Introduction

As defined by the United Nations, vulnerable groups are those that face structural discrimination, such as women, or groups that have difficulty defending themselves and therefore require special support. The number of asylum seekers is increasing annually due to social, economic, and political challenges. ¹ The Islamic Republic of Iran hosts a large population of Afghan asylum seekers. ² The growing number of refugees has posed significant challenges for healthcare systems, particularly during the COVID-19 pandemic in host countries . ³ Health is a key factor in the successful integration of immigrants into society and the labor market, as good health is a fundamental prerequisite for individuals to realize their developmental potential. ⁴

Lack of access to quality health services for asylum seekers not only poses a serious threat to their health but also endangers the overall health of the host community. ⁵ Therefore, ensuring that asylum seekers have access to appropriate and high-quality health services is essential. The quality of healthcare is a central dimension of health system performance, and evaluation plays a critical role in quality improvement. When conducted effectively, evaluation can help identify and address problems, inform decision-making, and contribute to knowledge development. ⁶

The responsive evaluation model, a management-oriented evaluation approach, was developed to assist service providers in making informed decisions and to provide a holistic and systematic review of programs. Stake introduced this model in the 1970s to address the need for evaluations that consider the practical goals of all stakeholders, rather than solely assessing whether predetermined objectives of the intervention were achieved. ⁷ Stakeholders can learn how to reduce ambiguity and power differences. In fact, one way to implement effective external projects in the region and carry out a useful evaluation is to consider all stakeholders in the dilemma and address the problems of the target group based on the evaluation criteria. ⁸ Evaluators and decision-makers determine the type of evaluation tailored to the needs of the program. The responsive evaluation model includes five stages: research, discovery and identification of problems, discussion, interpretation of findings, provision of a suitable context to facilitate dialogue among stakeholders, and Socratic education and guidance. ¹¹ The model is shown in Figure 1.

Fig. 1. The responsive evaluation model

Several studies have examined the quality of healthcare services provided to refugees. In a review study, Goetz et al. assessed the quality of health care for refugees and concluded that refugees often lack regular access to health care and face limited availability of services in their host countries. ² Similarly, Salim et al. investigated the satisfaction with health care services among refugees in a camp in Jordan and found that asylum seekers encountered difficulties in accessing health services, obtaining hospital referrals, receiving follow-up care, and accessing dental services; these areas were reported to have the lowest acceptable levels. ¹¹

To the best of our knowledge, no previous research has examined the health status or the quality of health care services provided to refugees in Iran. Therefore, the present study was conducted to evaluate the health care services delivered to residents of the UNHR in Sarvestan refugee camp using the responsive evaluation model.

Methods

The present research was conducted as a cross-sectional study. The study population consisted of Afghan refugees residing in the UNHR camp (Shahid Beheshti Hospital, Sarvestan, Fars province) who were over 18 years old. Inclusion criteria were: holding a service certificate from the Sarvestan UNHCR Health and Medical Center, being aged 18 years or older, and willingness to participate in the study. Census sampling was employed, and a total of 270 participants were included in the study.

Data were collected using the Persian version of a 20-item questionnaire, which was developed into two sections: demographic questions (including age, sex, and marital status) and main questions based on the ZAP Questionnaire. The reliability of this instrument was previously established by Grohl et al. ^{12 - 15} The questionnaire evaluates the quality of health services across four domains: medical services, physician-patient relationship, therapeutic collaboration, and access to health services. Each domain contains five questions, resulting in a total of 20 items. The first five questions assess satisfaction with medical services, the next five measure satisfaction with physician-patient communication, the third set evaluates internal coordination among personnel and departments, and the final five questions address access to services, including time, cost, and ease of access.

Responses were scored on a 5-point Likert scale ranging from “good” ⁵ , “relatively good” ⁴ , “moderate” ³ , “relatively poor” ² , to “poor” ¹ . The questionnaire’s validity has been confirmed for Middle Eastern populations in the study by Goetz et al. (2) (α = 0.80). Additionally, the reliability and validity of the questionnaire were evaluated and confirmed by two experts.

