"A person who does not have money does not enter": a qualitative study on refugee women's experiences of respectful maternity care.

BACKGROUND: Women's childbirth experiences in health facilities is at the core of quality of care. Their perceptions of poor-quality care, including disrespectful care at health facilities during childbirth, is recognized as a significant barrier to seeking care for subsequent births. Research that explores women's perspectives of the dimensions of disrespect and mistreatment during childbirth in Arab countries is scarce, and there is none pertaining to refugee groups who carry the burden of multiple vulnerabilities and who suffer from discontinued care, especially in fragile health systems. This paper aims at presenting Palestinian, Iraqi and Syrian refugee women's experiences, understanding and interpretation of disrespect and mistreatment during childbirth in hospitals in Lebanon. METHODS: This study employed phenomenology, a qualitative research design to generate data through in-depth interviews. Women who were 3 to 6 months postpartum were recruited through the non-governmental organizations (NGOs) that are actively engaged in providing welfare and healthcare services to different populations of refugee women in Lebanon. In total, 24 women were interviewed. All interviews were audio recorded, transcribed verbatim and subjected to thematic analysis. RESULTS: Of the 24 women who participated in this study, 9 were Palestinian, 12 were Syrian and 3 were Iraqi. The participants spoke of restricted choices to hospitals, care providers and to types of birth, while revealing adverse experiences during childbirth in healthcare facilities, including verbal and physical abuse, disrespectful verbal and non-verbal communication by healthcare providers. They also reported sub-standard care, denial of birth companions and breaches to their privacy. Our findings exemplify how the coverage of the cost of facility-based births by UN agencies and NGOs increase refugee women's vulnerability to disrespect and mistreatment during childbirth. CONCLUSION: This study shows how disrespect and mistreatment are intertwined in a complex system which is devised to ensure access to facility-based birth for displaced populations. Implications for programs and policies point to the need for strengthening capacity and for providing resources for the adaptation of global guidelines into context-specific strategies for the provision of quality maternity care during humanitarian crises and beyond.

A call to advance and translate research into policy on governance, ethics, and conflicts of interest in public health: the GECI-PH network.

Efforts to adopt public health policies that would limit the consumption of unhealthy commodities, such as tobacco, alcohol and ultra-processed food products, are often undermined by private sector actors whose profits depend on the sales of such products. There is ample evidence showing that these corporations not only try to influence public health policy; they also shape research, practice and public opinion. Globalization, trade and investment agreements, and privatization, amongst other factors, have facilitated the growing influence of private sector actors on public health at both national and global levels. Protecting and promoting public health from the undue influence of private sector actors is thus an urgent task. With this backdrop in mind, we launched the "Governance, Ethics, and Conflicts of Interest in Public Health" Network (GECI-PH Network) in 2018. Our network seeks to share, collate, promote and foster knowledge on governance, ethical, and conflicts of interest that arise in the interactions between private sectors actors and those in public health, and within multi-stakeholder mechanisms where dividing lines between different actors are often blurred. We call for strong guidance to address and manage the influence of private sector actors on public health policy, research and practice, and for dialogue on this important topic. Our network recently reached 119 members. Membership is diverse in composition and expertise, location, and institutions. We invite colleagues with a common interest to join our network.

A scoping review of reporting 'Ethical Research Practices' in research conducted among refugees and war-affected populations in the Arab world.

BACKGROUND: Ethical research conduct is a cornerstone of research practice particularly when research participants include vulnerable populations. This study mapped the extent of reporting ethical research practices in studies conducted among refugees and war-affected populations in the Arab World, and assessed variations by time, country of study, and study characteristics. METHODS: An electronic search of eight databases resulted in 5668 unique records published between 2000 and 2013. Scoping review yielded 164 eligible articles for analyses. RESULTS: Ethical research practices, including obtaining institutional approval, access to the community/research site, and informed consent/assent from the research participants, were reported in 48.2, 54.9, and 53.7% of the publications, respectively. Institutional approval was significantly more likely to be reported when the research was biomedical in nature compared to public health and social (91.7% vs. 54.4 and 32.4%), when the study employed quantitative compared to qualitative or mixed methodologies (61.7% vs. 26.8 and 42.9%), and when the journal required a statement on ethical declarations (57.4% vs. 27.1%). Institutional approval was least likely to be reported in papers that were sole-authored (9.5%), when these did not mention a funding source (29.6%), or when published in national journals (0%). Similar results were obtained for access to the community site and for seeking informed consent/assent from study participants. CONCLUSIONS: The responsibility of inadequacies in adherence to ethical research conduct in crisis settings is born by a multitude of stakeholders including funding agencies, institutional research boards, researchers and international relief organizations involved in research, as well as journal editors, all of whom need to play a more proactive role for enhancing the practice of ethical research conduct in conflict settings.

