The emergence and regression of political priority for refugee integration into the Jordanian health system: an analysis using the Kingdon's multiple streams model.

BACKGROUND: The prolonged presence of Syrian refugees in Jordan has highlighted the need for sustainable health service delivery models for refugees. In 2012, the Jordanian government adopted a policy that granted Syrian refugees access, free of charge, to the national health system. However since 2012, successive policy revisions have limited refugee access. This paper seeks to understand factors that initially put refugee integration into the health system on the policy agenda, as well as how these same factors later affected commitment to sustain the policy. METHODS: This paper draws on data from a document review of 197 peer-reviewed and grey literature publications, a media analysis of newspaper articles retrieved from four officially recognized newspapers in Jordan, and 33 semi-structured key informant interviews. We used Kingdon's Multiple Streams Model - a well-established tool for analyzing policy adoption - to understand how political priority developed for integration of refugees into the health system. RESULTS: We find that several factors helped bring attention to the issue, namely concerns over infectious disease transmission to host communities, high rates of chronic conditions among the refugee population and the increasingly urban and dispersed nature of refugees. At the outset of the conflict, the national mood was receptive to refugees. Politicians and government officials quickly recognized the crisis as an opportunity to secure material and technical support from the international humanitarian community. At the same time, global pressures for integrating refugees into national health systems helped move the integration agenda forward in Jordan and the region more broadly. Since 2012, there were several modifications to the policy that signal profound changes in national views around the continued presence of Syrian refugees in the country, as well as reduced external financial support which has undermined the sustainability of the policy. CONCLUSION: This case study underscores the dynamic nature of policymaking and the challenge of sustaining government commitment to the right to health among refugees. Our analysis has important implications for advocates seeking to advance and maintain momentum for the integration of refugees into national health systems.

Choosing and accessing COVID-19 treatment options: a qualitative study with patients, caregivers, and health care providers in Lebanon.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has strained healthcare systems globally, particularly in terms of access to medicines. Lebanon has been greatly affected by the pandemic, having faced concomitant financial and economic crises. The objective of the study was to understand the experiences of patients with COVID-19 in Lebanon, as well as those of their families, and healthcare providers, with regards to their treatment decisions and accessibility to COVID-19 medicines. METHODS: For this qualitative study, we conducted 28 semi-structured interviews. We used purposive sampling to recruit participants with a diverse range of perspectives. The data collection phase spanned from August to November 2021 and was conducted virtually. After transcribing and translating the interviews, we employed thematic analysis to identify recurring themes and patterns. RESULTS: In total, 28 individuals participated in this study. Participants highlighted challenges owing to the COVID-19 pandemic and economic crisis. Accessing COVID-19 medicines posed major hurdles for physicians and patients, given limited availability, global shortages, local circumstances, community hoarding and stockpiling by pharmacies. Providers based treatment decisions on research, local and international practice guidelines, experiences and expert feedback. Patients sought information from social media, community members and physicians, as well as through word of mouth. Accessing medicines involved navigating the healthcare system, the black market, charities, personal networks and political parties and sourcing from abroad. The medicines were either free, subsidized or at inflated costs. CONCLUSIONS: This study highlights the diversity and complexity of factors influencing decision-making and accessing medicines during the COVID-19 pandemic in Lebanon. Future research should explore strategies for ensuring medicine access during crises, drawing insights from comparative studies across different countries.

Long-term burden of war injuries among civilians in LMICs: case of the July 2006 war in Lebanon.

