As per the United Nations High Commissioner for Refugees (UNHCR), the term refugee refers to “persons who are outside their country and cannot return owing to a well-founded fear of persecution because of their race, religion, nationality, political opinion, or membership of a particular group.”Reference Otoukesh, Mojtahedzadeh and Figlin1 Throughout history, people have been forced to leave their homes because of various reasons.Reference Eckstein2 Recently, the number of refugees worldwide has topped 22 million.Reference Adam3 After the Soviet Union invasion of Afghanistan in 1979, Afghan refugees started fleeing, and Iran was the best choice for that largest refugee population in the world.Reference Ashrafi and Moghissi4 It has been more than 3 decades that Iran has been a suitable host for Afghan refugees.Reference Otoukesh, Mojtahedzadeh and Cooper5 In the worst period of the Afghanistan war crisis from 1991–1992, more than 3 million Afghans immigrated to Iran.Reference Zarghani, Gholami and Ghanbari6
Ensuring effective primary health care (PHC) for refugees is an increasing concern globally. Refugees have many complex health care needs, which should be addressed by the PHC services, both on their arrival in resettlement countries and in their transition to long-term care.Reference Joshi, Russell and Cheng7 Empowering refugees for timely and high-quality health care in PHC centers is essential for their successful adaptation in the new country.Reference Harris and Telfer8 Access to PHC is one of the important aspects of refugee health, and many immigrants throughout the world lack access to PHC.Reference Rakhshani, Moghadam and Hor9
Afghan refugees in Iran have many problems. Some of the problems specific to Afghan refugee women are marriage and first pregnancy at a very young age, a high number of births, and illiteracy.Reference Rakhshani, Moghadam and Hor9 According to the 2015 UNHCR, there are 982 027 registered refugees in Iran, and half of them are children.10 A large number of refugee visits to PHC centers include receiving services such as child care and prophylaxis and prenatal care, to ensure the health of the mother and the fetus.
There are many studies with a focus on PHC quality for refugees.Reference Pottie, Batista and Mayhew11 Unfortunately, in Iran, there is no information about the PHC status of Afghan refugees. Therefore, the aim of this study was to examine the lived experience of Afghan refugees concerning PHC delivery in Iran.
METHODS
The study was performed in 2016 on an interview-based qualitative study using content analysis.Reference Malterud12, Reference Elo and Kyngäs13 Content analysis was used as a research method for the subjective interpretation of the content of interview data through a systematic classification process of coding and identifying concepts or patterns. This study was conducted to understand the experiences of Afghan refugees in PHC centers. Therefore, a qualitative study design incorporating content analysis was selected; this design is a suitable method when new areas are to be investigated in an explorative manner or if an area needs to be explored from a new perspective.Reference Graneheim and Lundman14
We conducted 18 interviews with Afghan refugees who were more than 15 years old and living in Iran, possessed an ability to speak Persian, and had received PHC center services at least 1 time.
