Lessons from the profile of kidney diseases among Afghan refugees

Health condition of Afghan refugees residing in Iran in comparison to Germany: a systematic review of empirical studies

BACKGROUND

The re-emerging dominance of the Taliban in Afghanistan in 2021 caused a new wave of Afghan refugees heading Iran and neighboring countries. Iran in the Middle East and Germany in Europe are two major host countries to the largest populations of Afghan refugees. In both countries, several studies have been done to assess the health condition of refugees.

OBJECTIVES

To systematically review the existing literature to identify similarities and differences of health conditions of Afghan refugees living in the two countries, and to synthesize evidence on the health status and health care access of these populations.

METHODS

Related electronic databases and grey literature of Iran and Germany on the health of Afghan refugees were scanned and searched up for the period 2000-2020. Key terms were formed by combining "Afghan refugees or immigrants or populations or asylum seekers", "Physical or mental health", "Healthcare service or access or use", "Iran or Germany". Empirical studies were considered if they contained samples of Afghan refugees with particular outcomes for Afghans. Results were categorized for both countries in the three main areas of physical health, mental health, and access/use of healthcare services.

RESULTS

Nine hundred twenty-two documents were extracted, of which 75 full-texts were finally reviewed. 60 documents belonged to the health condition of Afghan refugees residing in Iran including 43 in physical health, 6 in mental health, 8 in healthcare access and use, and 3 in multiple aspects of health, and 15 belonged to Germany including 7 in physical health, 4 in mental health, 2 in healthcare access and use, and 2 in multiple aspects of health. A less explicit evaluation of the overall health condition of Afghan refugees was observable, particularly for Germany. While matches on the study subject exist for both countries, in comparison to Germany, we extracted more quantitative and qualitative health studies on Afghan refugees of the mentioned areas from Iran. German health studies were rare, less qualitative, and more on the health condition of diverse refugee groups in general.

CONCLUSIONS

Wide gaps and unanswered questions related to mental health and overall health status of the Afghan refugee population are observable, especially in Germany. Our systematic review identified the gap in evidence, which we would recommend to bridge using a wider lens to comprehensively assess the overall condition of refugees considering associations between health and socio-economic and cultural determinants instead of a one-dimensional approach. Further, within health studies on refugee populations, we recommend stratification of results by the country of origin to capture the within-group diversity among refugees with different countries of origin.

Management of pediatric dialysis and kidney transplant patients after natural or man-made disasters

Pediatric patients on kidney replacement therapy (KRT) are among the most vulnerable during large-scale disasters, either natural or man-made. Hemodialysis (HD) treatments may be impossible because of structural damage and/or shortage of medical supplies, clean water, electricity, and healthcare professionals. Lack of peritoneal dialysis (PD) solutions and increased risk of infectious/non-infectious complications may make PD therapy challenging. Non-availability of immunosuppressants and increased risk of infections may result in graft loss and deaths of kidney transplant recipients. Measures to mitigate these risks must be considered before, during, and after the disaster including training of staff and patients/caregivers to cope with medical and logistic problems. Soon after a disaster, if the possibility of performing HD or PD is uncertain, patients should be directed to other centers, or the duration and/or number of HD sessions or the PD prescription adapted. In kidney transplant recipients, switching among immunosuppressants should be considered in case of non-availability of the medications. Post-disaster interventions target treating neglected physical and mental problems and also improving social challenges. All problems experienced by pediatric KRT patients living in the affected area are applicable to displaced patients who may also face extra risks during their travel and also at their destination. The need for additional local, national, and international help and support of non-governmental organizations must be anticipated and sought in a timely manner.

Ethical Aspects of Kidney Donation and Transplantation for Migrants

Migrants represent a large and diverse population globally that includes international refugees, stateless persons, expatriate workers, and more. Many migrants face significant barriers in accessing health care, especially scarce and costly resources such as dialysis and kidney transplantation. Improving equity of access to these kidney replacement therapies for migrant populations may present a range of complex ethical dilemmas, particularly in the setting of crises and when considering the use of residency status and citizenship as eligibility criteria for access to treatment. In this article, we discuss ethical obligations to provide kidney care for migrants, the implications of the self-sufficiency concept with regard to access to deceased donation and transplantation, factors that may influence evaluation of the risks and benefits of transplantation for migrants with insecure access to care, and the vulnerability of migrants to organ trafficking. We also present a set of general recommendations to assist in preventing and managing ethical dilemmas when making decisions about policy or practice regarding kidney care for migrants.

Kidney disease profile and encountered problems during follow-up in Syrian refugee children: a multicenter retrospective study

BACKGROUND

Children are one of the most vulnerable groups in conflict zones, especially those with chronic diseases. This study aimed to investigate kidney disease profiles and problems during follow-up in a population of Syrian refugee children residing in Turkey.