Introduction: Lebanon, a country located on the eastern shore of the Mediterranean Sea, is one of the world's smaller sovereign states. In the past few decades, Lebanon endured a perpetual political turmoil and several armed conflicts. July 12, 2006, marked the start of a one-month war in Lebanon, which resulted in thousands of casualties. Little is known about the long-term consequences of war injuries inflicted on civilians during the July 2006 war. Methods: The objectives of this paper were to identify and evaluate: 1- civilians' access to healthcare and medicine under conditions of war; 2- the long-term socioeconomic burden on injured civilians; and 3- their quality of life more than a decade post-war. We adopted a mixed-method research design with an emphasis on the qualitative component. We conducted interviews with patients, collected clinical and financial data from hospital medical records, and administered a self-rated health questionnaire, the EQ-5D-5L. Simple descriptive statistics were calculated using Excel. NVivo 12® was used for data management and thematic analysis. Results: We conducted 25 interviews. Injured civilians were mostly males, average age of 27. The most common mechanism of injury was blast injury. Most patients underwent multiple surgeries as well as revision surgeries. The thematic analysis revealed three themes: 1- recall of the time of the incident, the thousand miles journey, and patients' access to services; 2- post-trauma sequelae and services; and 3- long-term impact. Patients described the long-term burden including chronic pain, poor mobility, anxiety or depression, and limited activities of daily living. Discussion: Civilians injured during the July 2006 war described the traumatising events they endured during the war and the limited access to medical care during and post-war. Up until this study was conducted, affected civilians were still experiencing physical, psychological, and financial sequelae. Acknowledging the limitations of this study, which include a small sample size and recall bias, the findings underscore the necessity for the expansion of services catering to civilians injured during wartime.

Determinants of influenza and COVID-19 vaccine intent or uptake in Lebanon: a scoping review of the literature.

BACKGROUND: Vaccination is essential to protect from influenza and recently from COVID-19, yet uptake in Lebanon is suboptimal. Several factors determine uptake including knowledge, attitude and policies. We conducted a scoping review of the literature to explore the determinants of influenza and COVID-19 vaccine intent or uptake in Lebanon. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines, thirty one peer reviewed studies indexed in six databases Pub Med, EMBASE, Scopus, CINAHL, Medline, and the Cochrane Library were screened. Two students, a senior Librarian and an Associate Professor in nursing searched for eligible studies. The library search strategy followed a combination of three broad concepts (viral influenzas; vaccines; Lebanon). The search timeframe was up till December 31, 2022. Determinants of influenza and COVID-19 vaccine intent or uptake were categorized following the constructs of the Theory of Planned Behavior. RESULTS: Nine studies investigated influenza vaccine intent or uptake among the public community, parents and healthcare workers. Twenty one studies investigated COVID-19 vaccine intent or uptake among the public community, older refugees, university students, patients with cancer, dentists, and social media users. One study investigated both types of vaccines. A conceptual model of the determinants of vaccine intent and uptake within the Lebanese context was developed. Various determinants included environmental factors, norms, knowledge, perceptions, attitudes, past experiences, behavioral control and hesitancy. CONCLUSIONS: Research on vaccine intent and uptake in Lebanon is still in its infancy, while that of COVID-19 is on the rise. Multifaceted reasons behind the low vaccination rates were observed yet few attempts were made to target vulnerable groups. Further research studies are needed to target vulnerable groups.

The validation of the Arabic version of the resilience scale 14 (RS-14).

BACKGROUND/OBJECTIVES: Nurses in Lebanon are facing multiple crises and the severity of the situation calls for an empirical examination of their resilience status. Evidence indicates that resilience can buffer the negative effect of workplace stressors on nurses and is associated with favorable patient outcomes. The objective of this study was to test the psychometric properties of the Arabic Resilience Scale-14 that was utilized to measure resilience among Lebanese nurses, METHODS: Data was collected from nurses working in health care centers using a cross-sectional survey design. We estimated the confirmatory factor analysis using the Diagonally Weighted least Squares. Fit indices for the confirmatory factor analysis model included Model chi-square, root-mean squared error of approximation and Standardized Root Mean Square Residual. Statistical significance was set at p < 0.05. RESULTS: 1,488 nurses were included in the analysis. The squared multiple correlations values ranged from 0.60 to 0.97 thus supporting the construct validity of the originally hypothesized five factor model (self-reliance, purpose, equanimity, perseverance, and authenticity). CONCLUSIONS: The Arabic version of the Resilience Scale 14 tool is considered a valid tool for measuring resilience in any situation involving Arabic speaking nurses.

