Introduction

A refugee is a person fleeing life-threatening conditions. In daily parlance and for journalistic purposes, this is roughly the meaning of "refugee hood." Predictably, in legal and political circles, among those officials who formulate refugee policies for states and international agencies, the meaning is considerably more circumscribed [1]. Worldwide, the number of refugees and asylum seekers is estimated to be about 11.5 million. Plus a much larger number of former refugees who have obtained a residence permit in a new country [2]. Among migrants fleeing war-torn areas, potentially traumatic events like close-quarters combat are frequent [3, 4], and many refugees may have mental illness as a result of these events [3, 5, 6] Everyone has the right to seek and receive asylum from persecution in other countries [7]. International assistance to refugees is channeled through United Nations High Commissioner for Refugees (UNHCR), through Non-Governmental Organizations (NGOs) and bilaterally. UNHCR is one of the few UN agencies that depends almost entirely on voluntary contributions to finance its operations. Less than two percent of UNHCR’s annual budget comes from the United Nations; the rest is contributed by states, individuals, and the private sector [8]. Pakistan is neither a party to the 1951 Convention relating to the Status of Refugees nor the 1967 Protocol relating to the Status of Refugees [9]. The cost of refugee relief to Pakistan in the mid-1980s was about 1 million dollars a day, all of which was financed by contributions from foreign governments (channeled through UNHCR) and private voluntary organizations [10]. More than $273 million in humanitarian aid has already been given by the US to Pakistan’s host communities and Afghan refugees there. The US donated approximately $60 million to the Pakistani host communities and Afghan refugees for the fiscal year 2022 [11]. Afghans in Pakistan are in some measure both refugees and economic migrants; they may face political threats in Afghanistan but are also working to support relatives there [12]. Migration and subsequent adjustment cause stress, which increases the risk of sickness [13]. Afghans comprise the largest refugee population in the world [14]. In general, social networks and support are seen as significant protective factors for both physical and mental health [15]. Pakistan has received Afghan refugees since the 1980s. There are 18 camps for Afghan refugees located in five districts of Balochistan Province. Six of the 18 camps are labeled as “new camps” and were established in response to the refugee influx in November 2001 [16]. The remaining 12 “old camps” cater to Afghan refugees who have been arriving since the time of the Russian invasion of Afghanistan in 1979. The number of Afghans in Pakistan is 3,049,268 individuals, as enumerated in the Census of Afghans in Pakistan 2005. Almost half reside in five districts (20.1 percent in Peshawar, 11.1 percent in Quetta, 7.6% in Nowshera, 5.1% in Pishin, and 4.3% in Karachi), while the balance is spread across the remaining 120 districts of Pakistan. According to the Census, there are 769,268 (25.2 percent) Afghans, or 115,565 families, in Balochistan province. The 2005 Census notes that if Pakistan’s population ratios have not changed since the 1998 Census, then Afghans in Balochistan would be equivalent to 10 percent of Pakistanis, and in the Northwest Frontier Province (NWFP) the figure would be 7.6 percent [17]. Following the American invasion of Afghanistan, the number of refugees has increased in recent years. [18]. While in Pushtun-dominated areas, Afghan Pashtuns were allowed to settle [10]. Quetta district ranks second in Pakistan among the top ten districts with Afghans under the age of five (11.6 percent) [17]. In the last few decades, there has been an enormous amount of research on quality of life (QOL). Providing the exact meaning of the term "QOL" is rather difficult because an elaborate theoretical framework is (still) lacking. Therefore, there are nearly as many definitions of QOL as there are studies on this subject [19]. Research suggests that poor perceived present quality of life (QOL) may be the most significant factor in psychological illness and stress related disorders in refugee populations [20].

Health-related quality of life (HRQOL) is a multidimensional concept that focuses on the impact health status has on quality of life and represents the subjective evaluation of physical, mental, emotional, and social functioning [21]. Other studies tried to analyze the quality of life of the immigrants, often using other questionnaires as a tool to measure it [22]. As we know, in a lot of studies concerning medicinal interventions, QOL has become an important endpoint. There is a connection between health and quality of life, i.e., better health means a better quality of life. The current study reveals good HRQOL among Afghan refugees. To the best of our knowledge, this study is the very first to assess the HRQOL of Afghan refugees in Pakistan.

Methodology

Results

The study sample consisted of 729 participants who took part in the study. Participants’ ages ranged from 12 to 98 years. Here the Table 1 reflects the demographic information of the participants studied. Majority of the respondents were from 21 to 31 year of age and the dominated 480 (65.8%) participated respondent were male, 450 (61.7%) participants were married with 441 (60.5%) had urban residency in Afghanistan. The majority of participants (90.1%) (n = 657) did not reside in any nation other than Pakistan, with 234 (32.1%) of them having lived there for at least ten years. The majority of respondents (n = 222) were from Kandahar, and 95.5% of the 696 participants lived with their families. Almost 42% (n = 306) had no education, and 33.7% (n = 246) had a private job. 294 (40.3%) had no monthly income, and 79.4% (n = 579) preferred to be treated in a hospital or Basic health unit (BHU). Most of the respondent were not arrested for a crime. Mobility (n = 654), self-care (n = 666) (91.4%), usual work (n = 594) (81.5%), pain and discomfort (n = 519) (71.2%), anxiety and depression (n = 450) (61.7%) were all indicated as not being a problem by the majority of respondents by using self-reporting EQ-5D as shown in Table 2. A total of 24 health conditions as shown in Table 3, the majority of respondents (55.6%) have 1111 health states and no health issues. The EQ-5D Health Index/Score is significantly associated with age (p = 0.001), marital status (p = 0.001), locality in Afghanistan (p = 0.008), year living as refugees (p = 0.001), living as a refugee somewhere other than Pakistan (p = 0.004), place of residence in Afghanistan (p = 0.018), education (p = 0.033), occupation (p = 0.001), and being arrested for crime (p = 0.005) as shown in Table 4. In Table 5, age (p = 0.001), marital status (p = 0.001), education (p = 0.003), occupation (p = 0.001), and arrest for crime (p = 0.041) are significantly associated with VAS score.

