Adaptation and psychometric assessment of a sexual and reproductive empowerment scale in Arabic among refugee and non-refugee adolescent girls.

BACKGROUND: Sexual and reproductive empowerment (SRE) is an important determinant of women's and girls' health yet measuring it is complex due to cultural and domain-specific variations. This study describes the process of adapting an SRE scale consisting of four domains (self-efficacy; future orientation; social support; and safety) and testing its psychometric properties among Arabic speaking adolescent girls in Lebanon. METHODS: An SRE scale developed in a Western context was adapted in four steps: (1) reviewing the scale and selecting culturally appropriate domains for translation to standard Arabic; (2) conducting cognitive interviews with 30 11-17-year-old adolescent girls in Lebanon; (3) administering the scale to 339 refugee adolescent girls who participated in an early marriage intervention; and (4) conducting confirmatory factor analysis (CFA) on the data to assess the scale's psychometric properties. RESULTS: The original model for the 13-item, four-domain adapted scale demonstrated poor fit in CFA. After iteratively removing two items, scale properties were improved, albeit were not optimal. The validity and reliability results for the self-efficacy domain were acceptable. Cognitive interview data revealed that Arab adolescent girls understood self-efficacy in relational terms, recognizing that autonomous decision-making is not necessarily favored but is influenced by parents and family. CONCLUSIONS: This study presents an effort to customize an SRE scale for use in studies on the health of adolescent girls in an Arab cultural context. Findings from cognitive interviews highlight the importance of taking into consideration relationality in adolescent sexual and reproductive decision-making. The self-efficacy domain in the adapted scale demonstrates acceptable psychometric properties and is recommended for use in health studies to capture SRE.

The global prevalence of female genital mutilation/cutting: A systematic review and meta-analysis of national, regional, facility, and school-based studies.

BACKGROUND: Female genital mutilation/cutting (FGM/C) is a nonmedical procedure entailing the modification of the external female genitalia. A description of the prevalence and distribution of FGM/C allows the tracking of progress toward ending FGM/C by 2030 (Sustainable Development Goal (SDG): target 5.3). This systematic review aimed to examine FGM/C prevalence and types, by World Health Organization (WHO) region and country. METHODS AND FINDINGS: A systematic search using Medical Subject Headings (MeSH) and keywords from 2009 to March 24, 2022 was undertaken in MEDLINE, PubMED, PsycINFO, Web of Science, and Embase to identify studies presenting FGM/C prevalence. Abstract and full-text screening, quality assessment, and data extraction were undertaken by 2 reviewers. Only nationally representative studies were included in the meta-analysis. Pooled FGM/C prevalence was estimated by random-effects meta-analysis using generalized linear mixed models (GLMMs). FGM/C prevalence with 95% confidence intervals (CIs), prediction intervals (PIs), and FGM/C type were presented separately by women aged 15 to 49 years and girls aged 0 to 14 years. A total of 163 studies met the inclusion criteria and 30 were included in the meta-analysis, of which 23 were from the WHO African Region (AFR), 6 from the Eastern Mediterranean Region (EMR), and 1 from the South East Asian Region (SEAR). These studies included data from 406,068 women across 30 countries and 296,267 girls across 25 countries; the pooled prevalence estimate of FGM/C among women aged 15 to 49 years was 36.9% (95% CI: 19.6% to 58.3%; PI: 0.4% to 99.0%), and 8.27% (95% CI: 3.7% to 17.3%; PI: 0.1% to 89.3%) among girls aged 0 to 14 years. Among included countries, this gave a total estimated prevalence of 84,650,032 women (95% CI: 45,009,041 to 133,834,224) and 13,734,845 girls with FGM/C (95% CI: 6,211,405 to 28,731,901). Somalia had the highest FGM/C prevalence among women (99.2%), and Mali had the highest among girls (72.7%). The most common type of FGM/C among women was "flesh removed" (Type I or II) in 19 countries. Among girls, "not sewn closed" (Type I, II, or IV) and "flesh removed" (Type I or II) were the most common types in 8 countries, respectively. Among repeated nationally representative studies, FGM/C decreased for both women and girls in 26 countries. The main limitation of the study methodology is that estimates were based on available published data, which may not reflect the actual global prevalence of FGM/C. CONCLUSIONS: In this study, we observed large variation in FGM/C prevalence between countries, and the prevalence appears to be declining in many countries, which is encouraging as it minimizes physical and physiological harm for a future generation of women. This prevalence estimate is lower than the actual global prevalence of FGM/C due to data gaps, noncomparable denominators, and unavailable surveys. Yet, considerable policy and community-level interventions are required in many countries to meet the SDG target 5.3. TRIAL REGISTRATION: Registration: CRD42020186937.

