TOP Solutions for facilitating primary health care delivery for refugees in Iran: a qualitative study

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Objectives we aimed to identify the most important challenges and corresponding solutions to facilitate PHC delivery for refuges in Iran. Method In this descriptive qualitative study, purposive sampling was used for selecting Participants. Semi-structured interviews were conducted for data collection. Interviews were continued as long as the saturation point was achieved at the 27 st interview. conventional content analysis using an inductive data-driven coding process and theme development used for analyzing the data. Results We extracted the top challenges and solutions. challenges including: language limitations and cultural challenges, Lack of identification and health documents, High rate of movement of their houses and lack of a special comprehensive health center, Lack of identification and health documents, lack of a referral system in Iran, especially for refugees and lack of financial resources, Lack of health literacy, Different cultural, beliefs and social background of refugees, Lack of financial ability to follow the orders of health care providers, lack of the health laws related to refugees, Lack of awareness and responsibility regarding individual and collective health. Accordingly, corresponding solutions were identified. Conclusions we conclude that facilitating PHC delivering for refugees requires taking solutions in areas of economic, social, cultural and political with the consideration of inter-sectoral collaboration. Immigrant Refugees Challenges Primary Health Care Background There is no universally accepted definition of the term Refugee. However, the Convention Relating to the Status of Refugees defines ( 1 ) an Refugee(s) as; "A person who, owing to a well-grounded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality, and is unable, or owing to such fear, is unwilling to avail himself of the protection of that country, or who not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or owing to such fear, is unwilling to return to it" ( 1 – 3 ). Globally, the number of immigrants, including refugees, asylum-seekers and displaced persons, is continuously increasing, from 70.8 million people in 2019 to 108.4 million people in 2022, confirming this unprecedented increase ( 4 ). Over half of all refugees (52%) under UNHCR’s mandate and other people in need of international protection come from just Syrian Arab Republic (6.8 million), Ukraine (5.7 million) and Afghanistan (5.7 million) countries. also, at the end of 2022, of the 108.4 million forcibly displaced people, an estimated 43.3 million (40 per cent) are children below 18 years of age. In addition to 1.9 million children were born as refugees, In this sense that between 2018 and 2022, an average of 385,000 children were born as refugees per year ( 4 ). 38% of all refugees hosted in five countries. Turkey with 3.6 million people, followed by the Islamic Republic of Iran with 3.4 million people the hosts largest numbers of refugees. It is followed by Colombia, Germany and Pakistan. Also 70 per cent of refugees and other people in need of international protection lived in countries neighboring their countries of origin ( 4 ). According to the latest data received from the Government of the Islamic Republic in December 2022, 762,000 refugees currently reside in Iran, out of which some 750,000 are indicated to be Afghan Amayesh cardholders and some 12,000 Iraqi identity cardholders. 586,000 Afghan passport holders with Iranian visas also live in Iran. These are official statistics, but the evidence shows that more than 4.5 million Afghans became refugees in Iran. 99% of refugees live in urban areas alongside the host community, while 1% live in refugee settlements ( 4 – 7 ). In Iran, as a result of the government's progressive and comprehensive policies, refugees have been given the opportunity to access education, health and livelihood, which not only helped them survive but also helped them progress ( 6 ). The growing trend of immigration is reflected by the demand to change the direction of health policies to better protect the health of refugees ( 8 ). The issue of refugee health has expanded from special care to health promotion and disease prevention ( 9 ). refugee's health is a very dynamic and complex issue and includes different stages of migration, from before departure to early and late migration ( 10 , 11 ). In addition, this issue is completely intertwined with several social factors, which are related not only to the characteristics (e.g., different gender roles, cultural diversity, immigration experiences and adverse legal status) of refugees, but also to the context of the countries of destination of refugees (such as health systems and unique cultural values) ( 12 , 13 ). Health care that is universally and equitably accessible must be provided to refugees in a wide range of national contexts and in response to the complex and evolving needs of the individual. In order to identify barriers to access to health care and better planning to make the necessary changes, it is important to look at the available evidence in the field of providing and accessing health care services for refugees ( 14 ). The reviewed literature confirms that despite the desire to ensure equality of access to health care, there is evidence of persistent inequalities between refugees and non-immigrants in access to health care services ( 14 ). The rapidly changing political situation in different countries of the world, the global financial crisis along with the growing consequences of climate change are affecting migration patterns. In the meantime, the access of refugees and refugees to adequate health services has continuously faced obstacles ( 15 – 17 ). These barriers can include regulations limiting access to health care based on legal status, language and cultural barriers, lack of information about where and how to receive care, Economic barriers and lack of cultural competence among health service providers( 18 , 19 ), low health literacy ( 20 – 22 ), beliefs ( 23 ), language and communication barriers ( 24 ), low-income status, race ( 22 , 25 – 29 ), limited trust of health service providers ( 26 – 28 , 30 ). Considering the importance and necessity of providing primary health care for all people regardless of their color, race and nationality, identifying the challenges of providing primary care to refugees in host countries, especially middle- and low-income countries, in line with universal health coverage and reducing the inequality in health in this vulnerable group seems necessary. Therefore, this study was conducted in order to identify practical solutions to the challenges of providing primary health care to refugees in the Iran context. Context of providing primary health care to refugees in Iran: Providing healthcare services to refugees is similar to Iranians. Paying attention to human, religious values and human dignity has caused the continuation of service to these groups. It is very valuable to mention that the healthcare services provided to this population are provided completely free of charge. In the villages of Iran, refugees go to health centers and basic health care is provided to them by Behvarz and general practitioners. Also, in cities, they receive these cares in health centers and from the health team. An electronic health record is created for them, and if they need more specialized services, they are referred to rural/urban health centers through GP, and through that, they are referred to hospitals and province health centers. All services such as vaccination, mother and child care, pregnancy, control and prevention of communicable diseases, old age care and various screenings such as deafness/hearing loss, diabetes, high blood pressure, thalassemia, PKU and hundreds of other cares It is done for refugees ( 4 , 6 ). Material and methods Data collection: To identify the Solutions for Challenges of providing primary health care to refugees in Iran, we conducted a qualitative descriptive study. The research was conducted from November 2022 to May 2023. Within emphasis on maximum variation, purposive sampling was used for selecting the interviewees. The criterion used for this purpose was having work experience as a community health worker. The participants were from local, provincial (community health centers and province health district) levels. Snowball sampling was employed within the interviews for identifying all informants. Overall, 27 interviews were done, with 19 and 8 interviews at local and province levels, respectively. The participants are as representatives of the Isfahan University of Medical Sciences, which primary health care services. The participants had the following organizational positions: primary health care providers (community health worker (Midwife, Nutritionist, Psychologist, Health expert, Behvarz, General physician (GP)), managers (Headquarter managers and Headquarters expert). The majority of respondents had direct experiences (minimum 10 years) concerning primary health care provide. All respondents completed a written informed consent form and they were ensured about the confidentiality and anonymity of their information. An interview guide was formulated according to a review of the related literature and it was ensured that all relevant challenges would be recognized.