Community-based participatory research in complex settings: clean mind-dirty hands.

Despite the abundance of the literature which discusses factors supporting or inhibiting effective participation of community members in community-based research, there is a paucity of publications analysing challenges to participation in complex settings. This manuscript describes an intervention built on researcher-community partnership amid complex social conditions which challenged participation of community members at different stages of the research process. The research took place in a Palestinian refugee camp in Beirut, Lebanon and 1 of 12 in Lebanon which suffer from deteriorating social, economic and physical conditions perpetuated by state-imposed restrictions. The research team developed a community coalition which was involved in all stages of planning, designing, implementation and dissemination. In all those stages the aim was to maintain rigorous research, to follow a 'clean mind' approach to research, but maintain principles of community participation which necessitate 'a dirty hand'. Despite commitment to the principles of community-based participatory research, participation of community members (including youth, parents and teachers) was affected to a great extent by the social, physical and structural conditions of the community context. Characteristics of the context where research is conducted and how it affects community members should not be overlooked since multiple factors beyond the researchers' control could interfere with the rigour of scientific research. Researchers need to develop a plan for participation with the community from the beginning with an understanding of the community forces that affect meaningful participation and address possible deterrence.

Benefits and risks: Views of humanitarian organizations in Lebanon on corporate assistance.

Compounding humanitarian and political crises within and across countries have been met with shrinking public resources for coordination, recovery, and mitigation. This resource constrained humanitarian environment presents opportunities for multinational corporations to supplement budgets and actively participate in new markets through connecting with humanitarian work. Given the well-established influence of corporations on public health, an assessment of industry funding to humanitarian assistance is necessary especially in the fragile context of Lebanon with a substantial refugee population and multiple compounding crises. This paper examines three aspects of corporate assistance in humanitarian crises in Lebanon. It investigates the modality of corporate assistance to humanitarian agencies, the extent to which humanitarian agency staff are aware of implications of this assistance along with any ethical considerations related to it, and both the risks and benefits for corporations and people. This study explores the views of 14 local and international humanitarian agencies in Lebanon) through in-depth interviews conducted between 2020 and 2022. Interviews were recorded, transcribed and subject to thematic analysis. All agencies participating in the study provided social and health assistance as well as education, vocational training, and other services to refugees or Lebanese. Findings indicate that the majority of them receive corporate funding in varying amounts and in-kind contributions to support various projects. Despite imposed conditions by the corporations, such as posting logos and stories, the agencies perceived the benefits of partnering, mentioning financial assistance in time of need, and flexible agendas that outweigh the risks of conflicts of interest of corporate branding on the populations they serve. Benefits to the corporations themselves relate to corporate social responsibility, increased market reach and visibility. Challenges in partnering with for-profits include ethical considerations and programmatic issues, however no guidelines were reported to exist to detect corporate conflicts of interest, instead most of the agencies rely on their value systems for screening.

'I felt that I was benefiting someone': youth as agents of change in a refugee community project.

Youth can be 'powerful catalysts' in their own and their community's development. The paper describes the experience of youth based on their participation as decision makers in and implementers of a community-based research project in a Palestinian refugee camp of Beirut, Lebanon. In-depth interviews were conducted with 18 youth and 10 of their family members or friends. The participants were asked to describe the reasons they joined the project, why they stayed on, what they liked most/least about the project, how the project influenced their lives and what they would change about the project. Thematic analysis identified recurrent themes. Youth joined the program because of its benefit to children and their community. They stayed with the program because of the solidarity they found with the team and because of their relationship with the children. They perceived that they had an important role to play in the project's success. Youth acknowledged all the skills they gained from the project. Focus groups with others corroborated their statements. This project confirmed that youth can be powerful change agents in their own development and that of their communities. An Enabling Attributes Model is proposed for projects that aim to actively engage youth as community catalysts.

"Hitting as Light as Feathers": Religious Leaders' Voices on Domestic Violence.

