Non-communicable diseases among Palestinian refugees from Syria: a cross-sectional study on prevalence, case management, access to and utilisation of UNRWA Health Services.

BACKGROUND: As of Feb 14, 2014, UNRWA had registered almost 53 000 Palestinian refugees from Syria (PRS) who had fled to Lebanon as the result of the conflict in Syria. Half of the PRS had gone to one of the 12 Palestinian camps, which are overcrowded and of poor infrastructure. Consequently, there is concern for the wellbeing of PRS; in particular, their health status and access to medical care. Little attention has been given to non-communicable diseases (NCDs) in the acute phases of emergencies. Therefore, an assessment of the prevalence of NCDs among PRS, as well as the patterns of use of available health care services by PRS, is warranted. METHODS: A cross-sectional study was conducted in April, 2018, with 1100 PRS residing inside and outside refugee camps across all governorates of Lebanon. A listing of all PRS families was the sampling frame. A random sample of families was selected and contacted, and then one adult randomly selected from each family was approached for data collection. Pregnant women and participants who were too ill to participate were excluded. After obtaining informed verbal consent, we did face-to-face interviews to collect data on household details (such as type of settlement, source of income) and sociodemographic information, major NCDs (for the household representative), lifestyle behaviours, and health-care use. We invited all participants to UNRWA clinics for physical and biochemical measurements. The study protocol was approved by the Institutional Review Board of the American University of Beirut. FINDINGS: We surveyed 959 PRS (59% male [465], 82% married [785], mean age 43 years [SD 12]). A quarter of those interviewed had at least one NCD; the most prevalent were hypertension (23%; 221 of 959), rheumatic diseases (17%; 166), cardiovascular diseases (CVDs, 13%; 126), diabetes (13%; 124), and chronic respiratory diseases (CRDs) (10%; 100). All these NCDs were more prevalent among PRS inside camps than in those residing outside camps, except for diabetes. Most participants who had been diagnosed with NCDs were adhering to their prescribed medications (90-98%). However, of those reporting CVDs, only 56% (71 of 126) had attended at least one follow-up appointment, and of those reporting rheumatic diseases, only 33% (55 of 166) had attended at least one follow-up appointment. About half of participants reported that they checked their blood pressure (55%; 528 of 959) or blood glucose (45%; 430). 111 of 221 (50%) participants with hypertension monitored their blood pressure, and 78 of 124 (63%) participants with diabetes monitored their blood glucose. 133 participants attended UNRWA clinics for measurements; 40% (54) had obesity (>30 kg/cm2), 10% (13) had elevated blood pressure, 12% (16) had stage 1 hypertension, and 8% (10) had stage 2 hypertension. Most participants had normal glucose (67%; 89 of 133), cholesterol (65%; 87), triglyceride (58%; 77), and glycosylated haemoglobin levels (64; 85). A substantial proportion of participants who were tested had undiagnosed diabetes (14%; 33 of 108 reporting no diabetes), undiagnosed hypertension (23%; 19 of 81), uncontrolled diabetes (79% of participants with diabetes; 19 of 24), or uncontrolled hypertension (64% of participants with hypertension; 29 of 45). INTERPRETATION: Further study is needed to understand why the prevalence of NCDs among PRS residing in Palestinian camps is higher than among those living outside, and to understand whether and why access to medicines is a problem, particularly outside camps. The burden of NCDs among PRS is high and their access to services is not optimal; therefore UNRWA should pay special attention to NCD services in this population. UNRWA should invest in efforts to increase awareness of free blood pressure and blood glucose monitoring services in its clinics, and could actively offer free testing in public areas inside camps. Doctors at UNRWA clinics should recommend that patients monitor their disease more frequently and educate them on how to do so. A limitation of the study was the low percentage of participants who attended UNRWA clinics for physical and biochemical measurements. FUNDING: UNRWA.

Sociodemographic characteristics and HIV risk behaviors of native-born and displaced Syrian men and transgender women who have sex with men in Lebanon.

HIV rates among men and transgender women who have sex with men (MTWSM) in Lebanon are consistent with a concentrated epidemic. Geopolitical and social circumstances leave these communities vulnerable to HIV spread. To document this risk encountered by Lebanese native and displaced Syrian MTWSM, participants, recruited by respondent driven sampling beginning with Syrian seeds, completed a survey with questions covering sociodemographic, behavioral, medical, and stigma, followed by opt-out HIV testing. Analyses included descriptive statistics and linear regression to differentiate between native Lebanese and Syrians who migrated after the onset of the civil war to identify correlations among sociodemographic factors, stigma, and risk behavior as a function of country of birth. Experienced and internalized stigmas were higher in the Syrian born MTWSM and correlated with elements of HIV risk. Combatting the intersectional stigmas of Syrian MTWSM in Lebanon would be most beneficial in mitigating HIV risk for these individuals.

