R Habib Health of Palestinian refugees in Lebanon

Health of Palestinian Refugees in Camps and Gatherings in LebanonCamps and Gatherings in Lebanon

As part of a Larger study:As part of a Larger study:

UNRWA‐AUB Socio‐Economic Survey of Palestinian Refugees in Lebanonof Palestinian Refugees in Lebanon

Ri R H bib PhD MPH MOHSRima R. Habib, PhD, MPH, MOHSAssociate ProfessorFaculty of Health SciencesAmerican University of BeirutAmerican University of [email protected]

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Multidisciplinary teamMultidisciplinary teamA team of investigators at AUB including:

Economists : Dr. Jad Chaaban

Dr. Nisrine SaltiDr. Nisrine Salti

Public Health : Dr. Rima Habib

Nutrition experts : Dr. Hala Ghattas

Dr. Nadine Sahyoun

Social scientists : Dr. Sari Hanafi2

Purpose of the SurveyPurpose of the Survey

Profile the socio‐economic conditions and evaluate incidence of poverty among Palestine Refugees

Devise poverty reduction strategy andDevise poverty reduction strategy and optimize poverty targeting programs

Develop policy recommendations based on data gathered

3Rima R. Habib, 23 June 2011

IndicatorsIndicators

FoodHealth

H i Food Security

Housing

ASSETS

EconomicEd i

ASSETS

Education

Social INCOMEEXPENDITURE

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ExclusionRima R. Habib, 23 June 2011

Study designStudy design

Nationally representative household surveyNationally representative household survey

Face‐to‐face interviews

l d l 20 0Late July and early August 2010

60 UNRWA social workers, trained and supervised by a working team at the American University of Beirut

Households in camps as well as in gatherings were interviewed, in a total of 32 localities,


Sampling2626 HH

C l bTyre

(552)

North

(601)

Central Lebanon Area

(593)

Bekaa

(262)

Saida

(618)

428 camps 355 camps 231 camps 113 camps 363 camps

Rashidieh, Beddawi, Nahr Debayeh, Mar Wavel Mia mia, ,Shemali, Buss

Beddawi, NahrElbared

y ,elias, Shatila, Burh Brajneh

Elhelweh

124 gatherings 246 gatherings 362 gatherings 149 gatherings 255 gatherings

Chabriha, jal El Nahr, Qasmeyeh, shemali

Zahriyeh, El‐Mina, Jabal Bedawi,

Haret Hriek, Mrayjeh, Burj Brajneh village,

Bar elias, jalala, taalbaya

Taameer, villat, old town, dalla, hay

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surr, Masaken, Machouk

Jabal Bedawi, Bedawi village0 Jnah, Sabra and shatila,

Ard Jalloul, Tareeqjdeedeh, Aramoun, Nameh, Haret Nameh

taalbaya, saadnayel

zuhour, dakerman, haj hafez, hay njasa, al barrad, wadi zeinah

Results of the Survey


Population demographicsPopulation demographicsOf the 425,000 refugees registered with UNRWA since 1948,

l 260 000 280 000 l id i L bonly 260,000‐280,000 currently reside in Lebanon– A Quarter live in Tyre, Saida and Beirut areas

– One fifth live in the NorthOne fifth live in the North

– 4% Live in the Bekaa.

The Palestine refugee population is young, with an average age of 30 years, and half the population younger than 25 years

53% of refugees are women53% of refugees are women

The average household size is 4.5 members (compared to 4.2 for Lebanese households)


Livelihoods and educationLivelihoods and education

Many Palestinian workers are discouraged fromMany Palestinian workers are discouraged from working: – 56% of refugees are jobless56% of refugees are jobless

– only 37% of the working age population is employed

Two thirds of Palestinians above the age of 15 doTwo thirds of Palestinians above the age of 15 do not have Brevet– compared to a Lebanese rate of 50%compared to a Lebanese rate of 50%

Only 50% of youths in Secondary school age (16‐18 years old) are enrolled in education18 years old) are enrolled in education


Health


Health indicatorsHealth indicators

Chronic illnesses and functional DisabilitiesChronic illnesses and functional DisabilitiesPersist for remainder of people’s lifecycleOngoing costs for treatmentg gConcentrated among most vulnerable populations (conflict, poverty, unsafe environments)