On average, each family in the camp consisted of five members, with two members over 18 years of age. The researcher, accompanied by a trained healthcare worker, conducted the data collection. Due to a high level of illiteracy among participants, the questions were read aloud to those who could understand Persian, and their responses were recorded. For participants who did not understand Persian, questions were translated into Pashto by friends or relatives, and their responses were subsequently recorded.

Data were analyzed using SPSS software version 21. Descriptive statistics, including mean, standard deviation, frequency, and percentage, were used to summarize the data. The Chi-square test was applied to examine the relationship between age and gender and the overall results of healthcare services provided. At the same time, ANOVA was employed to assess associations with the different dimensions of health services.

Ethical Consideration

This study was approved by the Ethics Committee of Shiraz University of Medical Sciences, with the code of SUMS98-477. Participants were fully informed about the research aims, and written informed consent was obtained from all participants. All procedures were conducted in accordance with relevant ethical guidelines. Confidentiality of participants’ information was strictly maintained throughout the study, and documentation of informed consent is available upon request.

Results

Following data collection, the data were first analyzed descriptively. The frequency distribution of participants according to their demographic characteristics is presented in Table 1.

According to the results, of the 270 participants, 145 were female (53.8%) and 125 were male (46.3%). In terms of age distribution, 44 participants were under 20 years (16%), 80 were aged 20-30 years (30%), 48 were 30-40 years old (18%), 52 were 40-50 years old (19%), and 46 were over 50 years (17%). Table 2 presents the mean scores for each of the four dimensions of health services provided to the participants, as reported by the participants themselves.

The total mean score for healthcare services provided to Afghan immigrants was 64.21 out of 100. Among the assessed components, the highest mean score was observed for the physician-patient relationship, whereas the lowest was recorded for therapeutic collaboration. To explore whether age and gender were associated with the overall health services score, a Chi-square test was conducted. The results of this analysis are presented in Table 3.

The results of the quantitative analysis showed a statistically significant relationship between age and gender and the total score of health services (p = 0.003 and p = 0.001, respectively). In other words, participants’ age and gender were significantly associated with their overall evaluation of health services. Participants’ opinions on the health services are presented in Table 4.

The analysis revealed that 66.9% of participants had a positive or relatively positive opinion regarding overall health services, 73.7% regarding the physician-patient relationship, 69.7% regarding treatment coordination, and 71.8% regarding access to services. Overall, a majority of participants reported good or relatively good opinions across all dimensions.

An ANOVA was performed to examine the relationship between age, gender, and the four dimensions of healthcare services. The results indicated that, in general, females were more satisfied with health services than males (54% vs. 46%). When comparing the mean scores across the four dimensions, females reported higher satisfaction, particularly in the physician-patient relationship (54%), compared with the other dimensions. In comparison, males expressed greater satisfaction with overall health services (41%). Analysis across different age groups revealed that participants under 20 years of age were more satisfied with staff-patient relationships (34%) and access to healthcare (29%). Conversely, participants over 50 years of age showed greater satisfaction with overall health services (32%) and access to healthcare (34%).

Discussion

Refugees and asylum seekers represent a vulnerable and underserved population. Addressing the healthcare needs of immigrants and facilitating access to services in the host country can yield benefits for both the host community and the immigrants themselves. Moreover, considering their current and past circumstances and providing support to improve their lives can have a substantial positive impact.

The present study aimed to evaluate the delivery of healthcare services to residents of the UNHR Sarvestan refugee camp, examining key components including demographic characteristics, health services, physician-patient relationships, therapeutic collaboration, and access to care. The results showed that more than half of the participants were satisfied with the quality of healthcare services provided. Additionally, a significant relationship was found between demographic characteristics, such as age and gender, and the total healthcare service scores. More than half of the participants reported high satisfaction across all components, reflecting the efforts, coordination, and planning of the responsible authorities in providing healthcare in this camp.