Domestic violence (DV) is described as a major public health issue that negatively affects women's physical, mental, reproductive, and sexual health. In Lebanon, there are 18 religious sects that are allowed by the Lebanese constitution to manage their own affairs, judge, legislate, and issue rulings. These laws discriminate against married women and favor men over women. The purpose of this research is to explore the views and attitudes of religious leaders on DV, and their experiences of dealing with DV in Lebanon. This study involved in-depth interviews with 13 male religious leaders from various religious denominations. Each religious leader participated in an in-depth interview to assess understanding and perceptions about DV, and how DV cases are usually dealt with. All of the participants stated that they were involved in the affairs of their communities by counseling on familial and marital problems. Thus, several themes emerged throughout this study which are related to types and prevalence of DV, causes of DV, responding to DV through counseling and taking legal measures, religious leaders' opinions on the DV law, and the support they need from the community and stakeholders to encourage the implementation of the law against DV. The results demonstrated that religious leaders are one of the many stakeholders concerned with addressing community-level issues because religion is a prominent part of people's lives in Lebanon. Therefore, religious leaders could have a pivotal role in raising awareness about and responding to DV. Providing them with proper information and referral options in the communities they serve would improve society's response to DV. Finally, their request for building their skills in DV counseling in the form of trainings or workshops indicates a need that can be met by local community organizations.

Parental attitudes towards and perceptions of their children's participation in clinical research: a developing-country perspective.

BACKGROUND: Paediatric clinical research faces unique challenges that compromise optimal recruitment of children into clinical trials. A main barrier to enrolment of children is parental misconceptions about the research process. In developing countries, there is a knowledge gap regarding parental perceptions of and attitudes towards their children's participation in clinical trials. OBJECTIVE: To explore such perceptions and attitudes in Lebanese parents. STUDY DESIGN: 33 in-depth interviews were conducted with parents with and without previous research experience. Interviews were tape-recorded, transcribed in colloquial Arabic, and later subjected to thematic analysis. RESULTS: Benefit/risk ratio assessment was a major determinant of parental consent. Fear of adverse events or painful procedures in research was a recurring theme in most interviews. Whereas perception of direct benefit to the child, trust in the physician or institution, financial gains or having a positive previous experience in research facilitated consent, a complex informed consent form and misunderstanding of the term 'randomisation' hindered parental approval of participation. CONCLUSION: Lebanese parents have perceptions of and attitudes towards children's participation in clinical trials that are similar to those reported from the industrialised world. Improving communication with parents and building trust between researchers and parents is important for successful recruitment. Investigators planning to conduct paediatric trials in developing countries need to simplify consent forms and devise new ways to explain randomisation.

Starting over from scratch: social support and youth coping with internal displacement.

This article presents findings from a qualitative research study with daughters of internally displaced families, more than a decade and half after the end of the Lebanese civil war. In-depth interviews with these adolescent girls indicate that in the absence of universal coverage of social security nets for the Lebanese, the effects of impoverishment and continuous mobility in the suburbs have adverse effects on their sense of stability, schooling, and coping. The article argues that although the effects of impoverishment are not new to similar urban youth populations, the quality of social support networks (ties to rural areas and support from welfare agency services) is a determining factor in the way they cope with adversity. Implications for policy are also presented.

Development and validation of the Arab Youth Mental Health Scale.

A variety of measures of mental health have been used with youth. The reason for choosing one scale over another in any given situation is rarely stated, and cross-cultural validation is scarce. Psychometric testing is crucial before utilizing any measure of mental health with a certain population, due to possible cultural variations in interpreting meaning. The research reported herein describes the development and psychometric testing of the Arab Youth Mental Health Scale. The process included 5 phases: (1) reviewing existing scales leading to the identification of 14 non-clinical and relatively short mental health scales used previously with youth; (2) rating the scales by the researchers and community members leading to the identification of 3 scales with apt structure, and that were judged to be suitable, applicable, and appropriate; (3) soliciting youth input to assess comprehension of each item in the selected 3 scales and to discover context specific mental health related feelings, thoughts, and expressions; (4) seeking expert opinion to classify items remaining after phase 3 that measured common mental disorders, and to limit repetitiveness; and (5) testing for psychometric properties of the 28 items that remained after the previous 4 phases. The contribution of each phase to the process is described separately. Results of the exploratory principal component analysis resulted in one factor which explained 28% of the variance and for which 21 items loaded above an eigenvalue of 0.5. No other factor added significantly to the explanation of variance, nor had items that added theoretical or conceptual constructs. The process of soliciting feedback from youth groups, the community and professionals; and of field testing was challenging; but resulted in a contextually sensitive, culturally appropriate and reliable scale to measure mental health of youth. We recommend that researchers measuring mental health of youth critically analyze the relevance of existing scales to their context; consider using the AYMH scale if appropriate to their target population; and when needed, use a similar methodology to construct a relevant, culturally and contextually sensitive measure.

