A positive yet complicated case of gender-based violence coordination: a qualitative study of Lebanon's protracted humanitarian emergency, 2012-22.

Gender-based violence (GBV), a global health and human rights concern, often intensifies during emergencies. This paper explores the evolution of GBV coordination in Lebanon's protracted Syrian refugee crisis from 2012-22. Utilising 38 in-depth interviews and a document review, the findings were analysed using the framework for effective GBV coordination. Lebanon provides a positive yet complicated example of GBV coordination. Initially established to address the refugee crisis, it matured into a collaborative national coordination mechanism, fostering trust and advancing localisation amidst sectarian complexities. However, the volatile, restrictive policy context hindered government co-leadership and engagement with refugee-led organisations. While essential GBV response services were expanded nationwide, lack of an interagency strategy on GBV risk mitigation and prevention compromised lasting change. The paper emphasises the importance of dedicated GBV coordinators, multi-year funding, and increased attention to GBV prevention. The findings underscore the transformative potential of humanitarian responses and advocate for enhanced engagement with national stakeholders to promote sustainability in protracted crises.

Development of an assessment tool to measure communication skills among family medicine residents in the context of electronic medical record use.

BACKGROUND: The introduction of the electronic medical record (EMR) has led to new communication skills that need to be taught and assessed. There is scarce literature on validated instruments measuring electronic-specific communication skills. The aim is to develop an assessment checklist that assesses the general and EMR-specific communication skills and evaluates their content validity and reliability. METHODS: Using the SEGUE theoretical framework for communication skills, the assessment checklist items were developed by the Communication Skills Working Group (CSWG) at the family medicine department using a literature review about the positive and negative aspects of EMR use on physician-patient communication. A group of faculty members rated real resident-patient encounters on two occasions, three weeks apart. Patients were asked to fill out the Communication Assessment Tool (CAT) at the end of the encounter. RESULTS: A total of 8 residents agreed to participate in the research, with 21 clinical encounters recorded. The average total score was 65.2 ± 6.9 and 48.1 ± 9.5 for the developed scale and the CAT scale, respectively. The scale reliability was good, with a Cronbach alpha of 0.694. The test-retest reliability was 0.873, p < 0.0001. For the total score on the developed checklist, the intraclass correlation coefficient between raters (ICC) was 0.429 [0.030,0.665], p-value of 0.019. The level of agreement between any two raters on the cumulative score of the 5 subsections ranged from 0.506 (interpersonal skills) to 0.969 (end encounter). CONCLUSION: This checklist is a reliable and valid instrument that combines basic and EMR-related communication skills.

Women family physicians' working conditions and career satisfaction: a multinational study.

BACKGROUND: As the proportion of women in family medicine increases, their well-being and job satisfaction become concerns. OBJECTIVES: This study aimed to uncover the working conditions and career satisfaction of women family physicians across multiple countries. METHODS: A cross-sectional survey of the WONCA Working Party on Women and Family Medicine listserv members to assess working conditions and career satisfaction, with snowballing recruitment. Aspects of physician job satisfaction were measured using the validated Physician Work-Life Survey and calculated as the sum of the scores of each positive item divided by the total number of questions and multiplied by 10. The association between satisfaction and the continent and the country income level was performed using a one-way ANOVA test (P < 0.05). RESULTS: A total of 315 participants across 49 countries responded to the survey with 205 complete responses. Women family physicians reported high overall career satisfaction (8.2 ± 2.3) but were less satisfied with some aspects of their career such as pay (5.3 ± 3.4), personal time (3.5 ± 2.6), and administrative tasks (3.2 ± 3.7). Despite the widespread experience of sexism at work, satisfaction with personal career aspects was universal at the continent and income level, while satisfaction with other career aspects relevant to relationships in work environment and resources varied. CONCLUSION: Women family physicians around the world are overall satisfied with their careers. However, variation in certain working conditions among countries leaves room for improvement, drawing attention to the need for national review of working environments and pay scales.

Predictors of Contraception Use Among Syrian Refugees in Lebanon: Results from a Cross-Sectional Study.

