileadmin/Document... and, among the Arabs, Syria, Palestine, Lebanon and Iraq are the countries of origin that had their refugee status most often recognized in Brazil ¹⁰10. Ministério da Justiça (BR) , Comitê Nacional para Refugiados . Refúgio em números . Brasília, DF : CONARE ; 2018 [ cited 2020 Oct 15 ]. Available from: https://www.acnur.org/portugues/wp-content/uploads/2018/04/refugio-em-numeros_1104.pdf
https://www.acnur.org/portugues/wp-conte... .

The status of refugee is per se an element of vulnerability considering forced migration, and because it represents a serious and widespread violation of human rights ¹¹11. World Health Organization . 2017. Vulnerability and resilience; Sri Lanka . Geneva (CH) : WHO ; 2017 [ cited 2020 Oct 1 ]. Available from: https://www.iom.int/sites/g/files/tmzbdl486/files/our_work/DMM/Migration-Health/GC2_TDP_Vulnerability-and-Resilience_FINAL_13.02.2017.pdf
https://www.iom.int/sites/g/files/tmzbdl... . This article aims at mapping and reviewing the elements of health vulnerability of Arab refugees in the scope of primary health care (PHC).

METHOD

This is a 5-stage scoping review, following Arksey and O’Malley ¹²12. Arksey H , O’Malley L . Scoping studies: towards a methodological framework . Int J Soc Res Methodol . 2005 ; 8 ( 1 ): 19 - 32 . https://doi.org/10.1080/1364557032000119616
https://doi.org/10.1080/1364557032000119... :

Stage I: Identification of the research question.

What are the elements of vulnerability, in the individual, programmatic, and social dimensions, that impact Arab refugees in the context of primary health care?

Stage II: Identification of relevant studies.

Two strategies were used ( Table 1 ), adapted according to the specificity of each database. Following databases were visited: Lilacs, SciELO, NYAM Grey Literature, Cochrane, Health System Evidence, MedLine/PubMed, Embase, Web of Science, CINAHL, BVS, Capes Theses and Dissertations Database, Refworld, and Journal of Refugee Studies. Studies published from January 1, 2011 to December 31, 2019 were included, considering the historical context of the Arab Spring.

Stage III: Study selection.

Following were the inclusion criteria: subjects of the studies were Arab, Syrian, Palestinian, Iraqi, and Lebanese refugees in the condition resulting from forced migration, because they are the nationalities that most had the refugee status recognized in Brazil ¹⁰10. Ministério da Justiça (BR) , Comitê Nacional para Refugiados . Refúgio em números . Brasília, DF : CONARE ; 2018 [ cited 2020 Oct 15 ]. Available from: https://www.acnur.org/portugues/wp-content/uploads/2018/04/refugio-em-numeros_1104.pdf
https://www.acnur.org/portugues/wp-conte... ; studies that made it possible to identify constitutive elements of the concept of vulnerability; studies that presented elements of vulnerability in any of the four phases of refuge (origin, transit, destination, and return); studies that had PHC as a setting.

The following studies were excluded: on voluntary migration (non-forced displacement and economic migration); did not bring original/primary data (article of opinion, experience reports, literature reviews). We did not delimit the length of migration of the studies’ subjects.

We consider vulnerability “a set of individual and collective aspects related to the greater susceptibility of individuals and communities to an illness or injury and, inseparably, the lower availability of resources for their protection” ¹³13. Ayres JRCM , Paiva V , França Jr I . Conceitos e práticas de prevenção: da história natural da doença ao quadro da vulnerabilidade e direitos humanos . In: Paiva V , Ayres JRCM , Buchalla CM , organizadores . Vulnerabilidade e direitos humanos: prevenção e promoção da saúde: Livro 1, Doença e cidadania . Curitiba, PR : Juruá ; 2012 . p. 71 - 94 . . We also consider the three interdependent, inextricable, and synergistic dimensions of the concept: individual, programmatic, and social ¹³13. Ayres JRCM , Paiva V , França Jr I . Conceitos e práticas de prevenção: da história natural da doença ao quadro da vulnerabilidade e direitos humanos . In: Paiva V , Ayres JRCM , Buchalla CM , organizadores . Vulnerabilidade e direitos humanos: prevenção e promoção da saúde: Livro 1, Doença e cidadania . Curitiba, PR : Juruá ; 2012 . p. 71 - 94 . . The individual dimension takes as its starting point aspects of the way of living that may contribute to the exposure to a given health problem, or aspects that may protect against certain problems. The programmatic dimension integrates the efforts of institutional programs, especially health programs. The social dimension covers all the contextual elements related to life in society: the legal, political, and ideological structure, governmental guidelines related to health and social issues, social relations, and religious beliefs, among others ¹⁴14. Ayres JRCM , Calazans GJ , Saletti Filho HC , França Júnior l . Risco, vulnerabilidade e práticas de prevenção e promoção da saúde . In: Campos GWS , organizador . Tratado de Saúde Coletiva . São Paulo : Hucitec; Fiocruz ; 2006 . p. 375 - 417 . .

After identifying the articles in databases, duplicates were excluded, followed by analysis by title; by abstract; and by the full text ( Figure ).

Stage IV: Mapping the studies.

We designed a form to extract and organize the following data: author, year of publication, country of study, country of origin and destination of refugees, objectives, type and population of the study, sample size, study setting, elements of vulnerability in the individual, programmatic and social dimensions, as indicators of stage V (Tables 2, 3 and 4).

Stage V: Conference, summary, and reporting of results.

Data were analyzed and summarized according to the following vulnerability indicators proposed by Nichiata, Takahashi and Bertolozzi ¹⁶16. Nichiata LYI , Takahashi RF , Bertolozzi MR . Perspectivas avaliativas das vulnerabilidades em saúde . In: Egry EY , organizadora . Necessidades em saúde na perspectiva da Atenção Básica: guia para pesquisadores . São Paulo : Dedone , 2008 . p. 41 - 47:

Individual dimension: 1) Demographic profile (gender, age, occupation); 2) Family structure (nuclear, non-nucleated, number of children); 3) Living conditions (domicile: tents/containers/urban house, basic sanitation); 4) Work (profession, occupation, working hours); 5) Social relations at work (owner, employee); 6) Morbidity and mortality profile; 7) Beliefs and values about the health-disease process.

Programmatic dimension: 1) Health Policies; 2) Actions of the Health Programs; 3) Access to Health Services.

Social Dimension: 1) Access to: education, culture, information, leisure and justice; 2) Participation in collective actions; 3) Religious belief; 4) Prejudice/stigma; 4) Migration (origin, transit, destination and return).

RESULTS

After selection, 40 studies remained for analysis and data extraction ( Figure ). In the process of reviewing the production of studies by continent it was found that Asia produced 15 studies (37.5%), North America 12 (30%), Europe 12 (30%), and Oceania 1 (2.5%). No original study published in a Brazilian or Latin American journal was found. No relevant grey literature was identified either. Studies on Syrians were prevalent (18: 45%), followed by Palestinians (13: 32%) and Iraqis (2: 5%). The predominance of studies with Syrians is justified by the historical interval studied (from 2011 onwards). We did not identify studies with Lebanese refugees. Most of the studies (30) were conducted with refugees in the destination countries: Jordan (17 studies: 42%); Lebanon (9: 22%); Syria (3: 7.5%); in urban areas (29: 72%). Most of the studies (31: 77%) were quantitative.

Health Vulnerabilities of Refugees: Categorization by dimensions (individual, programmatic and social) and country of origin

I - Syrian Refugees

Twenty-two studies were found ( Table 2 ) ¹⁷17. United Nations High Commissioner for Refugees ; UNICEF ; WFP . Vulnerability assessment of Syrian refugees in Lebanon 2016 . Geneva (CH) : UNHCR ; 2016 . . Regarding the elements of individual vulnerability, the morbidities that stood out most were: mental disorders, overweight/obesity, eating disorders, tuberculosis, chronic noncommunicable diseases, and sexually transmitted infections. Syrian refugees are about 10 times more susceptible than the host country population to mental health problems (52%) ³²32. Segal SP , Khoury VC , Salah R , Ghannam J . Contributors to screening positive for mental illness in Lebano´s Shatila Palestinian Refugee Camp . J Nerv Ment Dis . 2018 ; 206 ( 1 ): 46 - 51 . https://doi.org/10.1097/NMD.0000000000000751
https://doi.org/10.1097/NMD.000000000000... and post-traumatic stress disorder (PTSD) was present in almost half of the cases ²⁸28. Aoun A , Joundi J , El Gerges N . Prevalence and correlates of a positive screen for eating disorders among Syrian refugees . Eur Eat Disord Rev . 2019 ; 27 ( 3 ): 263 - 73 . https://doi.org/10.1002/erv.2660
https://doi.org/10.1002/erv.2660... , strongly associated with exposure to war ³²32. Segal SP , Khoury VC , Salah R , Ghannam J . Contributors to screening positive for mental illness in Lebano´s Shatila Palestinian Refugee Camp . J Nerv Ment Dis . 2018 ; 206 ( 1 ): 46 - 51 . https://doi.org/10.1097/NMD.0000000000000751
https://doi.org/10.1097/NMD.000000000000... and eating disorders ²⁸28. Aoun A , Joundi J , El Gerges N . Prevalence and correlates of a positive screen for eating disorders among Syrian refugees . Eur Eat Disord Rev . 2019 ; 27 ( 3 ): 263 - 73 . https://doi.org/10.1002/erv.2660
https://doi.org/10.1002/erv.2660... . Anxiety and depression were also highly prevalent (40.3% and 47.7%, respectively). Most of the refugees who developed anxiety and depression in the country of destination did not have it in the country of origin ³⁶36. Javanbakht A , Amirsadri A , Suhaiban HA , Alsaud MI , Alobaidi Z , Rawi Z , et al . Prevalence of possible mental disorders in Syrian refugees resettling in the United States screened at primary care . J Immigr Minor Health . 2019 ; 21 ( 3 ): 664 - 7 . https://doi.org/10.1007/s10903-018-0797-3
https://doi.org/10.1007/s10903-018-0797-... . The conditions that may result from adverse experiences at the destination (exposure to trauma, loss of family members, in relation to social status and material goods, chronic deprivation in basic needs); in the transition (unsafe means of transportation: risk at sea crossing, of exploitation by smugglers), in the camps (overcrowding, uncertainty about the future, and severe lack of resources), and after resettlement (unfamiliarity with the new context, language barriers, poverty, unemployment, lack of support, discrimination) ³⁶36. Javanbakht A , Amirsadri A , Suhaiban HA , Alsaud MI , Alobaidi Z , Rawi Z , et al . Prevalence of possible mental disorders in Syrian refugees resettling in the United States screened at primary care . J Immigr Minor Health . 2019 ; 21 ( 3 ): 664 - 7 . https://doi.org/10.1007/s10903-018-0797-3
https://doi.org/10.1007/s10903-018-0797-... .

Chronic noncommunicable diseases, especially diabetes (DM) and hypertension (SAH) were mentioned in eight studies ²²22. Al-Rousan T , Schwabkey Z , Jirmanus L , Nelson BD . Health needs and priorities of Syrian refugees in camps and urban settings in Jordan: perspectives of refugees and health care providers . East Mediterr Health J . 2018 ; 24 ( 3 ): 243 - 53 . https://doi.org/10.26719/2018.24.3.243
https://doi.org/10.26719/2018.24.3.243... , ²⁴24. Doocy S , Lyles E , Roberton T , Akhu-Zaheya L , Oweis A , Burnham G . Prevalence and care-seeking for chronic diseases among Syrian refugees in Jordan . BMC Public Health . 2015 ; 15 : 1097 . https://doi.org/10.1186/s12889-015-2429-3
https://doi.org/10.1186/s12889-015-2429-... , ²⁷27. Sethi S , Jonsson R , Skaff R , Tyler F . Community-based noncommunicable disease care for Syrian refugees in Lebanon . Glob Health Sci Pract . 2017 ; 5 ( 3 ): 495 - 506 . https://doi.org/10.9745/GHSP-D-17-00043
https://doi.org/10.9745/GHSP-D-17-00043... , ³¹31. Doocy S , Lyles E , Hanquart B ; LHAS Study Team , Woodman M . Prevalence, care-seeking, and health service utilization for non-communicable diseases among Syrian refugees and host communities in Lebanon . Confl Health . 2016 ; 10 : 21 . https://doi.org/10.1186/s13031-016-0088-3
https://doi.org/10.1186/s13031-016-0088-... , ³⁴34. Doocy S , Paik KE , Lyles E , Hei Tam H , Fahed Z , Winkler E , et al . Guidelines and mHealth to improve quality of hypertension and type 2 diabetes care for vulnerable populations in Lebanon: longitudinal cohort study . JMIR Mhealth Uhealth . 2017 ; 5 ( 10 ): e158 . https://doi.org/10.2196/mhealth.7745
https://doi.org/10.2196/mhealth.7745... , ³⁵35. Elliott JA , Das D , Cavailler P , Schneider F , Shah M , Ravaud A , et al . A cross-sectional assessment of diabetes self-management, education and support needs of Syrian refugee patients living with diabetes in Bekaa Valley Lebanon . Confl Health . 2018 ; 12 : 40 . https://doi.org/10.1186/s13031-018-0174-9
https://doi.org/10.1186/s13031-018-0174-... , ³⁸38. Lyles E , Hanquart B , Chlela L , Woodman M ; LHAS Study Team , Fouad FM , Sibai A , et al . Health service access and utilization among Syrian refugees and affected host communities in Lebanon . J Refugee Stud . 2018 ; 31 ( 1 ): 104 - 30 . https://doi.org/10.1093/jrs/fex014
https://doi.org/10.1093/jrs/fex014... , ⁵⁴54. Goosen S , Middelkoop B , Stronks K , Agyemang C , Kunst AE . High diabetes risk among asylum seekers in The Netherlands . Diabet Med . 2014 ; 31 ( 12 ): 1532 - 41 . https://doi.org/10.1111/dme.12510
https://doi.org/10.1111/dme.12510... , and the prevalence of DM was higher than in the local population; in women, it was almost twice as high, as was the risk for the disease ⁵⁴54. Goosen S , Middelkoop B , Stronks K , Agyemang C , Kunst AE . High diabetes risk among asylum seekers in The Netherlands . Diabet Med . 2014 ; 31 ( 12 ): 1532 - 41 . https://doi.org/10.1111/dme.12510
https://doi.org/10.1111/dme.12510... . The higher prevalence of DM refers mainly to individuals with a relatively long-lasting history of migration. There is an increased risk for DM about six months after arrival, and it is accentuated after four years of migration ⁵⁴54. Goosen S , Middelkoop B , Stronks K , Agyemang C , Kunst AE . High diabetes risk among asylum seekers in The Netherlands . Diabet Med . 2014 ; 31 ( 12 ): 1532 - 41 . https://doi.org/10.1111/dme.12510
https://doi.org/10.1111/dme.12510... . Refugees may face an accumulation of risk factors for DM: increased genetic susceptibility, low birth weight, exposure to childhood hunger, major socioeconomic change, acculturation stress, and distinct lifestyles in the host country. The refuge seekers with PTSD had almost 1.5 times greater chance of being diagnosed with DM compared to others in the same condition ⁵⁴54. Goosen S , Middelkoop B , Stronks K , Agyemang C , Kunst AE . High diabetes risk among asylum seekers in The Netherlands . Diabet Med . 2014 ; 31 ( 12 ): 1532 - 41 . https://doi.org/10.1111/dme.12510
https://doi.org/10.1111/dme.12510... . Also, fasting blood glucose levels above 120 mg/dl were found in 57.9% of the refugees with DM ³⁴34. Doocy S , Paik KE , Lyles E , Hei Tam H , Fahed Z , Winkler E , et al . Guidelines and mHealth to improve quality of hypertension and type 2 diabetes care for vulnerable populations in Lebanon: longitudinal cohort study . JMIR Mhealth Uhealth . 2017 ; 5 ( 10 ): e158 . https://doi.org/10.2196/mhealth.7745
https://doi.org/10.2196/mhealth.7745... .

