Main Points

• This study is the first ecological analysis examining the regional distribution of YEDAM centers and Syrian refugees in Türkiye.
• A significant positive correlation was found between the number of registered Syrians and YEDAM centers nationwide.
• Increasing YEDAM capacity in regions with higher migrant density may improve accessibility and service equity.

Introduction

Migration is a phenomenon that has persisted for centuries and whose effects have increasingly expanded on a global scale, profoundly influencing the demographic structure of societies and the dynamics of public health (Goldenberg & Fischer, 2023). Wars, poverty, discrimination, and adaptation difficulties leading to forced displacement constitute significant risk factors for mental disorders and addictive behaviors through multidimensional stressors (Cuadrado et al., 2023; López-Atanes et al., 2025). Refugees represent a group that is more vulnerable to addiction, as they are exposed to factors such as trauma, uncertainty, and social exclusion at every stage of the migration process (Aleer et al., 2023; López-Atanes et al., 2025; Vasic et al., 2021). In addition, a systematic review on forced migrants has demonstrated that substance use may increase as a maladaptive coping response to trauma, post-migration stressors, and social inequities (Horyniak et al., 2016).

As of October 2025, Türkiye is one of the countries hosting the largest number of refugees in the world, with approximately 2.5 million Syrians under temporary protection (T.C. İçişleri Bakanlığı Göç İdaresi Başkanlığı, 2025). The high proportion of the migrant population creates additional demands and an increasing need for mental health and addiction services; however, access to these services remains limited for these groups due to various cultural, linguistic, and structural barriers (Bilican et al., 2025; Fuhr et al., 2019; Schoenberger et al., 2024; Stylianopoulos et al., 2024). Supporting this observation, a systematic review reported that refugees and asylum seekers have high mental health needs but underutilize mental health services in European host countries (Satinsky et al., 2019). On the other hand, Türkiye has a well-established national structure addressing addiction within the general population. The Green Crescent Counseling Center (YEDAM), founded by the Turkish Green Crescent Society, provides free, accessible, and evidence-based counseling services across the country within the scope of addiction prevention and treatment, playing a significant role in promoting preventive and rehabilitative approaches throughout all segments of society (Yeşilay Danışmanlık Merkezi, 2025). However, the geographical distribution and number of these centers have not yet been systematically examined in relation to the size and density of the migrant population.

This study aims to analyze the relationship between the number of Syrians under temporary protection and the distribution of YEDAM centers across Türkiye’s seven geographical regions. As one of the first ecological-level investigations addressing the interaction between migration and addiction in Türkiye from a service accessibility perspective, the study seeks to raise awareness regarding migration-based regional planning of addiction counseling services and to provide scientific evidence on the inclusiveness of YEDAM’s field infrastructure.

Methods

Study Design

This study was designed as an ecological, descriptive, and cross-sectional research that examines, at the regional level, the relationship among the number of Syrians under temporary protection in Türkiye, the ratio of registered Syrians to the total provincial population, and the distribution of YEDAM centers. The study does not include individual-level data and was conducted solely based on publicly available statistical indicators.

Data Sources

Two primary data sources were used in this study. The first dataset was obtained from the publicly accessible database of the Presidency of Migration Management under the Ministry of Interior of the Republic of Türkiye, which presents, as of October 9, 2025, the number of Syrians under temporary protection by province and their ratios to the total provincial population (T.C. İçişleri Bakanlığı Göç İdaresi Başkanlığı, 2025). The second dataset was derived from the official website of YEDAM, which provides the provincial numerical distribution of YEDAM centers (Yeşilay Danışmanlık Merkezi, 2025). Both datasets were compiled by the researcher to include all 81 provinces and were classified according to Türkiye’s seven geographical regions (Marmara, Aegean, Mediterranean, Central Anatolia, Black Sea, Eastern Anatolia, and Southeastern Anatolia). Accordingly, for each province and region, the number of registered Syrians under temporary protection, the ratio of registered Syrians to the total provincial population (%), and the number of YEDAM centers were obtained as study variables.