OBJECTIVES: The aim of this study is to explore the factors that could predict contraceptive use. This will help develop interventions to increase the use of family planning methods among Syrian refugees. METHODS: We conducted a cross sectional survey on a random sample of male and female Syrian refugees residing in Lebanon. Data collection took place between September 2016 and February 2017 collected from 5 districts: Bekaa, Beirut and Mount Lebanon, North, and South Lebanon. Seven hundred and ninety-five Syrian refugees (males and females) were recruited from health care centers in areas with greatest concentration of Syrian refugees. The data were entered and analyzed using SPSS Version 22.0. Student t test was used for continuous variables and Chi-square test for categorical variables along with logistic regression models. Statistical significance was achieved at p-value < 0.05. RESULTS: Around 40% of the Syrian refugees currently use contraceptives. After adjusting for covariates, factors associated with use of contraceptives were discussing contraception use with a health care practitioner, originating from Damascus, planning for the desired number of children, and receiving any form of external assistance. On the other hand, factors associated with lack of use of contraceptives were residing in South Lebanon or Bekaa and living in unfinished buildings, work sites, or unused garage, with two or less rooms. CONCLUSIONS: Contraception use among Syrian refugees in Lebanon is multifactorial with some factors being modifiable. Efforts should be made to educate and motivate health care practitioners to discuss contraceptive use with refugees for optimal public health outcomes that would protect women from the risks of unintended pregnancies.

Perspectives of elder abuse in Lebanon.

Elder abuse is a preventable problem. Presently, little is known about this phenomenon in Middle Eastern settings. The purpose of this study was to explore elder abuse in Beirut, Lebanon from different stakeholders' points of view with a focus on identifying behaviors that are considered to be abusive to older adults and predisposing factors. Focus group discussions were carried out with 88 home- and institution-based older adults, their family members and caregivers, and with 49 stakeholders (medical professionals, institution directors, government officials). Results showed that behaviors considered abusive among Lebanese participants were comparable to reports from international studies. The most commonly mentioned risk factors were history of abuse in a seemingly dysfunctional family followed by caregivers' lack of acceptance of the physical changes that accompany aging. The response to elder abuse requires a multidimensional approach that spans protective policies to increase care providers' awareness about the physiologic changes of aging as well as concerted efforts to correct misinformation about the hidden problem of elder abuse.

Psychological Distress among Syrian Refugee Women and a Control Group in an Urban Settlement in Beirut- a Pilot Study.

The Syrian conflict has created approximately five million refugees. Of these, more than one million have settled in Lebanon. This project aimed to determine the prevalence of psychological distress (PD) amongst Syrian refugee mothers compared to a control group of local mothers living in the same informal urban settlement in Beirut. A convenient sample was selected from a primary care center. The General Health Questionnaire-12 items (GHQ-12) was administered to determine PD amongst women who were pregnant within 2 years of the study. Data was analyzed using SPSS. Sixty women were enrolled; 35 were Syrian refugees. All women had PD. The mean GHQ-12 scores were 7.5 and 7.2 for the control and Syrian refugee mothers, respectively. When asked about stressors, 91.7% of the women stated poverty. Syrian refugee women had similar PD as women who were not displaced and did not experience direct war related hostilities.

Prevalence and health outcomes of domestic violence amongst clinical populations in Arab countries: a systematic review and meta-analysis.

