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.

Impact of minimum unit pricing on youth alcohol consumption: insights from Lebanon.

This paper analyses the impact of introducing an alcohol minimum unit pricing policy on youth's off-premise alcohol consumption. We rely on price elasticities derived using stated preference alcohol purchase data from a survey of 1024 university students in Lebanon. Selectively targeting drinks with high ethanol concentration by applying a minimum unit pricing (MUP) corresponding to the maximum price that respondents are willing to pay per beverage achieves a reduction in ethanol intake close to 0.23 l/month (∼28% of pre-MUP ethanol intake). Imposing a flat MUP corresponding to the average price respondents are willing to pay for all alcoholic beverages decreases ethanol intake by nearly half the reduction from the previous targeted MUP. This work provides evidence in favour of MUP in conjunction with taxation capable of substantially reducing alcohol consumption. We also document a positive welfare benefit of MUP.

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.

A multidimensional measure of wellbeing among youth: a cross-sectional study of the Palestinian refugee youth in Lebanon.

BACKGROUND: Increasing refugee populations worldwide highlight the need for development indicators that cover refugees, especially as they tend to be excluded from national statistics. Refugee youth face double exclusion, as most wellbeing indices are not youth-specific. We developed a youth wellbeing index (YWI) for Palestinian refugees in Lebanon (PRL) and Palestinian refugees from Syria (PRS) living in Lebanon, with the aim of providing a snapshot of youth wellbeing to inform evidence-based youth-specific development strategies. METHODS: The YWI was developed and its data generated using information from the 2015 survey of PRL and PRS, which was approved by the American University of Beirut Institutional Review Board. The wellbeing of PRL (n=3940) and PRS (n=1581) aged 15-29 was measured using the YWI, which examines five wellbeing dimensions: educational attainment, health, housing, active education or employment, and access to information. Scores for each of the five dimensions are scaled to [0, 1], and YWI is their arithmetic mean. The data enable us to look at the YWI by gender, by camp residence, and by narrower age bands to detect any generational differences within youth. Findings are reported using sampling weights for representativeness. FINDINGS: 4 years after displacement (2011-2015), PRS youth showed lower levels of wellbeing (YWI=0·56, 95% CI 0·55-0·57) than PRL youth (YWI=0·65, 95% CI 0·64-0·67). Although money-metric poverty was significantly higher inside than outside camps for both PRL youth (inside camps, 75·00%, 95% CI 71·55-78·15; outside camps, 61·98%, 55·26-68·27) and PRS youth (inside camps, 93·89%, 90·56-96·1; ; outside camps, 88·72%, 85·35-91·39), there was no such disparity in the YWI for PRL youth (inside camps, YWI=0·65, 95% CI 0·63-0·66; outside camps, 0·66, 0·62-0·69) or PRS youth (inside camps, 0·55, 0·54-0·56; outside camps, 0·57, 0·54-0·59). Young male refugees had significantly higher YWI (PRL, 0·66, 95% CI 0·65-0·68; PRS, 0·57, 0·56-0·59) than young female refugees (PRL, 0·64, 0·62-0·66; PRS, 0·55, 0·53-0·56). Young female PRL and PRS scored significantly higher for education (PRL, YWI=0·60; PRS, 0·61) than young male refugees from these populations (PRL, 0·48; PRS, 0·47), but significantly lower on active education or employment (PRL, 0·45; PRS, 0·18) than the young male refugees (PRL, 0·72; PRS, 0·47). Older PRS scored higher on the YWI education dimension (20-24 years age group, 0·61; 25-29 years age group, 0·50) than their PRL peers (20-24 years age group, 0·53; 25-29 years age group, 0·45), but the reverse was true for the 15-19 years age group (PRL, 0·60; PRS, 0·53). INTERPRETATION: Residence inside versus outside camps showed no significant differences in wellbeing based on the YWI, whereas money-metric poverty was higher inside camps, which suggests a need to move beyond assistance policies based on money-metric measures alone. The female edge in educational attainment is reversed when considering active education or employment, signalling the need for gender-specific strategies for the school-to-work transition for both PRL and PRS. The reversal of the educational edge of PRS over PRL in the 15-19 years age group is another concerning indicator of the cost of conflict for PRS that persists even four years after their displacement. FUNDING: UNRWA funded the 2015 survey data collection and the Economic Research Forum funded the development of the YWI.

Self-Rated Health and Relative Socioeconomic Deprivation in the Palestinian Refugee Communities of Lebanon.

