https://doi.org/10.15218/ejnm.2024.03 Erbil j. nurs. midwifery, Vol. 7, No. (1), May, 2024 Original Article Assessment of Psychological Aspects among Refugees in Kurdistan Region-Iraq Refugee Camps ABSTRACT Background and objectives: Syria's civil war has received the highest refugee crisis of the twenty-first century. As a result of their exposure to conflict, violence, and post- displacement stresses, Syrian refugees living in refugee camps in Kurdistan are at a greater risk of developing common mental illnesses. This study investigates the preva- lence and predictors of depression, anxiety, and stress symptoms among Syrian refugees residing in the Kurdistan region of Iraq. Methods: A quantitative descriptive study was conducted in refugee camps in Erbil, Sulaymaniyah, and Duhok in the Kurdistan region of Iraq from 1st September 20021 to 1st June 2022. Convenient sampling was used to collect 400 participants, and the de- pression, anxiety, and stress scale-21 (DASS-21) questionnaire was used to measure the level of depression, anxiety, and stress. Results: The average age of participants was 37 ± 12.14 years; 71.8% were married, 53.3% had a smoking history, 92.2% were from Syria, and the average refugee duration was 9 ± 1.32 years. During the refugee process, 79.3% of refugees had a low socioeco- nomic position, 34.0% had anxiety, 23.1% had stress, 47.5% were depressed. There is a statistical association between gender and stress levels based on a p-value of 0.004 and between smoking history and stress with a p-value of 0.006. Conclusion: According to the findings, most refugees suffer from extreme depression, moderate anxiety, and severe stress. Further studies are required by competent authori- ties to overcome mental health disorders among refugees. Keywords: Depression; Anxiety; Stress; Refugees. Ahmad Naif Ali; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. (Correspondence: ahmed.ali@hmu.edu.krd). Abdulqader Hussein Hamad; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. 23 Received: 22/07/2022 Accepted: 06/11/2022 Published: 30/05/2024 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:ahmed.ali@hmu.edu.krd?subject=ahmed.ali@hmu.edu.krd%20 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.03 Erbil j. nurs. midwifery, Vol. 7, No. (1), May, 2024 Original Article When Iraq recovered from years of con- flict, thousands of vulnerable people stayed dislocated and required assistance. As of 31 August 2021, 248,721 Syrian refu- gees (61% urban, 39% camp) and 37,798 refugees of other nationalities lived in Iraq, with 98% of Syrian refugees residing in the Kurdistan Region. The United Nations High Commissioner for Refugees (UNHCR) con- ducted a participatory assessment in six offices/ten governorates (Erbil, Dohuk, Sulaymaniyah, Kirkuk, Ninewa, Baghdad, Basra, Anbar, Diyala, Kerbala, Salahaldeen) in July and August 2021 to ensure mean- ingful participation through structured dis- cussion [1]. The migration process had a significant detrimental impact on refugees' mental health, and the majority of Syrian refugees in camps in the Kurdistan area of Iraq reported feeling distressed and anx- ious [2]. There is a significant prevalence of anxiety and depression, as well as elevated stress levels, among refugees who have been through the refugee resettlement process in the past [3]. Syria's civil war re- sulted in one of the biggest refugee crises in contemporary history. Turkey has the highest number of registered Syrian refu- gees, who are more likely to suffer from prevalent mental illnesses due to their dealings with war, brutality, and the stress- ors that come with being moved [4]. Even in wealthy countries like Germany, immi- gration and refugee policies seem to have a detrimental effect on mental health, and roughly half of the refugees experienced trauma, although participants' self- reported rates of melancholy, anxiety and stress symptoms were high. Refugees in Sweden's refugee camps report high levels of psychological discomfort and low quality of life. However, the service system ap- pears to be able to assist them in overcom- ing this misery [6]. Syrian refugees in Kurdi- stan camps said that social interactions and environmental conditions are satisfactory but that home displacement has a detrimental effect on individual satisfaction [7]. The nature of the present study is descriptive and cross-sectional, conducted between 1st September 2021 to 1st June 2022. A questionnaire was adopted in English and Arabic and a face-to-face interview was used. The questionnaires were divided into two