Child deprivation among Palestinian refugees in Lebanon and Palestinian refugees from Syria living in Lebanon: a cross-sectional analysis of co-occurrence of deprivation indicators.

BACKGROUND: Palestinian refugees in Lebanon (PRL) and Palestinian refugees from Syria (PRS) living in Lebanon have high poverty rates. As the social, economic, and physical environment in which a child develops is a strong determinant of health and wellbeing, a comprehensive approach that recognises the influence of multidimensional deprivation on child wellbeing is needed. This study investigates overlaps (co-occurrences) in deprivation indicators experienced by Palestinian children compared to those experienced by other vulnerable children living alongside them in Lebanon; children who are Syrian refugees (SYR) and children who are Lebanese nationals (LBN). METHODS: This analysis adopted a life-cycle approach using data from the UNICEF 2016 Lebanon Household Survey, and included data on children aged 2-17 years (PRL, n=7106; PRS, n=2768; LBN, n=10555; SYR n=5891). We report on indicators relating to early childhood (24-59 months) and school age (6-17 years), including child survival (nutrition, health, water, sanitation, and overcrowding), child development (education), and child protection (labour, exposure to violence, and early marriage), as well as the co-occurrence of these deprivation indicators. Socio-demographic and geographical correlates of child deprivation were explored using univariate and multivariable logistic regression analysis, a using sampling weights and clustering for children in the same households. Analyses were conducted using Stata 15. FINDINGS: Among children aged 24-59 months, 28·9% (347 of 1202) of PRL and 46·2% (260 of 563) of PRS children were deprived in at least two dimensions, compared with 13·2% (67 of 508) of LBN and 68·5% (915 of 1335) of SYR children. Co-occurring deprivations were highest across the protection and overcrowding dimensions in Palestinian refugee children aged 6-17 years (PRL, 14·2% [769 of 5421]; PRS, 26·7% [531 of 1985]). Across all ages, PRS children were more likely to be deprived in two dimensions than PRL children. However, indicators of health and education deprivation were lower in PRL and PRS children than in SYR children. Geographical disparities in deprivation existed within all four populations, with the highest disparity among those living in North Lebanon and the Bekaa. Higher maternal education (completed intermediate education) was consistently associated with lower odds of having at least two concurrent deprivations among children aged 6-17 years (LBN odds ratio [OR] 0·1, 95% CI 0·1-0·2, p<0·0001; PRL OR 0·3, 95% CI 0·3-0·5, p<0·0001; PRS OR 0·5, 95% CI 0·3-0·7, p=0·0002; SYR OR 0·4, 95% CI 0·2-0·7, p=0·0004). INTERPRETATION: The most common overlaps in deprivation indicators were in housing (overcrowding) and protection (exposure to violence) among PRL and PRS children, highlighting the need to focus simultaneously on housing improvements and protection programmes. Deprivation in health and education were relatively low as PRS children have been included in the well-established UNRWA health and education systems, largely protecting them from poor health and education outcomes. FUNDING: UNICEF Lebanon. The findings, interpretations, and conclusions do not necessarily reflect the view of UNICEF.

Maternal Education and Low Birth Weight in Low- and Middle-Income Countries: Systematic Review and Meta-Analysis.

OBJECTIVE: Adverse birth outcomes, including low birth weight (LBW), remain the leading causes of child morbidity and mortality in many low- and middle-income countries (LMICs). We carried out a systematic review and meta-analysis to assess the strength and consistency of the association between maternal education and LBW in LMICs. METHODS: We conducted an electronic search of studies published between 2000 and 2014 in four databases using three MeSH keywords - birth outcomes including LBW; individual-level socioeconomic measures including maternal education; and a list of LMICs. The methodological quality of each eligible study was evaluated following the GRADE approach. A total of 26 studies were entered into meta-analysis. Subgroup analyses were performed to account for heterogeneity in the measurement of exposure and country development level. FINDINGS: The meta-analysis revealed a statistically significant pooled estimate (OR = 0.67; 95% CI = 0.61-0.74) indicating that maternal education is protective against LBW in LMICs. Heterogeneity was found high in subgroup analyses in studies from lower-middle income countries and in those measuring maternal education in academic classes, but drops considerably in studies from low-income countries and those measuring it in number of years of schooling. The quality of the overall body of evidence is moderate due to high observed heterogeneity in some subgroup analyses and the presence of studies with high risk of bias. INTERPRETATION: Higher maternal education associates with a moderate but statistically significant decrease in the risk of delivering a LBW infant in LMICs. Enhancing girls' and women's access to education operates through a number of pathways to improve birth outcomes and reduce LBW in LMICs.

Sexual and reproductive health of adolescent Syrian refugee girls in Lebanon: a qualitative study of healthcare provider and educator perspectives.