Research fellowship in a Lebanese academic medical center: What does it take to shift from an informal to a formal program?

Research fellowship programs help medical graduates acquire research skills for an academic career. While our institution employed a large number of research fellows, it did not offer them a formal training program. This study aimed to assess the views of fellows and their mentors regarding the current research fellowship program, and to seek their suggestions for a formal training program at our medical center. We conducted a qualitative descriptive study using both focus group discussions and individual interviews with research fellows, and individual interviews with their mentors. We recruited all eligible participants by email. We collected data in person and analyzed it thematically. We followed the consolidated criteria for reporting of qualitative research (COREQ) checklist. A total of 17 research fellows and 17 mentors participated in the study. Participants described the current non-formal program and proposed suggestions for a formal training program. The identification of available vacant positions and the recruitment process followed an unstructured approach, through networking with mentors and previous fellows. Although there is a formal contract, there is no job description, and no definition of roles, responsibilities and rights. Some fellows get the opportunity of being involved in all aspects of research and benefit from a favorable mentor-mentee relationship. Conversely, others struggle with authorship and with the projects allocated to them, some being "non-research" related. Not all fellows end up publishing their projects. Participants provided suggestions to shift into a formal training, including measures to improve on the recruitment process of fellows, defining roles and exposure to all aspects of research. Research fellows are eager to learn, but the currently available program is unstructured. They need a formal training program that meets their expectations, one that offers equitable learning opportunities and benefits to all.

A triangulated perspective for understanding CAM use in Lebanon: a qualitative study.

BACKGROUND: Existing evidence marked a prevalent use of Complementary and Alternative Medicine (CAM) therapies in Lebanon that is concomitant with low rates of disclosure to health care providers and limited knowledge among the general public of safety and side effects of CAM use. OBJECTIVES: To examine the perspectives of Lebanese CAM users, CAM providers, and health care providers (HCPs) regarding their understanding of CAM and of the Push and Pull factors that drive its use. METHODS: A qualitative research study was conducted using in-depth interviews, targeting Lebanese adults (CAM users; 18-65 years) (n=14), CAM providers such as yoga instructors, owners of CAM product outlets, herbalists, and religious figures (n=13); and HCPs including physicians, nurses, dietitians, and pharmacists (n=14). The topic guide covered, in addition to the understanding of CAM, the Push and Pull factors driving CAM use. The adults were recruited by convenient sampling, and CAM providers and HCPs using a purposive sampling approach. Interviews were audiotaped, transcribed, and translated into English. Analysis was performed using a qualitative thematic approach. Similarities and differences in the perceptions of the participants with regards to factors that influence CAM use were charted and contrasted, using a triangulated approach. RESULTS: The three study groups exhibited a similar understanding of CAM, referring to non-conventional therapies used to prevent/treat diseases or to enhance wellbeing. CAM users and CAM providers identified "distrust in HCPs", "lack of patient-centered care in CM", and "limitations and side effects of CM" as important Push factors. All study groups highlighted the limited CAM knowledge of HCPs as a main reason for the lack of patient-centered care. All three groups also underscored the affordability and the social and cultural support for CAM as main enablers of its prevalent use. Unlike HCPs who were skeptical about the safety and effectiveness of CAM, CAM users and CAM providers indicated that most of CAM therapies are safe and efficient. CONCLUSIONS: The triangulation of perspectives (CAM users, CAM providers, and HCPs) in this study allowed a comprehensive appraisal of CAM use and its drivers. Improving the HCPs' CAM-related knowledge, promoting patient-centered care and fostering an open dialogue between HCPs and CAM providers are among the recommendations of the study.

Stakeholders' views and perspectives on treatments of visceral leishmaniasis and their outcomes in HIV-coinfected patients in East Africa and South-East Asia: A mixed methods study.