parts. Part one included questions around sociodemographic characteristics such as age, sex, marital status, number of children, country of birth, migration status, level of education, employment status, insurance, types of education, duration of refugee, ownership before and after refugee, level of income before and after refugee, past psychiatry history, history of alcohol use, and history of smoking. Part two included questions using Lovibond's Depression, Anxiety, and Stress scale-21 (DASS 21). Lovibond's 1995 DASS-21 is a reliable quantitative screening instrument for depression, anxiety, and stress. There are seven items for depression, anxiety, and stress. They can be categorized as mild, moderate, severe, and extremely severe. The DASS-21 score was multiplied by two to determine the final result. Cronbach‘s coefficient was estimated to test the internal consistency of the measurement. The result for Cronbach’s alpha is 0.927 for depression, 0.916 for anxiety, 0.922 for stress, and 0.921 for all of them together. The inclusion criteria were all refugees over 18 years old. The participants were refugees from the Kurdistan region of Iraq refugee camps in Erbil, Sulaymaniyah, and Duhok cities. According to the Cochran formula, the population sizes of Erbil, Sulaymaniyah, Dohuk, and the entire country are 24 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. INTRODUCTION METHODS https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.03 Erbil j. nurs. midwifery, Vol. 7, No. (1), May, 2024 Original Article Table 1 shows the descriptive statistics for all demographic questions such as age, gender, marital status, number of children, education, past psychiatry history, past medical history, history of alcohol use, and history of smoking. The percentage of males (61.5%) is higher than the percent- age of female participants (38.5%), while most of them are married (71.8%). Most of the participants are aged between 21 and 30 years (30%), followed by 31-40 years (26.5%), 41-50 years (21.8%), more than 50 years (17%), and less than 21 years (4.8%) with the average being 37 years. The highest percentage of number of chil- dren in a family is between 1 and 3 chil- dren (32%), followed by 4-6 children (30.5%), and more than six children (7.5%). Thirty percent do not have any child, and the average number of children per family is 3. Most participants (27.3%) do not have any educational background, 24.8% can read and write, 17.3% completed primary school, 15.3% completed secondary school, 15% had a diploma/bachelor, and 5% were postgraduates. According to past psychiatry history, 88.8% did not have any past psychiatry history, 4.5% had depres- sion, 4.3% had stress, and 2.5% had anxie- ty. On the other hand, 69.5% did not have any past medical history, while 15.8% had hypertension. The majority of the partici- pants (87.8%) do not have a history of al- cohol ,while 53.3% reported a history of smoking. (15459, 9580, 26384, and 51423), respec- tively, with a sample size of 382 based on a 95% confidence interval, a 5% margin of error, and 50% of the population percent- age. In place of the 382 examples discov- ered by the Cochran formula, 400 cases were gathered in order to have a more re- liable sample size. Following that, the sam- ple sizes (400) were divided into three cities, Erbil, Sulaymaniyah, and Duhok, ac- cording to stratified sampling, as follows: Erbil (120), Sulamaniah (75), and Duhok (205). Then, convenience sampling was utilized to gather the data from Sulaymani- yah, Duhok, and Sulaymaniyah. Ethical ap- proval from Hawler Medical University/ College of Nursing ethical committee was obtained. Face-to-face interviews were used to collect the data. The study's pur- pose was explained to the respondents who voluntarily participated. Chi-square is used to determine if the distributions of categorical variables differ, and the chi- squared test for independence shows whether two categorical variables are in- dependent[11]. The respondents were also assurred that their responses would be considered confidential and utilized only for research, the data were entered into SPSS for analysis, and frequency, percent- age, mean, standard deviation, and chi- square test were used to analyze the data. 25 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. RESULT https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.03 Erbil j. nurs. midwifery, Vol. 7, No. (1), May, 2024 Original Article 26 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 1: Descriptive Statistics for Demographic Questions (A) Variables N (%) Age less than 21 19 (4.8%) 21 - 30 120 (30%) 31 - 40 106 (26.5%) 41 - 50 87 (21.8%) 51 and more 68 (17%) (Mean ± SD) (37 ± 12.14) Sex Male 246 (61.5%) Female 154 (38.5%) Marital Status Single 106 (26.5%) Married 287 (71.8%) Divorced 7 (1.8%) Number of Children No child 120 (30%) 1 - 3 Children 128 (32%) 4 - 6 Children 122 (30.5%) More than 6 children 30 (7.5%) (Mean ± SD) (3 ± 2.45) Level of Education Illiterate 109 (27.3%) Read and write 99 (24.8%) Primary School 69 (17.3%) Secondary School 61 (15.3%) Diploma or Bachelor 60 (15%) Postgraduate 2 (0.5%) Occupation Unskilled manual occupation 149 (37.3%) Semi-skilled manual occupations 37 (9.3%) Manual and non-manual occupations 8 (2%) Associate professional occupations 45 (11.3%) Skilled professional 8 (2%) Housewife 103 (25.8%) Student 50 (12.5%) Employment Employed 28 (7%) Unemployed 372 (93%) History of Smoking Presence 213 (53.3%) Absence 187 (46.8%) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.03 Erbil j. nurs. midwifery, Vol. 7, No. (1), May, 2024 Original Article 27 (11.3%), semi-skilled manual occupa- tions (9.3%), and both manual and non- manual occupations and skilled profes- sional (2%) respectively. The highest per- centage of duration of a refugee is be- tween 9 and 12 years (75.8%), with the average refugee’s duration being nine years. The majority of the participants had a medium level of income before ref- ugee (80%), while most of them have low income during refugee (79.3%). The percentage of refugees living in urban areas is higher than those living in rural areas (47.3%). Table 2 shows the descriptive statistics for all demographic questions such as migra- tion of status, employment, insurance, oc- cupation, duration of refugee, level of in- come before refugee, level of income dur- ing refugee, and place of living before refu- gee. The percentage of participants who migrated from Syria (92.2%) is higher than those who migrated to Turkey (7.8%). Most of them are unemployed (93%), and do not have insurance (99.5%). According to occu- pation results, most of the participants are in unskilled manual occupations (37.3%), followed by a housewife (25.8%), students )12.5 ,(% associate professional occupations Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 2 :Descriptive Statistics for Demographic Questions (B) Variables N (%) Migration of Status Turkey 31 (7.8%) Syria 369 (92.2%) Employment Employed 28 (7%) Unemployed 372 (93%) Insurance Not insured 398 (99.5%) Insured 2 (0.5%) Duration of Refugee 1 - 4 4 (1%) 5 - 8 93 (23.3%) 9 - 12 303 (75.8%) (Mean ± SD) (9 ± 1.32) Level of income before refugee Low 14 (3.5%) Medium 320 (80%) High 66 (16.5%) Level of income during refugee Low 317 (79.3%) Medium 81 (20.3%) High 2 (0.5%) Place of living before a refugee Urban 211 (52.8%) Rural 189 (47.3%) Past psychiatry history Anxiety 10 (2.5%) Stress 17 (4.3%) None 355 (88.8%) Past medical History No medical history 278 (69.5%) Hypertension 63 (15.8%) Asthma 1 (0.3%) Diabetes 31 (7.8%) arrhythmia 6 (1.5%) peptic ulcer 11 (2.8%) migraine 5 (1.3%) heart failure 5 (1.3%) History of alcohol use Presence 49 (12.3%) Absence 351 (87.8%) History of Smoking Presence 213 (53.3%) Absence 187 (46.8%) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.03 Erbil j. nurs. midwifery, Vol. 7, No. (1), May, 2024 Original Article reported moderate anxiety, 27% reported moderate depression, and 26% reported moderate stress. Most of the participants reported severe stress (23%), followed by severe depression (20.8%) and severe anxi- ety (17.8%). Less than half (47.5%) of the participants had extremely severe depres- sion, followed by extremely severe anxiety (35.8%) and extremely severe stress (18.8%). from extremely severe stress (65.3 %) is higher than the percentage of females (34.7%). There is no statistically significant association between gender (male and fe- male) and depression (p=0.896) and anxie- ty (p=0.341). 