Approximately 73.9% of the refugees had a family member with a chronic disease (SAH: 25.2% of patients) ³⁷37. Torun P , Karaaslan MM , Sandikli B , Acar C , Shurtleff E , Dhrolia S , et al . Health and health care access for Syrian refugees living in Istanbul . Int J Public Health . 2018 ; 63 ( 5 ): 601 - 8 . https://doi.org/10.1007/s00038-018-1096-4
https://doi.org/10.1007/s00038-018-1096-... . Respiratory diseases were mentioned in four studies ²²22. Al-Rousan T , Schwabkey Z , Jirmanus L , Nelson BD . Health needs and priorities of Syrian refugees in camps and urban settings in Jordan: perspectives of refugees and health care providers . East Mediterr Health J . 2018 ; 24 ( 3 ): 243 - 53 . https://doi.org/10.26719/2018.24.3.243
https://doi.org/10.26719/2018.24.3.243... , ²⁵25. Gammoh OS . A preliminary description of medical complaints and medication consumption among 375 Syrian refugees residing in North Jordan . Jordan J Pharm Sci . 2016 ; 9 ( 1 ): 13 - 21 . , ²⁷27. Sethi S , Jonsson R , Skaff R , Tyler F . Community-based noncommunicable disease care for Syrian refugees in Lebanon . Glob Health Sci Pract . 2017 ; 5 ( 3 ): 495 - 506 . https://doi.org/10.9745/GHSP-D-17-00043
https://doi.org/10.9745/GHSP-D-17-00043... , ³¹31. Doocy S , Lyles E , Hanquart B ; LHAS Study Team , Woodman M . Prevalence, care-seeking, and health service utilization for non-communicable diseases among Syrian refugees and host communities in Lebanon . Confl Health . 2016 ; 10 : 21 . https://doi.org/10.1186/s13031-016-0088-3
https://doi.org/10.1186/s13031-016-0088-... . In Lebanon, 89.1% of Syrian refugees in the study sample sought PHC due to chronic respiratory disease ³¹31. Doocy S , Lyles E , Hanquart B ; LHAS Study Team , Woodman M . Prevalence, care-seeking, and health service utilization for non-communicable diseases among Syrian refugees and host communities in Lebanon . Confl Health . 2016 ; 10 : 21 . https://doi.org/10.1186/s13031-016-0088-3
https://doi.org/10.1186/s13031-016-0088-... . Refugees experience exacerbation of respiratory diseases due to the desert climate of some refugee camps ²²22. Al-Rousan T , Schwabkey Z , Jirmanus L , Nelson BD . Health needs and priorities of Syrian refugees in camps and urban settings in Jordan: perspectives of refugees and health care providers . East Mediterr Health J . 2018 ; 24 ( 3 ): 243 - 53 . https://doi.org/10.26719/2018.24.3.243
https://doi.org/10.26719/2018.24.3.243... . Tuberculosis (TB) was noted in three studies ²⁷27. Sethi S , Jonsson R , Skaff R , Tyler F . Community-based noncommunicable disease care for Syrian refugees in Lebanon . Glob Health Sci Pract . 2017 ; 5 ( 3 ): 495 - 506 . https://doi.org/10.9745/GHSP-D-17-00043
https://doi.org/10.9745/GHSP-D-17-00043... , ³⁰30. Dogru S , Doner P . Frequency and outcomes of new patients with pulmonary tuberculosis in Hatay province after Syrian civil war . Indian J Tuberc . 2017 ; 64 ( 2 ): 83 - 8 . https://doi.org/10.1016/j.ijtb.2016.11.034
https://doi.org/10.1016/j.ijtb.2016.11.0... , ³³33. Heenan RC , Volkman T , Stokes S , Tosif S , Graham H , Smith A , et al . ‘I think we’ve had a health screen’: new offshore screening, new refugee health guidelines, new Syrian and Iraqi cohorts: recommendations, reality, results and review . J Paediatr Child Health . 2019 ; 55 ( 1 ): 95 - 103 . https://doi.org/10.1111/jpc.14142
https://doi.org/10.1111/jpc.14142... . About 11.8% of Syrian children (aged 7 months to 16 years) in Australia had tuberculosis ³³33. Heenan RC , Volkman T , Stokes S , Tosif S , Graham H , Smith A , et al . ‘I think we’ve had a health screen’: new offshore screening, new refugee health guidelines, new Syrian and Iraqi cohorts: recommendations, reality, results and review . J Paediatr Child Health . 2019 ; 55 ( 1 ): 95 - 103 . https://doi.org/10.1111/jpc.14142
https://doi.org/10.1111/jpc.14142... . Tuberculosis treatment success was lower among Syrian refugees in Turkey (63.6% of cases) than among local population (88.8%). The context of war is directly related to the increased prevalence of the disease. In Syria, before the beginning of the conflict, the incidence was 23 cases/100,000 inhabitants, and after the conflict it increased to 51 cases/100,000 ³⁰30. Dogru S , Doner P . Frequency and outcomes of new patients with pulmonary tuberculosis in Hatay province after Syrian civil war . Indian J Tuberc . 2017 ; 64 ( 2 ): 83 - 8 . https://doi.org/10.1016/j.ijtb.2016.11.034
https://doi.org/10.1016/j.ijtb.2016.11.0... . During the civil war, the main problems in relation to tuberculosis are related to diagnosis, treatment, and prevention of the disease, access to health services and drug supply, increased reactivation, transmission, due to living conditions: crowding, nutrition, shortage of medicines and health personnel, and psychological stress ³⁰30. Dogru S , Doner P . Frequency and outcomes of new patients with pulmonary tuberculosis in Hatay province after Syrian civil war . Indian J Tuberc . 2017 ; 64 ( 2 ): 83 - 8 . https://doi.org/10.1016/j.ijtb.2016.11.034
https://doi.org/10.1016/j.ijtb.2016.11.0... . Infectious/transmissible diseases were mentioned in three studies ²⁵25. Gammoh OS . A preliminary description of medical complaints and medication consumption among 375 Syrian refugees residing in North Jordan . Jordan J Pharm Sci . 2016 ; 9 ( 1 ): 13 - 21 . , ²⁶26. Kakalou E , Riza E , Chalikias M , Voudouri N , Vetsika A , Tsiamis C , et al . Demographic and clinical characteristics of refugees seeking primary healthcare services in Greece in the period 2015-2016: a descriptive study . Int Health . 2018 ; 10 ( 6 ): 421 - 9 . https://doi.org/10.1093/inthealth/ihy042
https://doi.org/10.1093/inthealth/ihy042... , ³⁸38. Lyles E , Hanquart B , Chlela L , Woodman M ; LHAS Study Team , Fouad FM , Sibai A , et al . Health service access and utilization among Syrian refugees and affected host communities in Lebanon . J Refugee Stud . 2018 ; 31 ( 1 ): 104 - 30 . https://doi.org/10.1093/jrs/fex014
https://doi.org/10.1093/jrs/fex014... , and in a study conducted in Lebanon with 1,218 Syrian refugees, these diseases were prevalent (40.5%) ³⁸38. Lyles E , Hanquart B , Chlela L , Woodman M ; LHAS Study Team , Fouad FM , Sibai A , et al . Health service access and utilization among Syrian refugees and affected host communities in Lebanon . J Refugee Stud . 2018 ; 31 ( 1 ): 104 - 30 . https://doi.org/10.1093/jrs/fex014
https://doi.org/10.1093/jrs/fex014... .

The vulnerability indicator “work” was found in three studies ²⁷27. Sethi S , Jonsson R , Skaff R , Tyler F . Community-based noncommunicable disease care for Syrian refugees in Lebanon . Glob Health Sci Pract . 2017 ; 5 ( 3 ): 495 - 506 . https://doi.org/10.9745/GHSP-D-17-00043
https://doi.org/10.9745/GHSP-D-17-00043... , ²⁸28. Aoun A , Joundi J , El Gerges N . Prevalence and correlates of a positive screen for eating disorders among Syrian refugees . Eur Eat Disord Rev . 2019 ; 27 ( 3 ): 263 - 73 . https://doi.org/10.1002/erv.2660
https://doi.org/10.1002/erv.2660... , ³⁷37. Torun P , Karaaslan MM , Sandikli B , Acar C , Shurtleff E , Dhrolia S , et al . Health and health care access for Syrian refugees living in Istanbul . Int J Public Health . 2018 ; 63 ( 5 ): 601 - 8 . https://doi.org/10.1007/s00038-018-1096-4
https://doi.org/10.1007/s00038-018-1096-... . The unemployment rate among Syrian refugees was 84.2% in the study population ²⁸28. Aoun A , Joundi J , El Gerges N . Prevalence and correlates of a positive screen for eating disorders among Syrian refugees . Eur Eat Disord Rev . 2019 ; 27 ( 3 ): 263 - 73 . https://doi.org/10.1002/erv.2660
https://doi.org/10.1002/erv.2660... . The indicator “beliefs and values” concerning the disease was found in four studies ²³23. Cherri Z , Cuesta JG , Rodriguez-Llanes JM , Guha-Sapir D . Early marriage and barriers to contraception among Syrian refugee women in Lebanon: a qualitative study . Int J Environ Res Public Health . 2017 ; 14 ( 8 ): 836 . https://doi.org/10.3390/ijerph14080836
https://doi.org/10.3390/ijerph14080836... , ²⁸28. Aoun A , Joundi J , El Gerges N . Prevalence and correlates of a positive screen for eating disorders among Syrian refugees . Eur Eat Disord Rev . 2019 ; 27 ( 3 ): 263 - 73 . https://doi.org/10.1002/erv.2660
https://doi.org/10.1002/erv.2660... , ²⁹29. Collins DRJ , Jobanputra K , Frost T , Muhammed S , Ward A , Shafei AA , et al . Cardiovascular disease risk and prevention amongst Syrian refugees: mixed methods study of Medecins Sans Frontieres programme in Jordan . Confl Health . 2017 ; 11 : 14 . https://doi.org/10.1186/s13031-017-0115-z
https://doi.org/10.1186/s13031-017-0115-... , ³⁵35. Elliott JA , Das D , Cavailler P , Schneider F , Shah M , Ravaud A , et al . A cross-sectional assessment of diabetes self-management, education and support needs of Syrian refugee patients living with diabetes in Bekaa Valley Lebanon . Confl Health . 2018 ; 12 : 40 . https://doi.org/10.1186/s13031-018-0174-9
https://doi.org/10.1186/s13031-018-0174-... . Only 58% of Syrian women in Lebanon used some method of contraception; the birth rate is high, noting that women over 40 years old reported having between 8 and 12 children ²³23. Cherri Z , Cuesta JG , Rodriguez-Llanes JM , Guha-Sapir D . Early marriage and barriers to contraception among Syrian refugee women in Lebanon: a qualitative study . Int J Environ Res Public Health . 2017 ; 14 ( 8 ): 836 . https://doi.org/10.3390/ijerph14080836
https://doi.org/10.3390/ijerph14080836... .

The indicator “living conditions” was found in five studies ¹⁷17. United Nations High Commissioner for Refugees ; UNICEF ; WFP . Vulnerability assessment of Syrian refugees in Lebanon 2016 . Geneva (CH) : UNHCR ; 2016 . , ²⁰20. Doocy S , Lyles E . Humanitarian needs among displaced and female-headed households in government-controlled areas of Syria . Am J Public Health . 2017 ; 107 ( 6 ): 950 - 9 . https://doi.org/10.2105/AJPH.2017.303710
https://doi.org/10.2105/AJPH.2017.303710... , ²²22. Al-Rousan T , Schwabkey Z , Jirmanus L , Nelson BD . Health needs and priorities of Syrian refugees in camps and urban settings in Jordan: perspectives of refugees and health care providers . East Mediterr Health J . 2018 ; 24 ( 3 ): 243 - 53 . https://doi.org/10.26719/2018.24.3.243
https://doi.org/10.26719/2018.24.3.243... , ³²32. Segal SP , Khoury VC , Salah R , Ghannam J . Contributors to screening positive for mental illness in Lebano´s Shatila Palestinian Refugee Camp . J Nerv Ment Dis . 2018 ; 206 ( 1 ): 46 - 51 . https://doi.org/10.1097/NMD.0000000000000751
https://doi.org/10.1097/NMD.000000000000... , ⁵⁶56. Kvittingen A , Valenta M , Tabbara H , Baslan D , Berg B . The conditions and migratory aspirations of Syrian and Iraqi refugees in Jordan . 2019 ; 32 ( 1 ): 106 - 24 . https://doi.org/10.1093/jrs/fey015
https://doi.org/10.1093/jrs/fey015... , disclosing insecurity, overcrowded housing, and absence of toilets in refuge camps ¹⁷17. United Nations High Commissioner for Refugees ; UNICEF ; WFP . Vulnerability assessment of Syrian refugees in Lebanon 2016 . Geneva (CH) : UNHCR ; 2016 . , ²²22. Al-Rousan T , Schwabkey Z , Jirmanus L , Nelson BD . Health needs and priorities of Syrian refugees in camps and urban settings in Jordan: perspectives of refugees and health care providers . East Mediterr Health J . 2018 ; 24 ( 3 ): 243 - 53 . https://doi.org/10.26719/2018.24.3.243
https://doi.org/10.26719/2018.24.3.243... . More than half, 54.3%, reported the use of extreme mechanisms to face food insecurity (reduction of the portion; of the number of meals taken/day; reduced consumption by adults to allow feeding the children) ²⁰20. Doocy S , Lyles E . Humanitarian needs among displaced and female-headed households in government-controlled areas of Syria . Am J Public Health . 2017 ; 107 ( 6 ): 950 - 9 . https://doi.org/10.2105/AJPH.2017.303710
https://doi.org/10.2105/AJPH.2017.303710... .