BACKGROUND: In visceral leishmaniasis (VL) patients coinfected with human immunodeficiency virus (HIV), combination therapy (liposomal amphotericin B infusion and oral miltefosine) is being considered as an alternative to liposomal amphotericin B monotherapy. We aimed to assess the views of stakeholders in relation to these treatment options. METHODOLOGY: In a mixed methods study, we surveyed and interviewed patients, government functionaries, programme managers, health service providers, nongovernmental organizations, researchers, and World Health Organization (WHO) personnel. We used the Evidence to Decision (EtD) framework for data collection planning and analysis. Constructs of interest included valuation of outcomes, impact on equity, feasibility and acceptability of the treatment options, implementation considerations, monitoring and evaluation, and research priorities. PRINCIPAL FINDINGS/CONCLUSION: Mortality and non-serious adverse events were rated as "critical" by respectively the highest (61%) and lowest percentages (47%) of survey participants. Participants viewed clinical cure as essential for patients to regain productivity. Non-patient stakeholders emphasized the importance of "sustained" clinical cure. For most survey participants, combination therapy, compared with monotherapy, would increase health equity (40%), and be more acceptable (79%) and feasible (57%). Interviews revealed that combination therapy was more feasible and acceptable than monotherapy when associated with a shorter duration of hospitalization. The findings of the interviews provided insight into those of the survey. When choosing between alternative options, providers should consider the outcomes that matter to patients as well as the impact on equity, feasibility, and acceptability of the options.

Public health effects of travel-related policies on the COVID-19 pandemic: A mixed-methods systematic review.

OBJECTIVES: To map travel policies implemented due to COVID-19 during 2020, and conduct a mixed-methods systematic review of health effects of such policies, and related contextual factors. DESIGN: Policy mapping and systematic review. DATA SOURCES AND ELIGIBILITY CRITERIA: for the policy mapping, we searched websites of relevant government bodies and used data from the Oxford COVID-19 Government Response Tracker for a convenient sample of 31 countries across different regions. For the systematic review, we searched Medline (Ovid), PubMed, EMBASE, the Cochrane Central Register of Controlled Trials and COVID-19 specific databases. We included randomized controlled trial, non-randomized studies, modeling studies, and qualitative studies. Two independent reviewers selected studies, abstracted data and assessed risk of bias. RESULTS: Most countries adopted a total border closure at the start of the pandemic. For the remainder of the year, partial border closure banning arrivals from some countries or regions was the most widely adopted measure, followed by mandatory quarantine and screening of travelers. The systematic search identified 69 eligible studies, including 50 modeling studies. Both observational and modeling evidence suggest that border closure may reduce the number of COVID-19 cases, disease spread across countries and between regions, and slow the progression of the outbreak. These effects are likely to be enhanced when implemented early, and when combined with measures reducing transmission rates in the community. Quarantine of travelers may decrease the number of COVID-19 cases but its effectiveness depends on compliance and enforcement and is more effective if followed by testing, especially when less than 14 day-quarantine is considered. Screening at departure and/or arrival is unlikely to detect a large proportion of cases or to delay an outbreak. Effectiveness of screening may be improved with increased sensitivity of screening tests, awareness of travelers, asymptomatic screening, and exit screening at country source. While four studies on contextual evidence found that the majority of the public is supportive of travel restrictions, they uncovered concerns about the unintended harms of those policies. CONCLUSION: Most countries adopted full or partial border closure in response to COVID-19 in 2020. Evidence suggests positive effects on controlling the COVID-19 pandemic for border closure (particularly when implemented early), as well as quarantine of travelers (particularly with higher levels of compliance). While these positive effects are enhanced when implemented in combination with other public health measures, they are associated with concerns by the public regarding some unintended effects.

People who use drugs in rehabilitation, from chaos to discipline: Advantages and pitfalls: A qualitative study.

