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Table 8 Characteristics of included publications by region: Eastern Mediterranean Region

From: Systematic review on chronic non-communicable disease in disaster settings



Territory of Interest

Target Population

Type of study

NCD studied

Years of observation

Number of study participants

Major findings

Abukhdeir (2013) [32]

Palestinian Territories-Gaza/ West Bank

Palestinian households in the West Bank and Gaza Strip

Cross-sectional nationally representative household survey

Diabetes, hypertension, cardiovascular disease (CVD) and cancer


4,456 households in the West Bank and 2118 in the Gaza Strip. The response rates for the 2 regions were 84.1% and 96.9% respectively

The authors emphasized that even though previous studies have combined Palestinians as one group, they live in different areas and are subject to different health systems which can result in different health outcomes. Being a refugee was a significant risk factor for diabetes and CVD while being married/engaged or divorced/ separated widowed was a risk factor for diabetes and hypertension. Non-refugees were 33% less likely to have diabetes and 46% less likely to have CVD than refugees

Abul (2001) [66]


Patients admitted to hospitals in Kuwait with asthma for six years (1987–1989 and 1992–1994)

Retrospective cross-sectional study



12,113 asthma patients during the pre-Gulf War period compared with 9,771 patients during the post-Gulf War period

During the war, a lot of oil wells were burned, giving suspicion to the potential for increase in asthma. No statistically significant difference in hospital admissions for to death rates attributable to asthma in the pre- and post-Gulf War periods in Kuwait. Notably, the war was 1990/1991, and no data is available for those years, so the immediate effect isn’t known

Ahmad (2015) [33]


Syrian national health system

Situational analysis using document analysis, key informant interviews, and direct clinic observation

Diabetes and cardiovascular disease (CVD

October 2009 -August 2010

53 semi-structured interviews

The rebuilding of a post-conflict heath care system in Syria may benefit from insights into the structural problems of the pre-crisis system. Weaknesses that existed before the crisis are compounded by the current conflict. The authors suggest an over reliance on secondary and tertiary care for DM patients with withdrawal of the Syrian government from the public health clinics, which led to escalating healthcare costs and fostered increasingly unequal access

Alabed (2014) [79]

Country of Asylum: Syria

Country of Origin: Palestinian Territories

Palestinian refugees living in Damascus attending three UNRWA health clinics

Cross sectional


August 2008—September 2008

154 DM patients

UNRWA clinic inspections highlighted shortages in drug stocks with 47.3% of patients reporting problems accessing prescribed medications and 67.7% reporting having to buy medications at their own expense at least once since their diagnosis. Patients’ knowledge of their condition was limited, Patients were generally unaware of the importance of good glucose control and disease management. Women were more likely to attend the clinic than men, with 71% of patients being female

Ali-Shtayeh (2012) [80]

Palestinian Territories-West Bank

Patients attending outpatient departments at Governmental Hospitals in 7 towns in the Palestinian territories (Jenin, Nablus, Tulkarm, Qalqilia, Tubas, Ramalla, and Hebron)

Cross-sectional survey


August 2010—May 2011

1,883 DM patients

The use of CAM differed significantly between residents of refugee camps versus residents of urban or rural areas (p = 0.034). Those who were on CAM reported they were using it to slow down the progression of the disease or relieve symptoms. All patients with DM who used CAM were also on conventional therapies

AlKasseh (2014)[81]

Palestinian Territories-Gaza

Patients at UNRWA clinics within Gaza

Retrospective case–control study

Gestational diabetes (GDM)

March 2011—June 2011

189 postnatal GDM women with 189 matched controls by age and place of residency

The present study showed that history of miscarriage more than once, being overweight before pregnancy, history of stillbirth, history of caesarean birth and positive family history of diabetes mellitus were strongly correlated with developing GDM. The WHO criteria for screening for GDM remains a good instrument to identify GDM in refugee populations in war-torn countries (like the Gaza Strip)