Context of the Study
Iran, officially the Islamic Republic of Iran, is located in Southwest Asia.Reference Iranmanesh, Banazadeh and Forozy15 The Ministry of Health and Medical Education in Iran is responsible for both population health and training health workforces. There are more than 42 medical universities distributed in 31 provinces of Iran. The chancellor of each medical university is in charge of health care provisions, as well as medical education in the related province.Reference Mehrdad16 In Iran’s PHC system, different referral levels have been defined; in rural areas, there is a health house for at least 1500 people. The health house is staffed by a multi-potential community health worker named Behvarz.Reference Barzegar and Djazayery17 The health houses are supervised by rural health centers. Each rural health center employs 1 or more general practitioners, several health technicians, midwives, and administrative personnel. Selected rural health centers also have delivery facilities attached to them. The first line of health care provision in urban areas is health posts that are similar to health houses but cover a much larger population. The health post is under the supervision of an urban health center, which is similar to a rural health center. The urban and rural health centers, in turn, are supervised by a district health network. In terms of patient care, the health centers refer to district general hospitals. The district general hospital, in turn, refers to the provincial university teaching hospitals as the highest level of referral system.Reference Couper18 All of the Iranian population have medical insurance. Afghan refugees who are registered and living in Iran legally can pay to obtain medical insurance. Unfortunately, there is no information regarding registered or non-registered refugees in Iran; however, illegal refugees do not have medical insurance. In the last 3 decades, the Iranian fertility rate was 6.515, and it was reduced during recent years to 1.912.Reference Hami and Taghavi Jelodar19 However, this fertility rate decreased from 6.6 to 3.9 in the Afghan population.Reference Carvalho, Goldie and Salehi20
This study was conducted in Saveh, one of the cities in the Arak province. According to the last census in 2011, Arak province with a population of 1 413 959 persons is northwest of Iran.Reference Center21 Arak University of Medical Sciences has 17 PHC centers, to which Afghan refugees are referred. Saveh is 1 of 2 authorized cities with Afghan refugees, but there is no information about their exact numbers.Reference Sohrabi and Albalushi22
Recruitment
In qualitative studies, research is designed on key informants based on their experience; in this study, participants were selected according to inclusion criteria sampling.Reference Motamedi, Saghafinia, Bafarani and Panahi23 The participants were included until data saturation and sample size were given by data saturation. Each interview lasted between 50 and 90 minutes. The interviews were conducted in Persian by the same interviewer. Some participants were unable to speak Persian very well, and so 1 of the Afghan refugees who spoke Persian well assisted on the research team. The interviews were transcribed verbatim, and content analysis was performed on the data written in Persian, before translation.
Data Collection
The interview guide included a list of general questions used as a tool for initiating the interviews. Probing questions were added when needed, and data collection and content analysis identified ideas, in accordance with the methodology. In-depth, semi-structured interviews were used for data collection.Reference Polit and Beck24, Reference Streubert Speziale and Carpenter25 Each interview was individually organized but usually began with an open question, for example, “Could you explain your experiences with PHC services in Iran? Complementary probing questions were added when needed. Interviews were guided by the main researcher, but all members of the research team checked and evaluated for interview trend and subjects that needed to be probed.
Trustworthiness
In this study, credibility was done by presenting the preliminary findings at a seminar to a group of faculty with expertise in research methodology. Moreover, coding and categorizing were done by researchers independently, and in cases of disagreement, discussions and clarifications continued until an agreement was achieved. In addition, the descriptions of themes were returned to some participants for member checking. A purposive sampling technique that included participants with maximum variation demographic characteristics was used to enhance the transferability of findings. More than 1 researcher were engaged in data analysis to strengthen dependability.
Ethical Consideration
Iran University of Medical Sciences (IUMS) approved this project. The Ethics Committee of IUMS confirmed all processes and procedures used in the study (Ethical code: IR.IUMS.REC.1394.9211567208). After approval, some oral information was given to the participants, including the goals and objectives of the study, the confidentiality and anonymity of the data, and that they were free to withdraw from the study at any time. The first researcher then invited each participant, and verbal consent was given individually.
RESULTS
A total of 18 interviews were held between 2016 and 2017. Our participants generally lived in crowded families or had many children themselves. On the other hand, some participants lived with their father after marriage. For example, 5 of our participants did not have any children, but they were living in a large family with a lot of nephews. The demographic characteristics of the participants are shown in Table 1.
TABLE 1 Participant Demographic
From approximately 500 first codes and after completing a content analysis process, 4 main themes and 12 subthemes were identified: (1) challenges before PHC delivery: large number of children, high service cost, not having medical insurance, problems going back to the clinic, appointment to get services, simultaneity of breastfeeding during pregnancy; (2) challenges during PHC delivery: understanding Iranian words, health care provider behaviors, delay in getting service in PHC centers, pregnancy problems; (3) challenges after PHC delivery: referral patient, high costs of paraclinics; and (4) free and good services. We obtained these themes on the basis of the content of the materials collected from the interviews and by collating similar content. Each theme is introduced, described, and supported by findings from the content analysis of the transcribed interviews.
