Deepening Social Inequalities in Health in the Maelstrom of War and Migration: A Multi-Criteria Approach

Emre Yılmaz

doi:10.26466/opusjsr.1784130

TR EN

Savaş ve Göç Girdabında Derinleşen Sağlıkta Sosyal Eşitsizlikler: Çok Kriterli Bir Yaklaşım

Öz

Bu çalışmada, savaş ve zorunlu göç süreçlerinde sağlık hizmetlerine erişimde ortaya çıkan sosyal eşitsizliklerin çok kriterli karar verme (ÇKKV) yöntemiyle analiz edilmesi amaçlanmıştır. Çalışma, kriz durumlarında derinleşen sağlık eşitsizliklerini sistematik biçimde ağırlıklandırmayı ve bu eşitsizlikleri azaltmaya yönelik politika önerileri geliştirmeyi hedeflemektedir. Sağlıkta sosyal eşitsizlikler literatür taraması neticesinde 10 ana başlıkta belirlenmiştir. Eşitsizliklerin göreceli ağırlık skorlarının belirlenmesi için sağlık yönetimi, psikoloji, sosyoloji, davranış bilimleri ve sağlık ekonomisi alanlarından 6 uzmanın görüşleri F-AHP soru formu aracılığıyla toplanmıştır. Yöntemin ilgili hesaplamaları yapılarak sağlıkta sosyal eşitsizliklerin önem dereceleri belirlenmiştir. Analiz sonuçlarına göre, savaş ve zorunlu göç sürecinde sağlık hizmetlerine erişimde ortaya çıkan en önemli sosyal eşitsizlikler sırasıyla; sosyoekonomik durum, kültürel ve etnik farklılıklar ve yasal durum olarak tespit edilmiştir. Sağlık hizmetlerine erişimin artırılması için kaynak tahsisi öncelikli olarak bu eşitsizliklere yönlendirilmelidir. Düşük gelirli, yoksulluk sınırının altında yaşayan göçmenler için hibeler yoluyla finansal destek ve sosyal yardım mekanizmalarının güçlendirilmesi, sağlık kurumlarında kültürel arabuluculuk hizmetlerinin genişletilmesi, diller ve kültürler arasında iletişim kanallarının oluşturulması önemlidir. Ayrıca göçmenler için hukuki statüye bakılmaksızın asgari düzeyde sağlık hizmeti garantisi sağlanmalı, adalet temelli bir yaklaşım benimsenmelidir.

Anahtar Kelimeler

sağlık , savaş , göç , eşitsizlik , çok kriterli karar verme

Deepening Social Inequalities in Health in the Maelstrom of War and Migration: A Multi-Criteria Approach

Abstract

This study analyzes social inequalities in access to healthcare that emerge during periods of war and forced migration using a multi-criteria decision-making (MCDM) approach. The aim is to systematically assess the severity of inequalities that intensify during crises and to propose policy recommendations to reduce them. Based on a literature review, ten main categories of social inequalities in health were identified. To determine their relative weights, expert opinions were collected through an F-AHP questionnaire from six specialists in health management, psychology, sociology, behavioral sciences, and health economics. The analysis revealed that the most important inequalities in accessing healthcare services during war and forced migration are socioeconomic status, cultural and ethnic differences, and legal status. These findings highlight that disadvantaged socioeconomic groups, cultural and linguistic barriers, and uncertainties in legal identity significantly hinder access to essential health services. To mitigate these challenges, resource allocation in crisis settings should primarily focus on reducing such inequalities. Recommended strategies include providing financial support and social assistance to low-income immigrants, expanding cultural mediation services in healthcare institutions, and ensuring multilingual communication. Additionally, adopting a justice-based approach by guaranteeing a minimum level of healthcare for all immigrants, regardless of their legal status, is crucial for promoting equity in health access.