Amini (2010) [98]


Completely blind Iranian survivors of the Iran-Iraq War

Cross-sectional study

Multiple NCDs including hypertension, Hypercholesterolemia, and erectile dysfunction


250 Iran-Iraq war survivors

As blind war survivors’ age, they will present with a greater set of burdens despite their relatively better quality of life (QOL) in the physical component scale when compared with lower limb amputees. Risk factors of cardiovascular attack such as high blood pressure and hypercholesterolemia were present: High systolic and diastolic blood pressure, hearing loss, and tinnitus had negative individual correlations to (QOL) (p = 0.016, 0.016, 0.005, p < 0.0001). Hypercholesterolemia showed significant correlation to QOL (p = 0.021)

Bijani (2002) [105]


Iranians injured by chemical weapons during the Iraq–Iran war who are under services of the Mostazafan and Janbazan Foundations of Babol, Iran


Chronic respiratory diseases


220 patients

The clinical evaluations, radiography, and PFTs revealed that the most prevalent effects of chemical weapons on respiratory tract were chronic obstructive lung disease. Victims of suphorous gas had demonstrated involvement of airways during acute and chronic phases of injury, however over time clinical manifestations, radiography, and PFT gradually became normal. Most patients reported mustard gas exposure.. Chest X-Ray was not reliable to diagnose lung injury in these patients. Diagnosis was completed most accurately by PFTs

Ben Romdhane (2015) [85]


Tunisian national health system

Situational analysis

Cardiovascular disease and diabetes


12 key informants were interviewed and eight documents were reviewed

Weaknesses that existed before the 2011 Revolution(Arab Spring) were compounded during the revolution. This study was conducted prior to political conflict but written post-conflict. Growth of the private sector fostered unequal access by socioeconomic status and reduced coordination and preparedness of the health system

Chan (2009) [106]


Patients ≥ 45 years who attended two different types of post-earthquake relief clinics during a 17-day field health needs assessment in response to the 2005 Kashmir earthquake

Comparative descriptive study

Multiple NCDs

February 2006

4 months post-earthquake

30,000 patients in a rural site, and 382 IDPs in a urban site

The greatest gap in health services post-earthquake in both sites was non-communicable disease management. Clinical records reviewed in all study locations showed a systematic absence of documentation of common NCDs. In rural areas, older women were less likely to receive medical services while older men were less likely to access psychological services in both sites. During days when solely male doctors provided clinical services in the rural site, medical services utilization decreased by 30%

Chan (2010) [99]


Face-to-face, household-based survey conducted 4 months after the 2005

Kashmir, Pakistan earthquake in internally displaced camps near Muzafarabad city

Cross sectional

Multiple NCDs

February 2006

4 months post-earthquake

167 households

Although the proportion of the population with chronic conditions was similar across these studied camps, 85% of residents in the smallest unofficial camp had no available drugs to manage their chronic medical conditions as compared with their counterparts residing in larger rural unofficial (40%) and official camps (25%)

Doocy (2013) [107]

Country of Asylum: Jordan/ Syria

Country of Origin: Iraq

Iraqi populations displaced in Jordan and Syria


Disability and multiple NCDs including hypertension, arthritis, diabetes, chronic respiratory diseases, and cardiovascular disease

October 2008-March 2009

1200 and 813 Iraqi households in Jordan and Syria, respectively

Chronic disease prevalence among adults was 51.5% in Syria and 41.0% in Jordan, with hypertension and musculoskeletal problems most common. Overall disability rates were 7.1% in Syria and 3.4% in Jordan, with the majority of disability attributed to conflict and depression the leading cause of mental health disability

Doocy (2015) [108]

Country of Asylum: Jordan

Country of Origin: Syria

Syrian refugees in non-camp settings in Jordan

Cross-sectional survey

Multiple NCDs including hypertension, arthritis, diabetes, chronic respiratory diseases, and cardiovascular disease