RESUMEN: Las tasas de VIH entre hombres y mujeres transgénero que tienen sexo con hombres (HMTSH) en el Líbano son consistentes con una epidemia concentrada. Las circunstancias geopolíticas y sociales dejan a estas comunidades vulnerables a la propagación del VIH. Para documentar este riesgo al que se enfrentan los HMTSH nativos libaneses y HMTSH sirios desplazados, los participantes, reclutados mediante un muestreo impulsado por los encuestados que comenzó con semillas sirias, completaron una encuesta con preguntas que cubrían aspectos sociodemográficos, conductuales, médicos y de estigma, seguidas de una prueba de VIH de exclusión voluntaria. Los análisis incluyeron estadísticas descriptivas y regresión lineal para diferenciar entre libaneses nativos y sirios que emigraron después del inicio de la guerra civil para identificar correlaciones entre factores sociodemográficos, estigma y comportamiento de riesgo como función del país de nacimiento. Los estigmas experimentados e internalizados fueron más altos en los HMTSH nacidos en Siria y se correlacionaron con elementos de riesgo de VIH. Combatir los estigmas interseccionales de los HMTSH sirios en el Líbano sería lo más beneficioso para mitigar el riesgo de VIH para estos individuos.

Strengthening vaccination delivery system resilience in the context of protracted humanitarian crisis: a realist-informed systematic review.

BACKGROUND: Childhood vaccination is among the most effective public health interventions available for the prevention of communicable disease, but coverage in many humanitarian settings is sub-optimal. This systematic review critically evaluated peer-review and grey literature evidence on the effectiveness of system-level interventions for improving vaccination coverage in protracted crises, focusing on how they work, and for whom, to better inform preparedness and response for future crises. METHODS: Realist-informed systematic review of peer-reviewed and grey literature. Keyword-structured searches were performed in MEDLINE, EMBASE and Global Health, CINAHL, the Cochrane Collaboration and WHOLIS, and grey literature searches performed through the websites of UNICEF, the Global Polio Eradication Initiative (GPEI) and Technical Network for Strengthening Immunization Services. Results were independently double-screened for inclusion on title and abstract, and full text. Data were extracted using a pre-developed template, capturing information on the operating contexts in which interventions were implemented, intervention mechanisms, and vaccination-related outcomes. Study quality was assessed using the MMAT tool. Findings were narratively synthesised. RESULTS: 50 studies were included, most describing interventions applied in conflict or near-post conflict settings in sub-Saharan Africa, and complex humanitarian emergencies. Vaccination campaigns were the most commonly addressed adaptive mechanism (n = 17). Almost all campaigns operated using multi-modal approaches combining service delivery through multiple pathways (fixed and roving), health worker recruitment and training and community engagement to address both vaccination supply and demand. Creation of collaterals through service integration showed generally positive evidence of impact on routine vaccination uptake by bringing services closer to target populations and leveraging trust that had already been built with communities. Robust community engagement emerged as a key unifying mechanism for outcome improvement across almost all of the intervention classes, in building awareness and trust among crisis-affected populations. Some potentially transformative mechanisms for strengthening resilience in vaccination delivery were identified, but evidence for these remains limited. CONCLUSION: A number of interventions to support adaptations to routine immunisation delivery in the face of protracted crisis are identifiable, as are key unifying mechanisms (multi-level community engagement) apparently irrespective of context, but evidence remains piecemeal. Adapting these approaches for local system resilience-building remains a key challenge.

Minimum initial service package (MISP) for sexual and reproductive health for women in a displacement setting: a narrative review on the Syrian refugee crisis in Lebanon.