Keywords

health , war , migration , inequality , multi-criteria decision making

References

Agbemenu, K., Mencia, J. J., Rosa, C. D., Aidoo‐Frimpong, G., & Ely, G. E. (2022). Family planning research in African immigrant and refugee women: A scoping review. Journal of Transcultural Nursing, 33(3), 416–426. https://doi.org/10.1177/10436596211072891
Balcılar, M., & Gulcan, C. (2022). Factors associated with self-reported chronic diseases of Syrian refugees in Turkey. Annals of Global Health, 88(1), Article 3794. https://doi.org/10.5334-/aogh.3794
Bozbura, F. T., & Beskese, A. (2007). Prioritization of organizational capital measurement indicators using fuzzy AHP. International Journal of Approximate Reasoning, 44(2), 124-147. https://doi.org/10.1016/j.ijar.2006.07.005
Buckley, J. J. (1985). Fuzzy hierarchical analysis. Fuzzy Sets and Systems, 17(3), 233-247. https://doi.org/10.1016/0165-0114(85)90090-9
Büyüközkan, G., & Çifçi, G. (2012). A novel hybrid MCDM approach based on fuzzy DEMATEL, fuzzy ANP and fuzzy TOPSIS to evaluate green suppliers. Expert Systems with Applications, 39(3), 3000–3011. https://doi.-org/10.1016/j.eswa.2011.08.162
Creswell, J. W., & Poth, C. N. (2018). Qualitative inquiry and research design: Choosing among five approaches (4th ed.). Sage Publications.
Crowley, G., Roberts, A., Stewart, R., & Das‐Munshi, J. (2024). Investigating mental healthcare inequalities associated with forced migration: Promise and potential pitfalls of electronic health records. The British Journal of Psychiatry, 225(2), 305–307. https://doi.org/10.1192-/bjp.2024.100
Dawkins, B., Renwick, C., Ensor, T., Shinkins, B., Jayne, D., & Meads, D. (2020). What factors affect patients’ access to healthcare? Protocol for an overview of systematic reviews. Systematic Reviews, 9(1), 1–8. https://doi.org/10.-1186/s13643-020-1278-z
Dzhus, M., & Golovach, I. (2022). Impact of Ukrainian-Russian war on health care and humanitarian crisis. Disaster Medicine and Public Health Preparedness, 17, e265. https://doi.org/-10.1017/dmp.2022.265
Ekzayez, A., Ahmad, Y. A., Alhaleb, H., & Checchi, F. (2021). The impact of armed conflict on utilisation of health services in north-west Syria: An observational study. Conflict and Health, 15(1), 1–10. https://doi.org/10.1186/s13031-021-00429-7