Most Palestinian refugees in Lebanon are marginalized as refugees, poor, and targets of discrimination. This study seeks to understand deprivation among these refugees through an exploration of the relationship between indicators of general health and economic deprivation. A nationally representative sample of 2501 Palestinian refugee households were randomly selected and surveyed in 2010. Social workers interviewed the homemaker in each household using a questionnaire on health, economic, and socio-demographic information. This data was analyzed to understand the associations between health and levels of deprivation. 31% of respondents reported poor health and nearly 52% of households had two or more poverty indicators. The logistic regression found each degree of deprivation associated with a 33% increase in poor health (OR 1.33; CI 1.20-1.47). This study suggests understanding deprivation among impoverished communities requires a nuanced approach. Generalizations about experiences of poverty will generate ineffective policy and intervention strategies.

Farmers' Willingness to Adopt Conservation Agriculture: New Evidence from Lebanon.

With increasing food insecurity and climate change, conservation agriculture has emerged as a sustainable alternative to intensive conventional agriculture as a source of food supply. Yet the adoption rate of conservation agriculture is still low. Our paper analyses the factors affecting farmers' willingness to adopt conservation agriculture in Lebanon. The findings show that household characteristics-years of farming and farm size affect conservation agriculture adoption. However, household characteristics alone were insufficient to explain conservation agriculture adoption. We found that farming experience, information sources, frequency of irrigation, and severity of weed infestation in the past, participation in specific trainings, and farmers' perception about the long-term impact of conservation agriculture, were key determinants of conservation agriculture adoption. Our paper encourages policymakers to invest in conservation agriculture to overcome food insecurity and environmental changes affecting food systems in the Middle East. The paper also informs agribusiness firms to view conservation agriculture as a viable alternative to strengthen their business relationship with farmers in arid and semi-arid regions.

The global economic and regulatory determinants of household food waste generation: A cross-country analysis.

Food is generally wasted all along the supply chain, with an estimated loss of 35percent generated at the consumer level. Consequently, household food waste constitutes a sizable proportion of the total waste generated throughout the food supply chain. Yet such wastes vary drastically between developed and developing countries. Using data collected from 44 countries with various income levels, this paper investigates the impact of legislation and economic incentives on household food waste generation. The obtained results indicate that well-defined regulations, policies and strategies are more effective than fiscal measures in mitigating household food waste generation.

The effect of taxation on tobacco consumption and public revenues in Lebanon.

BACKGROUND: Tobacco consumption rates in Lebanon are among the highest worldwide. The country ratified the Framework Convention on Tobacco Control in 2005. A law was passed in 2011 which regulates smoking in closed public spaces, bans advertising, and stipulates larger warnings. Despite international evidence confirming that increasing taxation on tobacco products lowers tobacco consumption, no such policy has yet been adopted: a cigarette pack costs on average US$1.50. To date no studies in Lebanon have addressed the welfare and public finance effects of increasing taxes on tobacco products. METHODS: Using the 2005 national survey of household living conditions, we estimate an almost ideal demand system to generate price elasticities of demand for tobacco. Using estimated elasticities and a conservative scenario for expected smuggling, we simulate the consumption and tax revenue effects of a change in the price of tobacco under various tax schemes. RESULTS: Increasing taxes on all tobacco products so as to double the price of imported cigarettes would lower their consumption by 7% and consumption of domestically produced cigarettes by over 90%. Young adults (ages 15-30) are more sensitive: consumption would drop by 9% for imported cigarettes and by 100% for domestic cigarettes. Government revenues would increase by approximately 52%. CONCLUSIONS: The estimated elasticities indicate that an increase in taxes on all tobacco products would lead to a reduction in consumption and an increase in government revenue. Evidence from Lebanon on the effectiveness of increased taxation may help initiate national debate on the need to raise taxes.

Associations between life conditions and multi-morbidity in marginalized populations: the case of Palestinian refugees.

BACKGROUND: Evidence suggests that higher multi-morbidity rates among people with low socioeconomic status produces and maintains poverty. Our research explores the relationship between socioeconomic deprivation and multi-morbidity among Palestinian refugees in Lebanon, a marginalized and impoverished population. METHODS: A representative sample of Palestinian refugees in Lebanon was surveyed, interviewing 2501 respondents (97% response rate). Multi-morbidity was measured by mental health, chronic and acute illnesses and disability. Multinomial logistic regression models assessed the association between indicators of poverty and multi-morbidities. RESULTS: Findings showed that 14% of respondents never went to school, 41% of households reported water leakage and 10% suffered from severe food insecurity. Participants with an elementary education or less and those completing intermediate school were more than twice as likely to report two health problems than those with secondary education or more (OR: 2.60, CI: 1.73-3.91; OR: 2.47, CI: 1.62-3.77, respectively). Those living in households with water leakage were nearly twice as likely to have three or more health reports (OR = 1.88, CI = 1.45-2.44); this pattern was more pronounced for severely food insecure households (OR = 3.41, CI = 1.83-6.35). CONCLUSION: We identified a positive gradient between socioeconomic status and multi-morbidity within a refugee population. These findings reflect inequalities produced by the health and social systems in Lebanon, a problem expected to worsen following the massive influx of refugees from Syria. Ending legal discrimination and funding infrastructural, housing and health service improvements may counteract the effects of deprivation. Addressing this problem requires providing a decent livelihood for refugees in Lebanon.

