Our study gives a unique overview of the health status and use of medication among Syrian refugees in two different migration phases: in a transit setting and in a recipient country. The prevalence proportion of NCDs in our sample is low. Yet a disproportionate number of those reporting NCDs does not seem to be under adequate treatment. The levels of psychological distress displayed in this study are similar to those reported among Syrian refugees elsewhere [27] while we lack comparators to the number reporting chronic pain. Further, our study confirms that migration related risk factors like exposure to traumatic events and migrating alone are associated with higher prevalence of mental health problems. As far as we know, a novel finding is the association between trauma exposure and chronic pain in an unselected population of refugees.
To our knowledge no other studies report lifetime prevalence of ill health among asylum seekers and refugees, nor among the general Syrian population. Studies of point prevalence among asylum seekers and refugees commonly report headache, injuries, and musculoskeletal, dermatological, dental, respiratory, gastrointestinal, and mental health problems to be frequent problems [13, 28,29,30,31]. Most of these studies evaluate clinic-based populations and rely on retrospective assessments of clinical records, making it impossible to extrapolate prevalence proportion to the population level. However, complaints of pain, particularly headache and musculoskeletal pain, seem to be a commonality.
In our material, approximately one third reported chronic pain lasting for more than 6 months. Further, almost one in three of our respondents reported chronic impairments lasting more than 1 year and impeding daily life. Comparing our data with the literature is challenging, as studies reporting chronic pain among refugees generally are restricted to selected groups such as torture survivors [32, 33]. Nevertheless, the high prevalence we find at the population level suggests that chronic pain and related impairment among forcibly displaced may be a barrier to integration that should be systematically addressed.
The prevalence proportions of NCDs in our sample are low compared to other studies among refugees from Syria. A study from Jordan found that 30% of the Syrian refugees surveyed had chronic disease [27], although the term “chronic disease” was not explicitly defined in the article. Another study reported that 22% of non-camp Syrian refugees in Jordan suffered from at least one NCD [13]. Concerning communicable disease, the incidence rate of tuberculosis in Syria has been estimated to 19 per 100,000 population [34]. In line with the relatively modest incidence rates in our respondent’s country of origin, there was only one case of reported tuberculosis in our sample. This finding supports the view that infectious diseases are not a major health problem among refugees from Syria. Indeed, a narrow focus on communicable diseases in health assessments of newly arrived refugees from this region may divert attention from more important health challenges.
The reported levels of psychological distress indicating anxiety and/or depression in this study correspond to levels reported among refugees in various sites (ranging from 32 to 44%) [35, 36], while the figure for PTSD symptoms is in the lower end of the range compared to prevalence proportions reported in systematic reviews and meta-analyses (ranging from 9 to 36%) [8, 37]. In a review looking particularly at Syrians in neighbouring countries, levels of PTSD ranged from 16 to 83% [38]. We do not have any full explanation for this comparatively low prevalence of PTSD but many of our respondents escaped the atrocities of the Syrian war at an early stage. Some papers report higher rates of depression and anxiety among asylum seekers compared to refugees, highlighting the impact of legal status, though in our material we only found evidence for such association between PTSD and lack of residence permit in the adjusted regression model. The relatively low level of PTSD symptoms in our sample contradicts the substantial share of our respondents exposed to potential traumatic events. However, factors acting protective to enhance resilience among refugees is not well understood. Further research is needed to identify interventions both outside and within the health care system that promote resilience, health and well-being among refugees exposed to traumatic events.
Regular use of medication may be challenging in the context of displacement. Previous studies from Jordan have shown that approximately a quarter of Syrian refugees in need of medication are lacking access to drugs [27] and interruptions in regular medication are predominantly due to restricted financial resources [13]. In our study, the access gap seems to be even broader. Health care providers involved in health assessments of refugees in transit and recipient settings should seek to identify discontinuity in use of regular medication and provide access to necessary drugs.
Migrating alone is a risk factor for adverse mental health outcomes in our study. Family separation has previously been shown to increase migration related stress [39]. Additionally, our study finds that exposure to potentially traumatic events is a risk factor not only for anxiety/depression and PTSD symptoms but also for chronic pain. The relationship between traumatic experiences and mental health problems is well established [40], and physical complaints are common among PTSD patients [41]. However, the association between trauma exposure and chronic pain in unselected refugee populations is poorly examined and should be further studied. We recommend that public health policies and practises address migration related risk factors among forcibly displaced individuals.
Strengths and limitations
Our study gives a unique approximation to a population-based overview of the health status and use of medication among Syrian refugees in two different migration phases.
Our sampling protocol reflects the inherent challenges in studying moving populations. Although we consider the study a close proxy to population-based study, as opposed to studies recruiting patients from health clinics, we lack a complete sampling frame, as there is no central register of Syrian refugees on the move. The connection to educational activities for refugees may have affected the representativeness of our study population. Nevertheless, the educational activities were compulsory for the refugees at the time of recruitment. The high response rate increases the representativeness of the sample.
The demographic patterns at the two recruitment sites were, as expected, clearly divergent; the sample from Lebanon corresponds well with the Norwegian authorities’ official resettlement policy that gives explicit priority to families [42]. In parallel, the sample from Norway includes many who arrived as asylum seekers among which men are known to be overrepresented. We have therefore reported prevalence proportions standardised to the demographic patterns of the overall population of Syrians in Norway and we adjust for age, gender and country in our regression analyses. There are well-known gender differences in the prevalence of many of the conditions we explore, and we have demonstrated variance in the prevalence of musculoskeletal complaints and use of painkillers. For other conditions and drugs, we have only displayed results stratified by gender in the supplementary material as we find few gender differences. The sample size might be insufficient to detect minor differences in the prevalence proportions between women and men.
Importantly, this study presents findings of self-assessed health. To increase rigor, we employed predominantly validated survey items and validated translation and adaption principles.