1,550 refugees

More than half of Syrian refugee households in Jordan reported a member with an NCD. Among adults, hypertension prevalence was the highest (9.7%, CI: 8.8–10.6). While care-seeking was high (85%) among those reporting a NCD, among those who did not seek care, cost was the primary reason

Ebrahimi (2014) [68]


Patients with cardiovascular and respiratory diseases who received medical services from the Center for Disaster and Emergency Medicine in Sanandaj, Iran during dust event days

Ecological study

Cardiovascular and respiratory diseases

March 2009—June 2010

The authors demonstrated a statistically significant increase in emergency admissions for cardiovascular diseases during dust storm episodes in Sanandaj, Iran(r 0.48, p < 0.05). The correlation between respiratory diseases and dust storm events were statistically insignificant (0.19)

Eljedi (2006) [88]

Palestinian Territories-Gaza

Diabetic patients who were recruited from three refugee camps in the Gaza strip with age- and sex-matched controls living in the same camps

Cross sectional


November 2003—December 2004

197 patients

Using the World Health Organization Quality of Life questionnaire (WHOQOL-BREF) four domains were strongly reduced in diabetic patients as compared to controls, with stronger effects in physical health (36.7 vs. 75.9 points of the 0–100 score) and psychological domains (34.8 vs. 70.0) and weaker effects in social relationships (52.4 vs. 71.4) and environment domains (23.4 vs. 36.2). The impact of diabetes on health-related quality of life was especially severe among females and older subjects

El-Sharif (2002) [69]

Palestinian Territories-West Bank

Schoolchildren aged 6–12 years attending 12 schools in the Ramallah District of the Palestinian West Bank



Autumn of 2000

3,382 children

Children from refugee camps were at a higher risk of asthma and asthma symptoms than children from neighboring villages or cities. Physician-diagnosed asthma was almost double in refugee camps than other places (15.6% versus 8.1% in villages and 7.3% in cities, pv0.001)

Forouzan (2014) [70]


Patients presenting with asthma or bronchospasm in western Iran

Prospective observational


November 2013

2,000 patients

Many patients presented with bronchospasm after a thunderstorm

Kallab (2015) [44]

Country of Asylum: Lebanon

Country of Origin: Syria

Syrian refugees and vulnerable Lebanese being treated in 8 health facilities run by Amel Association International

Program implementation reflection

Diabetes and hypertension

November 2014- May 2015

1,825 patients

Of the 1,825 patients enrolled in the program hypertension and diabetes accounted for 46% and 27% of cases respectively, with the remaining 27% of patients presenting with both diseases. The program addressed two main problems in Lebanon: lack of access to NCD services and lack of proper management of NCDs. Major challenges included insecurity in the country, patient transportation cost, and high workload for providers

Karrouri (2014) [91]

Country of Asylum: Tunisia

Country of Origin: Libya

Case of a 10-year-old Libyan boy

Case report


1 patient

Report of a 10 year old without personal or familial diabetes mellitus history who developed type 1 diabetes appeared immediately following severe psychological trauma

Khader (2012) [109]

Country of Asylum: Jordan

Country of Origin:

Palestinian Territories

Persons with DM at Nuzha PHC Clinic

Retrospective descriptive study of the cohort reporting framework to monitor burden of disease and management


October 2009- March 2012

2851 patients

A directly observed therapy (DOTS) cohort monitoring system can be successfully adapted and used to monitor and report on Palestinian refugees with DM in Jordan. A sizeable proportion of DM patients of the clinic failed to have postprandial blood glucose measurements, and BP measurements in those with comorbid HTN. The study demonstrated to the clinic that they were either not performing or not recording disease-specific procedures that should be done at the investigated visits—can now improve on these in the future and monitor thanks to e-Health system

Khader (2013) [110]