Challenges Before PHC Delivery
This category had 6 subgroups: large number of children, high service cost, not having medical insurance, problems going back to the clinic, appointment to get services, and simultaneity of breastfeeding during pregnancy. Afghan refugees living in Iran had a lot of challenges and problems during the period prior to PHC delivery. Many of these challenges are related to themselves. Challenges like number of children and problems going back to the clinic are related to themselves, and some of them – high service cost, not having medical insurance, and appointment to get services – are related to the Iran government and UNHCR. In the following sections, all themes and subthemes will be described in detail and supported with participants’ quotations.
Large Number of Children
Afghan refugees living in Iran have many children. This issue is one of the challenges to receiving services, since they have to arrange childcare before being able to receive care for themselves or one of their children. On the other hand, they live in family groups, and one of the positive aspects of these families is caring for each other’s children.
One pregnant refugee woman stated:
When I want to go to the PHC center for giving services for my pregnancy, I have to send my other children to my mother. It was so difficult for my mother because she had many children herself. (P1)
Another participant living in a crowded family with a lot of children stated:
We do not have brothers, we are 3 sisters, living together. My sister’s husband go to another city for his job, and my sister is alone with his children. My parents often care for my sister, and several times I’m here with her. We help each other caring for our children. (P2)
High Service Cost
Living in another country as refugees has high costs. According to a participant’s statement, paying some costs in a foreign country, for example, the right to reside and school tuition, are very difficult. Living in Iran with these high costs is a reason for less attention to PHC.
One mother with 3 school children stated:
We have 2 daughters and a son in school age. We have to pay a lot of money for them. Especially in winter when there is no permanent work for my husband, paying this money is so difficult for us. When we have financial problems we cannot focus on the health and our disease. (P4)
Not Having Medical Insurance
In spite of free PHC services, sometimes for specific services such as sonography, radiology, and expert visit the patient is referred to a higher level. In this level, the medical insurance is very essential, especially for Afghan refugees who have financial problems. At the second level, the cost of services is high and having medical insurance is very important. Not having medical insurance is a factor for Afghan refugees who do not even receive PHC.
One participant without medical insurance stated:
We do not have insurance because of its cost. For having insurance every month we have to pay a lot of money. Iran, too, is not ready, the government also does not give up our money. On the other hand, we are not persistent for a long time in Iran, So it’s better to live without being insured. (P9)
Another participant without medical insurance stated:
I’m a patient and we don’t have any medical insurance. When my husband tried for insurance, they said to him that we have to pay cost of insurance for all of family population. So it was very costly for us, we couldn’t pay this money. (P4)
Problems Going Back to the Clinic
Living on the outskirts of the city without any vehicles made receiving PHC services so difficult. The financial problems, inability to pay for a car rental, and the long distance between home and PHC centers are major problems for refugees’ access to PHC.
One poor participant stated:
My child was 3 months old. I went to Chamran Health Center by walking. It took 20 minutes to get to the center. It was so difficult for me. (P11)
Another woman stated:
We don’t have any car or motorcycle and the PHC center is so far from our home. We have to rent a car, but we don’t have any money, therefore I sit in my home and do not go to the clinic. (P9)
Appointment to Get Services
Based on financial problems and the high number of children, obtaining an appointment for a specific facility is very difficult for Afghan refugees.
One refugee, illiterate with 6 children, stated:
We have no money to be able to treat our babies or ourselves. We cannot go to ultrasound and specialist physicians. (P7)
Simultaneity of Breastfeeding During Pregnancy
Lack of information for Afghan refugees and their cultural behaviors is a factor in having many children. During the period of breastfeeding their child, they get pregnant again. It is a regular event with Afghan refugees.