(Supplementary File 1). First, two interviews were conducted as the pilot testing of the interview guide. Accordingly, some modifications were made to adjust the other interviews. First, the interviewees were contacted through email or phone, and they were informed on the research topic, research objectives, and justification for the necessity of this work. After accepting the interview meeting by informants, they were interviewed in their office or any other place suggested by them. A member of the research team (SB) who is skilled for a qualitative study, were conducted interviews applying the interview guide. The interviewer's information, including his academic position and the subject area of expertise, was explained to interviewees. Interviews were mostly audio-recorded, anonymized, and later were transcribed accurately. All participants were willing to interview while audio recording. Also, some notes were taken by the interviewer and were shared with the research team for discussing preliminary results, complications, and any corrections required in the interview guide. Interviews were conducted as long as reaching a saturation point, exceeding which no more data was needed. Thus, two new interviews were also conducted. Overall, we conducted twenty-seven semi-structured face-to-face interviews. Analysis: The present study used conventional content analysis ( 31 ) with an inductive data-driven process coding and theme development for the analysis ( 32 ). The interviews were reviewed several times for inferring a list of inductive themes. At the same time, deductive themes were recognized directly. The conventional content analysis was conducted as follows: In the first step, two authors independently coded data collected. They read and re-read the transcribed documents and listened to audio-recorded interviews for immersion in data. In the next step, primary themes were extracted from the obtained data and reviewed by the team members. The team members held a meeting to elaborate on conflicts and controversial points and reach an agreement on emerging themes. They continued discussion until addressing all the controversies. Then, themes and sub-themes were specified. In the last step, team members reviewed, modified, and collated coded statements. The duration of interviews varied between 50 to 75 minutes. MAXQDA Analytics Pro 2020 (VERBI GmbH Berlin) Release 20.2.1 was used to manage and organize the transcripts systematically. Quality Assurance: Trustworthiness was ensured using the criteria proposed by Lincoln and Guba ( 33 , 34 ). Also, a documented guide was constructed to enhance the credibility of sampling, interviews, and analysis. Besides, the researcher took notes within interviews for important points. The notes were taken into account during the coding process. The texts also contained some embedded quotations that helped ensure the transferability, which is directly dependent on external validity. In addition, data collection and data analysis were conducted simultaneously for improving transferability. An auditing method was used for ensuring the dependability of the research. In this approach, the authors, with provided complimentary comments, cross checked, examined inconsistencies, and addressed them for reaching an agreement. For confirmability improvement, the research team did not allow their values or theoretical inclinations to bias the study and the findings. Results Among the participants, 15 (55.56%) were Female and 12 (44.44%) were Male. The participants were in two groups of headquarters and line employees, 8 people (29.63%) were managers and officials of headquarters units and 19 people (70.37%) were community health workers. The average age of the participants was 44.25 years and they had an average of 16.62 years of work experience (Table 1 ). Table 1 Characteristics of the participants Participant Participants Gender Age, Mean yrs. Education Experience Mean N % M F physician B.S MSc Diploma community health worker Midwife 3 11.11 0 3 39 0 2 1 0 12 Nutritionist 2 7.40 0 2 37 0 1 1 0 10 Psychologist expert 2 7.40 0 2 36 0 0 2 0 11 Health expert 5 18.52 3 2 44 0 4 1 0 18 Behvarz* 3 11.11 2 1 49 0 0 0 3 23 General physician 4 14.82 2 2 48 4 0 0 0 19 Administrator Headquarter managers 4 14.82 3 1 49 3 0 1 0 17 Headquarters expert 4 14.82 2 2 52 0 1 3 0 23 Total Frequency 27 100 12 15 44.25 7 8 9 3 16.62 Percentage 100 44.54 55.56 25.93 29.63 33.33 11.11 *Behvarz: Iranian community health worker ( 35 ), called behvarze in the Farsi language, are local health workers with specialized training in the health needs of the rural population. Behvarzes are selected from the rural areas where they live and are committed to reside in their area for at least 4 years after training ( 36 ). Among the interviewees, 11.11%, 33.33%, 29.63% and 25.93% have diploma, bachelor's degree, master's degree and doctorate in medicine, respectively (Table 1 ). The main solutions for the TOP challenges in providing primary health care from the perspective of health service providers (community health workers) were (Table 2 ): Table 2 main solutions and 10 TOP challenges in providing primary health care for refugees Row challenges solutions 1 language limitations and cultural challenges Hiring and employing trained human resources from among the refugees 2 Lack of identification and health documents Providing identification and health documents to refugees to refer to primary health care centers 3 High rate of movement of their houses and lack of a special comprehensive health center Establishing centers providing primary health care services for refugees 4 Lack of identification and health documents Creating a database to provide primary health care services to refugees 5 lack of a referral system in Iran, especially for refugees and lack of financial resources Designing a referral system to higher levels and providing health insurance to refugees to receive specialized services 6 Lack of health literacy Increasing health literacy by considering the cultural and social background of refugees 7 Different cultural, beliefs and social background of refugees culturalization in refugees to create a desire to receive health services 8 Lack of financial ability to follow the orders of health care providers Financial support for refugees 9 lack of the health laws related to refugees Amending health laws related to refugees 10 Lack of awareness and responsibility regarding individual and collective health Provision of health services centered on refugees The most important challenge raised by the participants is the language limitations and cultural challenges caused by the difference in the life context of the service provider and the refugee as the recipient of the service. An issue that causes a deep understanding of health issues by the service provider to not be formed and access to the expected services does not happen. "We do not understand the conversations of a large number of refugees who refer to the Comprehensive Health Center... Sometimes we understand a small number of words and sometimes we have a wrong understanding of what they said ..."(P.11). Among the solutions presented for this challenge, hiring and employing trained human resources from among nationals in various fields. " ... we have to accept that the health of the resident community is greatly affected by so many refugees in city. We must train forces of these people in universities so that we can use them in providing services to other refugees..."(p.19) Many refugees do not provide identity or health documents such as vaccination card, child growth card for various reasons. "There are cases where a child has been living in Iran for 10 years, but does not have health documents, and the mother and family also do not have information about which health services they have received, and they cause a lot of confusion in the provision and repetition of services" (p.4). "It is better for the first time and when visiting any comprehensive health center to provide documents or health booklets about the provision of services to refugees, so that they can carry them with them in future visits, so that the health service provider is not confused…"(p.9). Refugees live in all parts of Isfahan city and surrounding villages and even slum centers and informal settlements. The rate of movement of their houses in different parts of the city is very high and their accommodation does not have a proper structure. In addition, the lack of a special comprehensive health center has made access difficult for them, and to solve this issue, the interviewees called the establishment of a primary health care service center for refugees as a suitable solution to create geographic access to services. "Establishing PHC centers in the places where refugees live solves many of our concerns. because often come to health centers with infectious diseases that cause fear and anxiety in the resident population. by doing this, we will reduce their contact with other clients of the resident population and reduce the risk of contracting infectious diseases, especially those that are being eliminated and eradicated, such as polio and measles, etc."