"If I have a cancer, it is not my fault I am a refugee”: A qualitative study with expert stakeholders on cancer care management for Syrian refugees in Jordan

Autoři: Manar Marzouk aff001;  Maureen Kelley aff002;  Ibtihal Fadhil aff003;  Slim Slama aff003;  Kajsa-Stina Longuere aff001;  Proochista Ariana aff001;  Gail Carson aff001;  Vicki Marsh aff001
Působiště autorů: Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom aff001;  Ethox Centre and Wellcome Centre for Ethics & Humanities, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom aff002;  WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt aff003;  KEMRI Wellcome Trust Research Programme, Kilifi, Kenya aff004
Vyšlo v časopise: PLoS ONE 14(9)
Kategorie: Research Article
prolekare.web.journal.doi_sk: 10.1371/journal.pone.0222496



Noncommunicable diseases including cancer are widespread amongst the 5.6 million Syrian refugees currently hosted in the Middle East. Given its prevalence as the third leading cause of death in Syria, cancer is likely to be an important health burden among Syrian refugees. Against this background, our aim was to describe the clinical, ethical and policy decision-making experiences of health actors working within the current refugee cancer care system; the impact of refugee cancer care health policies on health care providers and policy makers in this context; and provide suggestions for the way delivery of care should be optimised in a sustained emergency situation.


From April-July 2016, we conducted in-depth interviews with 12 purposively sampled health officials and health care workers from the Jordanian Ministry of Health, multilateral donors and international non-governmental organisations. Data were analysed using a framework analysis approach to identify systemic, practical and ethical challenges to optimising care for refugees, through author agreement on issues emerging from the data and those linked more directly to areas of questioning.


As has been previously reported, central challenges for policy makers and health providers were the lack of quality cancer prevalence data to inform programming and care delivery for this refugee population, and insufficient health resource allocation to support services. In addition, limited access to international funding for the host country, the absence of long-term funding schemes, and barriers to coordination between institutions and frontline clinicians were seen as key barriers. In this context where economic priorities inevitably drive decision-making on public health policy and individual care provision, frontline healthcare workers and policy makers experienced significant moral distress where duties of care and humanitarian values were often impossible to uphold.


Our findings confirm and expand understanding of the challenges involved in resource allocation decisions for cancer care in refugee populations, and highlight these for the particular situation of long term Syrian refugees in Jordan. The insights offered by frontline clinicians and policy makers in this context reveal the unintended personal and moral impact of resource allocation decisions. With many countries facing similar challenges in the provision of cancer care for refugees, the lessons learned from Jordan suggest key areas for policy revision and international investment in developing cancer care policies for refugees internationally.

Klíčová slova:

Cancer treatment – Emotions – Global health – Health care policy – Health care providers – Mental health and psychiatry – Public and occupational health – Patient advocacy


1. UNHCR. Syrian Regional Refugee Response. 2018. [online] http://data.unhcr.org/syrianrefugees/regional.php

2. UN High Commissioner for Refugees (UNHCR), Jordan. Operational Portal-refugee situations. 11 March 2019. [online] https://data2.unhcr.org/en/situations/syria/location/36.

3. World Health Organisation. Jordan Statistics. 2016. [online] https://www.who.int/countries/jor/en/

4. Medecins Sans Frontieres. A Silent Crisis: Treating Noncommunicable Diseases in Jordan. 13 May 2015. [online] https://www.doctorswithoutborders.org/what-we-do/news-stories/story/silent-crisis-treating-non-communicable-diseases-jordan.

5. World Health Organisation (WHO). Syrian Arab Republic: WHO statistical profile. 2015. [online] http://www.who.int/gho/countries/syr.pdf?ua=1.

6. Spiegel P, Khalifa A, Mateen F J. Cancer in refugees in Jordan and Syria between 2009 and 2012: challenges and the way forward in humanitarian emergencies. The Lancet Oncology

7. WHO (World Health Organization). Syrian Arab Republic: Cancer Country Profile. 2014. [online] www.who.int/cancer/country-profiles/syr_en.pdf.

8. Leaning J, Spiegel P, Crisp J. Public health equity in refugee situations. Conflict and Health. 2011. doi: 10.1186/1752-1505-5-6 21575218

9. UNOCHA. About the Crisis. 2017. [online] http://www.unocha.org/syrian-arab-republic/syria-country-profile/about-crisis. [Accessed August 2017]

10. World Bank. World Bank country and lending group. 2018. [online] https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups.

11. World Health Organisation. Deffinition of regional groupings. 2018. [online] http://www.who.int/healthinfo/global_burden_disease/definition_regions/en/

12. Abdel-Razeq H, Attiga F, Mansour A. Cancer Care in Jordan. Hematol Cell Ther. 2015. [online] https://doi.org/10.1016/j.hemonc.2015.02.001

13. UNHCR. Health Access and Utilization Survey. 2017. [online] https://reliefweb.int/report/jordan/health-access-and-utilization-survey-access-health-services-jordan-among-syrian-0

14. King Hussein Cancer Center. Frequently Asked Questions. [online] http://www.khcc.jo/ar/section/إذا-كنت-بحاجة-إلى-مساعدة-مالية. [Accessed April 2019]

15. Amnesty International. Jordan 2016/2017. 2017. [online] https://www.amnesty.org/en/countries/middle-east-and-north-africa/jordan/report-jordan/. [Accessed August 2017]

16. NRC. Securing Status: Syrian refugees and the documentation of legal status, identity, and family relationships in Jordan. 2016. [online] https://www.nrc.no/globalassets/pdf/reports/securing-status.pdf.