Regarding the programmatic dimension, the indicator “access to health services” was the most found in the studies (8) ²¹21. Ay M , Arcos González P , Castro Delgado R . The perceived barriers of access to health care among a group of non-camp Syrian refugees in Jordan . Int J Health Serv . 2016 ; 46 ( 3 ): 566 - 89 . https://doi.org/10.1177/0020731416636831
https://doi.org/10.1177/0020731416636831... , followed by the indicator “health policies” (7) ²²22. Al-Rousan T , Schwabkey Z , Jirmanus L , Nelson BD . Health needs and priorities of Syrian refugees in camps and urban settings in Jordan: perspectives of refugees and health care providers . East Mediterr Health J . 2018 ; 24 ( 3 ): 243 - 53 . https://doi.org/10.26719/2018.24.3.243
https://doi.org/10.26719/2018.24.3.243... and the indicator “program actions” (6) ²¹21. Ay M , Arcos González P , Castro Delgado R . The perceived barriers of access to health care among a group of non-camp Syrian refugees in Jordan . Int J Health Serv . 2016 ; 46 ( 3 ): 566 - 89 . https://doi.org/10.1177/0020731416636831
https://doi.org/10.1177/0020731416636831... , ²⁹29. Collins DRJ , Jobanputra K , Frost T , Muhammed S , Ward A , Shafei AA , et al . Cardiovascular disease risk and prevention amongst Syrian refugees: mixed methods study of Medecins Sans Frontieres programme in Jordan . Confl Health . 2017 ; 11 : 14 . https://doi.org/10.1186/s13031-017-0115-z
https://doi.org/10.1186/s13031-017-0115-... . Regarding access to health services, 60% of Syrian pregnant women in Turkey faced difficulties due to language and waiting time for care ³⁷37. Torun P , Karaaslan MM , Sandikli B , Acar C , Shurtleff E , Dhrolia S , et al . Health and health care access for Syrian refugees living in Istanbul . Int J Public Health . 2018 ; 63 ( 5 ): 601 - 8 . https://doi.org/10.1007/s00038-018-1096-4
https://doi.org/10.1007/s00038-018-1096-... . The lack of medical professionals and the cost ²¹21. Ay M , Arcos González P , Castro Delgado R . The perceived barriers of access to health care among a group of non-camp Syrian refugees in Jordan . Int J Health Serv . 2016 ; 46 ( 3 ): 566 - 89 . https://doi.org/10.1177/0020731416636831
https://doi.org/10.1177/0020731416636831... , ²³23. Cherri Z , Cuesta JG , Rodriguez-Llanes JM , Guha-Sapir D . Early marriage and barriers to contraception among Syrian refugee women in Lebanon: a qualitative study . Int J Environ Res Public Health . 2017 ; 14 ( 8 ): 836 . https://doi.org/10.3390/ijerph14080836
https://doi.org/10.3390/ijerph14080836... , ²⁴24. Doocy S , Lyles E , Roberton T , Akhu-Zaheya L , Oweis A , Burnham G . Prevalence and care-seeking for chronic diseases among Syrian refugees in Jordan . BMC Public Health . 2015 ; 15 : 1097 . https://doi.org/10.1186/s12889-015-2429-3
https://doi.org/10.1186/s12889-015-2429-... , ³⁸38. Lyles E , Hanquart B , Chlela L , Woodman M ; LHAS Study Team , Fouad FM , Sibai A , et al . Health service access and utilization among Syrian refugees and affected host communities in Lebanon . J Refugee Stud . 2018 ; 31 ( 1 ): 104 - 30 . https://doi.org/10.1093/jrs/fex014
https://doi.org/10.1093/jrs/fex014... were reported as barriers to access for perinatal care ²²22. Al-Rousan T , Schwabkey Z , Jirmanus L , Nelson BD . Health needs and priorities of Syrian refugees in camps and urban settings in Jordan: perspectives of refugees and health care providers . East Mediterr Health J . 2018 ; 24 ( 3 ): 243 - 53 . https://doi.org/10.26719/2018.24.3.243
https://doi.org/10.26719/2018.24.3.243... . In Greece, a study found that 50% of consultations in medical specialties were performed by national and international NGOs, unveiling a transfer of responsibility from the local government to these entities in providing access to health services. The main causes of referrals are obstetric/gynecological (35%) care, pediatric care (15%), and to obtain prescription drugs not available in PHC (16%) ²⁶26. Kakalou E , Riza E , Chalikias M , Voudouri N , Vetsika A , Tsiamis C , et al . Demographic and clinical characteristics of refugees seeking primary healthcare services in Greece in the period 2015-2016: a descriptive study . Int Health . 2018 ; 10 ( 6 ): 421 - 9 . https://doi.org/10.1093/inthealth/ihy042
https://doi.org/10.1093/inthealth/ihy042... .

Regarding the “Health Policies” indicator, the lack of a universal and free system stands out ²²22. Al-Rousan T , Schwabkey Z , Jirmanus L , Nelson BD . Health needs and priorities of Syrian refugees in camps and urban settings in Jordan: perspectives of refugees and health care providers . East Mediterr Health J . 2018 ; 24 ( 3 ): 243 - 53 . https://doi.org/10.26719/2018.24.3.243
https://doi.org/10.26719/2018.24.3.243... , ²⁷27. Sethi S , Jonsson R , Skaff R , Tyler F . Community-based noncommunicable disease care for Syrian refugees in Lebanon . Glob Health Sci Pract . 2017 ; 5 ( 3 ): 495 - 506 . https://doi.org/10.9745/GHSP-D-17-00043
https://doi.org/10.9745/GHSP-D-17-00043... , ⁵⁶56. Kvittingen A , Valenta M , Tabbara H , Baslan D , Berg B . The conditions and migratory aspirations of Syrian and Iraqi refugees in Jordan . 2019 ; 32 ( 1 ): 106 - 24 . https://doi.org/10.1093/jrs/fey015
https://doi.org/10.1093/jrs/fey015... . In a study with Syrian refugees in Jordan, 80% of respondents reported the need to pay some amount for health care in PHC ²²22. Al-Rousan T , Schwabkey Z , Jirmanus L , Nelson BD . Health needs and priorities of Syrian refugees in camps and urban settings in Jordan: perspectives of refugees and health care providers . East Mediterr Health J . 2018 ; 24 ( 3 ): 243 - 53 . https://doi.org/10.26719/2018.24.3.243
https://doi.org/10.26719/2018.24.3.243... .

As for the indicator “actions of health programs”, included in the programmatic dimension, it is evident the difficulty of PHC teams in interacting with Syrian refugees ³⁴34. Doocy S , Paik KE , Lyles E , Hei Tam H , Fahed Z , Winkler E , et al . Guidelines and mHealth to improve quality of hypertension and type 2 diabetes care for vulnerable populations in Lebanon: longitudinal cohort study . JMIR Mhealth Uhealth . 2017 ; 5 ( 10 ): e158 . https://doi.org/10.2196/mhealth.7745
https://doi.org/10.2196/mhealth.7745... , especially in Lebanon. About 40% of respondents in Jordan reported discrimination by the healthcare team ²¹21. Ay M , Arcos González P , Castro Delgado R . The perceived barriers of access to health care among a group of non-camp Syrian refugees in Jordan . Int J Health Serv . 2016 ; 46 ( 3 ): 566 - 89 . https://doi.org/10.1177/0020731416636831
https://doi.org/10.1177/0020731416636831... . It should be considered that health professionals suffer the tension resulting from structural processes and fragile local governance, exposing them to the extremes of lack of human and material resources, and especially of knowledge about the refugee’s health issue ⁵⁶56. Kvittingen A , Valenta M , Tabbara H , Baslan D , Berg B . The conditions and migratory aspirations of Syrian and Iraqi refugees in Jordan . 2019 ; 32 ( 1 ): 106 - 24 . https://doi.org/10.1093/jrs/fey015
https://doi.org/10.1093/jrs/fey015... .

In the social dimension, the indicator “access to education” ²¹21. Ay M , Arcos González P , Castro Delgado R . The perceived barriers of access to health care among a group of non-camp Syrian refugees in Jordan . Int J Health Serv . 2016 ; 46 ( 3 ): 566 - 89 . https://doi.org/10.1177/0020731416636831
https://doi.org/10.1177/0020731416636831... , ²³23. Cherri Z , Cuesta JG , Rodriguez-Llanes JM , Guha-Sapir D . Early marriage and barriers to contraception among Syrian refugee women in Lebanon: a qualitative study . Int J Environ Res Public Health . 2017 ; 14 ( 8 ): 836 . https://doi.org/10.3390/ijerph14080836
https://doi.org/10.3390/ijerph14080836... , ²⁴24. Doocy S , Lyles E , Roberton T , Akhu-Zaheya L , Oweis A , Burnham G . Prevalence and care-seeking for chronic diseases among Syrian refugees in Jordan . BMC Public Health . 2015 ; 15 : 1097 . https://doi.org/10.1186/s12889-015-2429-3
https://doi.org/10.1186/s12889-015-2429-... , ²⁷27. Sethi S , Jonsson R , Skaff R , Tyler F . Community-based noncommunicable disease care for Syrian refugees in Lebanon . Glob Health Sci Pract . 2017 ; 5 ( 3 ): 495 - 506 . https://doi.org/10.9745/GHSP-D-17-00043
https://doi.org/10.9745/GHSP-D-17-00043... , ²⁸28. Aoun A , Joundi J , El Gerges N . Prevalence and correlates of a positive screen for eating disorders among Syrian refugees . Eur Eat Disord Rev . 2019 ; 27 ( 3 ): 263 - 73 . https://doi.org/10.1002/erv.2660
https://doi.org/10.1002/erv.2660... , ³²32. Segal SP , Khoury VC , Salah R , Ghannam J . Contributors to screening positive for mental illness in Lebano´s Shatila Palestinian Refugee Camp . J Nerv Ment Dis . 2018 ; 206 ( 1 ): 46 - 51 . https://doi.org/10.1097/NMD.0000000000000751
https://doi.org/10.1097/NMD.000000000000... , ³³33. Heenan RC , Volkman T , Stokes S , Tosif S , Graham H , Smith A , et al . ‘I think we’ve had a health screen’: new offshore screening, new refugee health guidelines, new Syrian and Iraqi cohorts: recommendations, reality, results and review . J Paediatr Child Health . 2019 ; 55 ( 1 ): 95 - 103 . https://doi.org/10.1111/jpc.14142
https://doi.org/10.1111/jpc.14142... , ³⁵35. Elliott JA , Das D , Cavailler P , Schneider F , Shah M , Ravaud A , et al . A cross-sectional assessment of diabetes self-management, education and support needs of Syrian refugee patients living with diabetes in Bekaa Valley Lebanon . Confl Health . 2018 ; 12 : 40 . https://doi.org/10.1186/s13031-018-0174-9
https://doi.org/10.1186/s13031-018-0174-... , ³⁷37. Torun P , Karaaslan MM , Sandikli B , Acar C , Shurtleff E , Dhrolia S , et al . Health and health care access for Syrian refugees living in Istanbul . Int J Public Health . 2018 ; 63 ( 5 ): 601 - 8 . https://doi.org/10.1007/s00038-018-1096-4
https://doi.org/10.1007/s00038-018-1096-... , ⁵⁶56. Kvittingen A , Valenta M , Tabbara H , Baslan D , Berg B . The conditions and migratory aspirations of Syrian and Iraqi refugees in Jordan . 2019 ; 32 ( 1 ): 106 - 24 . https://doi.org/10.1093/jrs/fey015
https://doi.org/10.1093/jrs/fey015... was observed, and four of these studies ²¹21. Ay M , Arcos González P , Castro Delgado R . The perceived barriers of access to health care among a group of non-camp Syrian refugees in Jordan . Int J Health Serv . 2016 ; 46 ( 3 ): 566 - 89 . https://doi.org/10.1177/0020731416636831
https://doi.org/10.1177/0020731416636831... , ²⁴24. Doocy S , Lyles E , Roberton T , Akhu-Zaheya L , Oweis A , Burnham G . Prevalence and care-seeking for chronic diseases among Syrian refugees in Jordan . BMC Public Health . 2015 ; 15 : 1097 . https://doi.org/10.1186/s12889-015-2429-3
https://doi.org/10.1186/s12889-015-2429-... , ²⁸28. Aoun A , Joundi J , El Gerges N . Prevalence and correlates of a positive screen for eating disorders among Syrian refugees . Eur Eat Disord Rev . 2019 ; 27 ( 3 ): 263 - 73 . https://doi.org/10.1002/erv.2660
https://doi.org/10.1002/erv.2660... , ³⁷37. Torun P , Karaaslan MM , Sandikli B , Acar C , Shurtleff E , Dhrolia S , et al . Health and health care access for Syrian refugees living in Istanbul . Int J Public Health . 2018 ; 63 ( 5 ): 601 - 8 . https://doi.org/10.1007/s00038-018-1096-4
https://doi.org/10.1007/s00038-018-1096-... specifically approach with the difficulty of access to studies by the adult refugee population. In one of the studies, 42% had not completed any formal education ³⁵35. Elliott JA , Das D , Cavailler P , Schneider F , Shah M , Ravaud A , et al . A cross-sectional assessment of diabetes self-management, education and support needs of Syrian refugee patients living with diabetes in Bekaa Valley Lebanon . Confl Health . 2018 ; 12 : 40 . https://doi.org/10.1186/s13031-018-0174-9
https://doi.org/10.1186/s13031-018-0174-... . A high rate (55%) of school dropouts by children was also found ²¹21. Ay M , Arcos González P , Castro Delgado R . The perceived barriers of access to health care among a group of non-camp Syrian refugees in Jordan . Int J Health Serv . 2016 ; 46 ( 3 ): 566 - 89 . https://doi.org/10.1177/0020731416636831
https://doi.org/10.1177/0020731416636831... . In Australia, a study reported that 25% of Syrian children were out of school even after three months in the country, and 67.9% had missed at least one school year before getting to the country ³³33. Heenan RC , Volkman T , Stokes S , Tosif S , Graham H , Smith A , et al . ‘I think we’ve had a health screen’: new offshore screening, new refugee health guidelines, new Syrian and Iraqi cohorts: recommendations, reality, results and review . J Paediatr Child Health . 2019 ; 55 ( 1 ): 95 - 103 . https://doi.org/10.1111/jpc.14142
https://doi.org/10.1111/jpc.14142... .