(p.13). Refugees do not have proper identification and identification documents due to their migration, which is mostly forced and out of fear and worry. They sometimes do not have the exact age of their children to receive services, and in most cases they do not remember the health services (especially vaccinations) they have received. "Refugees, especially Afghan refugees, file cases at every health center they go to, because for various reasons they either lose their case number or forget its code... one of our major problems is the large number of cases It is formed by families in several centers..."(p.24) Basically, refugees are people with little financial resources, which makes them go more to primary health care centers that are completely free. The lack of a referral system in Iran, especially for refugees, and the lack of financial resources in such families to follow up on their health challenges make the problems in refugees chronic and sometimes create more serious challenges for them. "... the clients are out of reach after leaving the health centers and it is very difficult to find them... a system must be designed so that we can track them and trace the process of receiving health services"(p 18). Lack of health literacy among refugees is one of the most important challenges in providing primary health care services. "Some health-related topics are the first time many refugees have heard. For example, I had a client who did not know anything about anemia and thalassemia ... It was the first time that he heard that due to his and his wife's anemia, their child might suffer from a dangerous disease, and before that he did not know at all and did not even want to do the necessary tests..."(p.15). The specific culture of refugees makes them reluctant to receive many services. "One of the most difficult tasks for Afghan refugees who refer to comprehensive health centers is to perform clinical examinations related to women's gynecological diseases and childbirth. They often visit with their wives and do not allow their wives to receive such services..." (p.5). "...many refugees are unwilling to receive vaccines and do not allow their children to receive vaccines. Therefore, many times we see cases of measles, rubella, etc. in refugees ..."(p.16). One of the major challenges mentioned by most of the interviewees was the lack of financial ability among the refugees. " ...we have many cases where a pregnant woman with a high-risk pregnancy to give birth to a thalassemia baby does not come for genetic tests and PND one and two, and they say that we don't have money..."(p.17). It is very necessary to create or amend health-related laws regarding refugees. "The entry of people with diseases such as measles and polio into the country causes all the hard work of the health workers to go to waste, and once again, a large population in the areas of these people's passage must be vaccinated and treated, which brings a lot of cost to the country … Therefore, the rules and regulations should be modified if they exist, and if there are no rules, they should be created so that traffic can be inspected..."(p.2). Improving the sense of responsibility and awareness of refugees towards individual and collective health can be the most obvious benefit from the participation of refugees in their own centered health. "We need to involve the refugees themselves in basic health activities. We should teach them self-care and use active and literate refugee contacts to educate the rest of the population. This issue can increase trust between them and eliminate the linguistic and cultural gap that exists between us and the refugees…"(p.23). Discussion Because the context is very important in terms of the challenges of providing health care to refugees, in this research we focused on the centers with the highest population density of refugees. we interviewed the health care providers who had the most contact and decisions about providing care to refugees. Their work experience (16.62 years) shows their familiarity with how to provide services in this group of population. A population that has significant health needs and faces disparities in its health status, and providing health care to them has become a challenging public health center( 37 ). Topics identified in Branden berger study showed that the specific regional context with legal, financial, geographical and cultural aspects is important( 37 ). Establishing communication and the necessity of language understanding on the part of the provider and recipient of health services and the possibility of exchanging information are challenging issues that were emphasized by the interviewees in the present study and other studies( 38 , 39 ) also emphasized this issue and the difficulty of understanding different languages As an obvious obstacle, they stated that it leads to misunderstanding or lack of understanding( 40 ). Teaching language and communication skills in Iran is very difficult due to the large number of refugees and also their unwillingness. In addition, cultural challenges, which are mentioned as an important obstacle in the provision of health care, have been confirmed in many studies( 37 ). Although studies have mentioned different solutions, in this study, the solution stated by most of the interviewees was the Hiring and employing trained human resources from among the refugees to solve the language and culture problems. In other words On a structural level, confidence and services health care Quality was improved if migrants and refugees were empowered to take control in planning and deciding about the right location of health services for their communities ( 40 ).Also, the Shortages in workforces, which was mentioned by a number of other studies, will also be solved( 41 ). The lack of identification documents and the fear of providing health documents from the country of origin have caused many problems for health personnel in providing health services. Most refugees and their children obviously do not have documentation showing what health services they have previously received. It seems that there was no such challenge in other contexts where studies of this kind have been conducted. But in Isfahan context, the interviewees believed that the best work have Providing identification and health documents to refugees to refer to primary health care centers. Although Brandenberger( 37 ) called the ease of access to health care as one of the solutions for providing continuous and appropriate services, in the present study, the interviewees found the establishment of primary health care service centers for refugees as the best solution to reduce refugee displacement. in the city and the challenges caused by it. A subject that Azizi( 42 ) study confirms and shows that this challenge in the context of developing countries like Iran can be an important obstacle in providing services to refugees. In addition, creating a database to provide primary health care services to refugees is also a suitable solution for people who have forgotten their records or do not have identity documents. One of the most important solutions provided by the interviewees was the Designing a referral system to higher levels and providing health insurance to refugees to receive specialized services. by introducing Family physician specialists and creating Family physician’s teams and also by creating conditions such as limiting access to second-level care and providing health care through the referral route, it is possible to follow patients( 43 ). In this way, providing health insurance to control the ways of receiving health care by refugees in order to improve the quality and improve their health is also necessary and necessary. The issue that the structure and process of providing services in Iran for all levels requires changes, because health care services for refugees are provided according to caring components for Iranians And Azizi study confirms this issue( 42 ). studies also showed that Establishing referral pathway to different services in the healthcare system could direct refugees seekers to appropriate care( 44 ). Increasing health literacy by considering the cultural and social background of refugees is an issue that will increase the willingness of refugees to receive primary health care( 37 ). Farley( 45 ), Johnson( 41 ) and Suurmond( 46 ) mentioned this issue in their studies. In the vision of the United Nations 2030 Sustainable Development Goals (SDGs) is to leave no one behind and to strive for peace and reduction of inequity( 47 ), thus For migrants and refugees, ways to improve health care delivery are detailed by the WHO which include the need for patient-centered and intercultural approaches( 48 ). for this reason and according to the need felt by the interviewees, culture building in refugees and provision of primary health care centered on refugees were two approaches that were suggested in order to better access them to health services and create a desire to receive health services. Financial support for refugees and changes in laws are also important issues to facilitate the provision of services to refugees. Legal factors defined by international, regional and national policies have a major impact on access to health care( 49 ). One of these influential factors is the lack of targeted health policies focusing on the most vulnerable people, especially refugees ( 50 ). The lack of continued financial coverage for refugee and migrant health costs also directly limits the continuity of care provided( 51 ) and can create a large