BACKGROUND: Adolescent Syrian refugee girls in Lebanon are thought to experience a disproportionate risk of poor sexual and reproductive health, related in part to conflict and displacement. The purpose of this qualitative study was to explore healthcare provider and educator perceptions of the sexual and reproductive health determinants and care-seeking behaviors of this vulnerable population. The findings of the study will inform a health intervention that aims to reduce early marriage and improve access to sexual and reproductive health information and services. METHODS: In-depth interviews and focus group discussions were conducted with stakeholders who work with adolescent Syrian refugee girls in an under-resourced area of eastern Lebanon bordering Syria. Data analysis followed principles of Clarke and Braun's thematic analysis. RESULTS: Study participants perceived adolescent pregnancy, reproductive tract infections, and sexual- and gender-based violence as major population health needs. The study also identified a number of influencing structural and sociocultural determinants of health, including early marriage, adolescent disempowerment, and men's disengagement from care. A conceptual framework based upon the Gelberg-Andersen Behavioral Model for Vulnerable Populations was developed to relate these determinants and guide pathways for potential interventions. CONCLUSIONS: Adolescent sexual and reproductive health interventions among Syrian refugees in Lebanon should adopt a multi-pronged, community-based approach to address underlying health determinants and engage with men and parents of adolescents. Special attention should be given to provider biases in healthcare settings accessible to adolescents, as these may reflect underlying tensions between host and refugee populations and discourage adolescents from seeking care.

Studies suggest that adolescent Syrian refugee girls in Lebanon are at risk of early marriage and related poor sexual and reproductive health outcomes, yet little is known about this population's specific sexual and reproductive health needs and care-seeking practices. To help fill this gap, we conducted a qualitative study with healthcare providers and educators who provide adolescent Syrian refugee girls with sexual and reproductive health services and education. The study aimed to better understand this population's health needs and behaviors to aid in the development of a sexual and reproductive health program for Syrian refugee girls that seeks to reduce early marriage. Respondents identified adolescent pregnancy, reproductive tract infections and sexual and gender-based violence as major health issues in this population. Early marriage, disruption of education, restrictive gender roles and men's detachment from healthcare were all recognized as potential risk factors. Stigma and bias, even among the study participants themselves, were also found to be potential barriers to care. We adapted a behavioral model for healthcare-seeking practices among vulnerable populations to categorize these risks and develop recommendations for health interventions in this community. Sexual and reproductive health initiatives in this population should be multi-faceted, community-based and aimed not only at adolescents but also their spouses and parents, who hold decision-making power.

Sexual and Reproductive Health Information and Experiences Among Syrian Refugee Adolescent Girls in Lebanon.

Providing adolescent girls with sexual and reproductive health (SRH) information protects them from risks and improves their well-being. This qualitative study, conducted in Lebanon, examined Syrian refugee adolescent girls' access to SRH information about and experiences with puberty and menarche, sex, marriage, contraception, and pregnancy. We gathered data through three focus group discussions (FGDs) with unmarried adolescent girls, 11 in-depth interviews with early-married adolescents, and two FGDs with mothers. Our findings highlighted that adolescent participants received inadequate SRH information shortly before or at the time of menarche and sexual initiation, resulting in experiences characterized by anxiety and fear. They also revealed discordance between girls' views of mothers as a preferred source of information and mothers' reluctance to communicate with their daughters about SRH. We advance that mothers are important entry points for future interventions in this refugee population and offer recommendations aimed to improve adolescent girls' SRH and rights.

'Most at risk' for COVID19? The imperative to expand the definition from biological to social factors for equity.

First recognized in December 2019, the Coronavirus Disease 2019 (COVID19) was declared a global pandemic by the World Health Organization on March 11, 2020. To date, the most utilized definition of 'most at risk' for COVID19 morbidity and mortality has focused on biological susceptibility to the virus. This paper argues that this dominant biomedical definition has neglected the 'fundamental social causes' of disease, constraining the effectiveness of prevention and mitigation measures; and exacerbating COVID19 morbidity and mortality for population groups living in marginalizing circumstances. It is clear - even at this early stage of the pandemic - that inequitable social conditions lead to both more infections and worse outcomes. Expanding the definition of 'most at risk' to include social factors is critical to implementing equitable interventions and saving lives. Prioritizing populations with social conditions is necessary for more effective control of the epidemic in its next phase; and should become standard in the planning for, and prevention and mitigation of all health conditions. Reversing disparities and health inequities is only possible through an expansion of our 'most-at-risk' definition to also include social factors.

Implementing Community-Based Participatory Research with Communities Affected by Humanitarian Crises: The Potential to Recalibrate Equity and Power in Vulnerable Contexts.