The indicator “access to information” was also observed ²¹21. Ay M , Arcos González P , Castro Delgado R . The perceived barriers of access to health care among a group of non-camp Syrian refugees in Jordan . Int J Health Serv . 2016 ; 46 ( 3 ): 566 - 89 . https://doi.org/10.1177/0020731416636831
https://doi.org/10.1177/0020731416636831... , ²³23. Cherri Z , Cuesta JG , Rodriguez-Llanes JM , Guha-Sapir D . Early marriage and barriers to contraception among Syrian refugee women in Lebanon: a qualitative study . Int J Environ Res Public Health . 2017 ; 14 ( 8 ): 836 . https://doi.org/10.3390/ijerph14080836
https://doi.org/10.3390/ijerph14080836... , ²⁴24. Doocy S , Lyles E , Roberton T , Akhu-Zaheya L , Oweis A , Burnham G . Prevalence and care-seeking for chronic diseases among Syrian refugees in Jordan . BMC Public Health . 2015 ; 15 : 1097 . https://doi.org/10.1186/s12889-015-2429-3
https://doi.org/10.1186/s12889-015-2429-... , ³⁵35. Elliott JA , Das D , Cavailler P , Schneider F , Shah M , Ravaud A , et al . A cross-sectional assessment of diabetes self-management, education and support needs of Syrian refugee patients living with diabetes in Bekaa Valley Lebanon . Confl Health . 2018 ; 12 : 40 . https://doi.org/10.1186/s13031-018-0174-9
https://doi.org/10.1186/s13031-018-0174-... , ³⁷37. Torun P , Karaaslan MM , Sandikli B , Acar C , Shurtleff E , Dhrolia S , et al . Health and health care access for Syrian refugees living in Istanbul . Int J Public Health . 2018 ; 63 ( 5 ): 601 - 8 . https://doi.org/10.1007/s00038-018-1096-4
https://doi.org/10.1007/s00038-018-1096-... , identifying lack of information regarding the availability of family planning services in the Basic Healthcare Unit ( Unidade Básica de Saúde, UBS) ²¹21. Ay M , Arcos González P , Castro Delgado R . The perceived barriers of access to health care among a group of non-camp Syrian refugees in Jordan . Int J Health Serv . 2016 ; 46 ( 3 ): 566 - 89 . https://doi.org/10.1177/0020731416636831
https://doi.org/10.1177/0020731416636831... , ²³23. Cherri Z , Cuesta JG , Rodriguez-Llanes JM , Guha-Sapir D . Early marriage and barriers to contraception among Syrian refugee women in Lebanon: a qualitative study . Int J Environ Res Public Health . 2017 ; 14 ( 8 ): 836 . https://doi.org/10.3390/ijerph14080836
https://doi.org/10.3390/ijerph14080836... . One of the studies with Syrian refugees in Lebanon pointed out that 61% of the respondents were unaware of the availability of services ²¹21. Ay M , Arcos González P , Castro Delgado R . The perceived barriers of access to health care among a group of non-camp Syrian refugees in Jordan . Int J Health Serv . 2016 ; 46 ( 3 ): 566 - 89 . https://doi.org/10.1177/0020731416636831
https://doi.org/10.1177/0020731416636831... . On the other hand, international and local NGOs provide care for Syrian women through PHC, offering family planning free of charge (insertion of IUDs, contraceptive pills, and male condoms), as well as consultation with a midwife or obstetrician/gynecologist, and laboratory tests ²¹21. Ay M , Arcos González P , Castro Delgado R . The perceived barriers of access to health care among a group of non-camp Syrian refugees in Jordan . Int J Health Serv . 2016 ; 46 ( 3 ): 566 - 89 . https://doi.org/10.1177/0020731416636831
https://doi.org/10.1177/0020731416636831... .

The marker “migration” was found in three studies ²³23. Cherri Z , Cuesta JG , Rodriguez-Llanes JM , Guha-Sapir D . Early marriage and barriers to contraception among Syrian refugee women in Lebanon: a qualitative study . Int J Environ Res Public Health . 2017 ; 14 ( 8 ): 836 . https://doi.org/10.3390/ijerph14080836
https://doi.org/10.3390/ijerph14080836... , ³⁷37. Torun P , Karaaslan MM , Sandikli B , Acar C , Shurtleff E , Dhrolia S , et al . Health and health care access for Syrian refugees living in Istanbul . Int J Public Health . 2018 ; 63 ( 5 ): 601 - 8 . https://doi.org/10.1007/s00038-018-1096-4
https://doi.org/10.1007/s00038-018-1096-... , ⁵⁶56. Kvittingen A , Valenta M , Tabbara H , Baslan D , Berg B . The conditions and migratory aspirations of Syrian and Iraqi refugees in Jordan . 2019 ; 32 ( 1 ): 106 - 24 . https://doi.org/10.1093/jrs/fey015
https://doi.org/10.1093/jrs/fey015... . The pattern of migration flow affects the adherence to treatment of cardiovascular diseases in Syrian refugees arriving in Jordan, because during the trip they are unable to acquire the medicines ²⁹29. Collins DRJ , Jobanputra K , Frost T , Muhammed S , Ward A , Shafei AA , et al . Cardiovascular disease risk and prevention amongst Syrian refugees: mixed methods study of Medecins Sans Frontieres programme in Jordan . Confl Health . 2017 ; 11 : 14 . https://doi.org/10.1186/s13031-017-0115-z
https://doi.org/10.1186/s13031-017-0115-... . In Jordan, a study indicated that 50% of the Syrians had concrete plans to leave the country, mainly towards Europe, due to the lack of access to fundamental rights, including education, health, work, and food. Part of one statement stands out: “ a quick death at sea is better than dying a thousand deaths every day ” ⁵⁶56. Kvittingen A , Valenta M , Tabbara H , Baslan D , Berg B . The conditions and migratory aspirations of Syrian and Iraqi refugees in Jordan . 2019 ; 32 ( 1 ): 106 - 24 . https://doi.org/10.1093/jrs/fey015
https://doi.org/10.1093/jrs/fey015... .

II - Palestinian Refugees

Table 3 summarizes the 14 studies dealing with this refugee population ³⁹39. Al Baz M , Law MR , Saadeh R . Antibiotics use among Palestine refugees attending UNRWA primary health care centers in Jordan: a cross-sectional study . Travel Med Infect Dis . 2018 ; 22 : 25 - 9 . https://doi.org/10.1016/j.tmaid.2018.02.004
https://doi.org/10.1016/j.tmaid.2018.02.... . Diabetes was the most noticeable disease ⁴⁰40. Khader A , Ballout G , Shahin Y , Hababeh M , Farajallah L , Zeidan W , et al . Treatment outcomes in a cohort of Palestine refugees with diabetes mellitus followed through use of E-Health over 3 years in Jordan . Trop Med Int Health . 2014 ; 19 ( 2 ): 219 - 23 . https://doi.org/10.1111/tmi.12241
https://doi.org/10.1111/tmi.12241... , ⁴²42. Khader A , Ballout G , Shahin Y , Hababeh M , Farajallah L , Zeidan W , et al . What happens to Palestine refugees with diabetes mellitus in a primary healthcare centre in Jordan who fail to attend a quarterly clinic appointment? Trop Med Int Health . 2014 ; 19 ( 3 ): 308 - 12 . https://doi.org/10.1111/tmi.12256
https://doi.org/10.1111/tmi.12256... , ⁴³43. Alkasseh ASM , Zaki NM , Aljeesh YI , Soon LK . Risk factors of gestational diabetes mellitus in the refugee population in Gaza Strip: a case-control study . East Mediterr Health J . 2014 ; 19 Suppl 3 : S12 - 8 . , ⁴⁵45. Khader A , Farajallah L , Shahin Y , Hababeh M , Abu-Zayed I , Zachariah R , et al . Hypertension and treatment outcomes in Palestine refugees in United Nations Relief and Works Agency primary health care clinics in Jordan . Trop Med Int Health . 2014 ; 19 ( 10 ): 1276 - 83 . https://doi.org/10.1111/tmi.12356
https://doi.org/10.1111/tmi.12356... , ⁴⁸48. Khader A , Farajallah L , Shahin Y , Hababeh M , Abu-Zayed I , Kochi A , et al . Cohort monitoring of persons with hypertension: an illustrated example from a primary healthcare clinic for Palestine refugees in Jordan . Trop Med Int Health . 2012 ; 17 ( 9 ): 1163 - 70 . https://doi.org/10.1111/j.1365-3156.2012.03048.x
https://doi.org/10.1111/j.1365-3156.2012... , ⁵⁰50. Khader A , Farajallah L , Shahin Y , Hababeh M , Abu-Zayed I , Kochi A , et al . Cohort monitoring of persons with diabetes mellitus in a primary healthcare clinic for Palestine refugees in Jordan . Trop Med Int Health . 2012 ; 17 ( 12 ): 1569 - 76 . https://doi.org/10.1111/j.1365-3156.2012.03097.x
https://doi.org/10.1111/j.1365-3156.2012... , ⁵²52. Khader A , Ballout G , Shahin Y , Hababeh M , Farajallah L , Zeidan W , et al . Diabetes mellitus and treatment outcomes in Palestine refugees in UNRWA primary health care clinics in Jordan . Public Health Action . 2013 ; 3 ( 4 ): 259 - 64 . https://doi.org/10.5588/pha.13.0083
https://doi.org/10.5588/pha.13.0083... . In a study of 2,851 Palestinians aged up to 60 years and allocated in Jordan, the association between DM and SAH reaches 77% of the sample ⁵⁰50. Khader A , Farajallah L , Shahin Y , Hababeh M , Abu-Zayed I , Kochi A , et al . Cohort monitoring of persons with diabetes mellitus in a primary healthcare clinic for Palestine refugees in Jordan . Trop Med Int Health . 2012 ; 17 ( 12 ): 1569 - 76 . https://doi.org/10.1111/j.1365-3156.2012.03097.x
https://doi.org/10.1111/j.1365-3156.2012... , and obesity is one of the main additional associated risk factors. In another study, 59% of diabetic patients were obese (BMI > 30), 69% were women ⁵²52. Khader A , Ballout G , Shahin Y , Hababeh M , Farajallah L , Zeidan W , et al . Diabetes mellitus and treatment outcomes in Palestine refugees in UNRWA primary health care clinics in Jordan . Public Health Action . 2013 ; 3 ( 4 ): 259 - 64 . https://doi.org/10.5588/pha.13.0083
https://doi.org/10.5588/pha.13.0083... . One of the surveys of Palestinian refugees in Jordan showed an association between DM and SAH in 81% of the sample, affecting all age groups: 21% were younger than 5 years old, 36% between five and 10 years old, and 43% were older than 10 years ⁴²42. Khader A , Ballout G , Shahin Y , Hababeh M , Farajallah L , Zeidan W , et al . What happens to Palestine refugees with diabetes mellitus in a primary healthcare centre in Jordan who fail to attend a quarterly clinic appointment? Trop Med Int Health . 2014 ; 19 ( 3 ): 308 - 12 . https://doi.org/10.1111/tmi.12256
https://doi.org/10.1111/tmi.12256... . Hypertension also stands out among the main morbidities ⁴²42. Khader A , Ballout G , Shahin Y , Hababeh M , Farajallah L , Zeidan W , et al . What happens to Palestine refugees with diabetes mellitus in a primary healthcare centre in Jordan who fail to attend a quarterly clinic appointment? Trop Med Int Health . 2014 ; 19 ( 3 ): 308 - 12 . https://doi.org/10.1111/tmi.12256
https://doi.org/10.1111/tmi.12256... , ⁴⁴44. Saadeh R , Qato D , Khader A , Shahin Y , Seita A . Trends in the utilization of antihypertensive medications among Palestine refugees in Jordan, 2008-2012 . J Pharm Policy Pract . 2015 ; 8 : 7 . https://doi.org/10.1186/s40545-015-0036-4
https://doi.org/10.1186/s40545-015-0036-... , ⁴⁵45. Khader A , Farajallah L , Shahin Y , Hababeh M , Abu-Zayed I , Zachariah R , et al . Hypertension and treatment outcomes in Palestine refugees in United Nations Relief and Works Agency primary health care clinics in Jordan . Trop Med Int Health . 2014 ; 19 ( 10 ): 1276 - 83 . https://doi.org/10.1111/tmi.12356
https://doi.org/10.1111/tmi.12356... , ⁴⁸48. Khader A , Farajallah L , Shahin Y , Hababeh M , Abu-Zayed I , Kochi A , et al . Cohort monitoring of persons with hypertension: an illustrated example from a primary healthcare clinic for Palestine refugees in Jordan . Trop Med Int Health . 2012 ; 17 ( 9 ): 1163 - 70 . https://doi.org/10.1111/j.1365-3156.2012.03048.x
https://doi.org/10.1111/j.1365-3156.2012... , ⁵⁰50. Khader A , Farajallah L , Shahin Y , Hababeh M , Abu-Zayed I , Kochi A , et al . Cohort monitoring of persons with diabetes mellitus in a primary healthcare clinic for Palestine refugees in Jordan . Trop Med Int Health . 2012 ; 17 ( 12 ): 1569 - 76 . https://doi.org/10.1111/j.1365-3156.2012.03097.x
https://doi.org/10.1111/j.1365-3156.2012... , ⁵²52. Khader A , Ballout G , Shahin Y , Hababeh M , Farajallah L , Zeidan W , et al . Diabetes mellitus and treatment outcomes in Palestine refugees in UNRWA primary health care clinics in Jordan . Public Health Action . 2013 ; 3 ( 4 ): 259 - 64 . https://doi.org/10.5588/pha.13.0083
https://doi.org/10.5588/pha.13.0083... , with increased prevalence from 2008 to 2012 among Palestinian refugees in Jordan (two million), ranging from 13.8% to 16.3% of the patients seen. Noteworthy are patients with uncontrolled hypertension, which, in the same period, ranged from 31.5% to 45.9% of patients ⁴⁴44. Saadeh R , Qato D , Khader A , Shahin Y , Seita A . Trends in the utilization of antihypertensive medications among Palestine refugees in Jordan, 2008-2012 . J Pharm Policy Pract . 2015 ; 8 : 7 . https://doi.org/10.1186/s40545-015-0036-4
https://doi.org/10.1186/s40545-015-0036-... .

Regarding mental disorders, depression stands out (28%) ⁴⁷47. Alameddine M , Fouad FM , Diaconu K , Jamal Z , Lough G , Witter S , et al . Resilience capacities of health systems: accommodating the needs of Palestinian refugees from Syria . Soc Sci Med . 2019 ; 220 : 22 - 30 . https://doi.org/10.1016/j.socscimed.2018.10.018
https://doi.org/10.1016/j.socscimed.2018... , ⁴⁹49. Bastin P , Bastard M , Rossel L , Melgar P , Jones A , Antierens A . Description and predictive factors of individual outcomes in a refugee camp based mental health intervention (Beirut, Lebanon) . PLoS One . 2013 ; 8 ( 1 ): e54107 . https://doi.org/10.1371/journal.pone.0054107
https://doi.org/10.1371/journal.pone.005... and among infectious diseases, diarrhea draws attention. One of the studies points out that 20.3% were infected with Giardia duodenalis , related to low water quality. The lack of access to free public drinking water was associated with infectious diarrhea, highlighting that 62.4% had to buy water ⁴⁶46. Abouteir A , El Yaagoubi F , Bioh-Johnson I , Kamel A , Godard N , Cormerais L , et al . Water access and attendance for diarrhea in primary health care centers, Gaza strip . Trans R Soc Trop Med Hyg . 2011 ; 105 ( 10 ): 555 - 60 . https://doi.org/10.1016/j.trstmh.2011.07.002
https://doi.org/10.1016/j.trstmh.2011.07... .

One of the studies, conducted in Jordan, Lebanon, Syria, Gaza, and the West Bank, identified the main causes of infant death in the first year of life: low weight and prematurity (30%), congenital malformation (22%), and respiratory tract infection (13.4%) ⁴¹41. Riccardo F , Khader A , Sabatinelli G . Low infant mortality among Palestine refugees despite the odds . Bull World Health Organ . 2011 ; 89 ( 4 ): 304 - 11 . https://doi.org/10.2471/BLT.10.082743
https://doi.org/10.2471/BLT.10.082743... .

