1. Introduction
In mid-2021, 84 million forcibly displaced people were living worldwide, of whom about 26.6 million were refugees [1]. Afghan refugees are among the most well-known refugees worldwide, millions of whom have left their homeland due to long-lasting insecurity, wars, or persecution. As of March 2022, including newly arrived Afghan refugees (with recent Taliban dominance), almost 1.5 million registered refugees were living in Iran (around 6 million by considering illegal refugees) [2]. During the last four decades, this population has gradually gained ever-increasing levels of protection and access to public services, i.e., education and healthcare [3]. 
Refugee host countries worldwide are challenged with responding to the general needs of refugees (e.g., housing, language preparation, education, employment, and longer-term integration) and healthcare needs which might also differ from the indigenous population. With little dependence on international aid and almost solely domestically funded, the Iranian authorities have planned and combined financial resources to improve the living and health conditions of registered and, to a different extent, unregistered Afghan refugees [4]. For instance, since 2014, as a part of Iran’s Health Transformation Plan towards universal health coverage (UHC), registered Afghan refugees can formally receive the same financial protection and access to healthcare services, similar to Iranian citizens [5]. In addition, universal free education has been granted to all Afghan refugees, irrespective of their status. Nevertheless, the increasing demand for healthcare, inadequate resources, and cultural and socioeconomic characteristics of Afghan refugees render extra measures and engagement of other stakeholders, e.g., Non-Governmental Organizations, to respond to the current needs [3, 4, 5, 6, 7]. Gaining insight into the precise needs of this population, a critical evaluation of their living, health, and wellbeing conditions is pivotal for appropriate planning and meaningful interventions to improve the life experience of Afghan refugees residing in Iran. Iran is committed to including vulnerable populations in its national plans towards UHC.
2. Materials and Methods
Participants
To bridge this gap and in line with the sustainable development goals (SDG) of 17 to foster partnership, we established a collaborative international research team in 2019 between two pioneer academic institutions in the field of public health: Tehran University of Medical Sciences (Tehran, Iran) and Bielefeld University (Bielefeld, Germany). The ultimate aim of the joint research project is to assess the health conditions of Afghan refugees residing in Iran and compare them with Afghan refugees in Germany.
This short report inclusively refers to a pilot (pre-test) study on a sample of 20 legal Afghan refugees (above 12 years old) in the capital and megacity, Tehran, Iran. This sample is 5% of our main study sample, which investigates the health and living conditions of 400 legal Afghan refugees living in Tehran (400 is calculated based on the population of these refugees in this country).
Most Afghan refugees in Iran are settled among Iranian citizens, whereas only less than 3% are accommodated within designated camps [8]. To minimize selection bias and ensure diversity, we divided Tehran Province into five regions (north, south, east, west, and center) and randomly selected four legal Afghan refugees from each region to be surveyed. 
We used a questionnaire containing 100 questions in several dimensions, i.e., demographic characteristics, asylum history, physical and mental health (effects of COVID-19 were also included), access to and utilization of healthcare (including quality of care and health insurance), social wellbeing (e.g., social network and support, accommodation, safety, and security), and cultural aspects (e.g., religion, ethnicity). This questionnaire was previously developed and validated by our larger German research group consisting of professors and doctoral researchers in various disciplines ranging from public health to psychology and law at Bielefeld University [9]. We localized this questionnaire based on Iran’s situation and translated it into Persian (Farsi) language, and re-tested it in this pilot study.
For the data collection, two trained surveyors with prior trust-based access to Afghan refugees, face-to-face, asked the questions from participants (as some were uneducated and in need of assistance to answer questions): participants and the questioners strictly adhered to COVID-19 hygiene protocols. We received ethical clearance from Tehran University of Medical Sciences (TUMS) (IR.TUMS.SPH.REC.1399.072) and Bielefeld University (FlüGe refugee health study), assuring anonymity and data confidentiality. We obtained written informed consent and participation/withdrawal freedom during the entire period of study. Finally, all 20 questionnaires were filled out. The collected data were analyzed by SPSS software, v. 25. Then, descriptive statistics and the mean response rate to the questionnaire were reported.
3. Results
The mean response rate to the data collection tool (questionnaire) was 88%. Participants were mostly male (65%) and relatively young (16-48 years old). About 55% were born in Afghanistan, mostly in the cities of Kabul and Ghazni, while 45% were second- or third-generation Afghan refugees who were born in Iran, mainly in the cities of Tehran and Mashhad. Also, 90% were Muslims and belonged to the ethnicities of Hazara and Tajik (90%). About 80% were employed as manual laborers or self-employed, and the main resource for financing life expenses was either self-income or own-savings; 85% were worried about their financial situation. About half were married, had no child, and lived with their spouse in the same accommodation or with their parents/siblings. Participants had chosen Iran as a destination mainly due to re:union: with family members, Iran’s superior economic situation, and its proximity to Afghanistan (55% had traveled on foot).