BACKGROUND: An estimated 30% of women worldwide experience intimate partner violence (IPV) during their lifetime. Exposure to IPV is associated with poor health outcomes and the prevalence of violence may be higher amongst women seeking healthcare. Existing evidence from the Arab region is limited. We conducted a systematic review and meta-analysis of prevalence and health outcomes of domestic violence (IPV or violence from a family member) in clinical populations in Arab countries. METHODS: Using terms related to domestic violence, Arab countries, and date limit > year 2000, we searched seven databases: Medline, EMBASE, PsycINFO, CINAHL, Web of Science: core collection, IBSS, Westlaw, IMEMR. We included observational studies reporting estimates of prevalence or health outcomes of domestic violence amongst women aged > 15 years, recruited while accessing healthcare in Arab countries. Studies that collected data on/after 1st January 2000 and were published in English, Arabic or French were included. Title/abstract screening, full text screening, quality assessment and data extraction were carried out. Extracted data were summarised and meta-analysis was performed where appropriate. RESULTS: 6341 papers were screened and 41 papers (29 studies) met inclusion criteria. Total 19,101 participants from 10 countries were represented in the data. Meta-analysis produced pooled prevalence estimates of lifetime exposure to any type of IPV of 73·3% (95% CI 64·1-81·6), physical IPV 35·6% (95% CI 24·4-47·5), sexual IPV 22% (95% CI 13·3-32) and emotional/psychological IPV 49·8% (95% CI 37·3-62·3). Domestic violence (IPV or family violence) exposure was associated with increased odds of adverse health outcomes: depression OR 3·3 (95% CI 1·7-6·4), sleep problems OR 3·2 (95% CI 1·5-6·8), abortion OR 3·5 (95% CI 1·2-10·2), pain OR 2·6 (95% CI 1·6-4·1) and hypertension OR 1·6 (95% CI 1·2-2·0). CONCLUSIONS: Domestic violence is common amongst women seeking healthcare in Arab countries. Exposure to domestic violence is associated with several poor health outcomes. Further research into domestic violence in the Arab world is required. TRIAL REGISTRATION: Systematic review protocol was registered on PROSPERO: CRD42017071415 .

[Confluent and reticulated papillomatosis subsiding spontaneously after delivery: Report of one case]. / Papilomatosis confluente y reticulada que remite espontáneamente después del parto: Informe de un caso.

Gougerot and Carteaud confluent and reticulated papillomatosis (CARP) is an uncommon dermatosis characterized by hyperpigmented scaly macules or papillomatous papules coalescing into confluent patches or plaques centrally with a reticular pattern peripherally. We report a 28-year-old woman presenting at 16 weeks of gestation with an itchy rash that was biopsied and turned out to be consistent with CARP. Options for treatment were discussed but the woman refused to take any systemic therapy and used only moisturizers throughout her pregnancy. The rash subsided spontaneously after delivery.

Assessment of reproductive health and violence against women among displaced Syrians in Lebanon.

BACKGROUND: The current conflict in Syria continues to displace thousands to neighboring countries, including Lebanon. Information is needed to provide adequate health and related services particularly to women in this displaced population. METHODS: We conducted a needs assessment in Lebanon (June-August 2012), administering a cross-sectional survey in six health clinics. Information was collected on reproductive and general health status, conflict violence, stress, and help-seeking behaviors of displaced Syrian women. Bivariate and multivariate analyses were conducted to examine associations between exposure to conflict violence, stress, and reproductive health outcomes. RESULTS: We interviewed 452 Syrian refugee women ages 18-45 who had been in Lebanon for an average of 5.1 (± 3.7) months. Reported gynecologic conditions were common, including: menstrual irregularity, 53.5%; severe pelvic pain, 51.6%; and reproductive tract infections, 53.3%. Among the pregnancy subset (n = 74), 39.5% of currently pregnant women experienced complications and 36.8% of those who completed pregnancies experienced delivery/abortion complications. Adverse birth outcomes included: low birthweight, 10.5%; preterm delivery, 26.5%; and infant mortality, 2.9%. Of women who experienced conflict-related violence (30.8%) and non-partner sexual violence (3.1%), the majority did not seek medical care (64.6%). Conflict violence and stress score was significantly associated with reported gynecologic conditions, and stress score was found to mediate the relationship between exposure to conflict violence and self-rated health. CONCLUSIONS: This study contributes to the understanding of experience of conflict violence among women, stress, and reproductive health needs. Findings demonstrate the need for better targeting of reproductive health services in refugee settings, as well as referral to psychosocial services for survivors of violence.

Gender based violence (GBV) coordination in a complex, multi-crisis context: a qualitative case study of Lebanon's compounded crises (2019-2023).