disorganization in all health care for refugees and reduce the performance of the health system( 52 ). most challenges focused on cultural and language barriers, limited skills of providers, and health system inefficiencies that studies of Kavukcu( 44 ), Robertshaw( 53 ), Mudyarabikwa( 54 ) and Warmbein( 55 ) confirm to a large extent the our study results. Conclusion The results of the present study show that facilitating the provision of primary health care to refugees requires very simple measures that should be solved at different levels of decision-making. Involving refugees in the provision of health care through their employment in the health system, giving them a central role in the provision of health services, culturalization through education, identification through legal and cultural acceptance, and also providing identity documents to them, causing more access and Better access of refugees to health services and will prevent new challenges for the resident population. Declarations Ethics approval and consent to participate: Ethical approval was received by Isfahan university of medical sciences ethics committee (Research Ethics Sub Committee research ethics committees of nursing, rehabilitation and management schools- approval number: IR.MUI.NUREMA.REC.1400.164). this study was conducted in accordance with the Declaration of Helsinki, including the requirement of informed consent from participants (Informed consent was obtained from all individual participants included in the study). Consent for publication: Not Applicable Competing interests: The authors declare no competing interests, financial or non-financial. Funding: This manuscript has been derived from a Research project, supported financially by Isfahan University of Medical Sciences (Grant No. 2400163-2021 November 28). Availability of data and materials: Yes Acknowledgment: We express our gratitude to all the experts and researchers who took part in this study. Authors' contributions: MA, SB; participated equally in Study design, data collection and analysis, manuscript preparation. Authors have read and approved the manuscript. References Zimmermann A, Dörschner J, Machts F. The 1951 Convention relating to the status of refugees and its 1967 protocol: A commentary. Oxford University Press; 2011. Davies S. Convention Relating To The Status Of Refugees (189 UNTS 150). Legitimising Rejection: Brill Nijhoff; 2008. pp. 233–48. Ben-Yehuda H, Goldstein R. 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Telemedicine: bridging the gap between refugee Health and Health services accessibility in Hamilton, Ontario. Refuge. 2016;32:108. Omeri A, Lennings C, Raymond L. Beyond asylum: implications for nursing and health care delivery for Afghan refugees in Australia. J Transcult Nurs. 2006;17(1):30–9. Johnson DR, Burgess T, Ziersch AM. I don't think general practice should be the front line: Experiences of general practitioners working with refugees in South Australia. Australia New Z health policy. 2008;5(1). Azizi N, Delgoshaei B, Aryankhesal A. Barriers and facilitators of providing primary health care to Afghan refugees: A qualitative study from the perspective of health care providers. Med J Islamic Repub Iran. 2021;35:1. Kiani MM, Khanjankhani K, Shirvani M, Ahmadi B. Strengthening the Primary Health Care System in Iran: A Comprehensive Review Study. J School Public Health Inst Public Health Res. 2020;18(2):121–38. Kavukcu N, Altıntaş KH. The challenges of the health care providers in refugee settings: a systematic review. Prehosp Disaster Med. 2019;34(2):188–96. Farley R, Askew D, Kay M. Caring for refugees in general practice: perspectives from the coalface. Aust J Prim Health. 2014;20(1):85–91. Suurmond J, Rupp I, Seeleman C, Goosen S, Stronks K. The first contacts between healthcare providers and newly-arrived asylum seekers: a qualitative study about which issues need to be addressed. Public Health. 2013;127(7):668–73. WHO. Promoting migrant health – striving for peace and decent life for all Geneva: World Health Organization(WHO). 2017 [Available from: https://www.who.int/director-general/speeches/detail/promoting-migrant-health-striving-for-peace-and-decent-life-for-all Jaeger FN, Kiss L, Hossain M, Zimmerman C. Migrant-friendly hospitals: a paediatric perspective-improving hospital care for migrant children. BMC Health Serv Res. 2013;13:1–14. Rosano A, Dauvrin M, Buttigieg SC, Ronda E, Tafforeau J, Dias S. Migrant’s access to preventive health services in five EU countries. BMC Health Serv Res. 2017;17(1):1–11. Razum O, Wenner J, Bozorgmehr K. When chance decides about access to Health care: the case of refugees in Germany. Gesundheitswesen (Bundesverband der Arzte des Offentlichen Gesundheitsdienstes (Germany)). 2016;78(11):711–4. Rink N, Muttalib F, Morantz G, Chase L, Cleveland J, Rousseau C, et al. The gap between coverage and care—what can Canadian paediatricians do about access to health services for refugee claimant children? Paediatr Child Health. 2017;22(8):430–7. Bozorgmehr K, Samuilova M, Petrova-Benedict R, Girardi E, Piselli P, Kentikelenis A. Infectious disease health services for refugees and asylum seekers during a time of crisis: a scoping study of six European Union countries. Health Policy. 2019;123(9):882–7. Robertshaw L, Dhesi S, Jones LL. Challenges and facilitators for health professionals providing primary healthcare for refugees and asylum seekers in high-income countries: a systematic review and thematic synthesis of qualitative research. BMJ Open. 2017;7(8):e015981. Mudyarabikwa O, Regmi K, Ouillon S, Simmonds R. Refugee and Immigrant Community Health Champions: a Qualitative Study of Perceived Barriers to Service Access and Utilisation of the National Health Service (NHS) in the West Midlands, UK. J Immigr Minor Health. 2022;24(1):199–206. Warmbein A, Beiersmann C, Eulgem A, Demir J, Neuhann F. Challenges in health care services for refugees in Cologne, Germany: A providers’ perspective using a mixed-methods approach. J Migration Health. 2023;7:100158. Additional Declarations No competing interests reported. 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definition of the term Refugee. However, the Convention Relating to the Status of Refugees defines (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) an Refugee(s) as; \"A person who, owing to a well-grounded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality, and is unable, or owing to such fear, is unwilling to avail himself of the protection of that country, or who not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or owing to such fear, is unwilling to return to it\" (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eGlobally, the number of immigrants, including refugees, asylum-seekers and displaced persons, is continuously increasing, from 70.8\u0026nbsp;million people in 2019 to 108.4\u0026nbsp;million people in 2022, confirming this unprecedented increase (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Over half of all refugees (52%) under UNHCR\u0026rsquo;s mandate and other people in need of international protection come from just Syrian Arab Republic (6.8\u0026nbsp;million), Ukraine (5.7\u0026nbsp;million) and Afghanistan (5.7\u0026nbsp;million) countries. also, at the end of 2022, of the 108.4\u0026nbsp;million forcibly displaced people, an estimated 43.3\u0026nbsp;million (40 per cent) are children below 18 years of age. In addition to 1.9\u0026nbsp;million children were born as refugees, In this sense that between 2018 and 2022, an average of 385,000 children were born as refugees per year (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). 38% of all refugees hosted in five countries. Turkey with 3.6\u0026nbsp;million people, followed by the Islamic Republic of Iran with 3.4\u0026nbsp;million people the hosts largest numbers of refugees. It is followed by Colombia, Germany and Pakistan. Also 70 per cent of refugees and other people in need of international protection lived in countries neighboring their countries of origin (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). According to the latest data received from the Government of the Islamic Republic in December 2022, 762,000 refugees currently reside in Iran, out of which some 750,000 are indicated to be Afghan Amayesh cardholders and some 12,000 Iraqi identity cardholders. 