Worldwide, over 70.8 million people are forcibly displaced from their homes as a result of persecution, conflict, violence, or human rights violation. In humanitarian crises, protection and the provision of basic needs are often prioritized. Research may be seen as opportunistic. However, without documenting and researching humanitarian responses, knowledge is not shared and does not accumulate, limiting the application of evidence-based interventions where they are most needed. Research in humanitarian crises is complex, both ethically and methodologically. Community-engaged research, and specifically community-based participatory research (CBPR), can address some of the challenges of research in these settings. Using case studies of research we have conducted with communities affected by humanitarian crises, we highlight challenges and opportunities of the application of the ten core principles of CBPR in humanitarian settings. Despite some challenges and barriers, CBPR is a highly effective approach to use when engaging these populations in research. We argue that the application of CBPR in these settings has the potential to recalibrate the scales of equity and power among vulnerable populations.

The Social Patterning of Tobacco Use Among Women in Jordan: The Protective Effect of Education on Cigarette Smoking and the Deleterious Effect of Wealth on Cigarette and Waterpipe Smoking.

INTRODUCTION: The presence of social inequalities in tobacco-use has been fully recognized in the international literature. Even though cigarette and waterpipe tobacco smoking (WTS) are prevalent in the Arab region, the literature has not addressed the social determinants of the impending tobacco epidemic. This study examined the socioeconomic patterning of cigarette and WTS among Jordanian women. METHODS: We analyzed pooled data from four waves of the Jordan Demographic and Health Surveys: 2002 (N = 5851); 2007 (N = 10 654); 2009 (N = 9879), and 2012 (N = 11 113). We specified logistic regression models to test the association between education and household wealth and the two outcome measures, cigarette and WTS, adjusting for other covariates. For each outcome, we ran time-unadjusted and time-adjusted logistic models. RESULTS: Cigarette smoking prevalence among Jordanian women remained almost constant (around 10%) between 2002 and 2012. WTS prevalence steadily increased from 4.1% in 2002 to 10.2% in 2012. Increasing education predicted lower odds of cigarette smoking, whereas increasing household wealth weakly predicted higher odds. As to WTS, increasing household wealth strongly predicted higher odds of use. CONCLUSIONS: Among Jordanian women, increasing education is protective against cigarette smoking. Household wealth, on the other hand, exerts a deleterious effect on both forms of tobacco consumption, particularly WTS. This pattern shows that Jordan has not fully undergone the socioeconomic crossover in tobacco prevalence which characterizes high-income countries. Future control policies should aim to decrease prevalence but also preempt increasing social inequalities in tobacco use.

Family relations and health over the life course. A Lebanese perspective.

The link between family relations and well-being in old age has received ample attention in the international literature, but remains least examined in the Arab region where cultural ideals assume positive intergenerational relations within families as the norm. In this paper, we employ survey data collected in Greater Beirut in 2009 to explore associations between family relations and health. over the life course. We tested (1) the extent to which age and social relation characteristics predict health; and (2) whether the association between age and health is stronger for those who report: smaller social networks and poorer relationship quality. We employed self-rated health and self-reported chronic illness as the health outcome measures and:social network size, positive quality and negative quality with family members as the social relations measures. Our findings suggest that social relations are differentially important depending on the health status indicator examined. The single dimension that influenced both self-rated health and the probability of reporting a chronic illness was positive relationship quality with spouse. Further, social relations, particularly having a negative relationship quality with spouse and adult child, exert stronger effects on both self-rated health and chronic illness for older compared to younger adults. The findings of the present study are important for clinical practitioners who often consider the role and importance of available social resources as they address the health needs of older adults.

Predicting intention to vaccinate against COVID-19 in older Syrian refugees in Lebanon: Findings from a multi-wave study.

BACKGROUND: COVID-19 vaccine acceptance among refugees in the Arab region remains low. This study aimed to examine the prevalence, reasons and predictors of intention to refuse the COVID-19 vaccine among older Syrian refugees in Lebanon. METHODS: A nested cross-sectional study within a longitudinal study among older Syrian refugees in Lebanon. The sampling frame was a complete listing of beneficiary households of a humanitarian organization with at least one adult aged 50 years or older. Telephone surveys were completed at months 1 starting September 2020 (wave 1), months 2 (wave 2), months 5 (wave 3), months 6 (wave 4) and months 17 (wave 5) in March 2022. Logistic regression models were used to identify predictors of intention to refuse the COVID-19 vaccine. Models were internally validated using bootstrap methods and the models' calibration and discrimination were presented. FINDINGS: Of 3167 Syrian refugees, 61.3% intended to receive the COVID-19 vaccine, 31.3% refused, and 7.4% were undecided. Reasons for vaccine refusal were: preference to follow preventive measures (27.4%) and belief that the vaccine is not essential (20.7%). Furthermore, 57.1% of participants registered to take the COVID-19 vaccine in wave 5. Irrespective of vaccination intention, reasons for not registering included: not wanting to receive the vaccine, and being unsure whether to take it. Predictors of intention to refuse the COVID-19 vaccine included: being a female, older age, having elementary education or above, living outside informal tented settlements, perceiving COVID-19 as not severe and vaccines as not safe or effective, and using social media for information on COVID-19. After adjusting for optimization, the final model showed moderate discrimination (C-statistic: 0.651 (95% CI:0.630-0.672)) and good calibration (C-slope: 0.93 (95% CI: 0.823-1.065)). CONCLUSIONS: This study developed a predictive model for vaccination intention with a moderate discriminative ability and good calibration. Prediction models in humanitarian settings can help identify refugees at higher risk of not intending to receive the COVID-19 vaccine for public health targeting.