Country of Asylum: Jordan

Country of Origin: Palestinian Territories

Palestine refugees living in Jordan

Descriptive cohort study using routine data collected through e-Health


October 2009- June 2013

12,549 total patients

High burden of disease with predicted annual additional caseload is over 1,000 patients with DM. Many indicated risk factors: smoking, physically inactive, and obesity. Those who came had relatively good disease control. Points to the importance of using e-Health systems to monitor and evaluate and use for strategic planning. Complications, including myocardial infarction and end-stage renal disease were significantly more common in males. Females were more likely to be obese

Khader (2014) [111]

Country of Asylum: Jordan

Country of Origin: Palestinian Territories

Palestine refugees living in Jordan

Retrospective cohort study with program and outcome data collected and analyzed using E-Health


October 2009- June 2013

18,881 patients

Endorses the use of E‐Health and cohort analysis for monitoring and managing patients with HTN and DM. High case load from HTN and comorbid HTN and DM(40–50%) amongst Palestinian refugees being treated at UNRWA primary health care clinics in Jordan. Most common risk factors included smoking, physical inactivity, and obesity. 33% of males smoked, while more than 50% of the women were physically inactive. 75% of women were obese

Khader (2014) [104]

Country of Asylum: Jordan

Country of Origin: Palestinian Territories

Palestinian refugees living in Jordan with DM attending Nunzha Clinic

Retrospective cohort



119 DM patients

The E-health system was successful in monitoring annual outcomes, measures of disease control, and development of complications in a cohort of patients with DM. Three major findings were: a progressive loss of patients attending the clinic, mainly lost to follow-up; routine measurements were always performed, and there was a progressive increase in late-stage complications, predominately due to cardiovascular disease and stroke

Khader (2014) [45]

Country of Asylum: Jordan

Country of Origin: Palestinian Territories

Palestinian refugees living in Jordan with DM attending Nunzha Clinic

Retrospective cohort study



2,974 DM patients

E-Health systems are useful for monitoring patients, since over half of patients who fail to attend a scheduled quarterly appointment are declared lost to follow-up 1 year later. This suggests a need for monitoring and active follow-up

Khan (1997) [59]

Country of Asylum: Pakistan

Country of Origin: Afghanistan

Patients from North West Pakistan and Afghan refugees attending the Institute of Radiotherapy and Nuclear Medicine, Peshwar




13,359 patients

In male Afghan refugees, esophageal cancer represented 16.6% of the cases, compared to only 4.6% of the cases in Pakistani residents. Similar patterns in women (13.1% vs. 4.1%)

Khateri (2003) [100]


Individuals with confirmed exposure to mustard agent during the Iran–Iraq war of 1980–1988 and who were evaluated for exposure to mustard agent by medical authorities

Retrospective Cohort

Chronic pulmonary, ocular, and cutaneous lesions


34,000 cases

Among patients, there was a high degree of pulmonary disease: 42.5% of the exposed population exhibiting chronic lung lesions and associated symptoms. Ocular damage, which is observed to be present in 39.3% of mustard exposed Iranians, is another major consequence of exposure to these agents as a result of their ease of absorption through the unprotected eye

Lari (2014) [72]


Patients exposed to sulfur mustard gas

Cross sectional

Chronic obstructive pulmonary disease (COPD)

March 2010—April 2011

82 patients

The COPD Assessment Test (CAT) was found to be a valid tool for assessment of health-related quality of life in chemical warfare patients with COPD

Leeuw (2014) [101]

Country of Asylum: Jordan, Lebanon

Country of Origin: Syria

Syrian refugee households in Jordan and Lebanon

Cross sectional

Multiple NCDs


3,202 refugees

Impairments found in 22% of refugees and disproportionately affecting those over 60 years of age (70% with at least 1 impairment)

Mansour (2008) [93]