586,000 Afghan passport holders with Iranian visas also live in Iran. These are official statistics, but the evidence shows that more than 4.5\u0026nbsp;million Afghans became refugees in Iran. 99% of refugees live in urban areas alongside the host community, while 1% live in refugee settlements (\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn Iran, as a result of the government's progressive and comprehensive policies, refugees have been given the opportunity to access education, health and livelihood, which not only helped them survive but also helped them progress (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The growing trend of immigration is reflected by the demand to change the direction of health policies to better protect the health of refugees (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe issue of refugee health has expanded from special care to health promotion and disease prevention (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). refugee's health is a very dynamic and complex issue and includes different stages of migration, from before departure to early and late migration (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). In addition, this issue is completely intertwined with several social factors, which are related not only to the characteristics (e.g., different gender roles, cultural diversity, immigration experiences and adverse legal status) of refugees, but also to the context of the countries of destination of refugees (such as health systems and unique cultural values) (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Health care that is universally and equitably accessible must be provided to refugees in a wide range of national contexts and in response to the complex and evolving needs of the individual. In order to identify barriers to access to health care and better planning to make the necessary changes, it is important to look at the available evidence in the field of providing and accessing health care services for refugees (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The reviewed literature confirms that despite the desire to ensure equality of access to health care, there is evidence of persistent inequalities between refugees and non-immigrants in access to health care services (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe rapidly changing political situation in different countries of the world, the global financial crisis along with the growing consequences of climate change are affecting migration patterns. In the meantime, the access of refugees and refugees to adequate health services has continuously faced obstacles (\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). These barriers can include regulations limiting access to health care based on legal status, language and cultural barriers, lack of information about where and how to receive care, Economic barriers and lack of cultural competence among health service providers(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), low health literacy (\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), beliefs (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e), language and communication barriers (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), low-income status, race (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan additionalcitationids=\"CR26 CR27 CR28\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), limited trust of health service providers (\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eConsidering the importance and necessity of providing primary health care for all people regardless of their color, race and nationality, identifying the challenges of providing primary care to refugees in host countries, especially middle- and low-income countries, in line with universal health coverage and reducing the inequality in health in this vulnerable group seems necessary. Therefore, this study was conducted in order to identify practical solutions to the challenges of providing primary health care to refugees in the Iran context.\u003c/p\u003e\n\u003ch3\u003eContext of providing primary health care to refugees in Iran:\u003c/h3\u003e\n\u003cp\u003eProviding healthcare services to refugees is similar to Iranians. Paying attention to human, religious values and human dignity has caused the continuation of service to these groups. It is very valuable to mention that the healthcare services provided to this population are provided completely free of charge. In the villages of Iran, refugees go to health centers and basic health care is provided to them by Behvarz and general practitioners. Also, in cities, they receive these cares in health centers and from the health team. An electronic health record is created for them, and if they need more specialized services, they are referred to rural/urban health centers through GP, and through that, they are referred to hospitals and province health centers.\u003c/p\u003e\u003cp\u003eAll services such as vaccination, mother and child care, pregnancy, control and prevention of communicable diseases, old age care and various screenings such as deafness/hearing loss, diabetes, high blood pressure, thalassemia, PKU and hundreds of other cares It is done for refugees (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e"},{"header":"Material and methods","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003eData collection:\u003c/h2\u003e\u003cp\u003eTo identify the Solutions for Challenges of providing primary health care to refugees in Iran, we conducted a qualitative descriptive study. The research was conducted from November 2022 to May 2023. Within emphasis on maximum variation, purposive sampling was used for selecting the interviewees. The criterion used for this purpose was having work experience as a community health worker. The participants were from local, provincial (community health centers and province health district) levels. Snowball sampling was employed within the interviews for identifying all informants. Overall, 27 interviews were done, with 19 and 8 interviews at local and province levels, respectively.\u003c/p\u003e\u003cp\u003e The participants are as representatives of the Isfahan University of Medical Sciences, which primary health care services. The participants had the following organizational positions: primary health care providers (community health worker (Midwife, Nutritionist, Psychologist, Health expert, Behvarz, General physician (GP)), managers (Headquarter managers and Headquarters expert). The majority of respondents had direct experiences (minimum 10 years) concerning primary health care provide. All respondents completed a written informed consent form and they were ensured about the confidentiality and anonymity of their information.\u003c/p\u003e\u003cp\u003eAn interview guide was formulated according to a review of the related literature and it was ensured that all relevant challenges would be recognized.(Supplementary File 1). First, two interviews were conducted as the pilot testing of the interview guide. Accordingly, some modifications were made to adjust the other interviews. First, the interviewees were contacted through email or phone, and they were informed on the research topic, research objectives, and justification for the necessity of this work. After accepting the interview meeting by informants, they were interviewed in their office or any other place suggested by them. A member of the research team (SB) who is skilled for a qualitative study, were conducted interviews applying the interview guide.\u003c/p\u003e\u003cp\u003eThe interviewer's information, including his academic position and the subject area of expertise, was explained to interviewees. Interviews were mostly audio-recorded, anonymized, and later were transcribed accurately. All participants were willing to interview while audio recording. Also, some notes were taken by the interviewer and were shared with the research team for discussing preliminary results, complications, and any corrections required in the interview guide. Interviews were conducted as long as reaching a saturation point, exceeding which no more data was needed. Thus, two new interviews were also conducted. Overall, we conducted twenty-seven semi-structured face-to-face interviews.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eAnalysis:\u003c/h3\u003e\n\u003cp\u003eThe present study used conventional content analysis (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) with an inductive data-driven process coding and theme development for the analysis (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). The interviews were reviewed several times for inferring a list of inductive themes. At the same time, deductive themes were recognized directly.\u003c/p\u003e\u003cp\u003eThe conventional content analysis was conducted as follows: In the first step, two authors independently coded data collected. They read and re-read the transcribed documents and listened to audio-recorded interviews for immersion in data. In the next step, primary themes were extracted from the obtained data and reviewed by the team members. The team members held a meeting to elaborate on conflicts and controversial points and reach an agreement on emerging themes. They continued discussion until addressing all the controversies. Then, themes and sub-themes were specified. In the last step, team members reviewed, modified, and collated coded statements. The duration of interviews varied between 50 to 75 minutes. MAXQDA Analytics Pro 2020 (VERBI GmbH Berlin) Release 20.2.1 was used to manage and organize the transcripts systematically.\u003c/p\u003e\n\u003ch3\u003eQuality Assurance:\u003c/h3\u003e\n\u003cp\u003eTrustworthiness was ensured using the criteria proposed by Lincoln and Guba (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Also, a documented guide was constructed to enhance the credibility of sampling, interviews, and analysis. Besides, the researcher took notes within interviews for important points. The notes were taken into account during the coding process. The texts also contained some embedded quotations that helped ensure the transferability, which is directly dependent on external validity. In addition, data collection and data analysis were conducted simultaneously for improving transferability. An auditing method was used for ensuring the dependability of the research. In this approach, the authors, with provided complimentary comments, cross checked, examined inconsistencies, and addressed them for reaching an agreement. For confirmability improvement, the research team did not allow their values or theoretical inclinations to bias the study and the findings.