Acute illnessesUnpleasant short term consequencesSubstantial medical bills

Psychological problems


AGE < 20 yrs

20 – 55 yrs

> 55 yrs

Total Palestinian

Total Lebanese*

Prevalence of chronic illness % % % % %

Yes 10.07 32.94 83.32 31.1 17.4

No 89 79 67 06 16 68 68 8 82 6No 89.79 67.06 16.68 68.8 82.6

Prevalence of functional disability

Yes 2.2 4.64 9.63 4.4 2.0

No 97.8 95.36 90.37 95.6 98.0

Prevalence of acute illness in the pas 6 months

Yes 23.16 22.14 36.69 24.5 ‐

No 76.84 77.86 63.23 75.4 ‐

Prevalence of psychologicalPrevalence of psychological problems in the past 12 months

Yes 8.10 26.57 35.91 20.65 ‐

N 91 05 73 10 63 56 78 78No 91.05 73.10 63.56 78.78 ‐


Chronic Illness ‐ TypeChronic Illness TypeType of chronic illness %

Hypertension 32.32Hypertension 32.32

Back Pain 9.26

Asthma 8.50

Diabetes 8.31

Rheumatism 5.63

Heart Problems 3.61

Epilepsy 2.62

Other* 29 63Other 29.63

*Other chronic illness include cholesterol, chest pains, heart arrest, stroke, anemia, prostate, cancer, osteoporosis, kidney problems, Thalessemia, autism, down’s syndrome, schizophrenia, mental madness


Functional Disability ‐ TypeFunctional Disability TypeType of Functional Disability %

Disability of extremities – excluding paralysis and amputations 30 22Disability of extremities excluding paralysis and amputations 30.22

Paralysis 14.73

Blindness 8.91

Deafness 8.25

Amputation of extremities 8.78

Inability to speak 2.84

Other 26.04

About 1 in 4 extreme poor households have a disability case, whereas only 1 in 7 non‐extremepoor households do


Acute Illness ‐ TypeAcute Illness TypeType of Acute illness %

Cold/flu 19.41Cold/flu 19.41

Respiratory 17.24

Gastrointestinal 18.59

Musculoskeletal 9.26

Urinary/Reproductive 5.98

Other 29.53

Most common types of illnesses reported were /

yp pcold/flu and other respiratory problems

No difference between extreme poor households and

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No difference between extreme poor households and non‐extreme poor households

Rima R. Habib, 23 June 2011

Health indicators by AreaHealth indicators by Area


North Central Lebanon Area

Saida Tyre Bekaa

% within region

% across Lebanon

% within region

% across Lebanon

% within region

% across Lebanon

% within region

% across Lebanon

% within region

% across Lebanon

Chronicillness

24.4 15.6 35.5 25.1 32.4 27.9 31.3 27.7 30.8 3.8illness

Disability 3.2 14.5 5.5 27.2 5.0 30.3 3.8 24.3 4.3 3.7Acute illness

19.4 15.9 32.5 29.1 23.2 25.3 20.2 22.5 46.0 7.2

Psychol‐ogicalproblems

19.3 18.5 34.6 36.6 13.9 17.6 16.3 21.7 31.0 5.7

Chronic illnesses and psychological problems were most frequently reported in the Central Area

Acute illnesses were most frequently reported in Bekaa

Camps and gatherings in the North reported the lowest rates of illness compared to the other regionsrates of illness compared to the other regions


Cost and Expenditure on Health

IndicatorIndicator

Costs incurred in the past 6 months from:– Hospital visits– Acute illness Continues doctor visits and medications for– Continues doctor visits and medications for chronic illness

– Continues doctor visits and medications for functional disabilities


Household payment (in USD) for illness Mean (in USD)

Hospital visit in past 6 months 614

Non‐chronic illness in past 6 months 164

Regular doctor visits or medication for chronic illness 137Regular doctor visits or medication for chronic illness 137

Regular doctor visits or medication for disability 252

Source of financial contributions to Health sourcesSource of financial contributions to Health sources varied from friends, family and organizationsOrganizations (main source being UNRWA) were the primary benefactors assisting those in need

Helped in hospital payments 75% of the timeH l d ith t ill t f 61% fHelped with acute illness payments of 61% of casesHelped with doctor and medical payments of 71% of chronic casesof chronic cases


Health Expenditure/MonthMean (USD)

Share of Health Expenditure from Total Expenditure (%)( ) p ( )

Prevalence of Chronic Illness

Yes 139.4 14.7

N 88 5 6 2No 88.5 6.2

Prevalence of disability

Yes 168.4 15.2

No 125.1 10.9

Prevalence of acute illness

Yes 141 4 12.4Yes 141.4 12.4

No 116.6 10.4

Prevalence of psychological problems

Yes 162.5 13.6

No 106.8 10.1

Households with an illness spend a higher proportion ofHouseholds with an illness spend a higher proportion of total expenditure on health than those without illness


