Quality of Life and Psychometric Characteristics of Syrian Refugee Physicians Who Migrated to Turkey: A Cross-Sectional Study

Background The concept of migration comes with various problems, affecting the quality of life and psychological state of immigrants. This study aimed to investigate the quality of life and depression and anxiety states of physicians who immigrated to Turkey after the civil war that started in Syria in 2011. Methods In this cross-sectional study, a sociodemographic questionnaire form, the short version of the World Health Organization's quality of life assessment tool (WHOQOL-BREF), Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI) were applied to Syrian doctors who received integration training to work in refugee health centers established for immigrants in Turkey. Results A total of 570 participants were included in the study. The median scores of WHOQOL-BREF domains of the participants were 75 for DOM1 (min: 25, max: 100, IQR: 18), 69 for DOM2 (min: 6, max: 100, IQR: 25), 69 for DOM3 (min: 0, max: 100, IQR: 19), and 63 for DOM4 (min: 0, max: 94, IQR: 19). The median BDI score of the participants was 7 (min: 0, max: 41, IQR: 8), and the median BAI score was 5 (min: 0, max: 50, IQR: 8). Having primary care experience, having knowledge about the Turkish healthcare system, believing that they can adapt to work in refugee health centers, and not having a plan to return to their country were found to be associated with a higher score in at least one of the WHOQOL-BREF subdomains. Planning to turn back their country was significantly associated with higher BAI scores. Conclusions The overall quality of life of most refugee physicians in Turkey was high, and the BDI and BAI scores were also below the threshold values. Further qualitative studies that allow in-depth analyses may reveal underlying factors for this situation.


Introduction
Te civil war that began in Syria in 2011 has led to the forced migration of the Syrian population to other countries [1].Turkey, one of the frst and most afected countries by this migration, has had to host more than 3.5 million Syrian refugees [2].In order to fnd solutions to the health needs of these immigrants, the Turkish government has granted them broad rights in health, education, and employment by placing them under "temporary protection" status [3].Te government also established refugee health centers and enabled Syrian refugee doctors to provide services to their citizens [4].Tis project aimed to overcome the language barrier and social security problem, which are signifcant barriers for immigrants in accessing health care, and to provide employment opportunities for Syrian refugee doctors, who can be described as highly qualifed refugees.Te primary aim of these centers was to provide primary healthcare services.Initially, it was planned that all Syrian doctors would work as primary care doctors, regardless of their specialty, and extensive adaptation training was organized for this purpose [4].
Many studies in the literature have shown that the concept of immigration causes various problems in many aspects [5].It has been linked to quality of life and psychological problems such as posttraumatic stress disorder and anxiety [6].Moreover, such problems have been found to exist even among highly educated immigrants and even in the case of immigration to developed countries [7][8][9].Tis study aims to investigate the quality of life and some psychometric characteristics of Syrian physicians who migrated to Turkey as highly qualifed refugees and examine the factors associated with these parameters.

Study Design.
A cross-sectional study design was chosen.

Participants and Eligibility Criteria.
Between November 2016 and April 2018, a sum of 1,095 physicians who participated in "Syrian Physicians' Adaptation Training" were considered potentially eligible for the study.Among these, 570 physicians confrmed eligible, who accepted to participate in the study by reading the informed consent form and could read and write in English adequately enough to maintain the minimum standards to fll the forms, underwent a structured questionnaire.Te survey form included sociodemographic data, the World Health Organization Quality of Life (WHOQOL-BREF) questionnaire, the Beck Depression Inventory (BDI), and the Beck Anxiety Inventory (BAI).All survey forms were in English.Te power analysis revealed that the sample included in the study refected the entire population with a 95% confdence level and less than a 3% margin of error.

Data Collection Instruments
2.3.1.Sociodemographic Questionnaire.In the frst section, 18 sociodemographic questions were asked to the participants, including age, sex, marital status, having children, duration of living in Turkey, persons living with, place of residence, specialty in medicine, duration of working as a doctor, previous workplace, occupational status, experience in primary care, having information about Turkish Health System, expectations from the Turkish government, opinions on adapting to work in Refugee Health Centers, and plans about turning back to their country.

WHOQOL-BREF. WHOQOL-BREF tool assesses
individuals' perceptions of how their life positions coincide with their goals, expectations, and concerns.It is the abbreviated form of WHOQoL-100, developed by the World Health Organization's WHOQoL study group in 15 diferent cultural settings through years of collective work, encompassing a hundred questions about 24 facets of overall quality of life and general health [10].In this context, WHOQOL-BREF consists of 26 questions and ofers the opportunity to evaluate four main domains: physical health, psychological, social relationships, and environment (Table 1).Validity studies showed that domain scores produced by the WHOQOL-BREF correlate highly (0.89 or above) with WHOQoL-100 domain scores [10].
Te specifc calculation method is used for scoring WHOQOL-BREF as defned in the test instructions, and the domains' scores were transformed to a 0-100 scale [11].Te higher scores showed a higher quality of life; a score of 60 was accepted as the cutof value for a high quality of life [12].