Evidence-based models emphasizing on lifestyle behaviours for the treatment of drug use is still in its infancy. The development of multicomponent effective drug use intervention programs as part of health promotion is crucial to decrease risk of relapse. This study aims at exploring the lifestyle practices including dietary intake, physical activity and sleep of people who use drugs undergoing residential rehabilitation treatment in Lebanon with its perceived benefits and pitfalls. A purposive sample of 18 males and 9 females at different stages of recovery from drug use in rehabilitation centers participated in the qualitative discussions. The six phases thematic analysis revealed three themes: chaotic lifestyle, structuredlifestyle, benefits and pitfalls, and suggestions for making rehabilitation a better experience. Participants discussed their chaotic lifestyle during addiction with poor food intake, disrupted sleep and low physical activity moving to a more disciplined routine enforcing normality in lifestyle practices with social and professionlprofessional support. The early phases of treatment were marked with increased food intake and weight gain perceived as a health indicator and the sole divergent from drugs, moving towards more structured meals and efforts to lose weight in later stages. Lack of variety of Physical activity programs taking into consideration the motivational differences among the participants was also highlighted. Measures for improving rehabilitation services in terms of promoting healthy eating behaviours and environmental control were thoroughly addressed. These findings shed the light on the challenges faced in maintaining a healthy lifestyle in rehabilitation centers and the necessities of addressing them to improve the overall rehabilitation experience, prevent relapse and inform the development of future targeted intervention programs tackling all aspects of behavioural changes.

Voices of the vulnerable: Exploring the livelihood strategies, coping mechanisms and their impact on food insecurity, health and access to health care among Syrian refugees in the Beqaa region of Lebanon.

Lebanon has approximately one million Syrian refugees (SR) registered with the United Nations High Commission on Refugees (UNHCR) and an unknown number of unregistered SR, who cannot benefit from formal assistance. This study aimed to examine the livelihoods, coping strategies, and access to healthcare among SR based on registration status and accompanying formal assistance. A mixed-method approach with more emphasis on the qualitative design was adopted. A purposive convenient sampling approach was used to recruit SR from informal tented settlements (ITS) in the Beqaa region in Lebanon. Data collection included 19 focus group discussions (FGDs) that were conducted with participants, who were further divided into three groups: registered refugees with assistance, registered without assistance and unregistered. Twelve in-depth interviews were conducted with key informants from humanitarian organizations. All interviews and FGDs were audio recorded, transcribed, and thematically analyzed. SR were highly dependent on formal assistance when received, albeit being insufficient. Regardless of registration status, refugees resorted to informal livelihood strategies, including informal employment, child labor, early marriage, and accruing debt. Poor living conditions and food insecurity were reported among all SR. Limited healthcare access and high out-of-pocket costs led to limited use of antenatal care services, prioritizing life-threatening conditions, and resorting to alternative sources of healthcare. Severity of these conditions and their adverse health consequences were especially pronounced among unregistered refugees. Our findings shed light on the economic and health disparities among marginalized SR, with the lack of registration and formal assistance increasing their vulnerability. More tailored and sustainable humanitarian programs are needed to target the most vulnerable and hard-to-reach groups.

Assessing the capacity for conflict and health research in Lebanon: a qualitative study.