Statistical Analysis

All statistical analyses were performed using SPSS 27.0 software. Descriptive statistics (mean, standard deviation, median, minimum, and maximum values) were calculated for all variables. The distribution characteristics of the data were evaluated using the Shapiro–Wilk test, and non-parametric tests were preferred for variables not showing normal distribution. To evaluate differences among Türkiye’s seven geographical regions in terms of the ratio of registered Syrians to the total provincial population (%) and the ratio of registered Syrians to the number of YEDAM centers, the Kruskal–Wallis H test was applied. When significant differences were detected, the Bonferroni-corrected Dunn multiple comparison test was used to determine the source of the difference. In addition, Spearman’s rank correlation analysis was conducted to assess relationships between variables. A p-value of < 0.05 was considered statistically significant in all analyses.

Ethical Considerations

This study was conducted exclusively using publicly available statistical data obtained from the official websites of the Presidency of Migration Management of the Republic of Türkiye and YEDAM. The study does not include any individual-level human or patient data. Therefore, it is not classified as “human subjects research” and does not require ethical committee approval.

Results

Number of Registered Syrians and YEDAM Data

This ecological and cross-sectional study was conducted using data obtained from 81 provinces across Türkiye. The total number of Syrians under temporary protection registered in the country was 2,419,425. The mean ratio of Syrians under temporary protection to the total population was 1.77% ± 3.48 nationwide. In contrast, there were a total of 104 YEDAM centers across the 81 provinces. The average number of registered Syrians per YEDAM center was calculated as 23,205 ± 55,316 individuals.

Distribution of Variables by Geographical Regions

An analysis of regional distribution across Türkiye revealed that the Southeastern Anatolia Region had the highest number of Syrians under temporary protection, with 692,230 registered individuals and 10 YEDAM centers. The Marmara Region ranked second, hosting 642,695 Syrians and 29 YEDAM centers. The Mediterranean Region had 599,300 Syrians and 8 YEDAM centers, while Central Anatolia had 275,441 Syrians and 16 YEDAM centers. In the Aegean Region, there were 151,184 Syrians and 9 YEDAM centers; the Black Sea Region had 23,485 Syrians and 18 YEDAM centers; and the Eastern Anatolia Region had 35,090 Syrians and 14 YEDAM centers. Table 1 presents a comparison of the ratio of registered Syrians to the total provincial population (%) and the number of registered Syrians per YEDAM center across Türkiye’s geographical regions.

When examining the ratio of registered Syrians to the total provincial population, the Southeastern Anatolia Region had the highest Syrian density, with a mean Syrian ratio of 6.39% and an average of 75,778 Syrians per center. The Black Sea Region had the lowest Syrian density, with a mean ratio of 0.25% and 1,305 Syrians per center. The difference in Syrian ratios among regions was statistically significant (Kruskal–Wallis H = 41.30; p < 0.001). According to the Bonferroni-corrected Dunn multiple comparison test, the Southeastern Anatolia and Mediterranean regions had significantly higher ratios compared to the Black Sea and Eastern Anatolia regions (p < 0.01). Differences between the other regions were not statistically significant (p > 0.05).

The ratio of registered Syrians to the number of YEDAM centers was also analyzed across the seven geographical regions. The difference in the number of Syrians per YEDAM center among regions was statistically significant (H = 39.21; p < 0.001). According to the Bonferroni-corrected Dunn multiple comparison test, the Mediterranean and Southeastern Anatolia regions had significantly higher numbers of Syrians per YEDAM center than the Black Sea and Eastern Anatolia regions (p < 0.01). No significant differences were found between the remaining regions (p > 0.05).

Correlation Analyses

The statistical relationships among the number of registered Syrians, the ratio of registered Syrians to the total population, and the number of YEDAM centers are presented in Table 2. Nationwide, without regional distinction, the Spearman correlation analysis revealed a weak but significant positive relationship between the number of Syrians and the number of YEDAM centers (ρ = 0.27; p = 0.015). This finding suggests that YEDAM planning partially responds to the absolute number of migrants. A very strong positive correlation was identified between the Syrian ratio and the ratio of Syrians per YEDAM center (ρ = 0.961; p < 0.001), indicating that as the proportion of migrants increases across Türkiye, the service load per YEDAM center also rises. In regional-level correlation analyses, the variance of the YEDAM variable was found to be zero in some geographical regions where all provinces had a fixed number (one) of YEDAM centers; therefore, correlations could not be statistically calculated for those regions.

