Introduction
International migration is an old phenomenon carried out in various forms and for multiple purposes. Migration is not only the transfer of people from one place to another but also an essential element in societies’ social, economic, and cultural life [1]. Iran is one of the countries with the highest number of refugees, receiving about 3.4 million [2]. Due to recent political developments, this figure has increased. More than three decades after the presence of Afghan immigrants and the emergence of the second and third generations of immigrants in Iran, the need for careful attention to the living conditions of this group has doubled, and a review of past policies seems necessary [3]. Also, the conditions of Afghanistan have caused Iran to be the origin of the largest population of long-term displaced people and one of the first three refugee countries in the world [4].
Quality of life (QoL) is a new topic that has been considered by researchers and academics in recent decades, especially in Iran [5]. It is a complex and multidimensional concept, including a person’s perception of physical and mental status, level of independence, social relationships, personal beliefs, and relationship with the environment [6, 7]. In addition, health is a significant component of QoL. Still, the QoL concerning health has been paradoxically defined and operationalized in the immigrant scientific literature [8]. A person can assess part of the QoL. Evaluating the QoL from the perspective of refugees has been neglected in various studies [9], and few studies have been done in this area. In the meantime, studies have been conducted to determine the reason for migration and the desire or unwillingness to return [10]. In Iranian studies, the QoL issue has been discussed around urban dwellers, and less attention has been paid to rural areas, especially foreign immigrants [5].
Previous research in this field has shown that in many third-world and developing countries, foreign immigrants, even the native citizens of that country, face many problems in accessing and achieving welfare services [11]. In a handful of cases, a study on the QoL of Afghan immigrants in Robat Karim City, Iran, was conducted by Poorahmad et al. They studied the QoL from a mental point of view and concluded that the QoL of immigrants in Robat Karim was low and below the average [12].
Due to the ignorance of educational health status in the QoL in most previous studies, we attempted to find the challenges and obstacles in this area and draw the officials’ attention to the importance of the issue and proper planning to provide services in education, health, and livelihood of the refugees. Sarvestan camp is one of the strategically sensitive areas for immigrants in the country, and it is in good condition in terms of having a comprehensive health center, school, and other facilities. Also, the geographical location of this camp in the south of the country and its accessibility were essential points in accurately evaluating the situation of the immigrants. We investigated the refugees’ living conditions in Iran and issues such as QoL, education, health services, and their barriers and shortcomings.
Accordingly, this study aimed to examine the QoL, facilities, and limitations of the services related to the QoL, including educational, economic, and health quality in Iran for Afghan immigrants, and its consequences on their lives and the Iranian society.

Participants and Methods
This qualitative study was conducted in 2024 using content analysis and focused analysis of qualitative interviews with MAXQDA 10, which is a qualitative analysis, and its reliability and validity have been reported as desirable by Kuckartz and Rädiker. In this method, all the qualitative data are divided into small and then larger categories based on the questions asked by the researcher. Using the following criteria, we classified the data, converted them into different themes, and confirmed them [13]: 
¨Create an analysis plan including a schedule taking into account the available resources,
¨ Analyze the key categories in more detail,
¨Highlight important quotes from the interviewees for the research report,
¨Reflect on integrating a case-oriented perspective (how? in what way?) and, if suitable, include it in your analysis,
¨Compare selected interviews with each other (optional),
¨Compare groups that have been created based on sociodemographic and background variables (optional),
¨ Include linguistic aspects (metaphors, certain words, phrases, etc.) in the analysis (optional),
¨Use visualizations, which are suitable for the presentation of the findings, and
¨Create concept maps (optional).

Data analysis 
As to data analysis, it is emphasized by Kuckartz and Rädiker (2019) that researchers should carry out certain aspects of the underlying theory in their study, such as coding, to reach a conceptual sequence to gain a basic understanding of the subject under study [13].

Study participants
In the present study, we enrolled 30 refugees at the UNHCR Afghan Refugee Camp in Sarvestan City, Fars Province, Iran. In this study, purposive sampling with maximum diversity based on the group, age, gender, and residence history was used. The inclusion criteria were the refugees in the Sarvestan camp and the age group of 18 years and older. The participants in the camp were called. After they were gathered, we explained the study objectives and the conditions. Then, informed consent was taken from them. 

Data collection 
In this study, semi-structured and in-depth interviews were performed. In total, 30 residents (12 females and 18 males) were interviewed. The interviews were all done one-on-one and face-to-face in a private room at the health center of the Afghan refugees’ UN Camp in Fars Province, Iran. The participants had experienced 5-60 years of residence in Iran.
Each semi-structured interview began with the following general questions: What is your viewpoint about the QoL ? How much do you think the QoL is related to physical and mental health? Do you have other items that are related to your QoL ? What do you need right now? And what obstacles and problems do you have in your life? Each question was also used as a guide to design the following interview questions. Each interview lasted about 30-90 minutes. The interviews were all recorded with the permission of the interviewees and transcribed verbatim after each session. 