BACKGROUND: Conflicts pose new challenges for health systems, requiring rapid and practical approaches to meet emerging needs on the ground. Lebanon has been highly influenced by surrounding conflicts in the Middle East and North Africa (MENA) region, especially the Syrian crisis. Strengthening research capacity to collect evidence on conflict in the MENA region and beyond is crucial to inform healthcare policy and practice. For targeted capacity strengthening interventions, the main objective of this paper is to present key findings of a needs assessment of conflict and health research in Lebanon. This will support recent efforts to scale up context-specific policies, interventions to strengthen the country's health system, and research capacity. METHODS: The study is based on 30 semi-structured interviews with key informants such as specialist academics, humanitarian workers and public sector officials. RESULTS: Despite being ranked third in the number of publications on biomedical and health research per capita in MENA and in hosting reputable universities which are considered central academic hubs in the region, lack of nationwide research culture, insufficient funding and limited access to data were reported to be major challenges for health researchers in Lebanon. Even with the ongoing efforts, poor impact of research on policy continues to be a persistent gap. Large disparities in research capacities and taught skills were reported between different universities in Lebanon, with a disproportionate emphasis on quantitative over qualitative skills. Most medical students are not trained to conduct research or to practice in conflict settings. Concerns were also expressed regarding the ethics of research conducted, specifically by local non-governmental organizations. RECOMMENDATIONS: To conduct contextualized trainings on research skills with a stronger focus on qualitative approaches, medical practice, and ethical research in conflict. To better involve policymakers in designing research agendas by organizing multiple stakeholder meetings. CONCLUSION: The study indicates that health research in Lebanon is characterized by considerable strengths in terms of human capital and research capacities of certain universities. However, the Lebanese research infrastructure needs further development in terms of ensuring sustainable funding, providing access to data, teaching qualitative research skills, conducting ethical and multidisciplinary research, and promoting cross-sectoral knowledge transfer.

Users' acceptance of electronic patient portals in Lebanon.

BACKGROUND: Acceptance of Electronic patient portal (EPP) is instrumental for its success. Studies on users' acceptance in the Middle East region are scarce. This study aims to use the TAM as a framework to quantitatively describe potential users, diabetic and chronic high blood pressure patients and their providers, intention to use and factors influencing the intention to use EPP at AUBMC-FMC We concurrently test the internal construct validity and the reliability of the TAM. METHODS: A cross-sectional survey design and the vignette approach were used. For validation, we needed a minimum of 180 patients; all 35 attending physicians and 11 registered nurses were targeted. We used descriptive statistics to calculate the intention to use EPP and its determinants based on the TAM constructs. Exploratory factor analysis (EFA) and structural equation modeling (SEM) were employed to estimate significant path coefficients for patients only as the sample size of providers was too small. RESULTS: We had 199 patients, half intended to use EPP; 73% of providers (N = 17) intended to use EPP. Perceived ease of use and privacy concerns were significantly higher among providers than patients (Mean (M) = 0.77 vs M = 0.42 (CI: - 0.623; - 0.081)) and (M = 3.67 vs M = 2.13, CI: - 2.16; - 0.91) respectively; other constructs were not significantly different. Reliability of TAM revealed a Cronbach Alpha of α=.91. EFA showed that three components explained 73.48% of the variance: Behavioral Intention of Use (14.9%), Perceived Ease of Use (50.74%), Perceived Usefulness (7.84%). SEM found that perceived ease of use increased perceived usefulness (standardized regression weight = 0.49); perceived usefulness (0.51) had more predictive value than perceived ease of use (0.27) to explain the behavioral intention of use of the EPP. CONCLUSIONS: We found that providers valued the usefulness of EPP and were mostly intending to use it. This finding has yet to be tested in future studies testing actual use as intention and actual use may not be concordant. The intention to use among patients was lower than those reported in developed countries. We identified two factors that we need to address to increase use, namely perceived ease and usefulness, and proposed practical implications to address them; future research directions were also discussed.

Perspectives of Registered Nurses on refugee healthcare in Lebanon and Jordan (PROfILE): A multi-site cross-sectional study protocol.