The economics of tobacco in Lebanon: an estimation of the social costs of tobacco consumption.

OBJECTIVES: Assess the socioeconomic costs of smoking in Lebanon and understand the tobacco market and identify the winners and losers from the Lebanese tobacco trade. METHODS: We take a close look at the market for tobacco and related markets to identify the main stakeholders and estimate the direct costs and benefits of tobacco. We also estimate lower bounds for the costs of tobacco, in terms of lost productivity, the cost of medical treatment, lost production due to premature death, and environmental damage. The paucity of data means our cost estimates are conservative lower bounds and we explicitly list the effects that we are unable to include. RESULTS: We identify the main actors in the tobacco trade: the Régie (the state-owned monopoly which regulates the tobacco trade), tobacco farmers, international tobacco companies, local distributors, retailers, consumers, and advertising firms. We identify as proximate actors the Ministries of Finance and Health, employers, and patients of smoking-related illnesses. In 2008, tobacco trade in Lebanon led to a total social cost of $326.7 million (1.1% of GDP). CONCLUSION: Low price tags on imported cigarettes not only increase smoking prevalence, but they also result in a net economic loss. Lebanese policymakers should consider the overall deficit from tobacco trade and implement the guidelines presented in the Framework Convention on Tobacco Control to at once increase government revenue and reduce government outlays, and save the labor market and the environment substantial costs.

The economic cost of physical inactivity in China.

OBJECTIVE: To estimate the total economic burden of physical inactivity in China. METHOD: The costs of physical inactivity combine the medical and non-medical costs of five major Non Communicable Diseases (NCDs) associated with inactivity. The national data from the Chinese Behavioral Risk Factors Surveillance Surveys (2007) and the National Health Service Survey (2003) are used to compute population attributable risks (PARs) of inactivity for each major NCD. Costs specific to inactivity are obtained by multiplying each disease costs by the PAR for each NCD, by incorporating the inactivity effects through overweight and obesity. RESULTS: Physical inactivity contributes between 12% and 19% to the risks associated with the five major NCDs in China, namely coronary heart disease, stroke, hypertension, cancer, and type 2 diabetes. Physical inactivity is imposing a substantial economic burden on the country, as it is responsible alone for more than 15% of the medical and non-medical yearly costs of the main NCDs in the country. CONCLUSIONS: The high economic burden of physical inactivity implies the need to develop more programs and interventions that address this modifiable behavioral risk, in order to curb the rising NCDs epidemic in China.

Health equity in Lebanon: a microeconomic analysis.

BACKGROUND: The health sector in Lebanon suffers from high levels of spending and is acknowledged to be a source of fiscal waste. Lebanon initiated a series of health sector reforms which aim at containing the fiscal waste caused by high and inefficient public health expenditures. Yet these reforms do not address the issues of health equity in use and coverage of healthcare services, which appear to be acute. This paper takes a closer look at the micro-level inequities in the use of healthcare, in access, in ability to pay, and in some health outcomes. METHODS: We use data from the 2004/2005 Multi Purpose Survey of Households in Lebanon to conduct health equity analysis, including equity in need, access and outcomes. We briefly describe the data and explain some of its limitations. We examine, in turn, and using standardization techniques, the equity in health care utilization, the impact of catastrophic health payments on household wellbeing, the effect of health payment on household impoverishment, the equity implications of existing health financing methods, and health characteristics by geographical region. RESULTS: We find that the incidence of disability decreases steadily across expenditure quintiles, whereas the incidence of chronic disease shows the opposite pattern, which may be an indication of better diagnostics for higher quintiles. The presence of any health-related expenditure is regressive while the magnitude of out-of-pocket expenditures on health is progressive. Spending on health is found to be "normal" and income-elastic. Catastrophic health payments are likelier among disadvantaged groups (in terms of income, geography and gender). However, the cash amounts of catastrophic payments are progressive. Poverty is associated with lower insurance coverage for both private and public insurance. While the insured seem to spend an average of almost LL93,000 ($62) on health a year in excess of the uninsured, they devote a smaller proportion of their expenditures to health. CONCLUSIONS: The lowest quintiles of expenditures per adult have less of an ability to pay out-of-pocket for healthcare, and yet incur healthcare expenditures more often than the wealthy. They have lower rates of insurance coverage, causing them to spend a larger proportion of their expenditures on health, and further confirming our results on the vulnerability of the bottom quintiles.