In this study, the highest satisfaction scores were observed for physician-patient communication, while the lowest scores were related to therapeutic collaboration. Consistent with these findings, Durmaz (2023) reported that 95.2% of participants in his study expressed satisfaction with the healthcare services they received. ¹⁶

Mahmoudian (2006), in his study on Afghan immigrants and their socio-economic status, concluded that access to educational and health services was greater than to any other component. He further noted that the educational and health-related gap of Afghan immigrants was wider compared to their compatriots in Afghanistan than in any other socio-economic domain. The availability of free education in Iran provided Afghan immigrants with a unique opportunity to improve their situation. At the same time, access to health facilities contributed to a reduction in mortality and improved health outcomes among this population. Immigrants’ access to social and health services in Iran has largely been strengthened by their greater and longer-term integration into Iranian society, with adaptation improving among those who have resided in Iran for a longer period. ¹⁷

Moreover, in line with our findings, Aghaei Hashjin et al. (2024) evaluated the quality of primary care services from the perspective of refugees and migrants in Iran. They reported that, overall, the quality of services was rated as favorable by the refugees. ¹⁸ Similarly, Rakhshani investigated the knowledge, attitudes, and practices of Afghan refugee women residing in Zahedan regarding family planning and concluded that the Iranian health system provides Afghan refugee women with access to health services comparable to those of Iranian women. ¹⁹

Refugees and asylum seekers face multiple barriers to accessing healthcare and achieving improved health status. These barriers include language difficulties, financial hardship and unemployment, cultural differences, legal obstacles, and limited awareness among healthcare providers regarding refugee-specific issues. Several studies have examined the health problems of refugees in Iran. For instance, Safari (2013), in a study on the education and healthcare of Afghan citizens in Isfahan, reported that one of the main challenges faced by refugees was the inability to afford education and healthcare costs for Afghan students. ²⁰ In addition, unfamiliarity among employees in the Iranian administrative system with laws related to refugees has created further difficulties, leading to dissatisfaction among immigrants with the system. ²¹

Khan (2002) investigated the participation of Afghan refugees and non-governmental organizations in reproductive health education. His study concluded that raising awareness among vulnerable groups, particularly immigrants, played an important role in reducing maternal and child mortality—one of the key indicators of national development. The findings suggested that organizing workshops and training courses, particularly through Afghan volunteers and teachers, significantly improved the knowledge and awareness of immigrants about their health. ^{17 , 22} Similarly, Shams (2022) emphasized that refugees often experience dissatisfaction with the administrative system due to staff members’ lack of familiarity with refugee-related regulations. ²³

The results of this study across different age groups showed that participants under 20 years of age were more satisfied with staff-patient relationships (34%) and access to healthcare (29%). In line with our findings, Salim et al. (2021) reported a satisfaction rate of 72.5% among 500 participants, with younger individuals and those with a shorter stay in the camp showing higher overall satisfaction. ²⁴

In contrast, Riahi et al. (2016) examined the health information needs of immigrants attending health centers affiliated with medical universities in Iran. They found no significant differences in information needs based on demographic factors. This result is inconsistent with our findings. They further highlighted that immigrants’ unfamiliarity with traditional health information sources posed a major challenge, with schools and universities being the primary centers for providing health information. According to their study, immigrants’ health needs were generally high ^{22 , 25} , which differs from the findings of the present study.