AIM: This is a study protocol to investigate nurses' perspectives on refugee health care in two countries. The aims are to: (a) explore self-reported work environment factors, including work stressors, self-rated leadership, staffing and resources adequacy, and teamwork among Jordanian and Lebanese nurses caring for refugees; (b) investigate the relationship between nurse related outcomes (physical health; emotional exhaustion) and their psychosocial work environment; and (c) assess the association between nurses' perceived work environment factors and implicit rationing of care and quality of patient care. BACKGROUND: Globally, the care of refugees is achieving increased attention. Over 6.3 million people are internally displaced and 4.8 million recorded Syrian expatriates are residing in and receiving healthcare services in the neighbouring host countries. DESIGN: This is a cross-sectional, comparative study using a survey design. METHOD: The study setting involves both private and public hospitals and primary healthcare centres that provide care to refugees on regular basis in Lebanon and Jordan. The estimated sample size includes 3,000 Registered Nurses from Lebanon and 2,500 nurses and midwives from Jordan. DISCUSSION: Workplace factors affecting quality of nursing care and psychosocial status of nurses caring for refugees will be identified. Potential findings will help leaders design interventions to support nurses who are serving refugees for safer care and better patient outcomes. Findings will assist in more efficient resource allocation and management. IMPACT: New knowledge on the impact of providing health care for refugees will be generated based on the structure of nursing care (e.g., work environment), on the nursing process (e.g., implicit rationing of care), and nurse outcomes (health) in two hosting communities. Moreover, factors enabling resilience in patients, providers, and systems will be identified and be of potential use in addressing the growing global problem of caring for displaced persons.

Correction to: Informal healthcare provision in Lebanon: an adaptive mechanism among displaced Syrian health professionals in a protracted crisis.

[This corrects the article DOI: 10.1186/s13031-019-0224-y.].

Informal healthcare provision in Lebanon: an adaptive mechanism among displaced Syrian health professionals in a protracted crisis.

BACKGROUND: Syrian healthcare workers (HCWs) are among those who fled the Syrian conflict only to face further social and economic challenges in host countries. In Lebanon, this population group cannot formally practice, yet many are believed to be operating informally. These activities remain poorly documented and misunderstood by the academic, policy and humanitarian communities. This study aims to understand mechanisms of informal provision of services, the facilitators and barriers for such practices and to present policy recommendations for building on this adaptive mechanism. METHOD: A qualitative descriptive study based on an in-depth interview approach with a sample of Syrian informal healthcare workers (IHCWs) residing in Lebanon was adopted. Known sponsor networks followed by snowball sampling approaches were used to recruit participants. Data collection occurred between September and December 2017. All interviews were audio-recorded, transcribed and translated into English. An inductive thematic analysis was used. RESULTS: Twenty-two participants were recruited. Motivational factors that led HCWs to practice informally were personal (e.g. source of income/livelihood), societal (cultural competency), and need to fulfill a gap in the formal health service sector. Being connected to a network of IHCWs facilitated initiation of the informal practice until eventually becoming part of a community of informal practice. The central challenge was the informal nature of their practice and its negative consequences. Most IHCWs were afraid of arrest by the government upon identification. Most interviewees indicated being discriminated against by host communities in the form of differential wages and tense interpersonal relationships. Almost all recommended a change in policy allowing them to practice formally under a temporary registration until their return to Syria. CONCLUSION: Our study confirmed the presence of IHCWs operating in Lebanon. Despite its informal nature, participants perceived that this practice was filling a gap in the formal health system and was helping to alleviate the burden of IHCWs and refugee health needs. In line with interviewees' views, we recommend that policy decision makers within humanitarian agencies and the Government of Lebanon explore the possibilities for allowing temporary registration of displaced Syrian IHCW to benefit local host communities and refugee populations.

The Impact of the Syrian Refugee Crisis on Nurses and the Healthcare System in Lebanon: A Qualitative Exploratory Study.