'Nowhere and no one is safe': spatial analysis of damage to critical civilian infrastructure in the Gaza Strip during the first phase of the Israeli military campaign, 7 October to 22 November 2023.

BACKGROUND: Since the Hamas attacks in Israel on 7 October 2023, the Israeli military has launched an assault in the Gaza Strip, which included over 12,000 targets struck and over 25,000 tons of incendiary munitions used by 2 November 2023. The objectives of this study include: (1) the descriptive and inferential spatial analysis of damage to critical civilian infrastructure (health, education, and water facilities) across the Gaza Strip during the first phase of the military campaign, defined as 7 October to 22 November 2023 and (2) the analysis of damage clustering around critical civilian infrastructure to explore broader questions about Israel's adherence to International Humanitarian Law (IHL). METHODS: We applied multi-temporal coherent change detection on Copernicus Sentinel 1-A Synthetic Aperture Radar (SAR) imagery to detect signals indicative of damage to the built environment through 22 November 2023. Specific locations of health, education, and water facilities were delineated using open-source building footprint and cross-checked with geocoded data from OCHA, OpenStreetMap, and Humanitarian OpenStreetMap Team. We then assessed the retrieval of damage at and with close proximity to sites of health, education, and water infrastructure in addition to designated evacuation corridors and civilian protection zones. The Global Moran's I autocorrelation inference statistic was used to determine whether health, education, and water facility infrastructure damage was spatially random or clustered. RESULTS: During the period under investigation, in the entire Gaza Strip, 60.8% (n = 59) of health, 68.2% (n = 324) of education, and 42.1% (n = 64) of water facilities sustained infrastructure damage. Furthermore, 35.1% (n = 34) of health, 40.2% (n = 191) of education, and 36.8% (n = 56) of water facilities were functionally destroyed. Applying the Global Moran's I spatial inference statistic to facilities demonstrated a high degree of damage clustering for all three types of critical civilian infrastructure, with Z-scores indicating < 1% likelihood of cluster damage occurring by random chance. CONCLUSION: Spatial statistical analysis suggests widespread damage to critical civilian infrastructure that should have been provided protection under IHL. These findings raise serious allegations about the violation of IHL, especially in light of Israeli officials' statements explicitly inciting violence and displacement and multiple widely reported acts of collective punishment.

Predicting poor mental health among older Syrian refugees in Lebanon during the COVID-19 pandemic: a nested cross-sectional study.

INTRODUCTION: The COVID-19 pandemic has worsened pre-existing vulnerabilities among older Syrian refugees in Lebanon, potentially impacting their mental health. The study aims to describe the evolution of poor mental health over time and to develop and internally validate a prediction model for poor mental health among older Syrian refugees in Lebanon. METHODS: This prognostic study used cross-sectional data from a multiwave telephone survey in Lebanon. It was conducted among all Syrian refugees aged 50 years or older from households that received assistance from a humanitarian organisation. Data were collected between 22 September 2020 and 20 January 2021. Poor mental health was defined as a Mental Health Inventory-5 score of 60 or less. The predictors were identified using backwards stepwise logistic regression. The model was internally validated using bootstrapping. The calibration of the model was presented using the calibration slope (C-slope), and the discrimination was presented using the optimised adjusted C-statistic. RESULTS: There were 3229 participants (median age=56 years (IQR=53-62)) and 47.5% were female. The prevalence of poor mental health was 76.7%. Predictors for poor mental health were younger age, food insecurity, water insecurity, lack of legal residency documentation, irregular employment, higher intensity of bodily pain, having debt and having chronic illnesses. The final model demonstrated good discriminative ability (C-statistic: 0.69 (95% CI 0.67 to 0.72)) and calibration (C-slope 0.93 (95%CI 0.82 to 1.07)). CONCLUSION: Mental health predictors were related to basic needs, rights and financial barriers. These allow humanitarian organisations to identify high-risk individuals, organise interventions and address root causes to boost resilience and well-being among older Syrian refugees in Lebanon.