BACKGROUND: Women and girls are disproportionately affected in times of conflict and forced displacement, with disturbance in access to healthcare services leading to poor sexual and reproductive health outcomes. The minimal initial service package (MISP) was created to mitigate the consequences of conflict and prevent poor sexual and reproductive health (SRH) outcomes, especially among women and girls. The aim of this narrative review was to explore the SRH response for Syrian refugee women and girls in Lebanon, with a focus on MISP implementation. METHODOLOGY: A comprehensive literature search was conducted for peer-reviewed articles in 8 electronic databases and multiple grey literature sites for articles published from March 2011 to May 2019. The target population was Syrian refugee women in Lebanon displaced from Syria as a result of the conflict that erupted in March 2011. The selected articles addressed MISP, SRH needs and services, and barriers to service access. A narrative synthesis was conducted, guided by the six main objectives of the MISP. RESULTS: A total of 254 documents were retrieved, from which 12 peer-reviewed articles and 12 reports were included in the review. All identified articles were descriptive in nature and no studies evaluating MISP or other interventions or programs were found. The articles described the wide range of SRH services delivered in Lebanon to Syrian refugee women. However, access to and quality of these services remain a challenge. Multiple sources reported a lack of coordination, leading to fragmented service provision and duplication of effort. Studies reported a high level of sexual and gender-based violence, pregnancy complications and poor antenatal care compliance, and limited use of contraceptive methods. Very few studies reported on the prevalence of HIV and other STIs, reporting low levels of infection. Multiple barriers to healthcare access were identified, which included system-level, financial, informational and cultural factors, healthcare workers. CONCLUSION: This study highlights the main SRH services provided, their use and access by Syrian refugee women in Lebanon. Despite the multitude of services provided, the humanitarian response remains decentralized with limited coordination and multiple barriers that limit the utilization of these services. A clear gap remains, with limited evaluation of SRH services that are pertinent to achieve the MISP objectives and the ability to transition into comprehensive services. Improving the coordination of services through a lead agency can address many of the identified barriers and allow the transition into comprehensive services.

Health workers and the weaponisation of health care in Syria: a preliminary inquiry for The Lancet-American University of Beirut Commission on Syria.

The conflict in Syria presents new and unprecedented challenges that undermine the principles and practice of medical neutrality in armed conflict. With direct and repeated targeting of health workers, health facilities, and ambulances, Syria has become the most dangerous place on earth for health-care providers. The weaponisation of health care-a strategy of using people's need for health care as a weapon against them by violently depriving them of it-has translated into hundreds of health workers killed, hundreds more incarcerated or tortured, and hundreds of health facilities deliberately and systematically attacked. Evidence shows use of this strategy on an unprecedented scale by the Syrian Government and allied forces, in what human rights organisations described as a war-crime strategy, although all parties seem to have committed violations. Attacks on health care have sparked a large-scale exodus of experienced health workers. Formidable challenges face health workers who have stayed behind, and with no health care a major factor in the flight of refugees, the effect extends well beyond Syria. The international community has left these violations of international humanitarian and human rights law largely unanswered, despite their enormous consequences. There have been repudiated denunciations, but little action on bringing the perpetrators to justice. This inadequate response challenges the foundation of medical neutrality needed to sustain the operations of global health and humanitarian agencies in situations of armed conflict. In this Health Policy, we analyse the situation of health workers facing such systematic and serious violations of international humanitarian law. We describe the tremendous pressures that health workers have been under and continue to endure, and the remarkable resilience and resourcefulness they have displayed in response to this crisis. We propose policy imperatives to protect and support health workers working in armed conflict zones.

Early symptoms of nicotine dependence among adolescent waterpipe smokers.

BACKGROUND: Although waterpipe smoking is increasingly popular among youth and can lead to nicotine dependence (ND), no studies have documented how ND develops in waterpipe smokers. We examined the emerging symptoms of ND among adolescent waterpipe smokers in Lebanon. METHODS: Individual confidential interviews were used to evaluate ND in 160 waterpipe smokers and 24 cigarette smokers from a sample of 498 students enrolled in 8th and 9th grades in Lebanon. RESULTS: Among waterpipe smokers, 71.3% endorsed at least one Hooked on Nicotine Checklist (HONC) symptom and 38.1% developed the full syndrome of ND (≥3 criteria using the International Classification of Diseases, 10th revision). The early symptoms of ND among waterpipe smokers were craving (25%), feeling addicted (22.5%), and failed quit attempts (14.3%). Among those who reached the respective milestones, median tobacco use when the first HONC symptom emerged was 7.5 waterpipes/month with smoking frequency of 6 days/month; the median tobacco use for the full syndrome of ND was 15 waterpipes/month with smoking frequency of 15 days/month. Among those who had already reached these milestones, the first HONC symptom appeared 10.9 months after the initiation of waterpipe smoking, and the full syndrome of ND was reached at 13.9 months. In addition, cues such as seeing or smelling waterpipe, and the café environment triggered craving in most waterpipe smokers with symptoms of ND. CONCLUSIONS: Symptoms of ND develop among adolescent waterpipe smokers at low levels of consumption and frequency of use. Craving for nicotine triggered by waterpipe-specific cues is reported even at this young age. Waterpipe-specific ND prevention and intervention programmes for youth are needed.