Data extraction 
The researcher reviewed the transcripts several times and entered them into MAXQDA, software, version 10 for analysis in the first stage (content) of Glaser’s classical basic theory model. In this regard, the following measures were taken.
A) Open coding, consisting of three steps: Reading the full text and identifying related texts (incident), conceptualizing and analyzing comparative data, and writing notes for subsequent transcriptions.
B) Selective coding, the same as the previous one, but instead of selecting related texts and comparing them with other related texts, we tried to compare the concepts with each other to reduce the number of concepts and summarize them in terms of themes. Because the researcher focused on a list of key or identified topics in this step, it is called selective coding [14]. In the present study, after 30 interviews, the researcher was convinced that no additional information led to a new topic.

Rigor 
Credibility was ensured through long interaction with data during and after each interview, involving correct coding and anonymous people in coding, long and continuous fieldwork, use of a multi-method strategy in data collection, and use of quotes and real expressions of the participants [15]. To confirm the reliability of the questions, we asked the questions in different ways to reduce or eliminate the possibility of receiving incorrect or repeated information. We also tried to conduct the interviews accurately and without bias so that if other researchers repeated the same method in similar situations, they would get similar answers. In addition, to ensure the reliability of our data analysis, the researcher approached the participants and asked them if the final description of the findings could reflect their experiences (member review). If the participants added or deleted the data to or from what they first expressed, relative changes were made to their final transcript. In addition, peer review was used to ensure the consistency of our data analysis. The data collected in this study were reviewed by three experts in the field of qualitative research.

Results
The study participants included 30 people (18 men and 12 women) with an average age of 26. Their literacy level was as follows: 4 people had primary education, 10 had middle school education, 14 had diploma education, 2 had post-diploma education. Also, the duration of their residence in Iran was as follows: 8 people under 5 years, 10 people 5 to 10 years, 8 people 10 to 20 years, and 4 people over 20 years of residence.
From the analysis of the detailed descriptions of the participants, 32 codes were extracted. After reviewing and summarizing the data several times, the codes were classified into 12 categories based on similarity and appropriateness. The main themes included the QoL, quality of service, shortcomings and obstacles in Sarvestan camp. These categories will be explained below using the participants’ statements (Table 1).


In expressing the participants’ experiences, QoL was one of the most important and broad themes extracted. Most participants emphasized one or more factors affecting the QoL. QoL comprises health, security, employment and economic status, social acceptance, and education. Each category was extracted from the analysis and coding of the interviews and participants’ opinions. Subthemes were formed, which will be described separately. The contents of the subthemes and the extracted codes are shown in the Table 2.