Inequalities in Wellbeing in Lebanese Children and Different Refugee Subpopulations: A Multidimensional Child Deprivation Analysis.

Background and Objectives: This study constitutes the first attempt to describe the overlapping deprivations faced by Lebanese children (Lebanese) and that of the three sub-populations of refugees living in Lebanon: Palestinian refugees living in Lebanon, Palestinian refugees from Syria and Syrian refugees. Methods: Using data from the United Nations International Children's Emergency Fund (UNICEF) Household Survey 2016 (n = 10,555 Lebanese; 7,106 Palestinian refugees living in Lebanon; 2,768 Palestinian refugees from Syria and 5,891 Syrian refugee children aged 2 to 17 years old), we report on single and overlapping deprivations (at least two concurrent deprivations) using indicators related to survival (nutrition, health, water, sanitation and overcrowding), development (education) and protection (labor, exposure to violence and early marriage). Maternal education and geographical correlates of deprivation were explored using multivariable logistic regression models clustering for children in the same households. Main Results: In terms of co-occurrence of deprivations, Syrian refugees had the highest prevalence in all age groups (68.5%, 2-4y and 65.7%, 6-17y), followed by Palestinian refugees from Syria (46.2%, 2-4y and 45.5%, 6-17y), Palestinian refugees living in Lebanon (28.9%, 2-4y and 23.7%, 6-17y), with Lebanese children having the lowest prevalence (13.2%, 2-4y and 15.3, 6-17y). About half of Palestinian refugees from Syria and Syrian refugees (6-17y) were deprived in protection and housing. Education deprivation is of primary concern for Syrian children. Higher maternal education was consistently associated with lower odds of co-occurrence of deprivations among children aged 6-17y. Conclusion: This study highlights the importance of including refugee populations in reporting frameworks. This analysis additionally generates geographical and socio-economic profiles of the deprived children and identifies key deprivation areas of the affected sub-groups to inform effective policy design especially in light of the prevailing economic crisis. Supplementary Information: The online version contains supplementary material available at 10.1007/s12187-023-10040-2.

Predictors and barriers to vaccination among older Syrian refugees in Lebanon: a cross-sectional analysis of a multi-wave longitudinal study.

BACKGROUND: Vaccination is important to prevent morbidity and mortality due to COVID-19 among older Syrian refugees. We aimed to elucidate the predictors of COVID-19 vaccine uptake among Syrian refugees aged 50 years or older in Lebanon and to understand their main reasons for not receiving the vaccine. METHODS: This was a cross-sectional analysis of a five-wave longitudinal study, conducted through telephone interviews between Sept 22, 2020, and March 14, 2022, in Lebanon. For this analysis, data were extracted from wave 3 (Jan 21-April 23, 2021), which included a question on vaccine safety and on whether participants intended to receive the COVID-19 vaccine, and wave 5 (Jan 14-March 14, 2022), which included questions on actual vaccine uptake. Syrian refugees aged 50 years or older were invited to participate from a list of households that received assistance from the Norwegian Refugee Council, a humanitarian non-governmental organisation. The outcome was self-reported COVID-19 vaccination status. Multivariable logistic regression was used to identify predictors of vaccination uptake. Validation was completed internally with bootstrapping methods. FINDINGS: 2906 participants completed both wave 3 and 5; the median age was 58 (IQR 55-64) years and 1538 (52·9%) were male. 1235 (42·5%) of 2906 participants had received at least one dose of the COVID-19 vaccine. The main reasons for not receiving the first dose included being afraid of its side-effects (670 [40·1%] of 1671) or not wanting the vaccine (637 [38·1%] of 1671). 806 (27·7%) of 2906 participants received the second dose of the vaccine and 26 (0·9%) of 2906 received the third dose. The main reason for not receiving the second (288 [67·1%] of 429) or third dose (573 [73·5%] of 780) was waiting for a text message for an appointment. Predictors of receiving at least one dose of the COVID-19 vaccine included younger age (odds ratio 0·97; 95% CI 0·96-0·98), being male (1·39; 1·19-1·62), living inside informal tented settlements (1·44; 1·24-1·66), having elementary (1·23; 1·03-1·48) and preparatory education or above (1·15; 0·95-1·40), and having a pre-existing intention to receive the vaccine (1·29; 1·10-1·50). After adjusting for optimisation, the final model, which includes these five predictors of receiving at least one dose of the COVID-19 vaccine, showed moderate discrimination (C-statistic 0·605; 95% CI 0·584-0·624) and good calibration (c-slope 0·912; 95% CI 0·758-1·079). INTERPRETATION: There is an ongoing need to address COVID-19 vaccine uptake among older Syrian refugees by improving deployment planning and raising awareness about the importance of vaccination. FUNDING: ELRHA's Research for Health in Humanitarian Crisis Programme.