Changing therapeutic geographies of the Iraqi and Syrian wars.

The health consequences of the ongoing US-led war on terror and civil armed conflicts in the Arab world are much more than the collateral damage inflicted on civilians, infrastructure, environment, and health systems. Protracted war and armed conflicts have displaced populations and led to lasting transformations in health and health care. In this report, we analyse the effects of conflicts in Iraq and Syria to show how wars and conflicts have resulted in both the militarisation and regionalisation of health care, conditions that complicate the rebuilding of previously robust national health-care systems. Moreover, we show how historical and transnational frameworks can be used to show the long-term consequences of war and conflict on health and health care. We introduce the concept of therapeutic geographies--defined as the geographic reorganisation of health care within and across borders under conditions of war.

Integrating Syrian refugees into Lebanon's healthcare system 2011-2022: a mixed-method study.

INTRODUCTION: The Lebanese government estimates the number of Syrian refugees to be 1.5 million, representing 25% of the population. Refugee healthcare services have been integrated into the existing Lebanese health system. This study aims to describe the integration of Syrian refugee health services into the Lebanese national health system from 2011 to 2022, amid an ongoing economic crisis since 2019 and the COVID-19 pandemic. METHODS: This paper employs a mixed-methods approach drawing upon different data sources including: 1- document review (policies, legislation, laws, etc.); 2- semi-structured interviews with policymakers, stakeholders, and health workers; 3- focus group discussions with patients from both host and refugee populations; and 4- health systems and care seeking indicators. RESULTS: Although the demand for primary health care increased due to the Syrian refugee crisis, the provision of primary health care services was maintained. The infusion of international funding over time allowed primary health care centers to expand their resources to accommodate increased demand. The oversupply of physicians in Lebanon allowed the system to maintain a relatively high density of physicians even after the massive influx of refugees. The highly privatized, fragmented and expensive healthcare system has impeded Syrian refugees' access to secondary and tertiary healthcare services. The economic crisis further exacerbated limits on access for both the host and refugee populations and caused tension between the two populations. Our findings showed that the funds are not channeled through the government, fragmentation across multiple financing sources and reliance on international funding. Common medications and vaccines were available in the public system for both refugee and host communities and were reported to be affordable. The economic crisis hindered both communities' access to medications due to shortages and dramatic price increases. CONCLUSION: Integrating refugees in national health systems is essential to achieve sustainable development goals, in particular universal health coverage. Although it can strengthen the capacity of national health systems, the integration of refugees in low-resource settings can be challenging due to existing health system arrangements (e.g., heavily privatized care, curative-oriented, high out-of-pocket, fragmentation across multiple financing sources, and system vulnerability to economic shocks).

Implementing (and evaluating) peer support with people living with noncommunicable diseases in humanitarian settings.

In line with the peer reviewers comments, the authors have added highlights in stead of an abstract. It was felt that it was better able to capture the findings and is more in line with the paper's target audience.

Women and waterpipe tobacco smoking in the eastern mediterranean region: allure or offensiveness.

The prevalence of waterpipe tobacco smoking is increasing worldwide, despite evidence indicating its adverse health effects. Women and young people seem more likely to be choosing waterpipe tobacco smoking over cigarettes. The objective of this qualitative study was to understand better whether and why waterpipe smoking is a more acceptable form of tobacco use than cigarettes for women in the Eastern Mediterranean Region, and to understand whether the strategies used by multi-national corporations to attract women to cigarette smoking were perceived to be relevant in the context of waterpipe tobacco use. Focus groups (n = 81) and in-depth interviews (n = 38) were conducted with adults in Lebanon, Egypt, Palestine, and Syria. Discussions were thematically analyzed and recurrent themes identified. One of the themes which emerged was the negative image of women smoking waterpipes. Moreover, the sexual allure conveyed through waterpipe smoking as well as waterpipe tobacco smoking as a symbol of emancipation was illustrated. The latter was mainly expressed in Lebanon, in contrast with Egypt where traditional gender roles depict women smoking waterpipes as disrespectful to society. Understanding the social aspects of waterpipe tobacco smoking is crucial to planning future interventions to control waterpipe tobacco smoking among women and in society at large.

Between life & death: Political economy of breast cancer care for refugee populations in Lebanon.