Discussion 
Data analysis resulted in 415 open codes and three main themes: QoL, quality of services, and challenges and obstacles. Subthemes related to the QoL included health, security, tranquility, economic status, social acceptance, and education. Subthemes related to service quality in various forms included comprehensive services, accessibility, usefulness, and appropriateness. Subthemes related to the third theme included financial deficiencies, social barriers, and cultural-ethnic problems. The immigrants’ demands for improving the QoL included providing services to high-risk groups of refugees, continuing the education of the youth and adolescents, providing necessary equipment and settings for health and culture, and improving employment status.
This study aimed to examine and discover the experiences, perspectives, and challenges related to the QoL, demands, and shortcomings of Afghan immigrants in the Sarvestan camp. Although Iran has taken humanitarian, valuable, essential, and relatively comprehensive programs in cooperation with international organizations on the living conditions, health, and education for the refugees [3], the experiences and challenges of these participants comprised three issues: QoL, quality of service, and barriers and shortcomings. 
According to the participants, although the refugees are free of the war and the unhealthy situation in Afghanistan, they still have many problems achieving the desired QoL. One of their main goals is to achieve comprehensive health, including physical, mental, social, living, and working environments. Almost all of them considered health more critical to the quality of their life than anything else. Since most studies on the refugees’ life conditions in other countries have been quantitative and qualitative research in this field is scanty, we did not find similar studies to compare the results. Concerning the health needs of immigrants, the findings of Chen et al., Boyce et al., Hyman et al., and Koo and Gross, align with the present study’s results [16-19]. Participants associated their QoL with physical and mental health and, in some cases, even considered mental and social health more important than physical health.
During the interview, they expressed their satisfaction with the delivery of health services at the Camp Health Center. Still, they expressed some of their needs and shortcomings in addressing and improving the quality of services. Participants considered security and comfort essential in the national arena (including the absence of war) and the social arena related to community security. They were satisfied with having these two items in Iran. Participants considered social acceptance and respect effective in having life satisfaction. Participants expressed citizenship in Iran, and social acceptance among the cases needed to be achieved. According to them, having citizenship in all areas of their lives, whether economic or educational, significantly impacts their QoL. Having citizenship in Iranian society leads to material and spiritual privileges that effectively improve the QoL. Immigrants consider their economic status, employment, and income among the most essential factors in achieving health and effectiveness in all areas. They say that when their financial status is low in terms of inflation, high prices, and lack of jobs, they have difficulty providing necessities of life, such as medicine for treatment and wellbeing. In this area, the refugees stated that increasing education in the field of health and various dimensions and continuing the education of young people would help to enhance the QoL. Mahmoudian, in his study, stated that in terms of socio-economic status, most of the benefits are related to health and education [3]. According to the participants, if the services provided in the camp are comprehensive, sound, and appropriate to the needs and access item, it will affect the quality of health services and, consequently, the QoL.
Moreover, an integral part of the problems in the camp is improving the health and QoL of the migrants. Immigrants emphasized providing services to different cultural and sexual age groups and paying more attention to this area and the appropriateness of the services offered. They considered having cultural and sports places for children and girls and a library or a gym for young people essential. For participants in the first field (health), centers such as maternity facilities and pharmacies and the presence of experts, including pediatricians, gynecologists, and, most importantly, psychologists, are among the requirements.
A study entitled “immigration and mental health” by Alegría et al. [20] and other studies in different parts of the world and Iran indicate a higher prevalence of mental disorders among immigrants. The presence of required vehicles, such as an ambulance and a means of transit to Sarvestan City, are among the items mentioned by the participants regarding access to some services. Providing higher education for teenagers and young people is also one of their demands for improving their lives.
Among the items extracted from the interviews of the participants, we can mention the obstacles and problems raised in the form of lack of financial resources, social barriers, and cultural and ethnic issues. Lack of suitable jobs, low income, inflation in Iran (due to recent sanctions), and unavailability of necessary medicines are among the severe obstacles to improving the quality of health and fighting immigrant diseases. Participants considered the lack of educational facilities to be one of the significant obstacles in terms of QoL and education as a major component of improving living conditions. Discriminatory thinking and the Iranian-Afghan perspective of Iranian society continue to widen the gap between Afghans and Iranians, resulting in psychological pressure on immigrants. This problem (which exists in all immigrant parts of the world) is solved by the participants by accepting the citizenship of Afghan people who have lived in Iran for many years. There are some ethnic and cultural problems, most of which are due to a lack of awareness; they include the existence of religions and sects, obstacles in education for girls, early marriage, and child marriage.
Analysis of interviews with the UNHCR senior planning and training officer shows that a significant portion of the funds and funding allocated are related to improving the living and health conditions of migrants. Also, in education, increasing knowledge, raising the awareness and skills of immigrants, and holding comprehensive and complete programs and measures have been neglected [21]. Given the current situation, Akbari et al. mentioned that in a situation where the total return of migrants to their country in the short term is difficult and impractical, being marginalized and not paying attention to their various health and welfare needs will have irreparable social consequences [22]. Therefore, it is suggested that authorities should understand the problems and make serious efforts to solve them through appropriate policymaking and allocation of sufficient resources; also, refugee camps in other countries should be studied. Therefore, larger communities and larger numbers may encounter fewer conflicts in the public sector or may have more in common.
One of the limitations of this study was that it only examined the experiences of refugees in this camp. Also, obtaining opinions through the interview method was problematic. Further, the present study was conducted in 2024, which may have different results at other times.

Conclusion
According to the results, the problems of Afghan refugees in Iran include a lack of financial resources, social barriers, and cultural and ethnic problems. Lack of suitable jobs, low income, inflation in Iran (due to recent sanctions), and unavailability of necessary medicines are among serious obstacles to improving the quality of health and fighting immigrant diseases.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of Shiraz University of Medical Sciences (Code: IR.SUMS.REC.1398.577). Participants were provided with explanations about the purpose of the study. Informed consent was obtained. The participants were assured of the confidentiality of their information.

Funding
The paper was extracted from the master's thesis of Roghayeh Mohseni, approved by the Department of Medical Education, School of Medicine. This study was supported by Shiraz University of Medical Sciences.

Authors contributions
Conceptualization, methodology, funding, project administration, supervision, review and editing: Nasrin Shokrpour, and Leila Bazrafkan; Data collection, analysis and initial draft preparation: Roghayeh Mohseni; Final approval: All authors.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgements
The authors thank Shiraz University of Medical Sciences and all the refugees who cooperated in this study. 


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