One participant stated about her sister:
My sister had a 1 year child, she said that have vomiting with pregnancy signs. The PHC center send her for laboratory to check pregnancy. After a long time she understood that she was pregnant. (P2)
Challenges During PHC Delivery
This category had 3 subgroups: understanding Iranian words, health care provider behaviors, and delay in getting service in PHC centers. At the time of presence in the PHC center, the Afghan refugees state some experiences that are important. Some of their problems were lack of language comprehension, some of Iranian staff’s bad behaviors, spending a lot of time waiting for PHC services, and pregnancy problems. We will look into these subthemes in more detail in the following sections.
Understanding Iranian
Speaking in Persian and understanding the Iranian language are a challenge for Afghan refugees. Some of the refugees who have recently been refugees in Iran have a lot of difficulty understanding the Persian language.
One patient who presented a solution for this problem stated:
It is much better if they use Afghan staffs; these staffs can understand their local language better. Now many Iranian staff do not understand the Afghan language. My sister now lives where there are Afghan employees, and she has no problems. (P2)
One participant who can speak Persian very well stated:
Now I can speak the Iranian language very well. Some of my compatriots have a lot of problems. Sometimes I translate their statements to Iranian staffs. Many of my compatriot don’t have any translator or guidance and it can lead to misunderstanding. (P3)
Health Care Provider Behaviors
Because of cultural and linguistic differences, sometimes Iranian personnel demonstrate negative, conflicting behaviors toward Afghan refugees. Not understanding the Persian language causes misgivings and misunderstandings between the Iranian staff and refugees.
One participant with weak Persian language skills stated:
I was in PHC center for 15 minutes and the staffs were searching for my medical record. After some minutes I said, I am Afghan refugee. I did not know that they separated our medical records. At this time, she was angry and wrote on my record: Afghan refugee. (P5)
Delay in Getting Service in PHC Centers
Because of a high Afghan refugee population in Iran and lack of PHC centers creating crowded centers, there is a delay in receiving health care services, and only some Iranian PHC centers will offer delayed services.
One participant stated:
I was in a queue for physician visit; my child was very ill but I had to wait for other patients. After a long time, during which my child was getting worse, the physician visited him. (P9)
Challenges After PHC Delivery
This category had 2 subgroups: referral patient and high costs of paraclinics. Some Afghan refugees, after visiting a PHC center and being diagnosed with a disease requiring a follow-up, financial problems and lack of medical insurance prevented them from getting a follow-up for their condition. Refugees have to pay a large amount of money for referral centers and paraclinics.
Referral Patient
According to most of our participants’ experiences, their follow-up services were costly. Disease treatments impose heavy costs on the families, therefore many refugees do not seek treatment.
A participant with prenatal problems stated:
Because of my child’s high heart rate, I was referred to another clinic. However, at the first visit, I did not see any difference in behavior from the staff between myself and others. I moved to the health center. I would prefer to go to the center of Chamran, which is 5 minutes away from my home, but my case has been transferred to the center. Midwife checked my weight, and referred me to the gynecologist but I did not have any money. (P3)
High Costs of Paraclinics
Our participants described their situation and their financial problems. The primary reason for many Afghan refugees’ problems were financial related.
One patient stated:
The cost of pregnancy and childbirth is very high, several times I needed sonography. During this period, if a problem came up, we had to pay more. (P2)
Another participant with a physical pain stated:
For a long time I have a bad pain in my hand, but because of its cost I have not gone to any physician for treatment. (P4)
Free and Good Services
According to Iran’s Ministry of Health and Medical Education policy, PHC is completely free even for refugees. Based on researcher observations and participant statements, refugees received satisfaction from PHC free services.
One participant stated:
When my friends and my family understand that the PHC and laboratory tests are free they were very happy. (P8)
Another participant who went to an Iranian PHC center stated:
When I went to the PHC center everything was excellent. They check my pulse, control my blood pressure and give to me acid folic tablet. All of the services here are free and there isn’t any discrimination between Iranian or Afghani refugees. (P1)
DISCUSSION
The aim of this study was to explore the lived experience of Afghan refugees regarding PHC services in Iran. According to the participants’ experiences, PHC services in Iran has many problems. Some of their problems are related to themselves and some of them are related to the Iran PHC centers and their staffs.