BACKGROUND: Since 2019 Lebanon has faced multiple compounded crises. Political and social instability, the COVID-19 pandemic, and the Beirut Port explosion, alongside the influx of refugees related to the ongoing Syrian conflict, have resulted in a nationwide economic emergency. In the context of the humanitarian response to the Syrian conflict, the UN and government-led gender-based violence (GBV) task force has coordinated the sub-sector since 2012. The compounded crisis, however, created new challenges for GBV coordination and service delivery, which we explore in this paper. We highlight lessons for strengthening GBV coordination in Lebanon and other complex emergencies. METHODS: We conducted 29 remote in-depth interviews, reviewed key policy documents and observed seven GBV task force meetings. We analysed and presented our findings across three key themes: context-relevant and adaptable coordination mechanisms; coordination to support GBV service delivery; and stakeholders' roles, legitimacy and power. RESULTS: Parallel response frameworks developed to address the multiple crises, created a complex humanitarian architecture within an increasingly challenging operating context, with some perceived inefficiencies. Positively, coordination was integrated under the established government-UN interagency system and the GBV task force maintained GBV sub-sector coordination. The task force was commended for effectively adapting to the evolving context, including working remotely, maintaining essential GBV services, assessing the compounded crises' impact on programming and adjusting accordingly, and harmonising guidance, tools and approaches. The importance of ensuring a government co-led response was highlighted by both UN and government informants, who pointed to examples where marginalising government leadership compromised coordination effectiveness and sustainability. The participation of local actors had become increasingly important but more difficult, with the impact of the various crises, and remote modalities, challenging service delivery and staff wellbeing. CONCLUSION: Experiences from Lebanon highlight the essential role of government leadership in coordination; the value of investing in local GBV capacity; the significance of effective national, subnational and intersectoral coordination to support service delivery and address cross-cutting GBV issues; the importance of targeted interventions to support marginalised populations; and the need to prioritize the well-being of front-line staff during crisis response. In Lebanon, and other complex crises, donors are encouraged to increase flexible, multiyear funding for GBV coordination and services, while women-led organizations should be at the forefront of recovery efforts, contributing to a more equitable society.

Involving the health care system in domestic violence: what women want.

PURPOSE Domestic violence is prevalent among women using primary health care services in Lebanon and has a negative effect on their health, yet physicians are not inquiring about it. In this study, we explored the attitudes of these women regarding involving the health care system in domestic violence management. METHODS We undertook a qualitative focus group study. Health care professionals in 6 primary health care centers routinely screened women for domestic violence using the HITS (Hurt, Insult, Threaten, Scream) instrument. At each center, 12 women who were screened (regardless of the result) were recruited to participate in a focus group discussion. RESULTS Most of the 72 women encouraged involvement of the health care system in the management of domestic violence and considered it to be a "socially accepted way to break the silence." Women expected health care professionals to have an "active conscience"; to be open minded, ready to listen, and unhurried; and to respect confidentiality. Additionally, they recommended mass media and community awareness campaigns focusing on family relationships to address domestic violence. CONCLUSIONS Addressing domestic violence through the health care system, if done properly, may be socially acceptable and nonoffensive even to women living in conservative societies such as Lebanon. The women in this study described characteristics of health professionals that would be conducive to screening and that could be extrapolated to the health care of immigrant Arab women.

Prioritising women's and girls' health in disaster settings: Lessons from the COVID-19 pandemic and the overlapping crises affecting Beirut, Lebanon.

The COVID-19 pandemic has placed strain on healthcare systems across the world; however, countries experiencing overlapping crises such as economic or political unrest face immense pressure in ensuring routine healthcare services can continue to operate. Despite being less likely suffer severe disease or die from COVID-19, data suggest women have experienced poorer mental health, higher rates of unemployment, and more social isolation during the pandemic. In general, we know women and girls experience multiple forms of disadvantage in disaster contexts including being more likely to become homeless, work as an unpaid carer, and to experience poverty. Research from previous disaster contexts has demonstrated that women's healthcare services tend to be deprioritised in the emergency response, and reports suggest this has been the case during the COVID-19 pandemic. This paper highlights key priorities for safeguarding women's and girls' health in disaster contexts, especially during the COVID-19 pandemic, by drawing on learning from the multiple crises facing Beirut, including responding to the pandemic, economic collapse, and the Beirut Port Explosion in 2020.

Anxiety Among Healthcare Workers During COVID-19 Pandemic in Lebanon: The Importance of the Work Environment and Personal Resilience.