Patients struggling with diabetic control

Cross sectional


January 2007- December 2007

3,522 patients

Patient opinion for not achieving good glycemic control included the following: 50.8% cases reported no drug supply or drug shortage, while 50.2% reported high drugs and/or laboratory expenses. 30.7% percent of patients said that they were unaware of diabetic complications and 20.9% think that diabetes is an untreatable disease. 30% think that non-control of their diabetes is due to migration after the war. No electricity or erratic electricity, self-monitoring of blood glucose is not available, or strips were not available or could not be used, and illiteracy as a cause was seen in 15%, 10.8% and 9.9% respectively

Mateen (2012) [48]

Country of Asylum: Jordan

Country of Origin: Iraq

Iraqi refugees receiving UNHCR health assistance in Jordan

Cross sectional

Multiple NCDs including hypertension, visual disturbances, diabetes, and joint disorders

January 2010-December 2010

7,642 registered Iraqi refugees

Among adults 18 years or older, 22% had hypertension; 11% had type II diabetes mellitus; 4% had type I diabetes mellitus; 10% had visual disturbances; 10% had disorders of lipoprotein metabolism and other lipidemias; 9% had other joint disorders and 7% had chronic ischemic heart disease. Cancer care was required by 2% of refugees. For all refugees as a group, the largest number of visits were for essential hypertension (2067 visits); visual disturbances (1129); type II diabetes mellitus (1021); other joint disorders (969), and acute upper respiratory infections (952)

McKenzie (2015) [62]

Country of Asylum: Jordan

Country of Origin: Iraq, Syria

Iraqi/Syrian refugees residing in Jordan

Retrospective cohort

Neuro-psychiatric disorders


223 refugees

Among neuropsychiatric applications, stroke was the most common diagnosis, accounting for 16%. Brain tumors accounted for 13% of neuropsychiatric applications and was the most expensive diagnosis overall and per applicant. The ECC denied six applications for reasons of eligibility, cost, and/or prognosis. Of the 20 approved applications, 15% (n = 3) were approved for less than the requested amount, receiving on average 39% of requested funds

Mirsadraee (2011) [73]


Patients whose parents were exposed to chemical warfare

Case control


409 children

The prevalence of asthma was not significantly different in the offspring of chemical warfare victims

Mousa (2010) [50]

Country of Asylum: Jordan, Lebanon, Syria, West Bank/Gaza

Country of Origin: Palestinian Territories

Refugees registered by the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA)

Case series

Diabetes and hypertension

June 2007

7,762 refugees

A total of 9% of those screened were diagnosed with hypertension or diabetes. Being older than 40 years, obese or with a positive family history of diabetes or cardiovascular disease increased the risk of presenting with hypertension and/or hyperglycemia 3.5, 1.6 and 1.2 times respectively. Risk factors were very common (obesity and smoking)

Otoukesh (2012) [51]

Country of Asylum: Iran

Country of Origin: Afghanistan

Afghan refugees in Iran

Retrospective cross sectional

Multiple NCDs including ophthalmic diseases, neoplasm, nephropathies, ischemic heart disease, and perinatal disorders

2005 -2010

23,152 refugees

The Afghan refugees who received referrals for care represented a higher number of women, age 15- 59 years old, for ophthalmic diseases, neoplasms, and nephropathies

Shamseddine (2004) [64]


Lebanese population following the 1975 -1990 Lebanese Civil War

Nationwide, Population-Based Prevalence Study



4,388 cases

Among males, the most frequently reported cancer was bladder (18.5%), followed by prostate (14.2%), and lung cancer (14.1%) Among females, breast cancer alone constituted around one third of the total cancer caseload in the country, followed by colon cancer (5.8%), and cancer of the corpus uteri (4.8%). One limitation of the study is that the last and only census undertaken in Lebanon was in 1932, and the population estimates and projections may have been subject to minor inaccuracies

Sibai (2001) [52]


Lebanese aged 50 years and over residing in Beirut, Lebanon in 1983

Retrospective cohort study

Multiple NCDs including cancer, cardiovascular disease, cancer, and nephropathies