The determinants of sustained adherence to COVID-19 preventive measures among older Syrian refugees in Lebanon.

INTRODUCTION: Lebanon has battled the COVID-19 pandemic in the midst of an economic crisis. The evolution of the pandemic and a fragile health system have meant that public health policy has had to rely heavily on non-pharmaceutical interventions for disease control. However, changes in disease dynamics, an unraveling economy, and pandemic fatigue have meant that disease control policies need to be updated. METHODS: Using recent and timely data on older (50 years and above) Syrian refugees in Lebanon, this paper uses multivariate linear probability models to explore the determinants of adherence to two non-pharmaceutical COVID-19 prevention measures (wearing a mask and avoiding social gatherings) among this high-risk subgroup in a vulnerable population. Among respondents who report adhering to these measures, the paper also investigates the determinants of sustained adherence over a period of 6 months. RESULTS: The findings suggest that no individual-level characteristics were robustly associated with mask wearing. For avoiding social gatherings, education was inversely associated with adherence to this preventive measure. Avoiding social gatherings was also significantly lower for residents of informal tented settlements (ITSs). Among initial adherents, and for both preventive practices, ITS dwellers were also significantly less likely to maintain adherence. CONCLUSION: Identifying variables associated with adherence to non-pharmaceutical preventive practices, particularly for vulnerable groups, can help inform and refine interventions in the face of changing conditions. The material, physical, administrative and socio-economic constraints of life in an ITS suggest that avoiding social gatherings is hardly feasible. Yet despite the challenging conditions of ITSs, the indication to wear a mask is initially complied with, suggesting that tailoring policies to the limits and constrains of context can lead to successful outcomes even in very adverse settings.

Is self-rated health a valid measure to use in social inequities and health research? Evidence from the PAPFAM women's data in six Arab countries.

INTRODUCTION: Some evidence from high-income countries suggests that self-rated health (SRH) is not a consistent predictor of objective health across social groups, and that its use may lead to inaccurate estimates of the effects of inequities on health. Given increased interest in studying and monitoring social inequities in health worldwide, the aim of the present study was to evaluate the validity of SRH as a consistent measure of health across socioeconomic categories in six Arab countries. METHODS: We employed the PAPFAM population-based survey data on women from Morocco, Algeria, Tunisia, Lebanon, Syria, and the Occupied Palestinian Territories (OPT). Multivariate logistic regression analyses were performed to assess the strength of the association between fair/poor SRH and objective health (reporting at least one chronic condition), adjusting for available socio-demographic and health-related variables. Analyses were then stratified by two socioeconomic indicators: education and household economic status. RESULTS: The association between SRH and objective health is strong in Algeria, Tunisia, Lebanon, Syria, and OPT, but weak in Morocco. The strength of the association between reporting fair/poor health and objective health was not moderated by education or household economic status in any of the six countries. CONCLUSION: As the SRH-objective health association does not vary across social categories, the use of the measure in social inequities in health research is justified. These results should not preclude the need to carry out other validation studies using longitudinal data on men and women, or the need to advocate for improving the quality of morbidity and mortality data in the Arab region.

Developing a sexual and reproductive health educational intervention for adolescent Syrian refugee girls: Challenges and lessons learned.

In Lebanon, a country with the highest per capita refugee population in the world, roughly one in four persons is forcibly displaced. Early marriage is highly prevalent among Syrian refugees in Lebanon and qualitative studies suggest an unmet need for sexual and reproductive health (SRH) information and services in this community. Adolescent Syrian refugee girls in Lebanon are a vulnerable population at risk of negative SRH outcomes related to early sexual debut, which occurs primarily in the context of early marriage. Despite this need, cultural norms and gender roles generally restrict adolescent girls' access to SRH resources. To address this need for comprehensive sexuality education, our team developed a novel, rights-based, peer-led, adolescent SRH educational curriculum that is specific to the context of Syrian displacement in Lebanon. This curriculum was developed to be administered as part of Project Amenah, a community-based, multi-component intervention that aims to reduce early marriage and improve SRH among adolescent Syrian refugee girls displaced in Lebanon. The curriculum, which features eight discreet age-appropriate units, is based on extensive formative work conducted in this community, as well as adaptations of early marriage programs implemented in low-resource settings elsewhere. Topics covered include, but are not limited to, gender and human rights, communication, negotiation and decision-making, reproductive anatomy, puberty and menstruation, sexually transmitted infections, family planning and modern contraception, and adolescent pregnancy. We encountered several challenges when developing this curriculum, including those related to community acceptability, varying levels of literacy levels among participants, and limited engagement with married adolescents, who may experience mobility restrictions that preclude their participation. We recommend that investigators developing adolescent SRH interventions in similar settings utilize a behavior-determinant-intervention logic model to guide their study design, elucidate community priorities and capacity by conducting preliminary qualitative work and assembling a community advisory board, and follow a peer-led model, which has shown to be effective for adolescent SRH interventions.