Background: Healthcare workers (HCWs) have been severely impacted by the COVID-19 pandemic. In addition to their risk of direct exposure to the virus, they were subjected to long working hours, scarcity of PPE, and additional stressors that impacted their psychological wellbeing. The purpose of this study was to assess anxiety and its predictors among a sample of HCWs at the American University of Beirut Medical Center (AUBMC) and to evaluate the association between resilience and anxiety. Methods: This cross-sectional study was conducted using an online survey between March and June 2021 among HCWs at AUBMC. The psychosocial scale section included the 7-item generalized anxiety disorder (GAD-7) scale and a 25-item resilience scale, validated tools used to assess anxiety and resilience respectively. Data were analyzed on SPSS version 27, and descriptive statistics were applied. Predictors were evaluated using bivariate and multivariate linear regression. Results: From a total of 92 participants, 75% were involved in direct patient care, and of those, 95% worked directly with suspected or confirmed COVID-19 patients. The majority (83%) had minimal to mild anxiety, whereas the rest had moderate to high anxiety levels. Around 41% reported moderately high to high resilience, 47% were found to be between the low end and moderate resilience scale and only 12% had very low or low resilience. More than 80% of the participants received PPE training, reported always working with adequate preventive infection control measures, and were vaccinated. Further, more than 70% of participants reported trusting the management and agreed that the safety of the workers is considered a high priority. No significant association between sociodemographic and COVID-19 work exposure factors with anxiety was found. Multivariate analysis results showed that a lower anxiety score was associated with higher resilience (p = 0.011). Conclusion: This study has shown a strong association between low anxiety levels and high resilience scores in this group of mostly vaccinated HCWs caring for COVID-19 patients. The high percentage of vaccination along with PPE availability could explain the low anxiety levels reported among the participants.

Confronting Structural Inequities: The Limits of Participation when Developing a Community Health Intervention with Syrian Refugees and Host Communities in Lebanon.

Lebanon is one of the most unequal countries in the world, whose economy, social welfare and public health system struggle to meet the needs of the Lebanese and over one million Syrian refugees. Researchers applied Community Based Participatory Research (CBPR) methodology in collaboration with a non-governmental organization (NGO) in an underserved Beirut neighborhood from 2014 through 2016, aiming to address health inequities, build social cohesion among refugees and host populations, and empower community members to develop a community health intervention. We recruited a community advisory board (CAB), conducted six focus groups and sixteen individual interviews, and held several community meetings. In response to the study findings, NGO staff, researchers and community members agreed to work together on a trash collection initiative as a community health intervention. Ultimately, we found the CBPR toolkit to be insufficient to the empirical reality: a series of structural challenges due to entrenched local and national hierarchies, ineffective political processes, and inter- and intra-group conflict driven by competition over privatized social services. Together these resulted in a lack of trust in the collaborative process wherein study participants solicited researchers for aid in return for their involvement, mirroring the Lebanese patronage system. Ultimately, the most expedient path toward change was not through empowerment of oppressed community participants, but through the action of already powerful local individuals. In conclusion, structural inequalities limit the participatory and emancipatory possibilities of CBPR research. Power mapping exercises, which are often used in community organizing, offer an important opportunity to assess viability and lay the groundwork for CBPR projects. Academic and popular media in the Middle East often focus on religious, sectarian conflict; however, in our study conflict both between and among social groups was driven by competition over material resources more than cultural or religious differences.

Celiac disease, Behçet, and idiopathic thrombocytopenic purpura in siblings of a patient with multiple sclerosis.

Multiple sclerosis (MS) is a demyelinating disease of uncertain etiology. Many genetic and environmental risk factors have been associated with this disease including certain human leukocyte antigen haplotypes, Epstein-Barr virus infection, and vitamin D deficiency. We report a 30-year-old woman with MS, the product of consanguineous marriage, and three siblings with three different autoimmune diseases: idiopathic thrombocytopenic purpura, celiac disease, and Behçet's disease.

Impact of a communication skills audiovisual package on medical students' knowledge.