Health ExpenditureHealth Expenditure

On average Palestinian refugees spend anOn average, Palestinian refugees spend an average of 12% of their total expenditure on health ($132)health ($132)

– Lowest in the North: 6%

– Highest in Tyre: 14%

Lebanese population spend an average of 14%of their total expenditure on health ($343) p ($ )(Ammar, 2003)


Health Services available to Palestinian Refugees

Indicator:Indicator:

Where was the health care service received in h f ill i h 6the event of an acute illness in the past 6 months


Health services for Palestinian fRefugees

Palestinians receive health services from a wide variety of care providersUNRWA provides primary health care services (secondary and limited tertiary services) to refugees by way of 29 health centers located in areas with high densities of Palestinian refugees– Walk‐in general consultations– Maternal and child health care services– Treatment of chronic diseases– Provision of medications– Specialists, dental, and laboratory services available in some

centers • UNRWA clinics were the most frequently visited for cases of

acute illnesses (32%)


H i Q liHousing Quality


Housing QualityHousing Quality

Well established evidence on the negative impact of g ppoor housing conditions on health

Bonnefoy et al. 2003

WHO 2004

Habib et al. 2009

Harpham 2009


Results on Housing ConditionsResults on Housing Conditions

40% of households have water leaking through roof or40% of households have water leaking through roof or walls

8% of households live in shelters where the roof and/or walls are made from corrugated iron, wood or asbestos

9% of households have no water heater or fridge

8% of the studied population live in overcrowded conditions (more than three people live in one room)

– Surface area of camps has not increased with the population, leading to cramped shantytowns,

i t l diti d tpoor environmental conditions and exposure to health hazards


Linking Housing and Health IndicatorsLinking Housing and Health Indicators

Households with more than 3 people per room reported p p p phigher rates of acute illness and functional disability

Households that used kerosene fuel for cooking reported higher rates of disability, acute illness, and psychological problems

Households living in homes built of stone experienced theHouseholds living in homes built of stone experienced the lowest prevalence of illness

Households with dampness and leaks reported a higher prevalence of chronic and acute illnesses

Poor housing is concentrated in the South, particularly R hidi h d Ai l H l h d th iRashidiyeh and Ain el Helweh camps and gatherings throughout Tyre region


In summaryIn summaryA third of the Palestine refugee population was estimated to have chronic illnesshave chronic illness

4% of the Palestine refugee population was estimated to have a functional disability; Hypertension is particularly y; yp p yprevalent

A Quarter of refugee households had an acute illness in the past six months, often leading to additional expenses and periods out of work

A third of acute illness cases had the flu or common cold or otherA third of acute illness cases had the flu or common cold or other respiratory tract illnesses

21% of the Palestinian population experienced depression, i dianxiety or distress


In summaryIn summary

The Central Lebanon Area reported the highest incidence of chronic and psychological problems

The Bekaa area reported very high incidence of acute illillnesses


In summaryIn summaryHouseholds with poorer housing quality were more likely to report health problems

95% of the population are without insurance p pand most in precarious employment– They are unlikely to receive sick leaves and as such a y ycase of acute illness may push a household into poverty

Costly secondary and tertiary health care

UNRWA is the most frequently used health careUNRWA is the most frequently used health care provider


Policy RecommendationsPolicy Recommendations

Provision of mental health servicesProvision of mental health services

Primary health care ‐ Awareness campaignsF th ti f t itt bl i t– For the prevention of transmittable respiratory diseases and diarrheal illnesses

T ti h lthTertiary health care

Introduce initiatives for improving housing quality


THANK YOU


ReferencesReferences

B f X R t l 2003 H i d h lth i E li i lt fBonnefoy, X.R. et al., 2003. Housing and health in Europe: preliminary results of a pan‐European study. American Journal of Public Health, 93(9), 1559‐1563.

Habib, R. et al., 2009. Housing quality and ill health in a disadvantaged urban i P bli H l h 123(2) 174 181community. Public Health, 123(2), 174‐181

Harpham, T., 2009. Urban health in developing countries: what do we know and where do we go? Health & Place, 15(1), 107‐116.

Ugland, O., 2003. Difficult Past, Uncertain Future Fafo‐report 409, FAFO. Available at: http://www.fafo.no/pub/rapp/409/index.htm [Accessed October 30, 2010]

WHO, 2004. Housing and Health Health and environment briefing pamplhet serie, Copenhagen: WHO Regional Office for Europe.: WHO


Documents

R Habib Health of Palestinian refugees in Lebanon