METHODS

Syrian refugee children aged between 0 and 18 years were included in the study. Demographic data, diagnosis, particular interventions due to nephrological problems, and problems encountered during follow-up were obtained from all participating pediatric nephrology centers.

RESULTS

Data from 633 children from 22 pediatric nephrology centers were included. Mean age of the children was 94.8 ± 61.7 months and 375 were male (59%). 57.7% had parental consanguinity and 23.3% had a close relative(s) with kidney disease. The most common kidney diseases were congenital anomalies of the kidney and urinary tract (CAKUT) (31.0%), glomerular disease (19.9%), chronic kidney disease (CKD) (14.8%), and urolithiasis (10.7%). Frequent reasons for CAKUT were nonobstructive hydronephrosis (23.0%), vesico-ureteral reflux (18.4%), and neurogenic bladder (15.8%). The most common etiology of glomerular diseases was nephrotic syndrome (69%). Ninety-four children had CKD, and 58 children were on chronic dialysis. Six children had kidney transplantation. Surgical intervention was performed on 111 patients. The language barrier, lack of medical records, and frequent disruptions in periodic follow-ups were the main problems noted.

CONCLUSIONS

CAKUT, glomerular disease, and CKD were highly prevalent in Syrian refugee children. Knowing the frequency of chronic diseases and the problems encountered in refugees would facilitate better treatment options and preventive measures.

Digital and Economic Determinants of Healthcare in the Crisis-Affected Population in Afghanistan: Access to Mobile Phone and Socioeconomic Barriers

Despite recent progress in Afghanistan’s health system from the support of international donors and NGOs, protracted conflicts combined with a series of natural disasters have continued to present substantial health risks. Extreme poverty has still aggravated social determinants of health and financial barriers to healthcare. Little is known about the context-specific factors influencing access to healthcare in the crisis-affected population. Using a subset of data from ‘Whole of Afghanistan Assessment (WoAA) 2019’, this study analyzed 31,343 households’ data, which was collected between 17 July and 19 September 2019 throughout all 34 provinces in Afghanistan. The outcome measured was access to care in the healthcare facility, and multivariable binary logistic regression models were used to identify the specific factors associated with access to healthcare. Of 31,343 households exposed to complex emergencies in Afghanistan, 10,057 (32.1%) could not access healthcare facilities when one was needed in last three months. The access to healthcare was significantly associated with displacement status, economic factors such as employment status or total monthly income, and the distance to healthcare facilities. Significant increase in healthcare access was associated with factors related to communication and access to information, such as awareness of humanitarian assistance availability and mobile phone with a SIM card, while disability in cognitive function, such as memory or concentration, was associated with poorer healthcare access. Our findings indicate that the crisis-affected population remains vulnerable in access to healthcare, despite the recent improvements in health sectors. Digital determinants, such as access to mobile phone, need to be addressed along with the healthcare barriers related to poverty and household vulnerabilities. The innovative humanitarian financing system using mobile communication and cash transfer programs would be considerable for the conflict-affected but digitally connected population in Afghanistan.

Barriers and facilitators of providing primary health care to Afghan refugees: A qualitative study from the perspective of health care providers

Background: One of the important aspects in the field of refugee health is the availability of primary health care, and the quality improvement of health care requires identifying barriers and facilitators. The present study aimed to identify obstacles and facilitators of providing primary health care to Afghan refugees from the perspective of health care providers.

Methods: In this qualitative study, a semi-structured interview was conducted based on purposeful sampling with the involvement of 21 managers and experts in primary health care centers. Data were analyzed using the content analysis method and MaxQDA.

Results: Data analysis led to the production of 4 main themes: (1) challenges while providing primary health care, with 10 subthemes; (2) challenges after providing care, with 4 subthemes; (3) opportunities, with 3 subthemes; and (4) solutions, with 6 subthemes.

Conclusion: According to the results of this study, identifying the challenges and providing opportunities and solutions to existing problems seem to be effective steps in the quality improvement of providing primary health care to refugees.

Disasters, children and the kidneys

Following disasters, children are physically, psychologically and socially more vulnerable than adults; consequently, their morbidity and mortality are higher. The risks are especially high for orphans and unaccompanied children who are separated from their families, making them frequently victims of human trafficking, slavery, drug addiction, crime or sexual exploitation. Education of children and families about disaster-related risks and providing special protection in disaster preparedness plans may mitigate these threats. Kidney disease patients, both paediatric and adult, are extra vulnerable during disasters, because their treatment is dependent on technology and functioning infrastructure. Acute kidney injury, chronic kidney disease patients not on dialysis and dialysis and transplant patients are faced with extensive problems. Overall, similar treatment principles apply both for adults and paediatric kidney patients, but management of children is more problematic, because of substantial medical and logistic difficulties. To minimize drawbacks, it is vital to be prepared for renal disasters. Preparedness plans should address not only medical professionals, but also patients and their families. If problems cannot be coped with locally, calling for national and/or international help is mandatory. This paper describes the spectrum of disaster-related problems in children and the specific features in treating acute and chronic kidney disease in disasters.