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAmong the participants, 15 (55.56%) were Female and 12 (44.44%) were Male. The participants were in two groups of headquarters and line employees, 8 people (29.63%) were managers and officials of headquarters units and 19 people (70.37%) were community health workers. The average age of the participants was 44.25 years and they had an average of 16.62 years of work experience (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristics of the participants\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"12\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u003cp\u003eParticipant\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eParticipants\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAge, Mean yrs.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c11\" namest=\"c8\"\u003e\u003cp\u003eEducation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c12\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eExperience Mean\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eF\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003ephysician\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eB.S\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003eMSc\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c11\"\u003e\u003cp\u003eDiploma\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003ecommunity health worker\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMidwife\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNutritionist\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePsychologist expert\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHealth expert\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBehvarz*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGeneral physician\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAdministrator\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHeadquarter managers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHeadquarters expert\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFrequency\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e44.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e16.62\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePercentage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e44.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e55.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e25.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e29.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e33.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e11.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"12\" nameend=\"c12\" namest=\"c1\"\u003e\u003cp\u003e*Behvarz: Iranian community health worker (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e), called\u0026nbsp;\u003cem\u003ebehvarze\u003c/em\u003e\u0026nbsp;in the Farsi language, are local health workers with specialized training in the health needs of the rural population.\u0026nbsp;\u003cem\u003eBehvarzes\u003c/em\u003e\u0026nbsp;are selected from the rural areas where they live and are committed to reside in their area for at least 4 years after training (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAmong the interviewees, 11.11%, 33.33%, 29.63% and 25.93% have diploma, bachelor's degree, master's degree and doctorate in medicine, respectively (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe main solutions for the TOP challenges in providing primary health care from the perspective of health service providers (community health workers) were (Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e):\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003emain solutions and 10 TOP challenges in providing primary health care for refugees\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRow\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003echallenges\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003esolutions\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003elanguage limitations and cultural challenges\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHiring and employing trained human resources from among the refugees\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLack of identification and health documents\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProviding identification and health documents to refugees to refer to primary health care centers\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHigh rate of movement of their houses and lack of a special comprehensive health center\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEstablishing centers providing primary health care services for refugees\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLack of identification and health documents\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCreating a database to provide primary health care services to refugees\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003elack of a referral system in Iran, especially for refugees and lack of financial resources\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDesigning a referral system to higher levels and providing health insurance to refugees to receive specialized services\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLack of health literacy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIncreasing health literacy by considering the cultural and social background of refugees\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDifferent cultural, beliefs and social background of refugees\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eculturalization in refugees to create a desire to receive health services\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLack of financial ability to follow the orders of health care providers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFinancial support for refugees\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003elack of the health laws related to refugees\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAmending health laws related to refugees\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLack of awareness and responsibility regarding individual and collective health\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProvision of health services centered on refugees\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe most important challenge raised by the participants is the language limitations and cultural challenges caused by the difference in the life context of the service provider and the refugee as the recipient of the service. An issue that causes a deep understanding of health issues by the service provider to not be formed and access to the expected services does not happen.\u003c/p\u003e\u003cp\u003e\"We do not understand the conversations of a large number of refugees who refer to the Comprehensive Health Center... Sometimes we understand a small number of words and sometimes we have a wrong understanding of what they said ...\"(P.11).\u003c/p\u003e\u003cp\u003eAmong the solutions presented for this challenge, hiring and employing trained human resources from among nationals in various fields.\u003c/p\u003e\u003cp\u003e\" ... we have to accept that the health of the resident community is greatly affected by so many refugees in city. We must train forces of these people in universities so that we can use them in providing services to other refugees...\"(p.19)\u003c/p\u003e\u003cp\u003eMany refugees do not provide identity or health documents such as vaccination card, child growth card for various reasons.\u003c/p\u003e\u003cp\u003e\"There are cases where a child has been living in Iran for 10 years, but does not have health documents, and the mother and family also do not have information about which health services they have received, and they cause a lot of confusion in the provision and repetition of services\" (p.4).\u003c/p\u003e\u003cp\u003e\"It is better for the first time and when visiting any comprehensive health center to provide documents or health booklets about the provision of services to refugees, so that they can carry them with them in future visits, so that the health service provider is not confused\u0026hellip;\"(p.9).\u003c/p\u003e\u003cp\u003eRefugees live in all parts of Isfahan city and surrounding villages and even slum centers and informal settlements. The rate of movement of their houses in different parts of the city is very high and their accommodation does not have a proper structure. In addition, the lack of a special comprehensive health center has made access difficult for them, and to solve this issue, the interviewees called the establishment of a primary health care service center for refugees as a suitable solution to create geographic access to services.\u003c/p\u003e\u003cp\u003e\"Establishing PHC centers in the places where refugees live solves many of our concerns. because often come to health centers with infectious diseases that cause fear and anxiety in the resident population. by doing this, we will reduce their contact with other clients of the resident population and reduce the risk of contracting infectious diseases, especially those that are being eliminated and eradicated, such as polio and measles, etc.