Design and Implementation of the Amenah Early Marriage Pilot Intervention Among Syrian Refugees in Lebanon.

Implementing and evaluating interventions in humanitarian settings in low- and middle-income countries presents unique challenges that are little addressed in the implementation literature. We document the process of developing, implementing, and evaluating the Amenah pilot intervention that aimed to mitigate the drivers of early marriage in a Syrian refugee community in Lebanon. Adolescent girls' vulnerability to early marriage increases following displacement due to poverty, insecurity, and school disruptions. We delineate how, as a local research team, we triangulated evidence from the international literature and formative community research to make informed decisions during the intervention's design and implementation phases. The pilot was delivered to 203 Syrian refugee schoolgirls aged 11-14 years during the 2017-2018 academic year. It consisted of 16 structured, interactive sessions with girls and a set of facilitated meetings with the girls' mothers, both of which were implemented by trained female community workers from the Syrian refugee community. Process evaluation results showed that sociodemographic factors predicted attendance among mothers, but relationships with peers in the intervention were the only significant predictor of attendance among girls. The primary outcomes of the pilot were attitudinal measures related to education and marriage. Attitudes toward education were highly positive at baseline and did not change over the course of the intervention. There were no significant changes in girls' ideal age at marriage. Among girls aged 13 and older at endline, the mean self-reported expected age at marriage increased slightly from 20.2 to 20.8 years (P<.05). Our results also suggest that girls may adjust their expected age at marriage downward as they become older and if they drop out of school. We reflect in the discussion on some of the challenges encountered and lessons learned for the benefit of researchers intending to conduct community-based interventions in displacement settings.

Development of a Prediction Model for the Management of Noncommunicable Diseases Among Older Syrian Refugees Amidst the COVID-19 Pandemic in Lebanon.

Importance: Older Syrian refugees have a high burden of noncommunicable diseases (NCDs) and economic vulnerability. Objectives: To develop and internally validate a predictive model to estimate inability to manage NCDs in older Syrian refugees, and to describe barriers to NCD medication adherence. Design, Setting, and Participants: This nested prognostic cross-sectional study was conducted through telephone surveys between September 2020 and January 2021. All households in Lebanon with Syrian refugees aged 50 years or older and who received humanitarian assistance from a nongovernmental organization were invited to participate. Refugees who self-reported having chronic respiratory disease (CRD), diabetes, history of cardiovascular disease (CVD), or hypertension were included in the analysis. Data were analyzed from November 2021 to March 2022. Main Outcomes and Measures: The main outcome was self-reported inability to manage any NCD (including CRD, CVD, diabetes, or hypertension). Predictors of inability to manage any NCD were assessed using logistic regression models. The model was internally validated using bootstrapping techniques, which gave an estimate of optimism. The optimism-adjusted discrimination is presented using the C statistic, and calibration of the model is presented using calibration slope (C slope). Results: Of 3322 older Syrian refugees, 1893 individuals (median [IQR] age, 59 [54-65] years; 1089 [57.5%] women) reported having at least 1 NCD, among whom 351 (10.6% overall; 18.6% of those with ≥1 NCD) had CRD, 781 (23.7% overall; 41.4% of those with ≥1 NCD) had diabetes, 794 (24.1% overall; 42.2% of those with ≥1 NCD) had history of CVD, and 1388 (42.3% overall; 73.6% of those with ≥1 NCD) had hypertension. Among individuals with NCDs, 387 participants (20.4%) were unable to manage at least 1 of their NCDs. Predictors for inability to manage NCDs were age, nonreceipt of cash assistance, household water insecurity, household food insecurity, and having multiple chronic diseases, with an adjusted C statistic of 0.650 (95% CI, 0.620-0.676) and C slope of 0.871 (95% CI, 0.729-1.023). The prevalence of nonadherence to medication was 9.2%, and the main reasons for nonadherence were unaffordability of medication (40.8%; 95% CI, 33.4%-48.5%) and the belief that they no longer required the medication after feeling better (22.4%; 95% CI, 16.4%-29.3%). Conclusions and Relevance: In this cross-sectional study, the predictors of inability to manage NCDs among older Syrian refugees in Lebanon were mainly related to financial barriers. Context-appropriate assistance is required to overcome financial barriers and enable equitable access to medication and health care.