28 Table 3 shows the descriptive statistics for depression, anxiety, and stress. Overall, 26.8% had depression, 23.7% had stress, and 17.9% had anxiety. Most participants (32.3%) reported normal stress, 7.8% re- ported normal anxiety, and 2% reported normal depression. The percentage of mild anxiety (4.8%) is higher than mild depression (2.8%), while no participant reported mild stress. Thirty-four percent Table 4 demonstrates that there is a sta- tistically significant association between gender (male and female) with stress (p=0.004). The percentage of males expe- riencing severe stress (70.7%) is higher than the percentage of females (29.3 %), and the percentage of males suffering Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 3 :Descriptive Statistics for Depression, Anxiety, and Stress Levels Depression Anxiety Stress N (%) N (%) N (%) Normal 8 (2%) 31 (7.8%) 129 (32.3%) Mild 11 (2.8%) 19 (4.8%) 0 (0%) Moderate 108 (27%) 136 (34%) 104 (26%) Severe 83 (20.8%) 71 (17.8%) 92 (23%) Extremely severe 190 (47.5%) 143 (35.8%) 75 (18.8%) Mean 26.80 17.93 23.66 SD 9.70 8.55 9.38 Table 4 :Association between gender and (Depression, Anxiety, and Stress) using the Chi- square test Levels Sex Total Chi-Square P-value Male Female Depression Normal N (%) 5 (62.5%) 3 (37.5%) 8 (100%) 1.091 0.896 Mild N (%) 7 (63.6%) 4 (36.4%) 11 (100%) Moderate N (%) 67 (62%) 41 (38%) 108 (100%) Severe N (%) 47 (56.6%) 36 (43.4%) 83 (100%) Extremely severe N (%) 120 (63.2%) 70 (36.8%) 190 (100%) Anxiety Normal N (%) 17 (54.8%) 14 (45.2%) 31 (100%) 4.515 0.341 Mild N (%) 10 (52.6%) 9 (47.4%) 19 (100%) Moderate N (%) 82 (60.3%) 54 (39.7%) 136 (100%) Severe N (%) 40 (56.3%) 31 (43.7%) 71 (100%) Extremely severe N (%) 97 (67.8%) 46 (32.2%) 143 (100%) Stress Normal N (%) 63 (48.8%) 66 (51.2%) 129 (100%) 13.488 0.004 Moderate N (%) 69 (66.3%) 35 (33.7%) 104 (100%) Severe N (%) 65 (70.7%) 27 (29.3%) 92 (100%) Extremely severe N (%) 49 (65.3%) 26 (34.7%) 75 (100%) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.03 Erbil j. nurs. midwifery, Vol. 7, No. (1), May, 2024 Original Article smoking had less extremely severe stress (50.7%) compared to those without history of smoking (49.3%. There is no statistically significant association between the history of smoking (smoker and non-smoker) with depression (p=0.781) and anxiety (p=0.501). Most respondents expressed significant stress, despair, and anxiety. A study among a similar age group of Syrian refugees demonstrates the need for psychological services due to the high level of low quality of life as a result of psychological disorders in Kurdistan refugee camps [7]. Research from Sweden reveals a high level of stress disorder and depression between the ages of 18-64 years old [12]. Our findings indi- cate that there is a statistically significant difference between smoking history and Table 5 shows a statistically significant as- sociation between smoking history (smoker and non-smoker) and stress (p=0.006). The percentage of participants with a history of smoking had severe stress (56.5%) compared with those who do not have a past history of smoking (43.5%). Participants with a history of In the present study, we focused to assess the level of psychological aspects such as depression, anxiety, and stress among ref- ugees in the Kurdistan region. Men experi- ence severe stress more than females, whereas males suffer very severe stress more than females. In contrast, a study in Istanbul shows a significant association between depression and gender [4]. In our study, most respondents expressed ex- teremly severe anxiety (47.5%), anxiety (35.8%), and normal stress (32.3%), 29 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. DISCUSSION Table 5 :Association between the history of Smoking and (Depression, Anxiety, and Stress) using the Chi-square test Levels History of Smoking Total Chi- Square p- value Presence Absence Depression Normal N (%) 4 (50%) 4 (50%) 8 (100%) 1.755 0.781 Mild N (%) 6 (54.5%) 5 (45.5%) 11 (100%) Moderate N (%) 62 (57.4%) 46 (42.6%) 108 (100%) Severe N (%) 46 (55.4%) 37 (44.6%) 83 (100%) Extremely severe N (%) 95 (50%) 95 (50%) 190 (100%) Anxiety Normal N (%) 18 (58.1%) 13 (41.9%) 31 (100%) 3.352 0.501 Mild N (%) 9 (47.4%) 10 (52.6%) 19 (100%) Moderate N (%) 70 (51.5%) 66 (48.5%) 136 (100%) Severe N (%) 33 (46.5%) 38 (53.5%) 71 (100%) Extremely severe N (%) 83 (58%) 60 (42%) 143 (100%) Stress Normal N (%) 55 (42.6%) 74 (57.4%) 129 (100%) 12.586 0.006 Moderate N (%) 68 (65.4%) 36 (34.6%) 104 (100%) Severe N (%) 52 (56.5%) 40 (43.5%) 92 (100%) Extremely severe N (%) 38 (50.7%) 37 (49.3%) 75 (100%) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.03 Erbil j. nurs. midwifery, Vol. 7, No. (1), May, 2024 Original Article [1] UNHCR Iraq: 2021 Participatory Assessment of Refugees and Asylum-Seekers (June – August 2021) - Iraq | ReliefWeb [Internet]. 2021 [cited 2022 Jun 24]. Available from. [2] Mahmood HN, Ibrahim H, Goessmann K, Ismail AA, Neuner F. Post-traumatic stress disorder and depression among Syrian refu- gees residing in the Kurdistan region of Iraq. Confl Health. 2019;13:51. Available from. [3] Nissen A, Cauley P, Saboonchi F, J Andersen A, Solberg Ø. Mental health in adult refu- gees from Syria resettled in Norway be- tween 2015 and 2017: a nationwide, ques- tionnaire-based, cross-sectional prevalence study. Eur J Psychotraumatology. 