Fagundo-Rivera, J., García-Lozano, M. S., Portero-Prados, F. J., Romero‐Castillo, R., Badillo-Sánchez, N., & Fernández-León, P. (2025). Barriers to healthcare access for irregular immigrants after their arrival in Spain: A systematic review. European Journal of Public Health, 35(3), 407–422. https://doi.org/10.-1093/eurpub/ckaf042
Fares, H., & Puig‐Junoy, J. (2021). Inequity and benefit incidence analysis in healthcare use among Syrian refugees in Egypt. Conflict and Health, 15(1), 1–12. https://doi.org/10.1186-/s13031-021-00416-y
Fenny, A. P., Asuman, D., Crentsil, A. O., & Odame, D. A. (2019). Trends and causes of socioeconomic inequalities in maternal healthcare in Ghana, 2003–2014. International Journal of Social Economics, 46(2), 288–308. https://doi.-org/10.1108/ijse-03-2018-0148
Frounfelker, R. L., Mishra, T., Holmes, K. B., Gautam, B., & Betancourt, T. S. (2023). Mental health among older Bhutanese with a refugee life experience: A mixed-methods latent class analysis study. American Journal of Orthopsychiatry, 93(4), 304–315. https://doi.org/-10.1037/ort0000684
Gavurova, B., Kelemen, M., Polishchuk, V., Mudarri, T., & Smolanka, V. (2023). A fuzzy decision support model for the evaluation and selection of healthcare projects in the framework of competition. Frontiers in Public Health, 11, 1222125.
Gedikli, E., & Kocaman, E. (2025). Priorities for effective management of health expenditures in OECD countries: Fuzzy AHP application. Sosyoekonomi, 33(63), 11–29. https://doi.org/-10.17233/sosyoekonomi.2025.01.01
Gogishvili, M., Flórez, K. R., Costa, S. A., & Huang, T. T. (2021). A qualitative study on mixed experiences of discrimination and healthcare access among HIV-positive immigrants in Spain. BMC Public Health, 21(1), Article 10388. https://doi.org/10.1186/s12889-021-10388-6
Goniewicz, K., Burkle, F. M., Dzhus, M., & Khorram‐Manesh, A. (2023). Ukraine’s healthcare crisis: Sustainable strategies for navigating conflict and rebuilding for a resilient future. Sustainability, 15(15), 11602. https://doi.org/10.-3390/su151511602
Hamilton, E. R., Patler, C., & Savinar, R. (2022). Immigrant legal status disparities in health among first- and one-point-five-generation Latinx immigrants in California. Population Research and Policy Review, 41(3), 1241–1260. https://doi.org/10.1007/s11113-021-09689-w
Izquierdo‐Condoy, J. S., Salazar-Aguilar, J. P., Vásconez-González, J., & Ortiz‐Prado, E. (2025). The public health consequences of mandatory return migration: A call for action. Frontiers in Public Health, 13, 1577018. https://doi.org/10.3389/fpubh.2025.1577018
Kanengoni, B., Watson, K., Galindo, C., Charania, N. A., Mpofu, C., & Holroyd, E. (2023). Barriers to and recommendations for equitable access to healthcare for migrants and refugees in Aotearoa, New Zealand: An integrative review. Journal of Immigrant and Minority Health, 26(1), 164–180. https://doi.org/10.-1007/s10903-023-01528-8
Khalifeh, R., D’Hoore, W., Saliba, C., Salameh, P., & Dauvrin, M. (2023). Healthcare bias and health inequalities towards displaced Syrians in Lebanon: A qualitative study. Frontiers in Public Health, 11, 1273916. https://doi.org/10.-3389/fpubh.2023.1273916
Kumar, V., & Kumar, K. (2008). On the ideal convergence of sequences of fuzzy numbers. Information Sciences, 178(24), 4670–4678. https://-doi.org/10.1016/j.ins.2008.08.013
Lorini, C., Caini, S., Ierardi, F., Bachini, L., Gemmi, F., & Bonaccorsi, G. (2020). Health literacy as a shared capacity: Does the health literacy of a country influence the health disparities among immigrants? International Journal of Environmental Research and Public Health, 17(4), 1149. https://doi.org/10.3390/ijerph-17041149