The indicator “work” was found in two studies ³⁹39. Al Baz M , Law MR , Saadeh R . Antibiotics use among Palestine refugees attending UNRWA primary health care centers in Jordan: a cross-sectional study . Travel Med Infect Dis . 2018 ; 22 : 25 - 9 . https://doi.org/10.1016/j.tmaid.2018.02.004
https://doi.org/10.1016/j.tmaid.2018.02.... , ⁴⁶46. Abouteir A , El Yaagoubi F , Bioh-Johnson I , Kamel A , Godard N , Cormerais L , et al . Water access and attendance for diarrhea in primary health care centers, Gaza strip . Trans R Soc Trop Med Hyg . 2011 ; 105 ( 10 ): 555 - 60 . https://doi.org/10.1016/j.trstmh.2011.07.002
https://doi.org/10.1016/j.trstmh.2011.07... . The unemployment rate reaches 90% among Palestinian refugees in Jordan ³⁹39. Al Baz M , Law MR , Saadeh R . Antibiotics use among Palestine refugees attending UNRWA primary health care centers in Jordan: a cross-sectional study . Travel Med Infect Dis . 2018 ; 22 : 25 - 9 . https://doi.org/10.1016/j.tmaid.2018.02.004
https://doi.org/10.1016/j.tmaid.2018.02.... . Even in the Palestinian territory itself, the majority of those who found employment had informal working relationships ⁴⁶46. Abouteir A , El Yaagoubi F , Bioh-Johnson I , Kamel A , Godard N , Cormerais L , et al . Water access and attendance for diarrhea in primary health care centers, Gaza strip . Trans R Soc Trop Med Hyg . 2011 ; 105 ( 10 ): 555 - 60 . https://doi.org/10.1016/j.trstmh.2011.07.002
https://doi.org/10.1016/j.trstmh.2011.07... .

The indicator “living conditions” was verified in two studies ³²32. Segal SP , Khoury VC , Salah R , Ghannam J . Contributors to screening positive for mental illness in Lebano´s Shatila Palestinian Refugee Camp . J Nerv Ment Dis . 2018 ; 206 ( 1 ): 46 - 51 . https://doi.org/10.1097/NMD.0000000000000751
https://doi.org/10.1097/NMD.000000000000... , ⁴⁶46. Abouteir A , El Yaagoubi F , Bioh-Johnson I , Kamel A , Godard N , Cormerais L , et al . Water access and attendance for diarrhea in primary health care centers, Gaza strip . Trans R Soc Trop Med Hyg . 2011 ; 105 ( 10 ): 555 - 60 . https://doi.org/10.1016/j.trstmh.2011.07.002
https://doi.org/10.1016/j.trstmh.2011.07... . Palestinians live in the refugee camp for an average of 16.2 years, reaching up to 27.5 years, a much longer period than the Syrians. In this context, they live without public sanitation services, the houses/tents/containers are insufficient, and there is overcrowding ³²32. Segal SP , Khoury VC , Salah R , Ghannam J . Contributors to screening positive for mental illness in Lebano´s Shatila Palestinian Refugee Camp . J Nerv Ment Dis . 2018 ; 206 ( 1 ): 46 - 51 . https://doi.org/10.1097/NMD.0000000000000751
https://doi.org/10.1097/NMD.000000000000... .

Regarding Programmatic Vulnerability, the indicator “actions of health programs” ⁴⁰40. Khader A , Ballout G , Shahin Y , Hababeh M , Farajallah L , Zeidan W , et al . Treatment outcomes in a cohort of Palestine refugees with diabetes mellitus followed through use of E-Health over 3 years in Jordan . Trop Med Int Health . 2014 ; 19 ( 2 ): 219 - 23 . https://doi.org/10.1111/tmi.12241
https://doi.org/10.1111/tmi.12241... , ⁴¹41. Riccardo F , Khader A , Sabatinelli G . Low infant mortality among Palestine refugees despite the odds . Bull World Health Organ . 2011 ; 89 ( 4 ): 304 - 11 . https://doi.org/10.2471/BLT.10.082743
https://doi.org/10.2471/BLT.10.082743...

42. Khader A , Ballout G , Shahin Y , Hababeh M , Farajallah L , Zeidan W , et al . What happens to Palestine refugees with diabetes mellitus in a primary healthcare centre in Jordan who fail to attend a quarterly clinic appointment? Trop Med Int Health . 2014 ; 19 ( 3 ): 308 - 12 . https://doi.org/10.1111/tmi.12256
https://doi.org/10.1111/tmi.12256... - ⁴³43. Alkasseh ASM , Zaki NM , Aljeesh YI , Soon LK . Risk factors of gestational diabetes mellitus in the refugee population in Gaza Strip: a case-control study . East Mediterr Health J . 2014 ; 19 Suppl 3 : S12 - 8 . , ⁴⁶46. Abouteir A , El Yaagoubi F , Bioh-Johnson I , Kamel A , Godard N , Cormerais L , et al . Water access and attendance for diarrhea in primary health care centers, Gaza strip . Trans R Soc Trop Med Hyg . 2011 ; 105 ( 10 ): 555 - 60 . https://doi.org/10.1016/j.trstmh.2011.07.002
https://doi.org/10.1016/j.trstmh.2011.07... , ⁴⁹49. Bastin P , Bastard M , Rossel L , Melgar P , Jones A , Antierens A . Description and predictive factors of individual outcomes in a refugee camp based mental health intervention (Beirut, Lebanon) . PLoS One . 2013 ; 8 ( 1 ): e54107 . https://doi.org/10.1371/journal.pone.0054107
https://doi.org/10.1371/journal.pone.005...

50. Khader A , Farajallah L , Shahin Y , Hababeh M , Abu-Zayed I , Kochi A , et al . Cohort monitoring of persons with diabetes mellitus in a primary healthcare clinic for Palestine refugees in Jordan . Trop Med Int Health . 2012 ; 17 ( 12 ): 1569 - 76 . https://doi.org/10.1111/j.1365-3156.2012.03097.x
https://doi.org/10.1111/j.1365-3156.2012... - ⁵¹51. Saleh S , Farah A , Dimassi H , El Arnaout N , Constantin J , Osman M , et al . Using mobile health to enhance outcomes of noncommunicable diseases care in rural settings and refugee camps: randomized controlled trial . JMIR Mhealth Uhealth . 2018 ; 6 ( 7 ): e137 . https://doi.org/10.2196/mhealth.8146
https://doi.org/10.2196/mhealth.8146... was predominant. It is noteworthy the report of teams and patients that have mental and physical overload at work ⁴⁷47. Alameddine M , Fouad FM , Diaconu K , Jamal Z , Lough G , Witter S , et al . Resilience capacities of health systems: accommodating the needs of Palestinian refugees from Syria . Soc Sci Med . 2019 ; 220 : 22 - 30 . https://doi.org/10.1016/j.socscimed.2018.10.018
https://doi.org/10.1016/j.socscimed.2018... . It is relevant to mention the loss of follow-up in the treatment of DM and SAH ⁴⁰40. Khader A , Ballout G , Shahin Y , Hababeh M , Farajallah L , Zeidan W , et al . Treatment outcomes in a cohort of Palestine refugees with diabetes mellitus followed through use of E-Health over 3 years in Jordan . Trop Med Int Health . 2014 ; 19 ( 2 ): 219 - 23 . https://doi.org/10.1111/tmi.12241
https://doi.org/10.1111/tmi.12241... , ⁴²42. Khader A , Ballout G , Shahin Y , Hababeh M , Farajallah L , Zeidan W , et al . What happens to Palestine refugees with diabetes mellitus in a primary healthcare centre in Jordan who fail to attend a quarterly clinic appointment? Trop Med Int Health . 2014 ; 19 ( 3 ): 308 - 12 . https://doi.org/10.1111/tmi.12256
https://doi.org/10.1111/tmi.12256... , ⁴⁸48. Khader A , Farajallah L , Shahin Y , Hababeh M , Abu-Zayed I , Kochi A , et al . Cohort monitoring of persons with hypertension: an illustrated example from a primary healthcare clinic for Palestine refugees in Jordan . Trop Med Int Health . 2012 ; 17 ( 9 ): 1163 - 70 . https://doi.org/10.1111/j.1365-3156.2012.03048.x
https://doi.org/10.1111/j.1365-3156.2012... , ⁵⁰50. Khader A , Farajallah L , Shahin Y , Hababeh M , Abu-Zayed I , Kochi A , et al . Cohort monitoring of persons with diabetes mellitus in a primary healthcare clinic for Palestine refugees in Jordan . Trop Med Int Health . 2012 ; 17 ( 12 ): 1569 - 76 . https://doi.org/10.1111/j.1365-3156.2012.03097.x
https://doi.org/10.1111/j.1365-3156.2012... . The increase in the migratory flow directly impacts the supply of services. In Jordan, of the patients who sought the PHC, 58% could not have their postprandial glycaemia measured ⁵⁰50. Khader A , Farajallah L , Shahin Y , Hababeh M , Abu-Zayed I , Kochi A , et al . Cohort monitoring of persons with diabetes mellitus in a primary healthcare clinic for Palestine refugees in Jordan . Trop Med Int Health . 2012 ; 17 ( 12 ): 1569 - 76 . https://doi.org/10.1111/j.1365-3156.2012.03097.x
https://doi.org/10.1111/j.1365-3156.2012... . Among patients with hypertension, 37% did not have their blood pressure recorded ⁵⁰50. Khader A , Farajallah L , Shahin Y , Hababeh M , Abu-Zayed I , Kochi A , et al . Cohort monitoring of persons with diabetes mellitus in a primary healthcare clinic for Palestine refugees in Jordan . Trop Med Int Health . 2012 ; 17 ( 12 ): 1569 - 76 . https://doi.org/10.1111/j.1365-3156.2012.03097.x
https://doi.org/10.1111/j.1365-3156.2012... , and 38% missed the scheduled return visit ⁴⁰40. Khader A , Ballout G , Shahin Y , Hababeh M , Farajallah L , Zeidan W , et al . Treatment outcomes in a cohort of Palestine refugees with diabetes mellitus followed through use of E-Health over 3 years in Jordan . Trop Med Int Health . 2014 ; 19 ( 2 ): 219 - 23 . https://doi.org/10.1111/tmi.12241
https://doi.org/10.1111/tmi.12241... .

The second most common indicator refers to “health policies” ⁴³43. Alkasseh ASM , Zaki NM , Aljeesh YI , Soon LK . Risk factors of gestational diabetes mellitus in the refugee population in Gaza Strip: a case-control study . East Mediterr Health J . 2014 ; 19 Suppl 3 : S12 - 8 . , ⁴⁴44. Saadeh R , Qato D , Khader A , Shahin Y , Seita A . Trends in the utilization of antihypertensive medications among Palestine refugees in Jordan, 2008-2012 . J Pharm Policy Pract . 2015 ; 8 : 7 . https://doi.org/10.1186/s40545-015-0036-4
https://doi.org/10.1186/s40545-015-0036-... , ⁴⁷47. Alameddine M , Fouad FM , Diaconu K , Jamal Z , Lough G , Witter S , et al . Resilience capacities of health systems: accommodating the needs of Palestinian refugees from Syria . Soc Sci Med . 2019 ; 220 : 22 - 30 . https://doi.org/10.1016/j.socscimed.2018.10.018
https://doi.org/10.1016/j.socscimed.2018... mainly focused on drug intervention, with repercussions on spending on hypertension ⁴⁴44. Saadeh R , Qato D , Khader A , Shahin Y , Seita A . Trends in the utilization of antihypertensive medications among Palestine refugees in Jordan, 2008-2012 . J Pharm Policy Pract . 2015 ; 8 : 7 . https://doi.org/10.1186/s40545-015-0036-4
https://doi.org/10.1186/s40545-015-0036-... . Only in 2011 did the UN introduce family health teams in Syria, Lebanon, and Jordan; previously, interventions were limited to medical centrality ⁴⁷47. Alameddine M , Fouad FM , Diaconu K , Jamal Z , Lough G , Witter S , et al . Resilience capacities of health systems: accommodating the needs of Palestinian refugees from Syria . Soc Sci Med . 2019 ; 220 : 22 - 30 . https://doi.org/10.1016/j.socscimed.2018.10.018
https://doi.org/10.1016/j.socscimed.2018... .

Two studies addressed the Programmatic Vulnerability indicator “access to health services” ³⁹39. Al Baz M , Law MR , Saadeh R . Antibiotics use among Palestine refugees attending UNRWA primary health care centers in Jordan: a cross-sectional study . Travel Med Infect Dis . 2018 ; 22 : 25 - 9 . https://doi.org/10.1016/j.tmaid.2018.02.004
https://doi.org/10.1016/j.tmaid.2018.02.... , ⁴¹41. Riccardo F , Khader A , Sabatinelli G . Low infant mortality among Palestine refugees despite the odds . Bull World Health Organ . 2011 ; 89 ( 4 ): 304 - 11 . https://doi.org/10.2471/BLT.10.082743
https://doi.org/10.2471/BLT.10.082743... . In one, the majority (88%) of Palestinian refugees in Jordan reported waiting for long hours at the health facility, which resulted in doubling the risk of self-medication with antibiotics ³⁹39. Al Baz M , Law MR , Saadeh R . Antibiotics use among Palestine refugees attending UNRWA primary health care centers in Jordan: a cross-sectional study . Travel Med Infect Dis . 2018 ; 22 : 25 - 9 . https://doi.org/10.1016/j.tmaid.2018.02.004
https://doi.org/10.1016/j.tmaid.2018.02.... . In the Gaza Strip and West Bank, poor access to PHC services was the main determinant of neonatal death ⁴¹41. Riccardo F , Khader A , Sabatinelli G . Low infant mortality among Palestine refugees despite the odds . Bull World Health Organ . 2011 ; 89 ( 4 ): 304 - 11 . https://doi.org/10.2471/BLT.10.082743
https://doi.org/10.2471/BLT.10.082743... .