INTRODUCTION: Over the last decade more emphasis is being put on teaching communication skills (CS). Use of videos and role-play was suggested to improve CS. This article will present the impact of an audiovisual package on promoting the knowledge of medical students in CS. METHODS: Seventy-five second year medical students--distributed into eight groups led by four facilitators--critiqued a video clip immediately before and after the introduction of a communication skills audiovisual package. The skills taught included opening the interview, questioning, facilitation, clarification, reflection, confrontation, summarizing, and preparation of the patient for the physical exam. The students, also, role-played the reviewed scenario. The students' pre- and post-intervention responses were analyzed using a standardized grading form. RESULTS: There was a significant improvement in students' knowledge (p < 0.000) after the introduction of the intervention in all the CS taught except closed ended questioning. This improvement was consistent among the four facilitators. CONCLUSION: Reviewing video scenarios and role-playing improved the knowledge in core communication skills among second-year medical students assessed by a video-based written examination.

Violence Against Displaced Syrian Women in Lebanon.

This study used focus group discussions to explore 29 Syrian women's experiences of being displaced refugees in Lebanon. Women reported intimate partner violence (IPV), harassment, and community violence. They experienced difficult living conditions characterized by crowding and lack of privacy, adult unemployment, and overall feelings of helplessness. Most frequently, they used negative coping strategies, including justification and acceptance of IPV and often physically harmed their own children due to heightened stress. Some sought support from other Syrian refugee women. Although the study did not address the root causes of IPV, the results shed light on women's experiences and indicate that training them in positive coping strategies and establishing support groups would help them face IPV that occurs in refugee settings.

High rates of maternal depression amongst Syrian refugees in Lebanon - a pilot study.

This pilot study compares symptoms of depression and risk factors amongst Syrian refugees and low-income Lebanese mothers accessing a primary care centre in Beirut between January and June 2018. Women who gave birth in the previous two years or who were currently pregnant were included in the study. Depressive symptoms were assessed using the Arabic Edinburgh Postnatal Depression Scale (EPDS). Correlations between EPDS score and sociodemographic and mental health variables were analysed using Pearson's coefficient and ANOVA. 35 Syrian and 25 Lebanese women were recruited, 15 of whom were pregnant. EPDS scores were high in the whole group (mean 16.12 (SD 7.72), n = 60). Scores were higher amongst Syrian refugees than Lebanese mothers (17.77, SD 7.66 vs, 13.80, SD 7.34, p < 0.05). Illegal residence (p < 0.001), domestic violence (p < 0.05) and a history of mental illness (p < 0.01) were associated with higher scores. This pilot study demonstrates high rates of symptoms of depression amongst mothers in this population. Symptoms were particularly prevalent amongst Syrian refugees; three-quarters were 'probably depressed' and would warrant psychiatric assessment. This highlights the importance of improved mental healthcare for refugee mothers, the importance of addressing the social determinants of maternal mental health and further research into the effects of depression on these women and their children.

Women, war, and violence: surviving the experience.

OBJECTIVES: To investigate how Lebanese women were affected by the July 2006 conflict that erupted between the Hezbollah and the State of Israel, with a specific focus on their personal violence exposure and how they coped with these circumstances. METHODS: Participants were 310 women at Ministry of Social Affairs Centers (MOSA) located in six geographic areas with varying exposure to the conflict. A questionnaire was administered in interview format to collect information about the participants' demographic characteristics, experiences of the conflict, perceived psychological functioning, exposure to violence associated with the conflict, exposure to domestic violence during and after the conflict, and their coping strategies. RESULTS: Of the women, 89% had to leave their homes during the conflict because of fear or worry about safety. Of the 310 participants, 39% reported at least one encounter with violence perpetrated by soldiers, 27% reported at least one incident of domestic abuse during the conflict, and 13% reported at least one incident after the conflict perpetrated by their husbands or other family members. Women's self-reported negative mental health scores were positively correlated with the violence associated with the conflict and with domestic violence during and after the conflict. Women who reported that they did not know how to cope or had just tried to forget about their experiences reported more frequent domestic violence exposure during the conflict and had higher negative mental health outcomes associated with the conflict than did those who reported using active strategies. CONCLUSIONS: During armed conflict, domestic violence is also likely to increase. Therefore, when investigating the psychological impact of war on women, both forms of violence exposure should be considered. The use of active coping strategies may help in reducing psychological distress.

An unusual urinary tract infection caused by Vibrio fluvialis.

We describe an unusual case of a urinary tract infection (UTI) in a 52-year-old woman caused by Vibrio fluvialis. To our knowledge, this is the first report of this organism causing such an infection. The source of the organism could be the highly contaminated water she is using at home.