Analyzing the social context of health information and misinformation during the COVID-19 pandemic: a case of emerging inequities in Lebanon.

With the far-reaching COVID-19 pandemic starting in December 2019, a surge of misinformation, now coined by the World Health Organization (WHO) as an 'infodemic', has also taken the world by storm. False information and variations in interpretations about the pandemic and mitigation interventions/strategies continue to spread at a faster pace than the relevant scientific evidence. The WHO has called for a fight against this infodemic, describing it as the most contagious aspect of the pandemic. In this era of rapid information exchange, public health measures, and state interventions to control the pandemic, a contextual understanding of how information is communicated and shared is important for uncovering possible reasons for action or inaction by the general public. With the Lebanese state scrambling to implement and enforce different measures to control and mitigate the spread of COVID-19, adherence by the general public is not uniform. In this paper, we refer to social science and risk communication theory to discuss how the political, economic and social contexts in the country, and not only the content of the messages that people receive from officials, affect how they interpret and act on information. We highlight how this has played out in Lebanon and identify societal aspects of importance in a low-middle income country fraught with social, economic and political inequalities which continue to undermine the efforts to contain the spread. Implications to inform state response in the context of low-middle income countries are also discussed.

Ethics Reporting Practices in Aging Research From the Arab Region.

Objectives: This study aims to assess the extent of ethics reporting practices in aging research from Arab countries. Methods: A systematic scoping review of research on aging in 22 Arab countries from seven databases (1994-2013) identified 637 publications warranting institutional ethical approval and 612 publications warranting informed consent. We used multivariable regression analysis to examine variations by time, place, and study characteristics. Results: Only 36.6% of articles reported approval from a Research Ethics Committee and 38.7% reported informed consent. Reporting of ethical research practices increased significantly over time and as research collaborations and journal impact factor increased, and when sampling frame included institutionalized participants. In contrast, failure to report ethical research practices was significantly more common in non-English articles and those that did not report a funding source. Discussion: Despite gains across time, reporting of ethical research practices remains suboptimal in the Arab region. Further guidelines and capacity building are needed.

Understanding youth: using qualitative methods to verify quantitative community indicators.

Community- and individual-level data were collected from interviews with 1,294 boys and girls, 13 to 19 years old, in three impoverished urban communities of Beirut. Univariate analyses of variables provide quantitative indicators of adolescents' lives and communities. Researchers including the authors, interested in using these indicators to plan for community interventions with youth in the Palestinian refugee camp, discuss the pertinent results with youth from the camp in six focus groups. The authors find that many indicators misrepresent the situation of youth in the camp. For example, adolescents may have underreported cigarette and argileh (water pipe) smoking (8.3% and 22.4%, respectively) because of the lack of social desirability of these behaviors; other questions may have been misunderstood, such as perceived health and health compared to others. Also, important issues for them such as drug abuse, violence, and school problems were not asked. Implications for intervention research are discussed.

War as a positive medical educational experience.

CONTEXT: There is little empirical evidence in the literature regarding the nature of the experiences of medical students during war. In this study we set out to assess and analyse the experiences of medical students and residents in Beirut, Lebanon during the 2006 Lebanon-Israel war. METHODS: Students and residents working at the American University of Beirut Medical Center and the Beirut Government University Hospital during the July 2006 war were invited to participate. A total of 21 students or residents took part in either a focus group or one of 11 semi-structured interviews. These were recorded, transcribed and analysed to bring out common themes. RESULTS: Although the wartime experience was stressful, medical students and residents reported many largely positive effects of war on their medical training. Students adapted to the difficult conditions and became more resourceful. Participants connected emotionally with their patients and were able to show more compassion. They felt pride in their chosen profession and had higher levels of motivation for dealing with the normally irksome aspects of medical practice. Practical skills associated with the treatment of wartime injuries were learned, as were more general lessons about life priorities. CONCLUSIONS: Despite the curtailing of formal educational activities, participants benefited from positive learning experiences in a wartime environment. Strikingly, participants 'cared' more for their patients. Further research looking at the underlying cause of this increased level of compassion may be useful in the education of all medical students, not just those involved in conflict.