Regarding the elements of social vulnerability, the indicator most cited was “access to education” ³²32. Segal SP , Khoury VC , Salah R , Ghannam J . Contributors to screening positive for mental illness in Lebano´s Shatila Palestinian Refugee Camp . J Nerv Ment Dis . 2018 ; 206 ( 1 ): 46 - 51 . https://doi.org/10.1097/NMD.0000000000000751
https://doi.org/10.1097/NMD.000000000000... , ⁴³43. Alkasseh ASM , Zaki NM , Aljeesh YI , Soon LK . Risk factors of gestational diabetes mellitus in the refugee population in Gaza Strip: a case-control study . East Mediterr Health J . 2014 ; 19 Suppl 3 : S12 - 8 . , ⁴⁹49. Bastin P , Bastard M , Rossel L , Melgar P , Jones A , Antierens A . Description and predictive factors of individual outcomes in a refugee camp based mental health intervention (Beirut, Lebanon) . PLoS One . 2013 ; 8 ( 1 ): e54107 . https://doi.org/10.1371/journal.pone.0054107
https://doi.org/10.1371/journal.pone.005... . One of the studies points out that Palestinian refugees without any level of education in Lebanon accounted for 15.5% of the sample, almost double the local Lebanese population with the same level of education (8%) ³²32. Segal SP , Khoury VC , Salah R , Ghannam J . Contributors to screening positive for mental illness in Lebano´s Shatila Palestinian Refugee Camp . J Nerv Ment Dis . 2018 ; 206 ( 1 ): 46 - 51 . https://doi.org/10.1097/NMD.0000000000000751
https://doi.org/10.1097/NMD.000000000000... . Low educational level among pregnant Palestinian refugees in the Gaza Strip was a factor associated with predisposition to gestational diabetes ⁴³43. Alkasseh ASM , Zaki NM , Aljeesh YI , Soon LK . Risk factors of gestational diabetes mellitus in the refugee population in Gaza Strip: a case-control study . East Mediterr Health J . 2014 ; 19 Suppl 3 : S12 - 8 . . Studies confirm social exclusion in relation to participation in the economy with informal underemployment among this group of refugees. Legal restrictions in the host countries, such as Lebanon, corroborate the stigma about Palestinians.

III - Iraqi Refugees

Table 4 summarizes the five studies about this refugee population ⁵³53. Worabo HJ , Kuei-Hsiang H , Yakimo R , Worabo E , Burgess PA , Farberman SM . Understanding refugees’ perceptions of health care in the United States . J Nurse Pract . 2016 ; 12 ( 7 ): 487 - 94 . https://doi.org/10.1016/j.nurpra.2016.04.014
https://doi.org/10.1016/j.nurpra.2016.04... . The prevalence of infectious diseases, malnutrition, mental disorders, and diabetes stands out. In adults, the prevalence of DM was higher than in the local population, and almost twice as high in women ⁵⁴54. Goosen S , Middelkoop B , Stronks K , Agyemang C , Kunst AE . High diabetes risk among asylum seekers in The Netherlands . Diabet Med . 2014 ; 31 ( 12 ): 1532 - 41 . https://doi.org/10.1111/dme.12510
https://doi.org/10.1111/dme.12510... . Among children, we highlight vitamin D deficit; growth and nutritional problems; latent tuberculosis; neurological/metabolic and learning/behavioral disorders; delayed development; as well as exposure to trauma and separation from a family member ³³33. Heenan RC , Volkman T , Stokes S , Tosif S , Graham H , Smith A , et al . ‘I think we’ve had a health screen’: new offshore screening, new refugee health guidelines, new Syrian and Iraqi cohorts: recommendations, reality, results and review . J Paediatr Child Health . 2019 ; 55 ( 1 ): 95 - 103 . https://doi.org/10.1111/jpc.14142
https://doi.org/10.1111/jpc.14142... , ⁵³53. Worabo HJ , Kuei-Hsiang H , Yakimo R , Worabo E , Burgess PA , Farberman SM . Understanding refugees’ perceptions of health care in the United States . J Nurse Pract . 2016 ; 12 ( 7 ): 487 - 94 . https://doi.org/10.1016/j.nurpra.2016.04.014
https://doi.org/10.1016/j.nurpra.2016.04... , ⁵⁴54. Goosen S , Middelkoop B , Stronks K , Agyemang C , Kunst AE . High diabetes risk among asylum seekers in The Netherlands . Diabet Med . 2014 ; 31 ( 12 ): 1532 - 41 . https://doi.org/10.1111/dme.12510
https://doi.org/10.1111/dme.12510... .

“Work” was another indicator checked ⁵³53. Worabo HJ , Kuei-Hsiang H , Yakimo R , Worabo E , Burgess PA , Farberman SM . Understanding refugees’ perceptions of health care in the United States . J Nurse Pract . 2016 ; 12 ( 7 ): 487 - 94 . https://doi.org/10.1016/j.nurpra.2016.04.014
https://doi.org/10.1016/j.nurpra.2016.04... , ⁵⁶56. Kvittingen A , Valenta M , Tabbara H , Baslan D , Berg B . The conditions and migratory aspirations of Syrian and Iraqi refugees in Jordan . 2019 ; 32 ( 1 ): 106 - 24 . https://doi.org/10.1093/jrs/fey015
https://doi.org/10.1093/jrs/fey015... , ⁵⁷57. Doocy S , Burnham G , Biermann E , Tileva M . Household economy and livelihoods among Iraqi refugees in Syria . J Refugee Stud . 2012 ; 25 ( 2 ): 282 - 300 . https://doi.org/10.1093/jrs/fer049
https://doi.org/10.1093/jrs/fer049... . In a study with Iraqi refugees in the United States, unemployment reached 90% ⁵³53. Worabo HJ , Kuei-Hsiang H , Yakimo R , Worabo E , Burgess PA , Farberman SM . Understanding refugees’ perceptions of health care in the United States . J Nurse Pract . 2016 ; 12 ( 7 ): 487 - 94 . https://doi.org/10.1016/j.nurpra.2016.04.014
https://doi.org/10.1016/j.nurpra.2016.04... , with a predominance of informal work. The majority (61%) of Iraqi refugees in Syria hold casual jobs in the service sector (commerce), and only 12% have formal and stable jobs. Hard work is significant, with an average of 59 hours a week. There were also reports of child labor, underemployment, and payment for labor far below market rates, in addition to lack of payment after providing services ⁵⁶56. Kvittingen A , Valenta M , Tabbara H , Baslan D , Berg B . The conditions and migratory aspirations of Syrian and Iraqi refugees in Jordan . 2019 ; 32 ( 1 ): 106 - 24 . https://doi.org/10.1093/jrs/fey015
https://doi.org/10.1093/jrs/fey015... .

Regarding the “beliefs and values” indicator, the non-adherence to treatment for latent tuberculosis stands out. The lack of symptoms leads to the belief that treatment is unnecessary ⁵³53. Worabo HJ , Kuei-Hsiang H , Yakimo R , Worabo E , Burgess PA , Farberman SM . Understanding refugees’ perceptions of health care in the United States . J Nurse Pract . 2016 ; 12 ( 7 ): 487 - 94 . https://doi.org/10.1016/j.nurpra.2016.04.014
https://doi.org/10.1016/j.nurpra.2016.04... .

Regarding the programmatic dimension of vulnerability, the indicator “actions of health programs” ³³33. Heenan RC , Volkman T , Stokes S , Tosif S , Graham H , Smith A , et al . ‘I think we’ve had a health screen’: new offshore screening, new refugee health guidelines, new Syrian and Iraqi cohorts: recommendations, reality, results and review . J Paediatr Child Health . 2019 ; 55 ( 1 ): 95 - 103 . https://doi.org/10.1111/jpc.14142
https://doi.org/10.1111/jpc.14142... , ⁵³53. Worabo HJ , Kuei-Hsiang H , Yakimo R , Worabo E , Burgess PA , Farberman SM . Understanding refugees’ perceptions of health care in the United States . J Nurse Pract . 2016 ; 12 ( 7 ): 487 - 94 . https://doi.org/10.1016/j.nurpra.2016.04.014
https://doi.org/10.1016/j.nurpra.2016.04... , ⁵⁵55. Loenen T , Muijsenbergh M , Hofmeester M , Dowrick C , Ginneken N , Mechili EA , et al . Primary care for refugees and newly arrived migrants in Europe: a qualitative study on health needs, barriers and wishes . Eur J Public Health . 2018 ; 28 ( 1 ): 82 - 7 . https://doi.org/10.1093/eurpub/ckx210
https://doi.org/10.1093/eurpub/ckx210... stands out, mainly in the form of long waiting hours (in American health services), as well as lack of translator and empathy by the health team ⁵³53. Worabo HJ , Kuei-Hsiang H , Yakimo R , Worabo E , Burgess PA , Farberman SM . Understanding refugees’ perceptions of health care in the United States . J Nurse Pract . 2016 ; 12 ( 7 ): 487 - 94 . https://doi.org/10.1016/j.nurpra.2016.04.014
https://doi.org/10.1016/j.nurpra.2016.04... . In one study, only 1.8% of the children had a complete health evaluation according to the protocol recommended for refugees ³³33. Heenan RC , Volkman T , Stokes S , Tosif S , Graham H , Smith A , et al . ‘I think we’ve had a health screen’: new offshore screening, new refugee health guidelines, new Syrian and Iraqi cohorts: recommendations, reality, results and review . J Paediatr Child Health . 2019 ; 55 ( 1 ): 95 - 103 . https://doi.org/10.1111/jpc.14142
https://doi.org/10.1111/jpc.14142... .

Regarding “access to healthcare services” ³³33. Heenan RC , Volkman T , Stokes S , Tosif S , Graham H , Smith A , et al . ‘I think we’ve had a health screen’: new offshore screening, new refugee health guidelines, new Syrian and Iraqi cohorts: recommendations, reality, results and review . J Paediatr Child Health . 2019 ; 55 ( 1 ): 95 - 103 . https://doi.org/10.1111/jpc.14142
https://doi.org/10.1111/jpc.14142... , ⁵⁵55. Loenen T , Muijsenbergh M , Hofmeester M , Dowrick C , Ginneken N , Mechili EA , et al . Primary care for refugees and newly arrived migrants in Europe: a qualitative study on health needs, barriers and wishes . Eur J Public Health . 2018 ; 28 ( 1 ): 82 - 7 . https://doi.org/10.1093/eurpub/ckx210
https://doi.org/10.1093/eurpub/ckx210... , ⁵⁷57. Doocy S , Burnham G , Biermann E , Tileva M . Household economy and livelihoods among Iraqi refugees in Syria . J Refugee Stud . 2012 ; 25 ( 2 ): 282 - 300 . https://doi.org/10.1093/jrs/fer049
https://doi.org/10.1093/jrs/fer049... , difficulty to perform tuberculin skin test was observed among Iraqi refugees in the Australian PHC; and difficulty of access to health care in more crowded European borders ⁵⁵55. Loenen T , Muijsenbergh M , Hofmeester M , Dowrick C , Ginneken N , Mechili EA , et al . Primary care for refugees and newly arrived migrants in Europe: a qualitative study on health needs, barriers and wishes . Eur J Public Health . 2018 ; 28 ( 1 ): 82 - 7 . https://doi.org/10.1093/eurpub/ckx210
https://doi.org/10.1093/eurpub/ckx210... . Moreover, many patients did not use contraceptive methods, and 82% could not access them because they were unaware of the family planning services available ⁵⁷57. Doocy S , Burnham G , Biermann E , Tileva M . Household economy and livelihoods among Iraqi refugees in Syria . J Refugee Stud . 2012 ; 25 ( 2 ): 282 - 300 . https://doi.org/10.1093/jrs/fer049
https://doi.org/10.1093/jrs/fer049... .

As for the “health policies” indicator, one study mentions that Jordan revoked the free access of Iraqi refugees to health care and fundamental rights, a step backwards in this free health care offer, motivated by the discourse of financial deficit ⁵⁶56. Kvittingen A , Valenta M , Tabbara H , Baslan D , Berg B . The conditions and migratory aspirations of Syrian and Iraqi refugees in Jordan . 2019 ; 32 ( 1 ): 106 - 24 . https://doi.org/10.1093/jrs/fey015
https://doi.org/10.1093/jrs/fey015... .

The most common indicator regarding the social dimension of vulnerability is “access to education” ³³33. Heenan RC , Volkman T , Stokes S , Tosif S , Graham H , Smith A , et al . ‘I think we’ve had a health screen’: new offshore screening, new refugee health guidelines, new Syrian and Iraqi cohorts: recommendations, reality, results and review . J Paediatr Child Health . 2019 ; 55 ( 1 ): 95 - 103 . https://doi.org/10.1111/jpc.14142
https://doi.org/10.1111/jpc.14142... , ⁴⁹49. Bastin P , Bastard M , Rossel L , Melgar P , Jones A , Antierens A . Description and predictive factors of individual outcomes in a refugee camp based mental health intervention (Beirut, Lebanon) . PLoS One . 2013 ; 8 ( 1 ): e54107 . https://doi.org/10.1371/journal.pone.0054107
https://doi.org/10.1371/journal.pone.005... , ⁵⁶56. Kvittingen A , Valenta M , Tabbara H , Baslan D , Berg B . The conditions and migratory aspirations of Syrian and Iraqi refugees in Jordan . 2019 ; 32 ( 1 ): 106 - 24 . https://doi.org/10.1093/jrs/fey015
https://doi.org/10.1093/jrs/fey015... , ⁵⁷57. Doocy S , Burnham G , Biermann E , Tileva M . Household economy and livelihoods among Iraqi refugees in Syria . J Refugee Stud . 2012 ; 25 ( 2 ): 282 - 300 . https://doi.org/10.1093/jrs/fer049
https://doi.org/10.1093/jrs/fer049... . About 32% of Iraqi children in Australia missed three or more years of school in the pre-arrival period ³³33. Heenan RC , Volkman T , Stokes S , Tosif S , Graham H , Smith A , et al . ‘I think we’ve had a health screen’: new offshore screening, new refugee health guidelines, new Syrian and Iraqi cohorts: recommendations, reality, results and review . J Paediatr Child Health . 2019 ; 55 ( 1 ): 95 - 103 . https://doi.org/10.1111/jpc.14142
https://doi.org/10.1111/jpc.14142... . Children have difficulty enrolling in school because they lack an official residential address in Jordan ⁵⁶56. Kvittingen A , Valenta M , Tabbara H , Baslan D , Berg B . The conditions and migratory aspirations of Syrian and Iraqi refugees in Jordan . 2019 ; 32 ( 1 ): 106 - 24 . https://doi.org/10.1093/jrs/fey015
https://doi.org/10.1093/jrs/fey015... . Refugees with less education were more susceptible to mental illness ⁴⁹49. Bastin P , Bastard M , Rossel L , Melgar P , Jones A , Antierens A . Description and predictive factors of individual outcomes in a refugee camp based mental health intervention (Beirut, Lebanon) . PLoS One . 2013 ; 8 ( 1 ): e54107 . https://doi.org/10.1371/journal.pone.0054107
https://doi.org/10.1371/journal.pone.005... , poverty, and about twice as susceptible to a per capita income below $1/day ⁵⁷57. Doocy S , Burnham G , Biermann E , Tileva M . Household economy and livelihoods among Iraqi refugees in Syria . J Refugee Stud . 2012 ; 25 ( 2 ): 282 - 300 . https://doi.org/10.1093/jrs/fer049
https://doi.org/10.1093/jrs/fer049... . The “migration” indicator brings up the sense of constant threat, for fear of expulsion by the government, experienced by Iraqi refugees in Jordan ⁵⁶56. Kvittingen A , Valenta M , Tabbara H , Baslan D , Berg B . The conditions and migratory aspirations of Syrian and Iraqi refugees in Jordan . 2019 ; 32 ( 1 ): 106 - 24 . https://doi.org/10.1093/jrs/fey015
https://doi.org/10.1093/jrs/fey015... .