Similarly, Al-Qadi et al. reported findings that were not aligned with our results. Their study concluded that significant gaps existed in healthcare service utilization among Syrian refugees, largely due to the healthcare system's lack of preparedness to manage the surge in patient demand and the associated increased costs of care. Despite the Jordanian government’s efforts to establish a reliable system for refugee healthcare, the massive influx of refugees from the Syrian crisis strained the system. The authors stressed that both decision-makers and healthcare managers must intensify their efforts to improve access to and utilization of healthcare services for refugee communities. ²⁶

Although the present study suggested that healthcare services for refugees were adequate, Afshani et al. (2023) revealed weaknesses in Yazd, Iran, particularly inadequate supervision of Afghan migrants by Iranian health authorities. ²⁷

Limitations

This study, like others, faced several limitations. First, data were collected through a questionnaire administered to residents of the UNHCR Sarvestan refugee camp, which may introduce response bias despite the researcher’s presence to guide completion. Second, data collection took place during the COVID-19 pandemic, which made accessing participants challenging and may have influenced their responses. Third, as a cross-sectional study conducted in 2023, the findings reflect a single time point and may differ from results obtained in other periods. Finally, although this research was limited to residents of the UNHCR Sarvestan refugee camp, the findings may not be generalizable to refugee populations in other provinces or within medical universities nationwide.

Conclusion

The results of this study demonstrated a significant relationship between participants’ age and gender and their overall health service scores. In particular, increases in age were associated with higher scores. Moreover, more than half of the participants reported high satisfaction across all components—health services, physician-patient communication, therapeutic collaboration, and access—reflecting the efforts, cooperation, and planning of the authorities responsible for health services in the camp.

To further improve access to healthcare for immigrants, practical and effective strategies should be implemented. These may include revising and strengthening laws and regulations, expanding programs and authorities, and enhancing the role of international organizations in supporting and protecting migrants. Additional measures include increasing human resource support by health professionals, improving educational programs and university-based initiatives for immigrant health, and ensuring comprehensive collaboration across stakeholders to provide more equitable and sustainable health services.

Acknowledgments

We extend our sincere gratitude to Shiraz University of Medical Sciences for its support. We also acknowledge the Refugee Center of Fars Province, Sarvestan, for their valuable cooperation.

Authors’ Contribution

RM, LB, and NSh developed the concept and design of the study; RM collected and analyzed the data; LB and NSh prepared the first draft; all authors read and approved the final version of the manuscript.

Funding

No organization supported this study financially.

Conflict of Interest

All authors accept that there is no conflict of interest in this study.