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Table 1. Demographic characteristics of study respondents (n  =  729).

https://doi.org/10.1371/journal.pone.0288834.t001

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Table 2. Self-reported health status (EQ-5D).

https://doi.org/10.1371/journal.pone.0288834.t002

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Table 3. Frequency of self-reported (EQ-5D) health states.

https://doi.org/10.1371/journal.pone.0288834.t003

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Table 4. Different variables EQ-5D Score (0.85 ± 0.20).

https://doi.org/10.1371/journal.pone.0288834.t004

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Table 5. VAS Score (78.60 ± 11.10) among variables.

https://doi.org/10.1371/journal.pone.0288834.t005

Discussion

The current study reveals good HRQOL among Afghan refugees. Keeping in mind that the descriptive score was a little bit higher than the perceived health status, this indicates that the actual health condition is better than what was perceived by the participants. To the best of our knowledge, this study is the very first to access the HRQoL of Afghan refugees in Pakistan The HRQOL of the relatively young adult Palestinian refugee population was relatively good for physical health, psychological health, and social relations, but was poor for environment, as the study was conducted in Jordan about the health-related quality of life of Palestinian refugees [21].The finding were again supported by the study QOL among Syrian refugees in Kurdistan which falls largely within a range of QOL scores [20]. This is consistent with earlier studies of the general population [15], immigrants in Sweden [25], torture survivors among refugees in Denmark [26], and a recently released study among Syrian refugees [27]. In contrast the Northern Greece refugees showed poor HRQL [28].

The current study was done with the EQ-5D instrument, which has five dimensions to determine the health status of the participants, including mobility, self-care, usual activities, pain or discomfort, and anxiety or depression. Each of the five dimensions is divided into three levels of problem perception. The current study included a total of 24 health statuses, with the most dominant EQ-5D status having no problems in all five domains. The current study findings are also in line with what is reported in a study done in the Netherlands, which reported that Afghan refugees considered their physical and mental health to be good [2]. In comparison to the current study in the fifth domain, where the majority of respondents were not depressed, two different studies elsewhere in the world reported that distress symptoms occur at higher rates in the US and Afghans residing in Turkey are at high risk of psychopathology [29, 30]. There are many factors that influence the health of Afghan refugees. As we know, resettlement in a new culture may lead to many health problems. Health may be affected by starting your life in a country with different culture, religion, language, social structure, values, and environment, as well as by the behavior of the people where refugees are resettled. The areas of Pakistan where Afghan refugees are living have the same culture and religion. As we know, the majority of the Afghans living in Quetta are Pashtuns [17], and the residing people in Quetta are also of the same ethnicity having same values, environment, and social structure- even the dressing is same. Pashtunistan, the land of the Pashtuns or Pathans, lies on both sides of the Durand Line, the frontier between Pakistan and Afghanistan. Since 1947, Afghanistan has consistently repudiated the Durand Line and demanded the right of self-determination for the Pashtuns because she does not consider them a part of Pakistan [31], and the Pashtun areas of Balochistan, including Quetta, also believe in the ideology of Pashtunistan and behave like brothers with Afghan refugees.

HRQOL had a significant relationship with many of the demographic characteristics in our study like age, marital status, locality in Afghanistan, living as a refugee somewhere other than Pakistan, year of Living as a refugee, place of residence in Afghanistan, education, occupation and being arrested for crime. There are mixed results when our findings are compared with those of other studies of the same nature. A study conducted in Italy reported that age was influential variable on HRQOL among refugees and asylum seekers using the SF-36 tool [22]. A study done using WHOQOL-BREF reported that age is significantly associated with physical, social and environmental domains [32]. Gerritsen et al. found that age, marital status, education, and year as refugees in that country were all significant factors [2]. A study mentioned that immigration background, gender, and age are significantly associated with physical and mental health [33]. Demographic factors such as employment status and income were found to be significantly related to the mental health of Afghan refugees living in Istanbul [30]. Although the majority of the respondents were not arrested for any crime. Beside the crime, if someone has done something wrong, authorities should act against them, but targeting someone only because he is Afghan isn’t fair [34]. It can be a reason that some of the respondents had problems in the psychological domain and may be age -dependent. A greater HRQOL is achieved by taking into account factors like similarity in culture, religion, language, social structure, values, and surroundings, as well as how people treat refugees.

Conclusion

The current study reveals better HRQOL among refugees in Quetta, Pakistan. Results may vary elsewhere in Baloch areas and Panjab, Pakistan, due to changes in culture, language, social structure, values, and environmental conditions. Our study concluded that demographic characteristics like gender, living status, monthly income, and preferred place of treatment are not associated with health-related quality of life among Afghan refugees; however, the effect varies with age, marital status, locality in Afghanistan, year living as refugees, living as a refugee somewhere other than Pakistan, place of residence in Afghanistan, education, occupation, and being arrested for crime, which were significantly associated with the EQ-5D Health Index/Score. This study provides a baseline assessment for the health status of Afghan refugees and the results could be applied in improving HRQOL. It can improve more by improving the educational status and environmental variable such as income, which can result in better HRQOL. Future research should attempt to address educational issues in relation to the quality of life of refugees, as the identification of educational issues may assist in the design of educational-specific interventions in self-sustenance and improving quality of life.

Supporting information

Acknowledgments

We would like to thank all the contributors who helped us in the present research project.