2021;12 (1):1994218. Available from. [4] Acarturk C, McGrath M, Roberts B, Ilkkursun Z, Cuijpers P, Sijbrandij M, et al. Prevalence and predictors of common mental disorders among Syrian refugees in Istanbul, Turkey: a cross-sectional study. Soc Psychiatry Psychi- atr Epidemiol. 2021 Mar;56(3):475–84. Available from. [5] Tejada JJ, Punzalan JR. On the misuse of Slovin’s formula. The philippine statistician. 2012;61(1):129-36. [6] Leiler A, Bjärtå A, Ekdahl J, Wasteson E. Mental health and quality of life among asy- lum seekers and refugees living in refugee housing facilities in Sweden. Soc Psychiatry Psychiatr Epidemiol. 2019 May;54(5):543– 51. Available from. [7] Aziz IA, Hutchinson CV, Maltby J. Quality of life of Syrian refugees living in camps in the Kurdistan Region of Iraq. PeerJ. 2014;2:e670. Available from. [8] Böge K, Hahn E, Strasser J, Schweininger S, Bajbouj M, Karnouk C. Psychotherapy in the Kurdistan region of Iraq (KRI): Preferences and expectations of the Kurdish host com- munity, internally displaced- and Syrian refu- gee community. Int J Soc Psychiatry. 2022 Mar;68(2):346–53. Available from. [9] Fuhr DC, Acarturk C, McGrath M, Ilkkursun Z, Sondorp E, Sijbrandij M, et al. Treatment gap and mental health service use among Syrian refugees in Sultanbeyli, Istanbul: a cross- sectional survey. Epidemiol Psychiatr Sci. 2019 Nov 15;29:e70. Available from. [10] Eslam Parast N, Taştekin Ouyaba A. The im- pact of the demographic and migration pro- cess factors of refugee women on quality of life and the mediating role of mental health. stress (p=0.006). the percentage of histo- ry smokers have more severe stress (56.5%) in table 5 mention than those who do not have a smoking history, whereas the percentage of history smokers has less extremely severe stress than those who do not have a smoking history ((49.3%)). Some of the respondents used tobacco as a means of reducing their stress [13]. While Kurdish migrants used tobacco as a stress reliever, pre-migration trauma ap- peared to be related to lifelong tobacco use in Finland and Russia [14]. Additional- ly, Syrian refugees in Lebanon are inactive and smokers. Humanitarian organizations are developing regional healthcare sys- tems as the crisis persists to give refugee populations better mental health services [15]. This study shows that the majority of the refugee population screened positive for depression, anxiety, and stress. There were statistically significant association between stress and gender. Also, different levels of stress correlated with smoking habits. We recommend further study on refugees based on mental health promo- tion by more competent authorities. I would like to thank the higher education committee/ college of nursing for guiding us in the research process. The authors have disclosed no potential conflicts of interest or sources of financial assistance. 30 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. REFERENCES CONCLUSION ACKNOWLEDGEMENTS CONFLICT OF INTEREST https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.03 Erbil j. nurs. midwifery, Vol. 7, No. (1), May, 2024 Original Article Perspect Psychiatr Care [Internet]. 2022 [cited 2022 Jun 25];58(2):785–94. Available from. [11] Aroian K, Uddin N, Blbas H. Longitudinal study of stress, social support, and depres- sion in married Arab immigrant women. Health care for women international. 2017 Feb 1;38(2):100-17. [12] Tinghög P, Malm A, Arwidson C, Sigvardsdotter E, Lundin A, Saboonchi F. Prevalence of mental ill health, traumas and postmigration stress among refugees from Syria resettled in Sweden after 2011: a pop- ulation-based survey. BMJ Open. 2017 Dec 29;7(12):e018899. Available from. [13] Mehra R, Mohanty VR, Y B A, Mehra K, Ka- poor S. Afghan Frontier: Understanding Tobacco Practices among Migrant Popula- tion in India. Asian Pac J Cancer Prev APJCP. 2020 Jul 1;21(7):1931–7. avialable from. [14] Salama ES, Castaneda AE, Lilja E, Suvisaari J, Rask S, Laatikainen T, et al. Pre-migration traumatic experiences, post-migration per- ceived discrimination and substance use among Russian and Kurdish migrants-a pop- ulation-based study. Addict Abingdon Engl. 2020 Jun;115(6):1160–71. Available from. [15] Sethi S, Jonsson R, Skaff R, Tyler F. Commu- nity-Based Noncommunicable Disease Care for Syrian Refugees in Lebanon. Glob Health Sci Pract. 2017 Sep 27;5(3):495–506. Availa- ble from. 31 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/