1,567 cases

The most important causes were non-communicable diseases, mainly circulatory disease (60%); and cancer (15%). Among circulatory diseases, ischemic heart disease accounted for the majority of the mortality burden (68%) followed by cerebrovascular diseases (21%). In countries that lack reliable sources of mortality data, the utility of verbal autopsy can be viably extended to cohort studies for assessing causes of death

Sibai (2007) [112]


Lebanese aged 50 years and over residing in Beirut, Lebanon

Retrospective cohort study

Cardiovascular disease


1,567 cases

Most important causes of death were CVD and Cancer. High adjusted risk of CVD mortality associated with being single (never-married) versus married among men and women

Sofeh (2004) [113]

Country of Asylum: Peshawar, Pakistan

Country of Origin: Afghanistan

Afghan refugees attending Red Cross dispensaries and hospitals in Peshawar Pakistan


Multiple NCDs including diabetes mellitus

456 patients

Out of 456 patients examined during the study, 255 patients suffered from DM, 80 with hepatitis, 69 with nephritis, and 52 with hyperlipidemia

Strong (2015) [53]

Country of Asylum: Lebanon

Country of Origin: Syria

Syrian refugees over age 60 residing in Lebanon and registered with either Caritas Lebanon Migrant Center (CLMC) or the Palestinian Women’s Humanitarian Organization (PALWHO)


Multiple NCDs including hypertension, diabetes, heart disease, hyperlipidemia, arthritis, and ocular diseases

March 2011—March 2013

210 refugees

Older refugees reported a high burden of chronic illnesses and disabilities. Hypertension was most common (60%), followed by diabetes mellitus (47%), and heart disease (30%). The burden from these diseases was significantly higher in older Palestinians compared to older Syrians, even when controlling for the effects of sex and age. Financial difficulties were given as the primary reason for not seeking care by 79% of older refugees

Wright (2010) [78]


Kuwaiti nationals ages 50–69 exposed to the 1990 Iraqi invasion


Asthma and PTSD

December 2003—January 2005

5,028 subjects

War-related stressors were associated with elevated risk of incident asthma in elderly Kuwaiti civilians exposed to 1990 Iraqi invasion. Study suggested that those who reported highest stress exposure in the invasion were more than twice as likely to report asthma. Suggestive of correlation between war trauma and asthma

Yaghi (2012) [97]


Cases of amputations in Lebanon

Cross- sectional


January 2007—December 2007

661 amputations

Diabetes and vascular indications were not only more common than trauma-related amputation, but both were associated with more major surgery and longer hospital stay including conflict afflicted southern Lebanon where trauma, diabetes and vascular disease amputations all occurred at more than twice the national rate

Yusef (2000) [83]

Country of Asylum: Lebanon

Country of Origin: Palestinian Territories

Diabetic and hypertensive patients attending UNRWA primary health care facilities in Lebanon


Diabetes and hypertension


2,202 records

Presence of both diabetes and hypertension increased the risk for late-stage complications. Only 18.2% of diabetic patients and 17.7% of diabetic patients with hypertension were managed by lifestyle modification. About 50% of type 2 and 66% of type 1 patients who were on insulin were well controlled. Medication shortages may drive medication choices for hypertension

Zubaid (2006) [57]


Catchment area of Mubarak Al Kabeer Hospital


Acute myocardial infarction (AMI)

March 2003

1 Missile Attack Period (MAP) and 4 control periods

The number of admissions for AMI was highest during MAP, 21 cases compared to 14–16 cases in the four control periods, with a trend towards increase during MAP (incidence rate ratio = 1.59; 95% CI 0.95 to 2.66, p < 0.07).The number of admissions for AMI during the first 5 days of MAP was significantly higher compared to the first 5 days of the four control periods (incidence rate ratio = 2.43; 95% CI 1.23 to 4.26,p < 0.01). This indicates missile attacks were associated with an increase in the incidence of AMI