According to our results, one Afghan refugee problem for PHC services in Iran is due to their number of children. Afghan refugees have many children.Reference Tober, Taghdisi and Jalali26 The fertility rate in the Afghan refugee population in Iran is 3.5%,Reference Rakhshani, Ansari Moghadam and Hor27 whereas the rate in the Afghan population is 3.9%.Reference Carvalho, Goldie and Salehi20 It seems that living in Iran, perhaps due to economic problems, is affecting the Afghan refugees’ fertility rate. Exposure to armed conflict has an effect on civilian populations, and prenatal stress has detrimental effects on fetal development.Reference Keasley, Blickwedel and Quenby28 The low health status of the Afghan refugee women and their children is associated with not only poor hygiene, but also limited knowledge and lack of access to health care services.Reference Poureslami, MacLean, Spiegel and Yassi29
According to our findings, most of the participants’ problems in this study were related to financial issues and poverty. Not having medical insurance was one of the problems of Afghan refugees in Iran. Mohammadi (2015) argued that Afghan migrants’ socioeconomic situation in Iran is extremely bad.Reference Mohammadi30 Divkolaye and Burkle concluded in a study that Afghan refugees had a higher prevalence of most diseases among the Iranian population.Reference Divkolaye and Burkle31 However, Poureslami et al. found that limited knowledge and lack of access to health care services are associated with low health status of the Afghan refugees.Reference Poureslami, MacLean, Spiegel and Yassi29 Our finding was inconsistent with that study. The difference in the results may be due to the population participating in the studies. In the United States, all refugees must pass an overseas medical screening examination, Reference Eckstein2 but for refugees in Iran there is no screening.
Simultaneity of breastfeeding during pregnancy was one of the problems of Afghan refugee women in Iran. This is a main reason that they did not receive PHC services.
Some Afghan refugees speak Dari and Pashto, Reference Poureslami, MacLean, Spiegel and Yassi29, Reference Krause32 and it can be difficult for them to speak and understand Persian so they cannot receive suitable PHC services. In Eckstein’s 2011 study, she mentioned language barrier as a factor for caring for refugees in the United States and that a federal law providing a translator is necessary.Reference Eckstein2 In the present study, we could not interview with many Afghan refugees due to the language barrier and no translator was provided.
Afghan refugees living in Iran stated that providing PHC services sometimes was very difficult and with a long delay. Lebrun–Harris et al. (2013) reported that homeless patients were unable to get PHC services or were delayed in getting care.Reference Lebrun-Harris, Baggett and Jenkins33 A long-term delay in access to PHC is related with mortality.Reference Prentice and Pizer34
CONCLUSION
Afghan refugees who are living in Iran reported new experiences. Some of our findings were unique and have not been mentioned in previous studies. On the other hand, this study was done qualitatively by using interviews for extracting the experiences of the participants. Some of the participants’ experiences were due to their personal problems and some of them were related to the Iran PHC system. According to our results, because of crowded centers that provide services to Afghan refugees, designing a turning system that can provide PHC services to them is necessary. A manager can provide the facility for Afghan refugees to receive these services – facilities such as a bus station, especially for Afghan refugees, and the use of trained Afghani nurses as personnel to serve the refugees. In this study, we recommend birth control programs, using a translator, early initial screening, and prevention of illegal entry as some of the solutions to the Afghan refugee problems. Further study is required to understand the issues of Afghan refugee men and women in Iran.
Acknowledgments
This manuscript has been derived from a PhD thesis, supported financially by Iran University of Medical Sciences through Grant No. IUMS/SHMIS-1394/37. We thank all of the Afghan refugees who participated in our study.
Financial Support
This project was supported by the research deputy of Iran University of Medical Sciences.