DISCUSSION

All dimensions of vulnerability were present in the studies of our sample. The bibliometric findings indicate that the predominance (77%) of quantitative studies may result in partial assessments of the life experiences of the populations studied. Studies conducted entirely in refugee camps and studies with significant samples in Brazil and Latin America were also scarce (8%), in addition to the scarcity of multicenter studies. There was no mention in the studies or comparative analysis regarding the difference in access to health care between refugees and asylum seekers. There was no study on comparative analysis of health vulnerabilities between Arab refugees and refugees of other nationalities. It is worth noting that “refugees” and “asylum seekers” are part of the same forced migration bloc; however, asylum seekers are only waiting for a bureaucratic step for their recognition as refugees in the host country.

Among Syrians, there is a lack of studies on the health needs of specific groups such as children, adolescents and women, and no studies on the health needs of female Palestinian refugee in PHC have been identified. Although Turkey is one of the main destination routes of Syrians, it was observed in our sample scarcity of studies (5%) related to the context of PHC in that host country.

Regarding the dimensions of vulnerability, the individual dimension reveals the presence of chronic and infectious diseases, besides the significant presence of mental disorders. These are corroborated by and attributed to traumatic experiences, even before forced migration: violence, abuse, and uncertainty about the future ⁵⁸58. Patel K , Kouvonen A , Close C , Väänänen A , O Reilly D , Donnelly M . What do register-based studies tell us about migrant mental health? A scoping review . Syst Rev . 2017 ; 6 ( 1 ): 78 . https://doi.org/10.1186/s13643-017-0463-1
https://doi.org/10.1186/s13643-017-0463-... . Despite the significance of mental disorders, this review and other studies point to a new challenge regarding the escalation of NCDs, with repercussions on the health system of the host countries in areas of conflict, especially Jordan, Lebanon, and Turkey, and increased spending on treatment, especially for DM and hypertension ²²22. Al-Rousan T , Schwabkey Z , Jirmanus L , Nelson BD . Health needs and priorities of Syrian refugees in camps and urban settings in Jordan: perspectives of refugees and health care providers . East Mediterr Health J . 2018 ; 24 ( 3 ): 243 - 53 . https://doi.org/10.26719/2018.24.3.243
https://doi.org/10.26719/2018.24.3.243... , ²⁴24. Doocy S , Lyles E , Roberton T , Akhu-Zaheya L , Oweis A , Burnham G . Prevalence and care-seeking for chronic diseases among Syrian refugees in Jordan . BMC Public Health . 2015 ; 15 : 1097 . https://doi.org/10.1186/s12889-015-2429-3
https://doi.org/10.1186/s12889-015-2429-... , ²⁷27. Sethi S , Jonsson R , Skaff R , Tyler F . Community-based noncommunicable disease care for Syrian refugees in Lebanon . Glob Health Sci Pract . 2017 ; 5 ( 3 ): 495 - 506 . https://doi.org/10.9745/GHSP-D-17-00043
https://doi.org/10.9745/GHSP-D-17-00043... , ³¹31. Doocy S , Lyles E , Hanquart B ; LHAS Study Team , Woodman M . Prevalence, care-seeking, and health service utilization for non-communicable diseases among Syrian refugees and host communities in Lebanon . Confl Health . 2016 ; 10 : 21 . https://doi.org/10.1186/s13031-016-0088-3
https://doi.org/10.1186/s13031-016-0088-... , ³⁴34. Doocy S , Paik KE , Lyles E , Hei Tam H , Fahed Z , Winkler E , et al . Guidelines and mHealth to improve quality of hypertension and type 2 diabetes care for vulnerable populations in Lebanon: longitudinal cohort study . JMIR Mhealth Uhealth . 2017 ; 5 ( 10 ): e158 . https://doi.org/10.2196/mhealth.7745
https://doi.org/10.2196/mhealth.7745... , ³⁵35. Elliott JA , Das D , Cavailler P , Schneider F , Shah M , Ravaud A , et al . A cross-sectional assessment of diabetes self-management, education and support needs of Syrian refugee patients living with diabetes in Bekaa Valley Lebanon . Confl Health . 2018 ; 12 : 40 . https://doi.org/10.1186/s13031-018-0174-9
https://doi.org/10.1186/s13031-018-0174-... , ³⁸38. Lyles E , Hanquart B , Chlela L , Woodman M ; LHAS Study Team , Fouad FM , Sibai A , et al . Health service access and utilization among Syrian refugees and affected host communities in Lebanon . J Refugee Stud . 2018 ; 31 ( 1 ): 104 - 30 . https://doi.org/10.1093/jrs/fex014
https://doi.org/10.1093/jrs/fex014... , ⁴⁴44. Saadeh R , Qato D , Khader A , Shahin Y , Seita A . Trends in the utilization of antihypertensive medications among Palestine refugees in Jordan, 2008-2012 . J Pharm Policy Pract . 2015 ; 8 : 7 . https://doi.org/10.1186/s40545-015-0036-4
https://doi.org/10.1186/s40545-015-0036-... , ⁵⁴54. Goosen S , Middelkoop B , Stronks K , Agyemang C , Kunst AE . High diabetes risk among asylum seekers in The Netherlands . Diabet Med . 2014 ; 31 ( 12 ): 1532 - 41 . https://doi.org/10.1111/dme.12510
https://doi.org/10.1111/dme.12510... , ⁵⁹59. Naja F , Shatila H , El Koussa M , Meho L , Ghandour L , Saleh S . Burden of non-communicable diseases among Syrian refugees: a scoping review . BMC Public Health . 2019 ; 19 : 637 . https://doi.org/10.1186/s12889-019-6977-9
https://doi.org/10.1186/s12889-019-6977-... . It is noteworthy that in the studies analyzed in this review, PHC played a central role in providing access to health systems in countries neighboring the conflict zones ⁴⁷47. Alameddine M , Fouad FM , Diaconu K , Jamal Z , Lough G , Witter S , et al . Resilience capacities of health systems: accommodating the needs of Palestinian refugees from Syria . Soc Sci Med . 2019 ; 220 : 22 - 30 . https://doi.org/10.1016/j.socscimed.2018.10.018
https://doi.org/10.1016/j.socscimed.2018... , ⁶⁰60. Kruk ME , Ling EJ , Bitton A , Cammett M , Cavanaugh K , Chopra M , et al . Building resilient health systems: a proposal for a resilience index . BMJ . 2017 ; 357 : j2323 . https://doi.org/10.1136/bmj.j2323
https://doi.org/10.1136/bmj.j2323... .

Findings regarding women’s health are supported by a study that identified gestational diabetes, stillbirths, and children with low birth weight, in addition to inadequate prenatal care ⁶¹61. Liu C , Ahlberg M , Hjern A , Stephansson O . Perinatal health of refugee and asylum-seeking women in Sweden 2014-17: a register-based cohort study . Eur J Public Health . 2019 ; 29 ( 6 ): 1048 - 55 . https://doi.org/10.1093/eurpub/ckz120
https://doi.org/10.1093/eurpub/ckz120... . Congenital malformation was associated with early pregnancy and consanguineous marriage in Palestinian refugee women ⁴¹41. Riccardo F , Khader A , Sabatinelli G . Low infant mortality among Palestine refugees despite the odds . Bull World Health Organ . 2011 ; 89 ( 4 ): 304 - 11 . https://doi.org/10.2471/BLT.10.082743
https://doi.org/10.2471/BLT.10.082743... . Refugee children suffer from conditions resulting from inadequate nutrition, malnutrition, micronutrient deficiencies, as well as oral health needs and infectious diseases, in addition to the consequences of exposure to war conflicts, violence, and xenophobia, and developmental delays and failures in schooling, among others ⁶²62. Kroening ALH , Dawson-Hahn E . Health considerations for immigrant and refugee children . Adv Pediatr . 2019 ; 66 : 87 - 110 . https://doi.org/10.1016/j.yapd.2019.04.003
https://doi.org/10.1016/j.yapd.2019.04.0... . Recent findings show evident inequality in vaccination coverage among refugee children when compared to the general population: they are three times less likely to be vaccinated against preventable infections, especially measles, tetanus, and meningitis C ⁶³63. Perry M , Townson M , Cottrell S , Fagan L , Edwards J , Saunders J , et al . Inequalities in vaccination coverage and differences in follow-up procedures for asylum-seeking children arriving in Wales, UK . Eur J Pediatr . 2020 ; 179 : 171 - 5 . https://doi.org/10.1007/s00431-019-03485-7
https://doi.org/10.1007/s00431-019-03485... . The difficulty in access to vaccines, and low vaccination coverage upon arrival in the host countries are evident in this study ³³33. Heenan RC , Volkman T , Stokes S , Tosif S , Graham H , Smith A , et al . ‘I think we’ve had a health screen’: new offshore screening, new refugee health guidelines, new Syrian and Iraqi cohorts: recommendations, reality, results and review . J Paediatr Child Health . 2019 ; 55 ( 1 ): 95 - 103 . https://doi.org/10.1111/jpc.14142
https://doi.org/10.1111/jpc.14142... .

Regarding the programmatic dimension, fragmentation of policies, programs, services, and health teams stands out. The PHC teams that work in the front line, in regions of large migration flows, have difficulties in dealing with refugees and work overload, besides absenteeism ⁴⁷47. Alameddine M , Fouad FM , Diaconu K , Jamal Z , Lough G , Witter S , et al . Resilience capacities of health systems: accommodating the needs of Palestinian refugees from Syria . Soc Sci Med . 2019 ; 220 : 22 - 30 . https://doi.org/10.1016/j.socscimed.2018.10.018
https://doi.org/10.1016/j.socscimed.2018... . Another study supports and points out this phenomenon as a consequence of conflicts and war, which impact the entire local health system and that of neighboring countries, reducing the supply and quality of services, as well as promoting an exodus of health professionals. As a result, exclusionary policies that restrict and bureaucratize access to PHC have been adopted, such as more stringent document requirements for the acquisition of housing and food subsidies, end of gratuity, and beginning of charging for PHC services ⁶⁴64. Lafta RK , Al-Nuaimi MA . War or health: a four-decade armed conflict in Iraq . Med Confl Surviv . 2019 ; 35 ( 3 ): 209 - 26 . https://doi.org/10.1080/13623699.2019.1670431
https://doi.org/10.1080/13623699.2019.16... . There is inequality in access, especially for refugees with lower educational level, who are more vulnerable among the vulnerable and depend on assistance from local governments ¹⁷17. United Nations High Commissioner for Refugees ; UNICEF ; WFP . Vulnerability assessment of Syrian refugees in Lebanon 2016 . Geneva (CH) : UNHCR ; 2016 . , ²⁴24. Doocy S , Lyles E , Roberton T , Akhu-Zaheya L , Oweis A , Burnham G . Prevalence and care-seeking for chronic diseases among Syrian refugees in Jordan . BMC Public Health . 2015 ; 15 : 1097 . https://doi.org/10.1186/s12889-015-2429-3
https://doi.org/10.1186/s12889-015-2429-... , ²⁷27. Sethi S , Jonsson R , Skaff R , Tyler F . Community-based noncommunicable disease care for Syrian refugees in Lebanon . Glob Health Sci Pract . 2017 ; 5 ( 3 ): 495 - 506 . https://doi.org/10.9745/GHSP-D-17-00043
https://doi.org/10.9745/GHSP-D-17-00043... , ³²32. Segal SP , Khoury VC , Salah R , Ghannam J . Contributors to screening positive for mental illness in Lebano´s Shatila Palestinian Refugee Camp . J Nerv Ment Dis . 2018 ; 206 ( 1 ): 46 - 51 . https://doi.org/10.1097/NMD.0000000000000751
https://doi.org/10.1097/NMD.000000000000... . A cross-sectional study of 400 Syrian refugees in Canada points out that refugees accessing public or local government-funded health care compared to refugees accessing private or privately funded health care report more unmet health needs and more complex medical conditions, and are almost three times more likely (OR = 2.84; 95%CI: 1.55–5.20) to not have their health needs met. Of those refugees, only 58% report having a family doctor of referral ⁶⁵65. Oda A , Hynie M , Tuck A , Agic B , Roche B , McKenzie K . Differences in self-reported health and unmet health needs between government assisted and privately sponsored Syrian refugees: a cross-sectional survey . J Immigr Minor Health . 2019 ; 21 ( 3 ): 439 - 42 . https://doi.org/10.1007/s10903-018-0780-z
https://doi.org/10.1007/s10903-018-0780-... . There are reports of a growing need for refugees in Lebanon and Jordan to pay for PHC services ²²22. Al-Rousan T , Schwabkey Z , Jirmanus L , Nelson BD . Health needs and priorities of Syrian refugees in camps and urban settings in Jordan: perspectives of refugees and health care providers . East Mediterr Health J . 2018 ; 24 ( 3 ): 243 - 53 . https://doi.org/10.26719/2018.24.3.243
https://doi.org/10.26719/2018.24.3.243... , ²⁷27. Sethi S , Jonsson R , Skaff R , Tyler F . Community-based noncommunicable disease care for Syrian refugees in Lebanon . Glob Health Sci Pract . 2017 ; 5 ( 3 ): 495 - 506 . https://doi.org/10.9745/GHSP-D-17-00043
https://doi.org/10.9745/GHSP-D-17-00043... , ⁵⁶56. Kvittingen A , Valenta M , Tabbara H , Baslan D , Berg B . The conditions and migratory aspirations of Syrian and Iraqi refugees in Jordan . 2019 ; 32 ( 1 ): 106 - 24 . https://doi.org/10.1093/jrs/fey015
https://doi.org/10.1093/jrs/fey015... . Although refugees disburse less than the local population, it is noteworthy that this situation is added with high unemployment, and low income (less than two dollars/day among refugees) ²²22. Al-Rousan T , Schwabkey Z , Jirmanus L , Nelson BD . Health needs and priorities of Syrian refugees in camps and urban settings in Jordan: perspectives of refugees and health care providers . East Mediterr Health J . 2018 ; 24 ( 3 ): 243 - 53 . https://doi.org/10.26719/2018.24.3.243
https://doi.org/10.26719/2018.24.3.243... . The UN/UNHCR offers a program of income distribution and financial assistance for Syrian refugees in Jordan, for example, but only 23,000 families have access ²²22. Al-Rousan T , Schwabkey Z , Jirmanus L , Nelson BD . Health needs and priorities of Syrian refugees in camps and urban settings in Jordan: perspectives of refugees and health care providers . East Mediterr Health J . 2018 ; 24 ( 3 ): 243 - 53 . https://doi.org/10.26719/2018.24.3.243
https://doi.org/10.26719/2018.24.3.243... to it. It is a very restricted number considering the more than 676,300 Syrian refugees under UN protection in that country ⁴4. United Nations High Commissioner for Refugees . Global trends: forced displacement in 2018 . Geneva : UNHCR ; 2019 [ cited 2020 Oct 21 ]. Available from: https://www.unhcr.org/5d08d7ee7.pdf
https://www.unhcr.org/5d08d7ee7.pdf... . In Jordan, a biometric personal identification card is required for access to health and nutritional support, but there are a number of requirements to obtain it ¹⁷17. United Nations High Commissioner for Refugees ; UNICEF ; WFP . Vulnerability assessment of Syrian refugees in Lebanon 2016 . Geneva (CH) : UNHCR ; 2016 . , ²²22. Al-Rousan T , Schwabkey Z , Jirmanus L , Nelson BD . Health needs and priorities of Syrian refugees in camps and urban settings in Jordan: perspectives of refugees and health care providers . East Mediterr Health J . 2018 ; 24 ( 3 ): 243 - 53 . https://doi.org/10.26719/2018.24.3.243
https://doi.org/10.26719/2018.24.3.243... . As a result, many Syrians have been forced to further reduce their food intake, stop seeking health care, and take children out of school to offset costs or generate additional income through child labor ¹⁷17. United Nations High Commissioner for Refugees ; UNICEF ; WFP . Vulnerability assessment of Syrian refugees in Lebanon 2016 . Geneva (CH) : UNHCR ; 2016 . . The average number of meals for adult Syrian refugees in Lebanon was 1.8 meals/day, and among children, 2.3 meals/day ¹⁷17. United Nations High Commissioner for Refugees ; UNICEF ; WFP . Vulnerability assessment of Syrian refugees in Lebanon 2016 . Geneva (CH) : UNHCR ; 2016 . .