Beck Depression Inventory (BDI).
Te BDI is a wellknown 21-item self-report scale used to assess the severity of depression in normal and psychiatric populations.It was frst developed by Beck et al. in 1961 andrevised in 1996 [13].Te scores that can be obtained from the inventory range from 0 to 63, and in the interpretation of the test score, 0-9 points show minimal depression, 10-16 points show mild depression, 17-29 points show moderate depression, and 30-63 points show severe depression [14].In our study, the score of 17 was accepted as the cutof value for depression in the binary grouping as normal or depressive.

Beck Anxiety Inventory (BAI).
Te BAI is also a 21item handy self-report scale widely used to assess the severity of anxiety.Te scores that can be obtained from the inventory range from 0 to 63, and in the interpretation of the test scores, 0-7 points mean no signifcant anxiety, 8-15 points show minimal anxiety, 16-25 points show moderate anxiety, and 26-63 points show severe anxiety [15].In our study, the score of 16 was accepted as the cutof value for anxiety in the binary grouping as normal or anxious.

Statistical Analysis.
Numbers and percentages were used to represent descriptive data.Te Kolmogorov-Smirnov test was used to examine the normal distribution of data.Te mean ± standard deviation was given for the normally distributed data, and the median and minimum-maximum values besides interquartile range (IQR) were given for the data that did not distribute normally.Te chi-square test and adjusted residual analysis were preferred in comparing categorical variables and the binary WHOQOL-BREF grouping.Te Spearman correlation test was used to compare continuous numerical data between groups.Te Kruskal-Wallis test was preferred to analyze independent variables.Te IBM SPSS v.20 package program was used for all statistical analyses, and p < 0.05 was accepted as the limit of alpha error.

International Journal of Clinical Practice
Te median BDI score of the participants was 7 (min: 0, max: 41, IQR: 8), and the median BAI score was 5 (min: 0, max: 50, IQR: 8).While 10.4% of all participants had moderate or severe depression scores, 14.9% of them were classifed as moderate or severe anxiety.Te association of total BDI and BAI scores with sociodemographic variables is given in Table 4. Te association of binary-grouped BDI and BAI scores with sociodemographic variables is given in Table 5.
A moderate inverse correlation was found between the BDI score and WHOQOL-BREF domain scores.A similar inverse correlation was prominent between the BAI score and DOM1 and DOM2 scores.Te correlation analysis results between BDI, BAI, and WHOQOL-BREF domain scores are given in Table 6.