Initial findings revealed that the most frequent healthcare needs were visiting physiotherapists, dentists, and optometrists. About 35% had long-lasting illnesses or physical health complaints (e.g., head, hand, foot, back, and tooth pains), of which 57% were under treatment. The rest could not utilize healthcare due to financial barriers, e.g., dysfunctional health insurance. Inadequate health education or insufficient insight about healthcare facilities and providers, and the feeling of not being taken seriously by healthcare providers were other barriers to healthcare access. However, cultural and language barriers were not seen as preventing factors from accessing healthcare services. Nonetheless, 65% of respondents rated the quality of using healthcare services as good and excellent. 
We observed 30% physical disabilities, e.g., tendon rupture, finger cut, or living with one kidney. Overall, the participants rated physical health as good and excellent (80%). Mild smoking and drinking habits were reported in 35% of participants. Also, 35% reported their COVID-19 infection or of close family members. This figure is probably underestimated as some refugees either had low knowledge of COVID-19 symptoms or were not tested after showing similar symptoms. Besides, most refugees live together in small accommodations, that increase the risk of transmitting the COVID-19 virus among them. Only two patients were hospitalized due to COVID-19, with the disease duration of about three to four weeks. No mortality among close family members was reported. Most participants reported good access to COVID-19 protection tools and used them frequently. However, the lack of access to face protection masks among southern Tehran residents was observed mainly due to their weak financial status. Due to the COVID-19 economic consequences, job loss (themselves or close family members) was reported (35%), 85% stated financial shortcomings, 55% felt depressed due to either financial difficulties or social isolation, and 50% expressed willingness to return to Afghanistan due to the recent economic downturn in Iran in relation to unilateral economic sanctions against the country and the current COVID-19 epidemic in Iran [10]. Nonetheless, we collected data before the recent Taliban’s dominance in Afghanistan, and currently, new waves of Afghan refugees are heading to Iran and neighboring countries.
According to the participants, the main reasons for leaving Afghanistan were war or violent conflict (or fear of it), persecution (political, religious, ethnic, etc.), and perceived discrimination. Before or during taking refuge in Iran, 75% of the participants reported experiencing physical violence, 20% reported having been tortured, 30% had been arrested or imprisoned, and 35% were at risk of starving or thirst. Also, 50% were afraid of being returned to Afghanistan. All of that may cause mental vulnerability and more susceptibility to mental illnesses (e.g., depression or anxiety) for this population. However, most participants (90%) had no chance to access mental care in Iran, mainly due to financial barriers. Only one case of depression and one case of bipolar disorder, both under treatment, were self-reported. Stigma-associated questions, including criminal background, alcohol and drug use, and sexual behaviors, remained unanswered.
4. Discussion
Refugees endure structural vulnerabilities in refugee camps and during their resettlement, including fear of contacting the healthcare system, cultural differences, housing insecurity, food insecurity, discrimination, lack of health insurance, health illiteracy, and lack of readily available and culturally appropriate educational materials [11]. This study successfully re-tested the localized data collection tool (questionnaire) and then revealed up-to-date information comprising positive and negative aspects of the health and living conditions of legal Afghan refugees (above 12 years old) residing in Tehran. Our findings show that employment and education opportunities, personal physical access to healthcare (excluding mental care), quality of healthcare services in general, social network and support, security, and experiencing privacy are among the positive aspects of legal Afghan refugees living in Tehran Province. Generally, the weak economic status, insufficient financial resources, and inefficient healthcare insurance might increase out-of-pocket payments. Previous studies confirmed some of these barriers for this population in Iran which were in line with our study [4, 6, 12, 13, 14, 15].
COVID-19 has disproportionately affected racial and ethnic minorities, with a higher number of deaths in this group of the population [16, 17]. In our study, we identified inadequate circulation of COVID-19 health information among the refugee population, being not aware of COVID-19 infection symptoms, being afraid of the report the infection due to the fear of unwanted consequences, and lack of access to protective materials. Additionally, the stress and fear of COVID-19, as well as the isolation experienced during lockdowns, have exacerbated mental health issues among refugees [18].
This study faced some challenges, including several between-countries/universities coordination and difficult identification of refugee settlements in Tehran. Further, some participants were uneducated and needed assistance to answer questions, and we had to hire trained surveyors to read both informed consent forms and questions on behalf of refugees (participants). Additionally, we are aware that generalizing and comparing our findings with the findings of conducted studies is not applicable due to our small sample. However, we are conducting a larger study on a reliable sample of 400 refugees, and its findings will be reported in the near future.
5. Conclusions
In this preliminary empirical report, the authors emphasize that health and living conditions-related studies on refugees (and other marginalized populations) should be given more weight, especially during the difficult circumstances caused by the COVID-19 pandemic. We recommend conducting more studies on refugees’ health, aiming to perform a comprehensive assessment of the health and living conditions of refugee populations to address social determinants of health through equity lenses, particularly in the context of low- and middle-income countries.