As for the main destination and host countries, Jordan, Lebanon and Syria, there is no explicit information on the websites of their respective Ministries of Health about public health policies for refugees. Lebanon is not a signatory to the 1951 Refugee Convention and, in this sense, there is no domestic law addressing refugee needs in the country ⁶⁸68. United Nations High Commissioner for Refugees . UNHCR Global Appeal 2014-2015 . Geneva (CH) : UNHCR ; 2016 [ cited 2021 May 13 ]. www.unhcr.org./528a0a2da.pdf
www.unhcr.org./528a0a2da.pdf... . There are records that Palestinians and Syrians suffer from marginalization and discrimination as a result of policies that deny access to basic rights such as housing, work, education and health care ⁶⁹69. Majzoub A . Lebanon´s refugee restrictions could harm everyone´s health . New York : Human Rights Watch ; 2020 [ cited 2021 May 28 ]. Available from: https://www.hrw.org/news/2020/04/22/lebanons-refugee-restrictions-could-harm-everyones-health
https://www.hrw.org/news/2020/04/22/leba... . The United Nations Relief and Works Agency (UNRWA) has suffered major budget cuts, and its largest donor, the United States, has cut funding ⁶⁹69. Majzoub A . Lebanon´s refugee restrictions could harm everyone´s health . New York : Human Rights Watch ; 2020 [ cited 2021 May 28 ]. Available from: https://www.hrw.org/news/2020/04/22/lebanons-refugee-restrictions-could-harm-everyones-health
https://www.hrw.org/news/2020/04/22/leba... . However, there is controversy about governmental actions regarding refugees in this country, pointing out the existence of primary health care provision, which includes consultations, lab and diagnostic testing for groups previously defined as vulnerable, offered at a reduced cost to residents ⁶⁹69. Majzoub A . Lebanon´s refugee restrictions could harm everyone´s health . New York : Human Rights Watch ; 2020 [ cited 2021 May 28 ]. Available from: https://www.hrw.org/news/2020/04/22/lebanons-refugee-restrictions-could-harm-everyones-health
https://www.hrw.org/news/2020/04/22/leba... . Vaccination, two ultrasound examinations for pregnant women, and medication for acute and chronic conditions are free of charge ⁶⁹69. Majzoub A . Lebanon´s refugee restrictions could harm everyone´s health . New York : Human Rights Watch ; 2020 [ cited 2021 May 28 ]. Available from: https://www.hrw.org/news/2020/04/22/lebanons-refugee-restrictions-could-harm-everyones-health
https://www.hrw.org/news/2020/04/22/leba... .

In Jordan, it is noted that rental housing is affordable, and housing in settlements is offered in exchange for work on local farms ⁶⁹69. Majzoub A . Lebanon´s refugee restrictions could harm everyone´s health . New York : Human Rights Watch ; 2020 [ cited 2021 May 28 ]. Available from: https://www.hrw.org/news/2020/04/22/lebanons-refugee-restrictions-could-harm-everyones-health
https://www.hrw.org/news/2020/04/22/leba... . The reduced offer of labor determines the need to work or get married, which leads to dropping out school ⁶⁹69. Majzoub A . Lebanon´s refugee restrictions could harm everyone´s health . New York : Human Rights Watch ; 2020 [ cited 2021 May 28 ]. Available from: https://www.hrw.org/news/2020/04/22/lebanons-refugee-restrictions-could-harm-everyones-health
https://www.hrw.org/news/2020/04/22/leba... . To mitigate such situations, the government has implemented a program: “Cash+”, which includes social protection interventions for families in vulnerable situations, who get unconditional monthly cash transfer per child. Mental health programs are also offered in integration with primary health care services ⁶⁹69. Majzoub A . Lebanon´s refugee restrictions could harm everyone´s health . New York : Human Rights Watch ; 2020 [ cited 2021 May 28 ]. Available from: https://www.hrw.org/news/2020/04/22/lebanons-refugee-restrictions-could-harm-everyones-health
https://www.hrw.org/news/2020/04/22/leba... . Refugees in camps have free access to health care, subsidized by the government and international agencies. Refugees registered with the Ministry of Interior in Jordan have access to healthcare and government benefits, in the same way as uninsured Jordanians. However, it is noteworthy that refugees have financial burden to afford with consultations and medication in private health services ⁷⁰70. Dator W , Abunab H , Dao-Ayen N . Health challenges and access to health care among Syrian refugees in Jordan: a review . East Mediterr Health J . 2018 ; 24 ( 7 ): 680 - 6 . https://doi.org/10.26719/2018.24.7.680
https://doi.org/10.26719/2018.24.7.680... .

As for the social dimension of vulnerabilities, inequality was evidenced in the access to education, information, decent work, besides prejudice/stigma, and difficulties of participation in collective actions and consequent difficulty of integration in the host countries ¹⁷17. United Nations High Commissioner for Refugees ; UNICEF ; WFP . Vulnerability assessment of Syrian refugees in Lebanon 2016 . Geneva (CH) : UNHCR ; 2016 . , ²¹21. Ay M , Arcos González P , Castro Delgado R . The perceived barriers of access to health care among a group of non-camp Syrian refugees in Jordan . Int J Health Serv . 2016 ; 46 ( 3 ): 566 - 89 . https://doi.org/10.1177/0020731416636831
https://doi.org/10.1177/0020731416636831...

22. Al-Rousan T , Schwabkey Z , Jirmanus L , Nelson BD . Health needs and priorities of Syrian refugees in camps and urban settings in Jordan: perspectives of refugees and health care providers . East Mediterr Health J . 2018 ; 24 ( 3 ): 243 - 53 . https://doi.org/10.26719/2018.24.3.243
https://doi.org/10.26719/2018.24.3.243...

23. Cherri Z , Cuesta JG , Rodriguez-Llanes JM , Guha-Sapir D . Early marriage and barriers to contraception among Syrian refugee women in Lebanon: a qualitative study . Int J Environ Res Public Health . 2017 ; 14 ( 8 ): 836 . https://doi.org/10.3390/ijerph14080836
https://doi.org/10.3390/ijerph14080836... - ²⁴24. Doocy S , Lyles E , Roberton T , Akhu-Zaheya L , Oweis A , Burnham G . Prevalence and care-seeking for chronic diseases among Syrian refugees in Jordan . BMC Public Health . 2015 ; 15 : 1097 . https://doi.org/10.1186/s12889-015-2429-3
https://doi.org/10.1186/s12889-015-2429-... , ²⁷27. Sethi S , Jonsson R , Skaff R , Tyler F . Community-based noncommunicable disease care for Syrian refugees in Lebanon . Glob Health Sci Pract . 2017 ; 5 ( 3 ): 495 - 506 . https://doi.org/10.9745/GHSP-D-17-00043
https://doi.org/10.9745/GHSP-D-17-00043... , ³²32. Segal SP , Khoury VC , Salah R , Ghannam J . Contributors to screening positive for mental illness in Lebano´s Shatila Palestinian Refugee Camp . J Nerv Ment Dis . 2018 ; 206 ( 1 ): 46 - 51 . https://doi.org/10.1097/NMD.0000000000000751
https://doi.org/10.1097/NMD.000000000000... , ³³33. Heenan RC , Volkman T , Stokes S , Tosif S , Graham H , Smith A , et al . ‘I think we’ve had a health screen’: new offshore screening, new refugee health guidelines, new Syrian and Iraqi cohorts: recommendations, reality, results and review . J Paediatr Child Health . 2019 ; 55 ( 1 ): 95 - 103 . https://doi.org/10.1111/jpc.14142
https://doi.org/10.1111/jpc.14142... , ³⁵35. Elliott JA , Das D , Cavailler P , Schneider F , Shah M , Ravaud A , et al . A cross-sectional assessment of diabetes self-management, education and support needs of Syrian refugee patients living with diabetes in Bekaa Valley Lebanon . Confl Health . 2018 ; 12 : 40 . https://doi.org/10.1186/s13031-018-0174-9
https://doi.org/10.1186/s13031-018-0174-... , ³⁷37. Torun P , Karaaslan MM , Sandikli B , Acar C , Shurtleff E , Dhrolia S , et al . Health and health care access for Syrian refugees living in Istanbul . Int J Public Health . 2018 ; 63 ( 5 ): 601 - 8 . https://doi.org/10.1007/s00038-018-1096-4
https://doi.org/10.1007/s00038-018-1096-... , ⁴³43. Alkasseh ASM , Zaki NM , Aljeesh YI , Soon LK . Risk factors of gestational diabetes mellitus in the refugee population in Gaza Strip: a case-control study . East Mediterr Health J . 2014 ; 19 Suppl 3 : S12 - 8 . , ⁴⁹49. Bastin P , Bastard M , Rossel L , Melgar P , Jones A , Antierens A . Description and predictive factors of individual outcomes in a refugee camp based mental health intervention (Beirut, Lebanon) . PLoS One . 2013 ; 8 ( 1 ): e54107 . https://doi.org/10.1371/journal.pone.0054107
https://doi.org/10.1371/journal.pone.005... . Indeed, social disconnection and comorbidities are prevalent, and lack of engagement in the community was associated with unfavorable health outcomes, especially in relation to mental health. Difficult social integration persisted for three or more decades after arrival in the US, constituting a health risk factor ⁶⁶66. Berthold SM , Loomis AM , Kuoch T , Scully M , Hin-McCormick MM , Casavant B , et al . Social disconnection as a risk factor for health among Cambodian refugees and their offspring in the United States . J Immigr Minor Health . 2019 ; 21 ( 2 ): 290 - 8 . https://doi.org/10.1007/s10903-018-0760-3
https://doi.org/10.1007/s10903-018-0760-... . Other findings point to the social exclusion of refugees as a consequence of structural inequalities, including marginalizing policies, and lack of social security. The lack of basic services in the host countries leads to disputes between local population and refugees, besides the progressive degradation of living conditions ⁶⁷67. Jirmanus LZ , Ziadee M , Usta J . Confronting structural inequities: the limits of participation when developing a community health intervention with Syrian refugees and host communities in Lebanon . Soc Sci Med . 2021 ; 272 : 113699 . https://doi.org/10.1016/j.socscimed.2021.113699
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Regarding the recommendations for policies and practices in PHC, there is a need for screening cases and strengthening programs and policies, especially in the field of mental health, with Syrian and Palestinian refugees ³⁶36. Javanbakht A , Amirsadri A , Suhaiban HA , Alsaud MI , Alobaidi Z , Rawi Z , et al . Prevalence of possible mental disorders in Syrian refugees resettling in the United States screened at primary care . J Immigr Minor Health . 2019 ; 21 ( 3 ): 664 - 7 . https://doi.org/10.1007/s10903-018-0797-3
https://doi.org/10.1007/s10903-018-0797-... . Evidence suggests the indication of diabetes screening for newly arrived refugees older than 35 years ⁵⁴54. Goosen S , Middelkoop B , Stronks K , Agyemang C , Kunst AE . High diabetes risk among asylum seekers in The Netherlands . Diabet Med . 2014 ; 31 ( 12 ): 1532 - 41 . https://doi.org/10.1111/dme.12510
https://doi.org/10.1111/dme.12510... . Healthcare providers should be aware of the high risk for diabetes among Syrian, Palestinian, and Iraqi refugees ⁵⁴54. Goosen S , Middelkoop B , Stronks K , Agyemang C , Kunst AE . High diabetes risk among asylum seekers in The Netherlands . Diabet Med . 2014 ; 31 ( 12 ): 1532 - 41 . https://doi.org/10.1111/dme.12510
https://doi.org/10.1111/dme.12510... . Moreover, there is a need to strengthen women’s health programs, aiming at early identification of gestational diabetes, including in the postpartum period, especially among Palestinian refugees ⁴³43. Alkasseh ASM , Zaki NM , Aljeesh YI , Soon LK . Risk factors of gestational diabetes mellitus in the refugee population in Gaza Strip: a case-control study . East Mediterr Health J . 2014 ; 19 Suppl 3 : S12 - 8 . . In order to improve adherence and success in the treatment of tuberculosis among refugees, there is a need for a specific program for the group mainly addressing beliefs about the disease and the treatment of latent tuberculosis ³⁰30. Dogru S , Doner P . Frequency and outcomes of new patients with pulmonary tuberculosis in Hatay province after Syrian civil war . Indian J Tuberc . 2017 ; 64 ( 2 ): 83 - 8 . https://doi.org/10.1016/j.ijtb.2016.11.034
https://doi.org/10.1016/j.ijtb.2016.11.0... .

One of the limitations of this research is the restriction to studies with subjects who forcibly migrated; therefore, the vulnerabilities mapped are not generalizable to the bloc of non-forced migrations. The vulnerability elements found do not encompass the context of the 22 Arab countries in the world, being restricted to Syrians, Palestinians, and Iraqis. It is also important to point out the heterogeneity of the methods used, which made the process of data extraction difficult, even when the study dealt with refugees from more than one country of Arab origin, because some did not separate outcomes by nationality, which made the extraction and synthesis of this review difficult.

CONCLUSION

The Asian continent, the Middle East, followed by North America and the European Union produced the most studies with Arab refugees in the context of PHC. There is an evident gap in the production of knowledge about this subject in the Latin American continent, and none of the studies used the concept of vulnerability, as adopted in this scoping review.

Arab refugees experience contexts of high vulnerability, placing them in profound inequality and disadvantage before the health programs, services and system of the host country. Therefore, there is a need for programs and policies that consider the elements of vulnerability and promote actions in PHC in order to respond to the health needs of refugees. It should be considered that the clash of forces between countries, mainly due to economic interests, causes destructive repercussions to populations, imposing its urgent overcoming and intransigence, besides the repudiation of actions that show social injustice. We defend the need for policies of inclusion, social justice and dignified living conditions for all people in situations of refuge, rejecting all kinds of stigmatizing attitudes and practices that show dehumanization.

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