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Musculoskeletal impairment among Syrian refugees living in Sultanbeyli, Turkey: prevalence, cause, diagnosis and need for related services and assistive products

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Dorothy Boggs, Oluwarantimi Atijosan-Ayodele, Hisem Yonso, Nathaniel Scherer, Timothy O’Fallon, Gülten Deniz, Selin Volkan, Ahmed Örücü, Isotta Pivato, Ammar Hasan Beck, İbrahim Akıncı, Hannah Kuper, Allen Foster, Andrea Patterson & Sarah Polack


Epidemiological population-based data on musculoskeletal impairment (MSI) and the need for related services and assistive products (APs) are limited in low- and middle-income countries (LMIC) despite evidence that MSI-related difficulties are common. In the World Health Survey, difficulties with mobility and pain were amongst the most commonly reported functional difficulties for adults aged 18 years and older, with more than 16.5% of respondents reporting mild or greater difficulty with ‘moving around’.

MSI data are particularly lacking for refugee populations despite increasing recognition of and commitment to disability inclusion in humanitarian contexts. A survey among Syrian refugees in Lebanon and Jordan found that 14.4% of adults reported difficulties walking, however these data were based on self-report only and may not capture all functional limitations related to MSI. Conflict and displacement can increase the risk of impairment and disability either directly, such as new trauma and injuries related to war, especially in the context of disrupted health services, or indirectly, such as through the breakdown of infrastructure and social structures and loss/damage of APs. These risks may be especially common in situations of displacement where there can be varying levels of access to health and social care in host countries, which further cause and/or exacerbate impairments. Data on MSI are needed in order to inform and advocate for services to maximise functioning, participation and quality of life among marginalised refugee populations.

MSI can result from many different health conditions, such as neurological, musculoskeletal, developmental and pain related conditions [including more than 150 of the 350 Global Burden of Disease (GBD) health conditions]; MSI assessment is therefore complex. The Rapid Assessment of Musculoskeletal Impairment (RAM) is a validated clinical impairment screening tool developed by Oxford University and the International Centre for Evidence in Disability (ICED) to estimate population-based prevalence, aetiology and diagnoses of MSI. It uses a two step-process which includes six initial screening questions to assess self-reported difficulties with the musculoskeletal system, followed by a clinician-led examination. The RAM has been used in Rwanda, Cameroon and India where all age prevalence of MSI was found to be 5.2%, 11.6 and 19.6%, respectively. Experience of using the RAM in these settings has identified a need to review and update the methodology including the screening questions, the method for assigning presence and severity of MSI, and the data collection on service and AP needs to improve utility of the data for health and rehabilitation service planning.

Estimates suggest that Turkey hosts 64% of Syrian refugees, totalling more than 3.6 million people. The vast majority (96%) live among host communities in urban, peri-urban and rural areas. Specifically, at the time of this study, approximately 20,000 Syrian refugees lived in the Sultanbeyli District, a sub-urban area on the outskirts of Istanbul hosting the largest number of refugees in a single district on the Anatolian side of the city. Data on MSI and associated service needs among this displaced population are lacking, which hinders evidence-based advocacy and planning of services for this population. Using an updated version of the RAM tool, this study aims to estimate the prevalence, aetiology and diagnoses of MSI and the need for related services and APs among Syrian refugees living in Sultanbeyli.