\"(p.13).\u003c/p\u003e\u003cp\u003eRefugees do not have proper identification and identification documents due to their migration, which is mostly forced and out of fear and worry. They sometimes do not have the exact age of their children to receive services, and in most cases they do not remember the health services (especially vaccinations) they have received.\u003c/p\u003e\u003cp\u003e\"Refugees, especially Afghan refugees, file cases at every health center they go to, because for various reasons they either lose their case number or forget its code... one of our major problems is the large number of cases It is formed by families in several centers...\"(p.24)\u003c/p\u003e\u003cp\u003eBasically, refugees are people with little financial resources, which makes them go more to primary health care centers that are completely free. The lack of a referral system in Iran, especially for refugees, and the lack of financial resources in such families to follow up on their health challenges make the problems in refugees chronic and sometimes create more serious challenges for them.\u003c/p\u003e\u003cp\u003e\"... the clients are out of reach after leaving the health centers and it is very difficult to find them... a system must be designed so that we can track them and trace the process of receiving health services\"(p 18).\u003c/p\u003e\u003cp\u003eLack of health literacy among refugees is one of the most important challenges in providing primary health care services.\u003c/p\u003e\u003cp\u003e\"Some health-related topics are the first time many refugees have heard. For example, I had a client who did not know anything about anemia and thalassemia ... It was the first time that he heard that due to his and his wife's anemia, their child might suffer from a dangerous disease, and before that he did not know at all and did not even want to do the necessary tests...\"(p.15).\u003c/p\u003e\u003cp\u003eThe specific culture of refugees makes them reluctant to receive many services.\u003c/p\u003e\u003cp\u003e\"One of the most difficult tasks for Afghan refugees who refer to comprehensive health centers is to perform clinical examinations related to women's gynecological diseases and childbirth. They often visit with their wives and do not allow their wives to receive such services...\" (p.5).\u003c/p\u003e\u003cp\u003e\"...many refugees are unwilling to receive vaccines and do not allow their children to receive vaccines. Therefore, many times we see cases of measles, rubella, etc. in refugees ...\"(p.16).\u003c/p\u003e\u003cp\u003eOne of the major challenges mentioned by most of the interviewees was the lack of financial ability among the refugees.\u003c/p\u003e\u003cp\u003e\" ...we have many cases where a pregnant woman with a high-risk pregnancy to give birth to a thalassemia baby does not come for genetic tests and PND one and two, and they say that we don't have money...\"(p.17).\u003c/p\u003e\u003cp\u003eIt is very necessary to create or amend health-related laws regarding refugees.\u003c/p\u003e\u003cp\u003e\"The entry of people with diseases such as measles and polio into the country causes all the hard work of the health workers to go to waste, and once again, a large population in the areas of these people's passage must be vaccinated and treated, which brings a lot of cost to the country \u0026hellip; Therefore, the rules and regulations should be modified if they exist, and if there are no rules, they should be created so that traffic can be inspected...\"(p.2).\u003c/p\u003e\u003cp\u003eImproving the sense of responsibility and awareness of refugees towards individual and collective health can be the most obvious benefit from the participation of refugees in their own centered health.\u003c/p\u003e\u003cp\u003e\"We need to involve the refugees themselves in basic health activities. We should teach them self-care and use active and literate refugee contacts to educate the rest of the population. This issue can increase trust between them and eliminate the linguistic and cultural gap that exists between us and the refugees\u0026hellip;\"(p.23).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eBecause the context is very important in terms of the challenges of providing health care to refugees, in this research we focused on the centers with the highest population density of refugees. we interviewed the health care providers who had the most contact and decisions about providing care to refugees. Their work experience (16.62 years) shows their familiarity with how to provide services in this group of population. A population that has significant health needs and faces disparities in its health status, and providing health care to them has become a challenging public health center(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTopics identified in Branden berger study showed that the specific regional context with legal, financial, geographical and cultural aspects is important(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Establishing communication and the necessity of language understanding on the part of the provider and recipient of health services and the possibility of exchanging information are challenging issues that were emphasized by the interviewees in the present study and other studies(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e) also emphasized this issue and the difficulty of understanding different languages As an obvious obstacle, they stated that it leads to misunderstanding or lack of understanding(\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Teaching language and communication skills in Iran is very difficult due to the large number of refugees and also their unwillingness. In addition, cultural challenges, which are mentioned as an important obstacle in the provision of health care, have been confirmed in many studies(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Although studies have mentioned different solutions, in this study, the solution stated by most of the interviewees was the Hiring and employing trained human resources from among the refugees to solve the language and culture problems. In other words On a structural level, confidence and services health care Quality was improved if migrants and refugees were empowered to take control in planning and deciding about the right location of health services for their communities (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e).Also, the Shortages in workforces, which was mentioned by a number of other studies, will also be solved(\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe lack of identification documents and the fear of providing health documents from the country of origin have caused many problems for health personnel in providing health services. Most refugees and their children obviously do not have documentation showing what health services they have previously received. It seems that there was no such challenge in other contexts where studies of this kind have been conducted. But in Isfahan context, the interviewees believed that the best work have Providing identification and health documents to refugees to refer to primary health care centers.\u003c/p\u003e\u003cp\u003eAlthough Brandenberger(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) called the ease of access to health care as one of the solutions for providing continuous and appropriate services, in the present study, the interviewees found the establishment of primary health care service centers for refugees as the best solution to reduce refugee displacement. in the city and the challenges caused by it. A subject that Azizi(\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e) study confirms and shows that this challenge in the context of developing countries like Iran can be an important obstacle in providing services to refugees. In addition, creating a database to provide primary health care services to refugees is also a suitable solution for people who have forgotten their records or do not have identity documents.\u003c/p\u003e\u003cp\u003eOne of the most important solutions provided by the interviewees was the Designing a referral system to higher levels and providing health insurance to refugees to receive specialized services. by introducing Family physician specialists and creating Family physician\u0026rsquo;s teams and also by creating conditions such as limiting access to second-level care and providing health care through the referral route, it is possible to follow patients(\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). In this way, providing health insurance to control the ways of receiving health care by refugees in order to improve the quality and improve their health is also necessary and necessary.\u003c/p\u003e\u003cp\u003eThe issue that the structure and process of providing services in Iran for all levels requires changes, because health care services for refugees are provided according to caring components for Iranians And Azizi study confirms this issue(\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). studies also showed that Establishing referral pathway to different services in the healthcare system could direct refugees seekers to appropriate care(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Increasing health literacy by considering the cultural and social background of refugees is an issue that will increase the willingness of refugees to receive primary health care(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Farley(\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e), Johnson(\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e) and Suurmond(\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e) mentioned this issue in their studies.