Discussion

This study represents one of the first ecological analyses to examine the relationship between the number of Syrians under temporary protection, the ratio of registered Syrians to the total population, and the regional distribution of YEDAM centers across Türkiye. The findings indicate that the migrant population is particularly concentrated in the Southeastern Anatolia and Mediterranean regions, whereas YEDAM centers are generally evenly distributed across the country but show potential for capacity expansion in provinces with higher migrant density. A strong positive correlation was observed between the proportion of Syrians and the ratio of migrants per YEDAM center nationwide, suggesting that while YEDAM’s existing structure demonstrates broad coverage, establishing new centers in regions with higher migrant populations could further enhance service accessibility.

Previous research has shown that the YEDAM model provides a strong framework in terms of clinical effectiveness for addiction treatment. A study conducted with 554 clients reported that YEDAM is an effective national model in the treatment of alcohol and substance addiction, characterized by high treatment retention rates, prolonged abstinence duration, and high client satisfaction (Simsek et al., 2019). Studies examining the interaction between psychological trauma and addiction among clients applying to YEDAM have shown that a history of trauma is a critical determinant in understanding addictive behaviors. In a study conducted with 322 YEDAM clients, 97.5% of participants were found to have experienced at least one traumatic event, and 21.7% met the risk criteria for Post-Traumatic Stress Disorder (PTSD) (Şeker et al., 2019). In the PTSD risk group, higher levels of addiction severity, functional impairment related to substance use, and impulsivity were identified. These findings highlight the importance of trauma-informed approaches in addiction treatment centers; considering the high trauma burden observed among migrant populations, they also emphasize the necessity for YEDAM to develop service models strengthened by trauma awareness. Our study, however, complements these individual-based findings on the YEDAM model not in terms of clinical outcomes or client characteristics, but rather from the perspective of regional distribution and service inclusiveness of the centers.

Previous studies have demonstrated that post-migration factors such as daily stressors, anxiety, acculturation processes, and perceived social support play an important role in shaping substance use behaviors among forced migrants. For example, a study conducted among Syrian migrants in Türkiye found that general anxiety predicted cigarette dependence, while psychological and socio-cultural adaptation processes were significant predictors of risky alcohol consumption, highlighting the complex interplay between psychological and social determinants of addiction (Demircan & Guler, 2024). Taşdemir et al. (2020) examined risk factors for alcohol and substance use disorders among migrants using a multidimensional approach and demonstrated that, at the individual level, young age, low educational attainment, unemployment, a history of trauma, and separation from family members, and, at the environmental level, illicit trade, insecurity, harsh working conditions, and social exclusion are key factors increasing the risk of addiction. The same study emphasized that migrants with substance dependence often possess awareness and motivation to quit substance use yet encounter significant environmental and structural barriers to accessing services. These findings indicate that not only individual factors but also the spatial and structural characteristics of service provision play a decisive role in combating addiction. In this context, our study makes an important contribution to the literature by jointly examining the regional distribution of YEDAM centers in Türkiye and the distribution of the Syrian population under temporary protection.

Recent studies in the literature have shown a significant imbalance between migrant density and healthcare service capacity. A field study conducted in Sultanbeyli, Istanbul, reported that there were marked spatial and institutional disparities in Syrian refugees’ access to mental health and addiction-related healthcare services, and that these services were not sufficiently located in regions with high migrant density (Fuhr et al., 2019). In a review study published by Uwishema et al. in 2025, it was emphasized that access to healthcare services for refugees in Türkiye is unequal due to factors such as location, language, and legal status; moreover, the increasing number of refugees has deepened these inequalities, highlighting the need for capacity expansion and comprehensive systemic reforms (Uwishema et al., 2025). Similarly, the international literature also reports spatial and institutional limitations in access to mental health and addiction services in regions with high refugee and migrant density. A study conducted in Germany indicated that refugees’ access to addiction treatment services is limited and that their needs are not adequately met within the system; this situation was suggested to be associated with insufficient service capacity and lack of integration (López-Atanes et al., 2025). Another study conducted in Germany reported that refugees face institutional barriers to accessing addiction treatment services, including language difficulties, cultural mismatches, limited system capacity, and shortages of qualified personnel (Saleh et al., 2023). A study conducted in the United States showed that migrant workers have limited spatial access to healthcare services and that, particularly in rural areas, available services remain inadequate to meet the needs of this population (Decicco et al., 2025). Another study conducted in the United States demonstrated that refugees face various barriers to accessing addiction treatment services and that existing services are inadequate to meet the specific needs of this group (McCleary et al., 2016). Furthermore, it has been emphasized that the lack of healthcare system capacity complicates the referral process for treatment. In line with the existing literature, our study also found a positive correlation between the ratio of registered Syrians to the total provincial population and the service load per YEDAM center. These findings indicate that capacity expansion and regional planning strategies sensitive to migrant density could further strengthen the inclusiveness of the YEDAM model.