Lv, B., Zhang, L., & Meng, K. (2023). Effect of multiple chronic conditions on family doctor contracting in the elderly in China: The moderating role of socioeconomic status. BMC Public Health, 23(1), Article 16438. https://doi.org/-10.1186/s12889-023-16438-5
Maia, A. C., Marques, M. J., Goes, A. R., Gama, A., Osborne, R. H., & Dias, S. (2024). Health literacy strengths and needs among migrant communities from Portuguese-speaking African countries in Portugal: A cross-sectional study. Frontiers in Public Health, 12, Article 1415588. https://doi.org/10.3389/fpubh.2024.-1415588
Mbanya, V. N., Terragni, L., Gele, A. A., Díaz, E., & Kumar, B. N. (2020). Barriers to access to the Norwegian healthcare system among Sub-Saharan African immigrant women exposed to female genital cutting. PLOS ONE, 15(3), e0229770. https://doi.org/10.1371/journal.pone.0229770
Mladenović, M., Simjanović, D. J., Ranđelović, B. M., Dobričanin, S., Zdravković, N., & Đokić, D. (2025). New Frontiers in Determining Criteria and Strategies in Rural Area Sustainable Development in Serbia: Fuzzy AHP Approach. World, 6(4), 141. https://doi.org/10.-3390/world6040141
Moeti, T., Mokhele, T., Weir-Smith, G., Dlamini, S., & Tesfamicheal, S. (2023). Factors affecting access to public healthcare facilities in the City of Tshwane, South Africa. International Journal of Environmental Research and Public Health, 20(4), 3651. https://doi.org/10.-3390/ijerph20043651
Murata, C., & Kondo, K. (2020). Access to healthcare and health disparities. In Springer series on epidemiology and public health (pp. 199–206). Springer. https://doi.org/10.1007/978-981-15-1831-7_18
Newaz, S., & Riediger, N. D. (2020). A qualitative study on needs and barriers to mental healthcare service access by refugee women in Winnipeg, Manitoba, Canada. International Journal of Health Services Research and Policy, 5(3), 276–293. https://doi.org/10.33457/-ijhsrp.798280
Ngo, H. Y., & Li, H. (2016). Cultural identity and adaptation of mainland Chinese immigrants in Hong Kong. American Behavioral Scientist, 60(5–6), 730–749. https://doi.org/10.1177/000-2764216632837
Odhiambo, A. J., Forman, L., Nelson, L. E., O’Campo, P., & Grace, D. (2022). Legislatively excluded, medically uninsured and structurally violated: The social organization of HIV healthcare for African, Caribbean and Black immigrants with precarious immigration status in Toronto, Canada. Qualitative Health Research, 32(5), 847–865. https://doi.org/10.11-77/10497323221082958
Oliveira, E. C. T., Louvison, M. C. P., Duarte, Y. A. d. O., & Andrade, F. B. d. (2025). Socioeconomic inequalities related to perceived difficulty in accessing health services among older adults: A cross-sectional analysis of SABE study data. PLOS One, 20(5), e0322333. https://doi.org/10.1371/journal.pone.0322333
Ommane, Y., Lachgar, M., Hanine, M., Laanaoui, M. D., & Kaouri, S. (2025). Optimizing healthcare supply chain capacity planning during disasters using fuzzy AHP and TOPSIS methods. Scientific Reports, 15(1), 35335. https://doi.org/10.1038/s41598-025-19338-3
Owczarzak, J., Fuller, S., Coyle, C., Davey‐Rothwell, M., Kiriazova, T., & Tobin, K. E. (2022). The relationship between intersectional drug use and HIV stigma and HIV care engagement among women living with HIV in Ukraine. AIDS and Behavior, 27(6), 1914–1925. https://doi.org/10.1007/s10461-022-03925-w
Palinkas, L. A., Horwitz, S. M., Green, C. A., Wisdom, J. P., Duan, N., & Hoagwood, K. (2015). Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Administration and Policy in Mental Health and Mental Health Services Research, 42(5), 533–544. https://doi.org/10.-1007/s10488-013-0528-y
Raharjo, I., Ekawati, M., & Syafitri, W. (2022). Forced migration and household welfare in Indonesia. Journal of Innovation in Business and Economics, 6(1), 27–36. https://doi.org/10.22-219/jibe.v6i01.20787