Discussion
Tis study on a special group of refugee doctors, the like of which is rare in the literature, reveals some interesting results.Te doctors in the study had been forced to leave their country because of civil war.Terefore, low quality of life and high levels of depression and anxiety might be expected in such a vulnerable group.Interestingly, our study showed that the mean quality-of-life scores were mostly above the threshold.Similarly, no signifcant depression or anxiety was found in the majority of participants.
Te negative impact of migration on mental health is well documented.A systematic review of the mental health status of Syrian migrants examined 64 studies, focusing mainly on the prevalence of posttraumatic stress disorder (PTSD), depression, and anxiety, with varying rates.Other outcomes examined included challenges in the postmigration period and factors that promote mental health, such as resilience, positive coping strategies, and psychosocial wellbeing.As a result, studies have shown a high prevalence of mental health disorders among refugees [16].However, a study of Syrian refugee doctors found that the level of social adaptation of Syrian doctors living in Turkey was high and highlighted the cultural similarities between the two countries and the extensive social rights granted to Syrian refugees by the Turkish government as possible reasons for this situation [17].Besides social adaptation, these reasons and the historical and geographical proximity of the two countries may have positively impacted the quality of life of the refugee doctors and may also be efective in reducing depression and anxiety levels.Te literature also reports that the quality-of-life scores of health professionals working in migrant health centers in S ¸anlıurfa, one of the cities with a large population of Syrian refugees in Turkey, were also higher than expected [18].Another substantial study argued that Turkey's immigration policy is quite comprehensive and efective compared to the policies adopted by various countries to integrate immigrants.Te study highlighted the importance of Turkey's initiatives in subjects such as recognition of legal residence, employment, housing, education, public assistance, security, health care, family unity, and others for the integration of migrants [19].Given these fndings, it can be concluded from the relevant literature that the quality of life of Syrian refugee doctors in Turkey is relatively high compared to those in similar situations [20][21][22].
Regarding the parameters related to quality of life, we found that having experience in primary care, having   International Journal of Clinical Practice knowledge about the Turkish health system, believing that they can adapt to working in refugee health centers, and not having a plan to return to their country were associated with higher scores in at least one of the WHOQOL-BREF subdomains.Te fact that the health system in Turkey has been transformed to meet the needs of Syrian migrants is likely to be one of the reasons for these fndings [23].In this context, priority has been given to primary health care, which is one of the leading health needs of migrants, and Syrian refugee doctors have been allowed to work mainly in refugee health centers [23,24].A recent study of refugee doctors in Turkey reported that refugee doctors, defned as qualifed refugees, face difculties in obtaining equivalence of medical qualifcations and that the employment of specialists from different felds as general practitioners can lead to deskilling or overqualifcation [3].It was also noted that the participants had diferent resistance capacities to cope with this situation [3].Tis may explain the diferent responses to the phenomenon of forced migration.Other studies have reported similar problems for highly skilled refugees, even in highincome countries such as Norway and the USA [25,26].
In addition, married participants and those living in an extended family had higher scores in the social subdomain (DOM3).Tis result is not surprising, given the association of these parameters with social life.Tus, studies show a signifcant relationship between marital status, family status, and social quality of life.For example, a study of Syrian refugees in Sweden highlights the signifcant impact of social support on overall health [27].Another study conducted in Norway suggests the positive impact of the social environment on the health-related quality of life of young Syrian refugees [28].Ermanson et al. conducted   [29].Another systematic review on this topic focused on the health-related quality of life of refugees living in the host community and found that factors such as lower employment rates, income, loss of social networks, limited access to health care, and higher rates of mental disorders contribute to their lower quality of life.
Comparing the two groups, the general refugee population has higher scores in the physical domain but lower scores in the environmental domain.In comparison, the clinical refugee group (selected specifcally because of their mental status or because they had experienced relevant trauma in the past) has higher scores in the environmental domain but lower scores in the psychological domain.Tese results highlight the complexity of the refugee experience and the need for comprehensive support [30].
When we analyzed the relationship between depression and anxiety with the variables we examined, we saw that female participants and those who were apprehensive about adjusting to working in refugee health centers had higher anxiety scores.Tose who did not have primary care experience and those who planned to return to their country had higher depression and anxiety scores.However, in the binary grouping analysis based on the BDI and BAI cutof scores, the most signifcant relationship was observed between those planning to return to their country and those with high anxiety scores.Tis fnding primarily suggests that uncertainty about the future may be related to depression and anxiety, although causality cannot be inferred in our study design.Nevertheless, it is noteworthy that most participants did not have scores indicating signifcant depression and anxiety.In this context, Topaloglu's study of Syrian refugee doctors in Turkey is fascinating in that it documents that despite all the diferent characteristics of the participants, such as experience, specialty, age, gender, and ofcial status, they perceive themselves as Syrian doctors rather than Syrian refugees [3].Tis situation leads us to believe that the Syrian refugee doctors' physician identity overrides their refugee identity.Tey do not feel like foreigners in Turkey as respected physicians serving their refugee citizens, which may also be associated with lowerthan-expected BDI and BAI scores.
Te correlation analysis in Table 6 shows that there was a signifcant relationship between the BDI, BAI, and all WHOQOL-BREF domains, with the most signifcant association being between DOM1, which indicates physical quality of life, and DOM2, which indicates psychological quality of life.Studies of similar populations in the literature show a strong relationship between psychiatric status and QOL [31][32][33].While this fnding reiterates the importance of mental and physical integrity, it also reminds us that a biopsychosocial approach is essential, especially for vulnerable groups such as refugees [29,34].
4.1.Limitations.Since the questionnaires and inventories used were in English, which was not the native language of the participants, only participants with a sufcient level of English were included in the study.It was found that most of the participants had sufcient knowledge of English to answer the questionnaire, and that lack of fuency in English was a reason for refusing to participate in the study for only a few of them.However, the reasons for not participating in the study were not investigated in detail.Tis situation could be a possible confounding factor afecting the external validity of the study.

Conclusions
Te overall quality of life of most refugee physicians in Turkey was high, and the BDI and BAI scores were also below the threshold values.Among the possible explanations for this situation, we believe that the transformation of the healthcare system in Turkey to meet the needs of immigrants, the opportunity for refugee doctors to provide health care to their own citizens, and the historical and cultural similarities between the two countries could be considered.Te determinants of migrants' quality of life are complex and depend on the integration policies of governments, the contribution of nongovernmental organizations, and other factors [19,35].However, qualitative studies that allow indepth analyses are needed to clarify this situation.

Table 2 :
Te association of WHOQOL-BREF transformed scores with sociodemographic variables.

Table 3 :
Te association of binary grouped WHOQOL-BREF domain scores with sociodemographic variables.
a Column percentage.b Row percentage.Te values signifcant at p < 0.05 level are shown in bold.

Table 4 :
Te association of total BDI and BAI scores with sociodemographic variables.

Table 5 :
Te association of binary grouped BDI and BAI scores with sociodemographic variables.Beck Depression Inventory, and BAI: Beck Anxiety Inventory.Te values signifcant at p < 0.05 level are shown in bold.