This study has several limitations. As it is based on an ecological and cross-sectional design, causal relationships at the individual level cannot be established. Ecological analyses reflect relationships at the collective level and do not directly represent individual-level service accessibility or utilization behaviors. Such ecological assessments, however, serve as a fundamental tool for evaluating the responsiveness of national service planning to the dynamics of the migrant population. In addition, the data were obtained exclusively from publicly available sources, and individual service applications or center-based performance indicators were not included in the analysis. Therefore, the results reflect general regional trends but remain limited in explaining micro-level service differences. It should also be noted that, in Türkiye, the fight against addiction involves not only YEDAM but also centers affiliated with the Ministry of Health and various other governmental and non-governmental organizations. While this is acknowledged, the present study aimed not to include all institutions working in addiction services, but to examine the regional distribution of the YEDAM model at an ecological level. YEDAM was chosen because it is a civil-society-based organization with a widespread presence and a standardized data system within the national addiction response framework.

In future studies, the inclusion of reliable and accessible data from other addiction treatment centers could provide a more comprehensive overview of national service capacity and regional disparities. This would contribute to the development of a broader and more in-depth literature on the holistic structure of addiction services in Türkiye. Although the present ecological study provides an initial overview of the relationship between the regional distribution of the Syrian population under temporary protection and the number of YEDAM centers across Türkiye, future studies incorporating more detailed center-level data such as personnel numbers, service capacity and volume, application numbers and types among individuals under temporary protection, and center-based performance indicators could contribute to a more comprehensive evaluation of service adequacy and equity. A major strength of this study lies in its ecological approach, being the first to jointly examine the distribution of the population under temporary protection and the regional numerical capacity of YEDAM in Türkiye. In this respect, it provides an important reference for service planning and regional capacity-building strategies, while also offering scientific evidence on potential areas where the accessibility and inclusiveness of the YEDAM model can be further enhanced. The findings demonstrate that YEDAM has established a strong foundation with its nationwide service network; however, capacity expansion in regions with high migrant density could further promote equity in service delivery.

Conclusion

This study examined, at an ecological level, the relationship between the regional distribution of the Syrian population under temporary protection and the number of YEDAM centers across Türkiye. The analyses revealed a statistically significant positive correlation between the number of registered Syrians and the number of YEDAM centers, indicating that the service infrastructure of YEDAM aligns with the dynamics of the Syrian population.

The study also found that the number of Syrians per YEDAM center was significantly higher in the Mediterranean and Southeastern Anatolia regions compared with the Black Sea and Eastern Anatolia regions. At this stage, our study serves as a reference model that may guide regional planning and diversification efforts within YEDAM’s strong and extensive service network. It is anticipated that increasing the numerical capacity and enhancing regional diversity of YEDAM centers, particularly in the Mediterranean and Southeastern Anatolia regions, could further improve accessibility for the Syrian population.

Author contributions

Conception and design: E.V.; Data acquisition: E.V.; Data analysis: E.V.; Data interpretation: E.V.; Drafting of the manuscript: E.V.; Critical revision of the manuscript: E.V. The author reviewed the results, approved the final version of the manuscript, and agreed to be accountable for all aspects of this study.

Ethical approval

Ethics committee approval and informed consent were not required for this study.

Data availability statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Conflict of interest

The author declares that this study was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Funding

The author declares that this study received no funding.

Generative AI statement

The author declares that during the preparation of this study, the following AI-assisted technology was used: ChatGPT-5 on 15 October 2025. Extent of Use: Artificial intelligence tools were used in a limited manner solely for language editing and improving clarity of expression during the manuscript preparation process. The study design, data collection, statistical analyses, interpretation of the findings, and all scientific conclusions were entirely performed by the author. The author confirms that he/she has critically reviewed and edited any AI-generated content and takes full responsibility for the integrity, accuracy, and originality of the publication. The author certifies that the original human contribution is maintained and that AI-assisted tools are not listed or cited as authors.