17. International Labour Organisation. Refugees right to work in Jordan, a view of the Syrian refugee crisis through labour law and policy. data.unhcr.org/syrianrefugees/download.php?id = 8394.

18. UNHCR. The 1951 Convention and its 1967 Protocol. 1967. [online] www.unhcr.org/3b66c2aa10.pdf.

19. Medecins Sans Frontieres. Jordan: MSF opens new clinic treating chronic diseases close to Syrian border. 31 March 2016. [online] http://www.msf.org/en/article/jordan-msf-opens-new-clinic-treating-chronic-diseases-close-syrian-border. Published 2016. Accessed July 23, 2016.

20. UNHCR. Guide to UNHCR Supported Health Care Services in Jordan. [online] data.unhcr.org/syrianrefugees/download.php?id = 2862.

21. UNHCR & JHAS. Jordan Medical Referrals at a Glance Year End Report. 2016. [online] data.unhcr.org/syrianrefugees/download.php?id = 13386.

22. UNHCR. Global Trends, Forced Displacement in 2015. 2016. [online] www.unhcr.org/576408cd7.pdf.

23. Morrison T B, Flynn PM, Weaver A L, Wieland M L. Cervical cancer screening adherence among Somali immigrants and refugees to the United States. Health Care for Women International. 2013. doi: 10.1080/07399332.2013.770002 23659268

24. Sandelowski M. Sample size in qualitative research. 1995. Research in Nursing and Health, 18: 179–183. doi: 10.1002/nur.4770180211 7899572

25. Patton MQ. Qualitative research and evaluation methods (3rd ed.). Thousand Oaks, CA: Sage (2002).

26. Kvale S, Brinkmann S. Learning the Craft of Quaitative Research Interviewing. 2009. SAGE.

27. Green J, Thorogood N. Qualitative methods for health research. SAGE Publications. 2009.

28. Mason M. Sample size and saturation in PhD studies using qualitative interviews. Forum: Qualitative Social Research, 11(3) [Article No. 8]. 2010.

29. Morse J M. The significance of saturation. Qualitative Health Research, 5, 147–149. 1995.

30. Crisp J. Syrian’s Refugees: A global responsibility. Refugee Studies Centre. 2015. [online] https://www.rsc.ox.ac.uk/news/syria2019s-refugees-a-global-responsibility.

31. WHO (World Health Organization). Regional Situation Report, January 2015- WHO response to the Syrian crisis. 2015. [online] www.who.int/hac/crises/syr/sitreps/syria_regional_health_sitrep_january2015.pdf

32. UNHCR. UNHCR Projected Global Resettlment Needs 2016. 2015. [online] http://www.unhcr.org/uk/protection/resettlement/558019729/unhcr-projected-global-resettlement-needs-2016.html.

33. Jameton A. Dilemmas of Moral Distress: Moral Responsibility and Nursing Practice. AWHONN’s Clinical Issues in Perinatal and Women’s Health Nursing. 1993;4:542–551 8220368

34. Doocy S, Lyles E, Roberton T, Akhu-zaheya L, Oweis A, Burnham G. Prevalence and care-seeking for chronic diseases among Syrian refugees in Jordan. BMC Public Health; 2015. doi: 10.1186/s12889-015-2429-3 26521231

35. Achilli L.Syrian Refugees in Jordan: A Reality Check.Migration Policy Centre: Policy Brief. 2015. doi: 10.2870/821248

36. kerasidou A, Kingori P, legido-Quigley H. "You have to keep fighting": maintaining healthcare services and professionalism on the frontline of austerity in Greece. Int J for equity in health; 2016. doi: 10.1186/s12939-016-0407-8 27457098

37. Rachiotis G, Kourousis C, Kamilaraki M, Symvoulakis E K, Dounias G, Hadjichristodoulou C. Medical supplies shortages and burnout among greek health care workers during economic crisis: a pilot study. Int J Med Science; 2014. doi: 10.7150/ijms.7933 24688306

38. Anderson B, Shyyan R, Eniu A et al. Breast cancer in limited-resrouce countries: an overview of the Breast Health Global Initiative 2005 guidelines. Breast Journal.2005. doi: 10.1111/j.1075-122X.2006.00199.x

39. Walt G, Shiffman J, Schneider H, Murray S F, Brugha R, Gilson L. (2008) “Doing” health policy analysis: Methodological and conceptual reflections and challenges. Health Policy Plan; 2008. doi: 10.1093/heapol/czn024

40. Greene M J. On the Inside Looking In: Methodological Insights and Challenges in Conducting Qualitative Insider Research. The Qualitative Report, 19(29), 1–13. 2014. Retrieved from: http://nsuworks.nova.edu/tqr/vol19/iss29/3.

41. Pappaioanou M, Malison M, Wilkins K, et al. Strengthening capacity in developing countries for evidence-based public health: The data for decision-making project. Soc Sci Med; 2003. https://doi.org/10.1016/S0277-9536(03)00058-3

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