References

1. Liebe U, Schwitter N. Explaining ethnic violence: On the relevance of geographical, social, economic, and political factors in hate crimes on refugees. European Sociological Review. 2021; 37(3):429-48. DOI
2. Goetz K, Hahn K, Steinhäuser J. Psychometric properties of the Arabic version of the EUROPEP questionnaire. Patient Prefer Adherence. 2018; 12:1123-8.
3. Mangrio E, Sjögren Forss K. Refugees’ experiences of healthcare in the host country: A scoping review. BMC Health Services Research. 2017; 17(1):814.
4. Zwi AB, Fustukian S, Chauvin J. Equity, post-conflict, and human rights. The Lancet. 2000; 355(9220):2069. DOI
5. Donabedian A. Evaluating the quality of medical care. The Milbank Memorial Fund Quarterly. 1966; 44(3):166-206. Publisher Full Text | DOI | PubMed [ PMC Free Article ]
6. Stake RE. Program evaluation, particularly responsive evaluation. In: Madaus GF, Scriven MS, Stufflebeam DL, editors. Evaluation models: Viewpoints on educational and human services evaluation. Dordrecht: Springer Netherlands; 1983. DOI
7. Bawden R. Messy issues, worldviews and systemic competencies. In R Bawden (Ed) Social Learning Systems and Communities of Practice. 2010;89-101. DOI
8. Koster M, Nakken H, Pijl S, Houten E. Being part of the peer group: A literature study focusing on the social dimension of inclusion in education. International Journal of Inclusive Education. 2009; 13:117-40. DOI
9. Curran V, Christopher J, Lemire F, Collins A, Barrett B. Application of a responsive evaluation approach in medical education. Medical Education. 2003; 37(3):256-66. DOI | PubMed
10. Abma TA. Responsive evaluation: Its meaning and special contribution to health promotion. Evaluation and Program Planning. 2005; 28(3):279-89.
11. Salim NA, Meyad SH, Sawair FA, Satterthwaite JD, Sartawi S. Satisfaction with healthcare services among refugees in Zaatari camp in Jordan. BMC Health Services Research. 2021; 21(1):507. DOI
12. Takbiri A, Takian A, Foroushani A, Jaafaripooyan E. The challenges of providing primary health care to Afghan immigrants in Tehran: A key global human right issue. International Journal of Human Rights in Healthcare. 2020. DOI
13. Grohl R, Baker R, Wensing M, Jacobs A. Quality assurance in general practice: The state of the art in Europe. Family Practice. 1994; 11(4):460-7. DOI | PubMed
14. Dimova R, Stoyanova R, Keskinova D. The EUROPEP questionnaire for patient’s evaluation of general practice care: Bulgarian experience. Croatian Medical Journal. 2017; 58(1):63-74. Publisher Full Text | DOI | PubMed [ PMC Free Article ]
15. National Association of Statutory Health Insurance Physicians ZAP - questionnaire in Arabic language. [Accessed March 26, 2018]. Available at:http://www.kbv.de/media/sp/ZAP_Fragebogen_Arabisch.pdf 2016
16. Durmaz N, Ulukol B, Bilirer S, Erguder T. A refugee mother’s perspective: Healthcare satisfaction and access to health services as an immigrant in Turkiye. North Clin Istanb.  2023; 10(2): 146-156. DOI
17. Mahmoudian H. Afghan migration to Iran: Change in social, economic, and demographic characteristics and adaptation to the destination community. Tehran: Iranian Demographic Association; 2006.
18. Aghaei Hashjin A, Bagherzadeh R, Faraji A, Rouzbahani MP. Evaluating primary healthcare quality from migrants and refugees’ viewpoint. Medical Journal of The Islamic Republic of Iran (MJIRI). 2024; 38(1):68-74.
19. Rakhshani R. Knowledge, attitude and practice of Afghan refugee women residing in Zahedan about family planning. Journal of Reproduction and Fertility. 2002; 3(4):47-54.
20. Safari R, Rezwani SM, Ghanouni H, Azad B. The reasons of establishment as well as consequences of Afghan immigrants self-run schools in Isfahan (Iran). Journal of Educational and Social Research. 2013; 3(2):23. DOI
21. Mousavi SA. The hazaras of Afghanistan: A historical, cultural, economic and political study. Routledge. 2018. DOI
22. Khan A. Afghan refugee women's experience of conflict and disintegration. Meridians Feminism Race Transnationalism. 2002; 3(1):89-121. DOI
23. Shams L, Tajik M, Heidari P, Nasiri T, Mohammadshahi M. Quality of life of Iranian and Afghan pregnant women in rural Iran. Ann Ig. 2022; 34(1):7. DOI
24. Salim N, Meyad SH, Sawair F, Satterthwaite JD. Satisfaction with healthcare services among refugees in Zaatari camp in Jordan. BMC Health Services Research. 2021; 21(1):507-515. DOI
25. Riahi A, Hariri N, Nooshinfard F. Health information needs of immigrant patients with cancer in Iran. Journal of Modern Medical Information Sciences. 2016; 2(1):21-30.
26. Al-Qadi M, Al-Hussami M, Riza E. Indicators of healthcare services utilization among the Syrian refugee population in Jordan: An observational study. Healthcare.  2023; 11(4):478. DOI
27. Afshani SA, Shiri-Mohammadabadi H. Afghan immigrants in the world city of Yazd (Iran): Strengths, weaknesses, threats and opportunities. International Journnal of Intercultural Relations. 2023; 96:101845. DOI