The Global Refugee Status
Globally, the number of forcibly displaced individuals including refugees has reached the highest levels on record (1). Official figures from the United Nations High Commissioner for Refugees (UNHCR) indicate that 70.8 million individuals have been forcibly displaced (1). Among these are nearly 26 million refugees, half of whom are below the age of 18 (1). Notably, the highest number of refugees has been hosted by low- and middle-income countries (LMICs) (2), with inconsistent and varying numbers reported (3).
The majority of refugees are of Syrian nationality (4) who have fled to Syria’s neighboring countries-namely Lebanon, Jordan, Egypt, Turkey and Iraq since the eruption of the Syrian conflict in 2011 (5). As a result, a significant internal and external displacement of over 13 million Syrian refugees has been witnessed (6). Approximately, 6.6 million Syrian refugees were displaced within Syria itself (6) and 5.6 million escaped to Syria’s neighboring countries (7), which are currently heavily burdened, hosting nearly 95% of the total number of registered Syrian refugees worldwide (6). With such unprecedented figures, the Syrian crisis has been widely described as ‘one of the biggest and worst humanitarian crises of our time’ (8).
The Context of Lebanon
Lebanon, an LMIC with a population of over 4 million (9), has become, as reported in 2015 (10), the country with the highest concentration of refugees per capita worldwide (11). Recent data shows that around 1.5 million Syrian refugees reside in Lebanon (11), a number equivalent to 25% of Lebanon’s population size (12, 13). More than half of them are women and children who are in urgent need for healthcare services (14). Additionally, nearly 450,000 Palestinian refugees among which 50,000 are Palestinian refugees from Syria (PRS) (15), and around 18,000 Iraqi and Sudanese refugees among others reside in Lebanon (11).
Many Syrian refugees have been settled in the poorest and most underserved areas in Lebanon, leading to an increased socio-economic vulnerability of both refugees and host communities (16). The dense distribution of refugees in such areas with suboptimal capacities created social tensions and competition for access to basic healthcare services (17, 18). This, in turn, overburdened the Lebanese healthcare system, which already suffers from significant fragmentation prior to the influx of Syrian refugees. As a result, the already limited capacities characterized by insufficient staff, medications and equipment, made it even more challenging to deal with the additional load (9). An estimated 50% increase in healthcare services utilization was reported as a result of the influx of Syrian refugees to Lebanon (19). Of specific note, a two-fold increase in services occurred at the primary healthcare level related to vaccination, management of communicable diseases, and non-communicable diseases (NCDs), including hypertension, cardiovascular diseases (CVDs), diabetes, chronic respiratory diseases and arthritis (19).
In response to the exponential increase in demand for healthcare services, joint efforts have been made among different healthcare stakeholders present in Lebanon to respond to the needs of refugee populations and to ensure the widest possible coverage of services (20). Yet, these efforts were inefficient (21) due to several impediments (22), with inability to pay out-of-pocket costs, and lack of knowledge about available healthcare services reported as the major barriers to access among refugees (23).
Disease Profile of Refugees
Refugees are at an increased risk of health problems due to the traumatic and stressful events they are exposed to pre-, during- and post- the migration journey, coupled with the compromised access to healthcare in host countries (24). Evidence suggests that communicable diseases, NCDs (25, 26), mental health disorders mainly depression and post-traumatic stress disorder (PTSD) (27), obstetrics and gynecologic (OBGYN) conditions, accidental injuries, malnutrition and anemia (28) emerge as the top prevalent health conditions among refugees. Women, children and older adults are particularly vulnerable to develop such serious health conditions (29).
Over the past decades, refugee populations underwent an epidemiologic transition from communicable diseases, maternal, neonatal, and nutritional conditions to NCDs (30–32). As such, a steady rise in NCDs burden has been marked in the refugee context and calls for specific attention (9, 33). Recent evidence indicates that healthcare systems face challenges in addressing and managing these diseases (33), mainly due to the high expenses and the limited resources available for refugee healthcare (30, 34).
Burden of Non-communicable Diseases (NCDs) Among Refugees
NCDs are the leading causes of morbidity and mortality worldwide (33, 35). Globally, over 70% of annual deaths are attributable to NCDs, mainly CVDs, diabetes, cancers, chronic respiratory diseases and cerebrovascular diseases (36, 37). The burden of NCDs is unevenly distributed between high-income countries (HICs) and LMICs, with around 85% of premature deaths occurring in LMICs (37). Notably, the effects of this heavy burden are more pronounced in fragile and conflict-affected countries in the Middle East and North Africa (MENA) region that are receiving large numbers of refugees fleeing conflict (33). High rates of NCDs have been reported among these countries with percentages of concomitant deaths reaching 89% in Lebanon (37).