Saaty, T. L. (2008). Decision making with the analytic hierarchy process. International Journal of Services Sciences, 1(1), 83–98. https://doi.-org/10.1504/IJSSCI.2008.017590
Sevkli, M., Oztekin, A., Uysal, O., Torlak, G., Turkyilmaz, A., & Delen, D. (2012). Development of a fuzzy ANP based SWOT analysis for the airline industry in Turkey. Expert Systems with Applications, 39(1), 14–24. https://doi.org-/10.1016/j.eswa.2011.06.047
Small, M., Allen, T. K., & Brown, H. L. (2017). Global disparities in maternal morbidity and mortality. Seminars in Perinatology, 41(5), 318–322. https://doi.org/10.1053/j.semperi.2017.04.009
Spytska, L. (2025). The psyche of people with preexisting mental disorders during the war. The Humanistic Psychologist, 53(3), 493–506. https://doi.org/10.1037/hum0000362
Tang, L. (2024). The impact of inequality in socioeconomic status on healthcare services utilization. Journal of Education, Humanities and Social Sciences, 28, 455–458. https://doi.-org/10.54097/zxymv497
Tuzkaya, U. R., & Önüt, S. (2008). A fuzzy analytic network process based approach to transportation-mode selection between Turkey and Germany: A case study. Information Sciences, 178(15), 3133–3146. https://doi.org/10.1016/-j.ins.2008.03.015
Wenner, J., Biddle, L., Gottlieb, N., & Bozorgmehr, K. (2021). Inequalities in access to healthcare by local policy model among newly arrived refugees: Evidence from population-based studies in two German states. medRxiv. https://doi.org/10.1101/2021.07.13.21260241
Xiaoqiong, W., Fang, P., Shihuang, S., & Jianan, F. (2004, June). Trapezoidal fuzzy AHP for the comprehensive evaluation of highway network programming schemes in Yangtze River Delta. In Fifth World Congress on Intelligent Control and Automation (IEEE Cat. No. 04EX788) (Vol. 6, pp. 5232–5236). IEEE. https://doi.org/10.1109/WCICA.2004.1343719
Yemane, A., Kahsay, Z. H., Teka, H., Berhe, E., Abera, B. T., Amdeselassie, F., … & Bazzano, A. N. (2024). Lived experience of healthcare providers amidst war and siege: A phenomenological study of Ayder Comprehensive Specialized Hospital of Tigray, Northern Ethiopia. BMC Health Services Research, 24(1), Article 10655. https://doi.org/10.1186/s12913-024-10655-3
Yu, J., & Meng, S. (2022). Impacts of the internet on health inequality and healthcare access: A cross-country study. Frontiers in Public Health, 10, 935608. https://doi.org-/10.3389/fpubh.2022.935608
Yüksel, İ., & Dağdeviren, M. (2010). Using the fuzzy analytic network process (ANP) for Balanced Scorecard (BSC): A case study for a manufacturing firm. Expert Systems with Applications, 37(2), 1270–1278. https://doi.org/10.1016-/j.eswa.2009.06.002
Zadeh, L. A. (1965). Fuzzy sets. Information and Control, 8(3), 338–353. https://doi.org/10.1016-/S0019-9958(65)90241-X

Details

Primary Language

English

Subjects

Migration Sociology

Journal Section

Research Article

Authors

Emre Yılmaz ^*
0000-0003-4502-9846
Türkiye

Publication Date

October 30, 2025

Submission Date

September 15, 2025

Acceptance Date

October 30, 2025

Published in Issue

Year 2025 Number: Reimagining Social Entanglement

DOI

https://doi.org/10.26466/opusjsr.1784130

IZ

https://izlik.org/JA99ND48PM

APA

Yılmaz, E. (2025). Deepening Social Inequalities in Health in the Maelstrom of War and Migration: A Multi-Criteria Approach. OPUS Journal of Society Research, Reimagining Social Entanglement, 176-187. https://doi.org/10.26466/opusjsr.1784130

Savaş ve Göç Girdabında Derinleşen Sağlıkta Sosyal Eşitsizlikler: Çok Kriterli Bir Yaklaşım

Öz

Anahtar Kelimeler

Deepening Social Inequalities in Health in the Maelstrom of War and Migration: A Multi-Criteria Approach

Abstract

Keywords

References

Details

Primary Language

Subjects

Journal Section

Authors

Publication Date

Submission Date

Acceptance Date

Published in Issue

DOI

IZ

Cite