Ethical Considerations
Compliance with ethical guidelines
We received ethical clearance from the Tehran University of Medical Sciences (TUMS)  (Code: IR.TUMS.SPH.REC.1399.072) and from Bielefeld University (FlüGe Research Consortium on Refugee Health) assuring anonymity and data confidentiality. Informed consent was obtained from all subjects involved in the study.

Funding
This research was funded by the Ministry of Arts and Science of the German State of North Rhine-Westphalia through a doctoral fellowship of Parisa Rahimitabar within the FlüGe Research Consortium on Refugee Health at Bielefeld University, Germany.

Authors' contributions
Conceptualization, methodology, and writing--review & editing: All authors; Validation and supervision: Alexander Kraemer, and Amirhossein Takian; Formal analysis, investigation, resources, data curation, visualization, writing-original draft preparation: Parisa Rahimitabar; Project administration and funding acquisition: Alexander Kraemer. 

Conflict of interest
All authors have read and agreed to the published version of the manuscript. The authors declared no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

Acknowledgments
We acknowledge the Faculties of Public Health at Bielefeld University and Tehran University of Medical Sciences for their administrative support, data collection-related support by the Health Equity Research Center (Iran), and support of the publication fee by the German Research Foundation (Deutsche Forschungsgemeinschaft) and the Open Access Publication Funds of Bielefeld University. We also acknowledge the Bielefeld School of Public Health for its financial support (doctoral scholarship).


References

1. United Nations High Commissioner for Refugees (UNHCR). Refugee Data Finder: Key indicators. June 2022. [Link]
2. United Nations High Commissioner for Refugees (UNHCR). Afghanistan situation: Emergency preparedness and response in Iran [Internet]. 2022 [2022 January 23]. Available from: [Link]
3. European Commission. Iran factsheet. Brussels: European Commission; 2021. [Link]
4. Kiani MM, Khanjankhani K, Takbiri A, Takian A. Refugees and sustainable health development in Iran. Archives of Iranian Medicine. 2020; 24(1):27-34. [PMID]
5. Doshmangir L, Bazyar M, Majdzadeh R, Takian A. So near, so far: Four decades of health policy reforms in Iran, Achievements and challenges. Archives of Iranian Medicine. 2019; 22(10):592-605. [PMID]
6. Takbiri A, Takian A, Rahimi 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; 13(3):259-73. [DOI:10.1108/IJHRH-06-2019-0042]
7. United Nations High Commissioner for Refugees (UNHCR). Iran needs more help to support Afghan refugees – UNHCR chief. Geneva: United Nations High Commissioner for Refugees; 2018. [Link]
8. United Nations High Commissioner for Refugees (UNHCR). Islamic Republic of Iran; key figures. 2021. [Link]
9. FlüGe Research Consortium on Refugee Health, School of Public Health, Bielefeld University, Bielefeld, NRW, Germany.
10. Takian A, Raoofi A, Kazempour-Ardebili S. COVID-19 battle during the toughest sanctions against Iran. The Lancet. 2020; 395(10229):1035-6. [DOI:10.1016/S0140-6736(20)30668-1]
11. Saifee J, Franco-Paredes C, Lowenstein SR. Refugee health during COVID-19 and future pandemics. Current Tropical Medicine Reports. 2021; 8(3):1-4. [PMID]
12. Salmani I, Seddighi H, Nikfard M. Access to health care services for Afghan refugees in Iran in the COVID-19 pandemic. Disaster Medicine and Public Health Preparedness. 2020; 14(4):e13-4. [PMID]
13. Azizi N, Delgoshaei B, Aryankhesal A. Lived experience of Afghan refugees in Iran concerning primary health care delivery. Disaster Medicine and Public Health Preparedness. 2019; 13(5-6):868-73. [PMID]
14. Roozbeh N, Sanati A, Abdi F. Afghan refugees and immigrants health status in Iran: A systematic review. Journal of Clinical and Diagnostic Research. 2018; 12(9):1-4. [DOI:10.7860/JCDR/2018/34869.12001]
15. Heydari A, Amiri R, Nayeri N, AboAli V. Afghan refugees’ experience of Iran’s health service delivery. International Journal of Human Rights in Healthcare. 2016; 9(2):75-85. [DOI:10.1108/IJHRH-06-2015-0020]
16. United Nations High Commissioner for Refugees (UNHCR). Refugees and the impact of COVID-19. Geneva: United Nations High Commissioner for Refugees; 2022. [Link]
17. Matlin SA, Karadag O, Brando CR, Góis P, Karabey S, Khan MMH, et al. COVID-19: Marking the gaps in migrant and refugee health in some massive migration areas. International Journal of Environmental Research and Public Health. 2021; 18(23):12639. [PMID]
18. Bhala N, Curry G, Martineau AR, Agyemang C, Bhopal R. Sharpening the global focus on ethnicity and race in the time of COVID-19. The Lancet. 2020; 395(10238):1673-6. [DOI:10.1016/S0140-6736(20)31102-8]