\u003c/p\u003e\u003cp\u003eIn the vision of the United Nations 2030 Sustainable Development Goals (SDGs) is to leave no one behind and to strive for peace and reduction of inequity(\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e), thus For migrants and refugees, ways to improve health care delivery are detailed by the WHO which include the need for patient-centered and intercultural approaches(\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). for this reason and according to the need felt by the interviewees, culture building in refugees and provision of primary health care centered on refugees were two approaches that were suggested in order to better access them to health services and create a desire to receive health services.\u003c/p\u003e\u003cp\u003eFinancial support for refugees and changes in laws are also important issues to facilitate the provision of services to refugees. Legal factors defined by international, regional and national policies have a major impact on access to health care(\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). One of these influential factors is the lack of targeted health policies focusing on the most vulnerable people, especially refugees (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). The lack of continued financial coverage for refugee and migrant health costs also directly limits the continuity of care provided(\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e) and can create a large disorganization in all health care for refugees and reduce the performance of the health system(\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). most challenges focused on cultural and language barriers, limited skills of providers, and health system inefficiencies that studies of Kavukcu(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e), Robertshaw(\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e), Mudyarabikwa(\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e) and Warmbein(\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e) confirm to a large extent the our study results.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe results of the present study show that facilitating the provision of primary health care to refugees requires very simple measures that should be solved at different levels of decision-making. Involving refugees in the provision of health care through their employment in the health system, giving them a central role in the provision of health services, culturalization through education, identification through legal and cultural acceptance, and also providing identity documents to them, causing more access and Better access of refugees to health services and will prevent new challenges for the resident population.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was received by Isfahan university of medical sciences ethics committee (Research Ethics Sub Committee research ethics committees of nursing, rehabilitation and management schools- approval number: IR.MUI.NUREMA.REC.1400.164). this study was conducted in accordance with the Declaration of Helsinki, including the requirement of informed consent from participants (Informed consent was obtained from all individual participants included in the study).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests, financial or non-financial.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis manuscript has been derived from a Research project, supported financially by Isfahan University of Medical Sciences (Grant No. 2400163-2021 November 28).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe express our gratitude to all the experts and researchers who took part in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMA, SB; participated equally in Study design, data collection and analysis, manuscript preparation. Authors have read and approved the manuscript.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eZimmermann A, D\u0026ouml;rschner J, Machts F. The 1951 Convention relating to the status of refugees and its 1967 protocol: A commentary. Oxford University Press; 2011.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDavies S. Convention Relating To The Status Of Refugees (189 UNTS 150). Legitimising Rejection: Brill Nijhoff; 2008. pp. 233\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBen-Yehuda H, Goldstein R. Forced Migration Magnitude and violence in international crises: 1945\u0026ndash;2015. J Refugee Stud. 2020;33(2):336\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUNHCR\u0026rsquo;s Refugee Population Statistics Database [Internet]. The United Nations High Commissioner for Refugees. 2022 [cited 06/2023]. 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J School Public Health Inst Public Health Res. 2020;18(2):121\u0026ndash;38.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKavukcu N, Altıntaş KH. The challenges of the health care providers in refugee settings: a systematic review. Prehosp Disaster Med. 2019;34(2):188\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFarley R, Askew D, Kay M. Caring for refugees in general practice: perspectives from the coalface. Aust J Prim Health. 2014;20(1):85\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSuurmond J, Rupp I, Seeleman C, Goosen S, Stronks K. The first contacts between healthcare providers and newly-arrived asylum seekers: a qualitative study about which issues need to be addressed. Public Health. 2013;127(7):668\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWHO. 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Challenges in health care services for refugees in Cologne, Germany: A providers\u0026rsquo; perspective using a mixed-methods approach. J Migration Health. 2023;7:100158.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Immigrant, Refugees, Challenges, Primary Health Care","lastPublishedDoi":"10.21203/rs.3.rs-7348196/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7348196/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThe existing challenges in the provision of primary health care (PHC) to refugees is an important issue in governments agendas.\u003c/p\u003e\u003ch2\u003eObjectives\u003c/h2\u003e\u003cp\u003ewe aimed to identify the most important challenges and corresponding solutions to facilitate PHC delivery for refuges in Iran.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e\u003cp\u003eIn this descriptive qualitative study, purposive sampling was used for selecting Participants. Semi-structured interviews were conducted for data collection. Interviews were continued as long as the saturation point was achieved at the 27 st interview. conventional content analysis using an inductive data-driven coding process and theme development used for analyzing the data.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eWe extracted the top challenges and solutions. challenges including: language limitations and cultural challenges, Lack of identification and health documents, High rate of movement of their houses and lack of a special comprehensive health center, Lack of identification and health documents, lack of a referral system in Iran, especially for refugees and lack of financial resources, Lack of health literacy, Different cultural, beliefs and social background of refugees, Lack of financial ability to follow the orders of health care providers, lack of the health laws related to refugees, Lack of awareness and responsibility regarding individual and collective health. Accordingly, corresponding solutions were identified.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003ewe conclude that facilitating PHC delivering for refugees requires taking solutions in areas of economic, social, cultural and political with the consideration of inter-sectoral collaboration.\u003c/p\u003e","manuscriptTitle":"TOP Solutions for facilitating primary health care delivery for refugees in Iran: a qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-30 04:37:26","doi":"10.21203/rs.3.rs-7348196/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"187088779429795646797143404420031323974","date":"2025-09-29T15:27:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"2074453507121234263289685234911162259","date":"2025-09-21T19:47:48+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-19T08:00:13+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-16T04:29:20+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-28T07:08:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-27T04:40:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-08-25T21:08:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"234ef19e-1f2d-4c6e-beff-251da3d0991b","owner":[],"postedDate":"September 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-30T04:37:26+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-30 04:37:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7348196","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7348196","identity":"rs-7348196","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}