Research Ethics 2.0: New Perspectives on Norms, Values, and Integrity in Genomic Research in Times of Even Scarcer Resources.

Research ethics anew gained importance due to the changing scientific landscape and increasing demands and competition in the academic field. These changes are further exaggerated because of scarce(r) resources in some countries on the one hand and advances in genomics on the other. In this paper, we will highlight the current challenges thereof to scientific integrity. To mark key developments in research ethics, we will distinguish between what we call research ethics 1.0 and research ethics 2.0. Whereas research ethics 1.0 focuses on individual integrity and informed consent, research ethics 2.0 entails social scientific integrity within a broader perspective of a research network. This research network can be regarded as a network of responsibilities in which every stakeholder involved has to jointly meet the ethical challenges posed to research.

The Practice of Research Ethics in Lebanon and Qatar: Perspectives of Researchers on Informed Consent.

Informed consent requirements for conducting research with human participants are set by institutional review boards (IRBs) following established guidelines. Despite this, researchers continue to face challenges in seeking and obtaining informed consent. This study discusses researchers' views of such problems in Lebanon and Qatar, which vary in research regulation. We conducted in-depth interviews with 52 academic researchers from various fields of research in both countries and analyzed them using thematic analysis. Important disjunctions emerged between IRB requirements and actual practice. Variations in obtaining informed consent were affected by the research context, type of research, and the prevalent cultural norms and values. Regulatory systems and guidelines for informed consent do not necessarily ensure ethical research conduct. Implications for improvement are presented.

"Protecting" or "Policing": Academic Researchers' View of IRBs in an Arab Context.

A recent surge of research universities and human subjects research funding in the Arab world raises concerns about applied research ethics and oversight. In-depth interviews conducted with 52 researchers in Lebanon and Qatar about their research conduct and the problems they face while conducting it indicate that although researchers admit to the added value of institutional review board (IRB) functions, the researchers have several complaints, such as rigid and contextually insensitive requirements, delays, and inadequate resources at IRBs, and a lack of outreach and effective communication with researchers. The study discusses these challenges pointing to the need for socioculturally adaptive regulations and forms and strengthening outreach and communication between IRBs and their users to improve ethical practices. Implications for future research are also presented.

Developing a logic model for youth mental health: participatory research with a refugee community in Beirut.

Although logic models are now touted as an important component of health promotion planning, implementation and evaluation, there are few published manuscripts that describe the process of logic model development, and fewer which do so with community involvement, despite the increasing emphasis on participatory research. This paper describes a process leading to the development of a logic model for a youth mental health promotion intervention using a participatory approach in a Palestinian refugee camp in Beirut, Lebanon. First, a needs assessment, including quantitative and qualitative data collection was carried out with children, parents and teachers. The second phase was identification of a priority health issue and analysis of determinants. The final phase in the construction of the logic model involved development of an intervention. The process was iterative and resulted in a more grounded depiction of the pathways of influence informed by evidence. Constructing a logic model with community input ensured that the intervention was more relevant to community needs, feasible for implementation and more likely to be sustainable.

Validation of the Arab Youth Mental Health scale as a screening tool for depression/anxiety in Lebanese children.

BACKGROUND: Early detection of common mental disorders, such as depression and anxiety, among children and adolescents requires the use of validated, culturally sensitive, and developmentally appropriate screening instruments. The Arab region has a high proportion of youth, yet Arabic-language screening instruments for mental disorders among this age group are virtually absent. METHODS: We carried out construct and clinical validation on the recently-developed Arab Youth Mental Health (AYMH) scale as a screening tool for depression/anxiety. The scale was administered with 10-14 year old children attending a social service center in Beirut, Lebanon (N = 153). The clinical assessment was conducted by a child and adolescent clinical psychiatrist employing the DSM IV criteria. We tested the scale's sensitivity, specificity, and internal consistency. RESULTS: Scale scores were generally significantly associated with how participants responded to standard questions on health, mental health, and happiness, indicating good construct validity. The results revealed that the scale exhibited good internal consistency (Cronbach's alpha = 0.86) and specificity (79%). However, it exhibited moderate sensitivity for girls (71%) and poor sensitivity for boys (50%). CONCLUSIONS: The AYMH scale is useful as a screening tool for general mental health states and a valid screening instrument for common mental disorders among girls. It is not a valid instrument for detecting depression and anxiety among boys in an Arab culture.