Refugees and displaced groups have been shown to face increased risk of developing advanced cancer stages. This has been shown to be evident in Lebanon, whereby refugees are detected at later stages when compared to the Lebanese population. Lebanon is one of the biggest host (per capita) of refugees worldwide, and suffers from difficult political situation, compounded by an economic crisis, the COVID-19 pandemic and a blast which hit the capital Beirut in 2020. The main determinants of poor health outcomes among migrant populations in Lebanon include a fragmented and inequitable healthcare system and legal constraints to healthcare accessibility. The health care system is largely privatised with multiple health systems operating simultaneously for different nationalities. The current multi-crisis situation has exacerbated the fragility of the health system and its ability to cope with increasing needs. On the other hand, legal constraints for refugees to obtain residency in Lebanon has also contributed to insufficient access to health care and poor health outcomes among this population. Health system reforms, improved emergency preparedness and response measures, and an ease on legal and political restrictions for the refugee populations in Lebanon are considered key policy recommendations to ensure refugees right to health in Lebanon.

Perceived facilitators and barriers to the provision of sexual and reproductive health services in response to the Syrian refugee crisis in Lebanon.

BACKGROUND: The Syrian crisis has resulted in one of the worst humanitarian disasters in modern history. Inadequate access to and use of sexual and reproductive health services is a prevailing issue among adolescent girls and young refugee women in humanitarian settings. OBJECTIVES: This article aimed to explore and describe the perceived extent of implementation of the different objectives and activities outlined within the minimum initial service package for reproductive health in crisis services in Lebanon, from the perspectives of a diverse set of stakeholders from leading organizations (public, private, primary health centers, nongovernmental organizations) that were directly engaged with the Syrian refugee crisis response. DESIGN: This study is a cross-sectional survey conducted using a standardized and validated questionnaire. METHODS: Centers that provided sexual and reproductive health services to Syrian refugees in Lebanon were mapped. The study was based on a purposive sampling approach, retrieving 52 eligible organizations to cover most areas in the country. A total of 43 centers accepted to take part in the study. The head of the center was then asked to identify one person in their center who holds adequate knowledge of the explained objectives of the survey. Accordingly, the identified person was asked to fill out the survey. RESULTS: A considerable portion of the respondents had limited knowledge about the specific minimum initial service package objectives and related sexual and reproductive health services. The study found the presence of a leading reproductive health agency, the Lebanese MoPH, as an essential facilitating factor for sexual and reproductive health service provision in Lebanon and has helped in overseeing the overall sexual and reproductive health coordination response for Syrian refugees (76.74% of all respondents). The identified challenges impeding adequate sexual and reproductive health services provision for Syrian refugees included (1) insufficient supplies (46.51%); (2) insufficient funds (39.53%); and (3) shortage of staff (39.53%). CONCLUSION: The recommendations for improved sexual and reproductive health service provision include the need for (1) enforcing the lead minimum initial service package agency for adequate and effective coordination, reporting, and accountability and (2) increasing funding for training staff and healthcare workers, as well as improving the overall quality of services available with the inclusion of family planning services, purchasing the necessary commodities, supplies and equipment, and covering fees associated with the different sexual and reproductive health services.

Experiences of stigma, mental health, and coping strategies in Lebanon among Lebanese and displaced Syrian men who have sex with men: A qualitative study.

BACKGROUND: In Lebanon, men who have sex with men (MSM) face high rates of stigma, discrimination, and violence. Minority stress, or the unique stressors related to anti-MSM stigma and discrimination, negatively impacts the mental health of MSM. These stressors are heightened for those with intersectional minority identities such as displaced Syrian MSM in Lebanon. METHODS: In this qualitative study conducted in 2020-21, part of a larger study focused on the mental and sexual health risks among MSM, we collected qualitative data from Lebanese and displaced Syrian MSM living in Lebanon and analyzed reports of their experiences with stigma, mental health, and coping strategies. We conducted semi-structured, in-depth interviews with 12 displaced Syrian MSM and 13 Lebanese MSM. RESULTS: Our findings highlight how MSM in Lebanon navigate stigma and the mental health risks that result. Common stressors among Lebanese and displaced Syrian MSM were related to finances, sexual orientation discrimination, and social isolation. Comparing the two groups, we found that stressors specific to displaced Syrian MSM were related to adverse childhood experiences, recent exposure to the Syrian war, displacement, and discrimination in Lebanon based on their intersectional identities as MSM and Syrians. For Lebanese participants, the most common stigma coping strategies were avoidance, drinking alcohol, using drugs, or having sex. As for displaced Syrian MSM, the most common stigma coping strategy was seeking the freely available mental health services offered to them through non-governmental organizations. CONCLUSION: Our findings suggest that increased targeted mental health and social support interventions, informed by the unique experiences of Lebanese and displaced Syrian MSM, are highly needed to improve the coping and mental health resources of all MSM in Lebanon.