Renal Crisis in Children during Armed Conflict

Armed conflicts continue to occur in some regions of the globe, mostly in developing countries. These man-made disasters affect all segments of the population; however, some groups are more vulnerable and suffer more seriously from the unfavorable consequences of such conflicts. Among these, the pediatric population deserves special attention because they cannot protect themselves, and hence carry a higher threat of injuries and probability of death during conflicts. In addition, children who do survive the disaster are more prone to exploitation. Pediatric victims, including those who sustain acute kidney injury or those suffering from chronic kidney disease before armed conflicts, face higher risks of morbidity and mortality as a result of treatment problems, specifically limited dialysis options. Displaced children, forced to flee their homes as a result of armed conflicts, are also at risk for various health problems because they may not find ideal circumstances for disease treatment. Making preparations in anticipation of armed conflicts, such as disaster-relief scenarios and action plans, may be useful to decrease the death toll in these children, who are dependent on their caregivers for survival. Adopting principles of disaster nephrology may contribute to improved survival chances of pediatric kidney patients in chaotic circumstances.

Lived Experience of Afghan Refugees in Iran Concerning Primary Health Care Delivery

OBJECTIVE

Access to primary health care (PHC) is very important for refugees. The aim of this study was to illuminate lived experience of Afghan refugees in Iran regarding PHC delivery.

METHODS

This qualitative study was conducted in 2016-2017 by using the content analysis technique. Data were collected through individual deep interviews with Afghan refugees who lived in Iran. The data were analyzed by using a method by Graneheim and Lundman.

RESULTS

Four main categories and 12 subcategories were emerged, including (1) challenges before PHC delivery: large number of children, high service cost, not having medical insurance, access to health centers, appointment to get services, simultaneity of breastfeeding, and pregnancy; (2) challenges during PHC delivery: understanding Iranian words, health care provider's behavior, delay in getting service in PHC centers; (3) challenges after delivery PHC: referral patient, high costs of paraclinics; and (4) free and good services.

CONCLUSION

Our results showed that Afghan refugees have several challenges in every stage of PHC delivery. Awareness of such problems can help medical personnel improve delivery of service to Afghan refugees, as well as using trained Afghani nurses to serve the refugees.

The Enduring Health Challenges of Afghan Immigrants and Refugees in Iran: A Systematic Review

INTRODUCTION

Iran is the third country in the world with the highest number of registered refugees with the majority coming from Afghanistan. They suffer major health and social risks yet their health status has never been comprehensively determined.

METHODS

This systematic review of the literature highlights major disparities among documented immigrants in health access, communicable and non-communicable diseases and the increasingly desperate plight of undocumented immigrants.

RESULTS

Comparing with Iranian population, the findings suggest the higher prevalence of most diseases among Afghan immigrants and refugees. This highlights the importance of increasing the migrants' access to health services from both public health as well as human rights perspectives.

DISCUSSION

Although the Iranian government has taken new initiatives to overcome this challenge, certain issues have still remained unaddressed. Potential solutions to improve this process are discussed.

Renal replacement therapy for refugees with end-stage kidney disease: an international survey of the nephrological community

Provision of health care for refugees poses many political, economical, and ethical questions. Data on the prevalence and management of refugees with end-stage kidney disease (ESKD) are scant. Nevertheless, the impact of refugees in need for renal replacement can be as high for the patient as for the receiving centers. The International Society of Nephrology and the European Renal Association/European Dialysis and Transplant Association surveyed their membership through Survey Monkey questionnaires to obtain data on epidemiology and management practices of refugees with ESKD. Refugees represent 1.5% of the dialysis population, but their geographic distribution is very skewed: ±60% of centers treat 0, 15% treat 1, and a limited number of centers treat >20 refugees. Knowledge on financial and legal management of these patients is low. There is a lack of a structured approach by the government. Most respondents stated we have a moral duty to treat refugee patients with ESKD. Cultural rather than linguistic differences were perceived as a barrier for optimal care. Provision of dialysis for refugees with ESKD seems sustainable and logistically feasible, as they are only 1.5% of the regular dialysis population, but the skewed distribution potentially threatens optimal care. There is a need for education on financial and legal aspects of management of refugees with ESKD. Clear guidance from governing bodies should avoid unacceptable ethical dilemmas for the individual physician. Such strategies should balance access to care for all with equity and solidarity without jeopardizing the health care of the local population.