There is a growing evidence that refugees are at high risk of developing NCDs (37). Although causes are not fully extrapolated, it is hypothesized that stress, acquired as a result of displacement, emerges as one of the contributing factors (38, 39). The poor living conditions accompanied by shortages in medication supplies (40), poor chronic diseases management, and improper lifestyle habits could be recognized as additional potential contributing factors to the occurrence and worsening of NCDs (41, 42).
Aspects of NCDs Among Syrian Refugees in Lebanon
The burden of NCDs is growing swiftly among Syrian refugees in Lebanon and the region (43). Previous studies found a high prevalence of reported hypertension, diabetes, CVDs and other NCDs amongst Syrian refugees in Lebanon (43, 44), and prevalence was most pronounced among adults above 40 (45). One study indicated that the prevalence rates reached 21% for hypertension, 11% for CVDs and 10% for diabetes (46). In Lebanon, prevalence of hypertension and diabetes has been estimated to be 28.8% (47–50) and 14.9% (51), respectively among the general population. The prevalence of hypertension in Syria was reported to be 24.9% (47–50), while diabetes and CVDs accounted for 8.8% (51) and 5.8%, respectively (52). Moreover, around 77% of total deaths in Syria were attributable to NCDs, with CVDs alone being responsible for 44% of total deaths (53). CVDs, as well, and type II diabetes are considered the leading causes of morbidity and mortality in Syria (45, 54), while cancer is responsible for 9% of total deaths in the country (55).
Although the prevalence of NCDs among the Syrian refugee population in Lebanon has reached alarming rates and regardless of the presence of healthcare actors to respond to the needs of the refugee population, very little is being done to control and manage these costly diseases which remain to be a heavy burden within this population (44).
Care-seeking and Associated Medication Use Among Syrian Refugees with NCDs in Lebanon
Given the large caseload of Syrian refugees with NCDs in Lebanon coupled with the high costs of providing NCD care, implications on the Lebanese healthcare system are substantial (56). In light of this, the Lebanese Ministry of Public Health (MoPH) and the UNHCR undertook measures in response to the Syrian crisis to provide primary healthcare services for Syrian refugees through the primary healthcare centers (PHCs) across the country’s governorates at subsidized costs (44, 45, 57). The UNHCR pays 75% or up to 100% of hospitalization costs for the most vulnerable refugees and for those who need life-saving (9). However, due to limited funding, the UNHCR has insufficient capacities to provide health coverage for chronic conditions such as renal failures, diabetes and certain cancers, except for life-threating cases (9, 58). In parallel to the Lebanese MoPH system, international non-governmental agencies have been providing free-of-charge primary care for Syrian refugees with NCDs, including diabetes and hypertension, in both North Lebanon and in the Bekaa valley since early 2012 (57, 59), and in South of Beirut since 2013 (44).
Based on some evidence, care-seeking for NCDs among Syrian Refugees in Lebanon was high (82.9%), distributed as: 88.2% for diabetes, 82.6% for CVDs and 80.9% for hypertension (45). Comparable findings were reported with regards to NCD-associated medication use (60, 61); however, interval discontinuation of medications was documented (19, 62). Nonetheless, despite the reportedly high rates of healthcare seeking, Syrian refugees in Lebanon declared that they faced complications in seeking healthcare to manage their NCDs (44). The primary obstacle that limited these populations from seeking NCDs healthcare in Lebanon was the costs of NCDs treatment. It was stated that 33–77% of Syrian refugees in Lebanon suspended NCDs treatment due to high costs (61). Coupled with other barriers that involved transportation costs, limited capacities of healthcare facilities, and suboptimal NCDs health education, where only 39% of Syrian refugees in Lebanon reported attending healthcare facilities or mobile clinics of local non-governmental organizations (NGOs) to receive NCDs health education (44).
The number of studies evaluating the prevalence of NCDs among Syrian refugees in Lebanon is on the rise; however, literature still lacks a country-wide study with a representative large sample size of Syrian refugees through which prevalence of NCDs can be widely studied.
With that being said, this study aims to determine the prevalence of NCDs among adult Syrian refugees in Lebanon, with a focus on hypertension, diabetes, CVDs and cancer. The study also aims to explore factors potentially related to the prevalence figures, and understand the medication use associated with these morbidities.