PURPOSE: To explore Lebanese nurses' perspectives on the impact of the protracted Syrian refugee (SR) crisis on nurses working in hospitals and primary healthcare centers in Lebanon. DESIGN: A qualitative research design drawing on a semistructured in-depth interview approach. METHODS: We recruited participants through the Order of Nurses in Lebanon. We interviewed six primary healthcare nurses and six nursing directors working in regions with high concentration of SRs. We used the thematic inductive approach to analyze the data. FINDINGS: Two themes emerged. In Theme I, nurses and nursing directors described the SR health profile as poor at baseline, and as the crisis was protracting the type of diseases shifted from acute to chronic with convoluted complications. As for determinants of health, SRs had poor health literacy and poor living conditions. In Theme II, nurses and nursing directors voiced the impact of the SR crisis on nurses, nursing practice, healthcare system, and host community. They cited fatigue, burnout, and depleted compassionate care at the individual level; rationing and stressed interpersonal relationships at the practice level; shortage in resources and poor performance at the healthcare system level; and a shift in the patient population that led the host community to seek health care elsewhere. Alternatively, more money was injected, and new services and clinical programs were introduced. CONCLUSIONS: Lebanese nurses bore a profound burden as a result of the SR crisis. Should this crisis be replicated in other contexts, the important lessons learned encompass (a) increasing access to care to refugees, coupled with an emergency plan to increase human health resources; (b) improving preparedness of nurses in handling priority health conditions; (c) documenting and reporting the challenges and resilience of health workers, especially nurses facing the crisis; and (d) engaging more nurses to be at the policy table. CLINICAL RELEVANCE: There is a need to prepare nurses for efficient response to crisis related to refugee health by increasing human resources and training them to be competent in delivering safe and high-quality care necessary to respond to the special healthcare needs of the refugees.

Perceived impact of community kitchens on the food security of Syrian refugees and kitchen workers in Lebanon: Qualitative evidence in a displacement context.

Community kitchens (CKs) have been recommended as public health strategies with social and nutritional health benefits for low-income participants and their families in different settings. The benefit of CKs in improving the food security status of participants in the context of conflict and displacement is less conclusive. This study aimed to qualitatively explore the impact of CKs on the food security status of community kitchen workers (CWs) and Syrian refugee (SR) families in Lebanon. An exploratory qualitative descriptive approach was adopted. Focus group discussions were conducted with 15 CWs and 49 SRs, and transcripts were analyzed thematically. Emerging themes included: motivation to join the CKs (CWs only), perception towards CKs, impact of these CKs, and their sustainability (both groups). Motivating factors for CWs included financial, internal and societal drivers, and the favorable type of work in kitchens. The perception towards CKs was overall positive among CWs and SR beneficiaries. Both groups reported the positive impact of CKs on their food security and financial status, which in turn affected positively their psychological health. At the social level, CWs indicated that the kitchen's friendly atmosphere increased social cohesion and companionship between Syrians and Lebanese within the kitchen. In addition, CWs reported increased sense of empathy towards SRs benefiting from the CK services. According to study participants, the positive impact of the CKs was almost completely reversed when their operation and services were interrupted for two months. Both CWs and SRs identified facilitators and barriers that can affect the sustainability of the kitchens, including financial and entrepreneurial skills. In conclusion, findings from this study highlight that CKs can be promising programs to improve the food security and livelihoods of participants, while also increasing social cohesion and integration of refugees within host communities in protracted crisis contexts.

The interaction of personal, contextual, and study characteristics and their effect on recruitment and participation of pregnant women in research: a qualitative study in Lebanon.

BACKGROUND: Declining participation rates are impeding health research. Little is known about factors influencing the decision to participate in low- and middle-income countries (LMIC). Therefore, this paper reports on the various individual factors and their with contextual factors in influencing participation in research among pregnant women and the recommendations to enhance their recruitment in Lebanon. METHODS: This study used a qualitative research design drawing on focus groups and in-depth interviews. The Theoretical Domain Framework guided data collection and analysis. The three participant groups included: Group 1-Pregnant women (n = 25) attending public pre-natal events and antenatal clinics in Beirut; Group 2-Pregnant women (n = 6) already enrolled in the ongoing Mother and Infant Nutritional Assessment birth cohort study; Group 3-Key informants (n = 13) including health care workers involved in recruiting pregnant women. Conversations were audio recorded, transcribed, translated into English, and thematically analyzed. RESULTS: Three main factors influencing participation were revealed, with each factor encompassing several sub-themes: (1) personal factors (altruism, self-confidence, personal interest in the topic, previous understanding of the nature and purpose of research, education level, and previous research experience), (2) contextual factors (societal factors, family and friends), and (3) study characteristics (burden of the study, ethical considerations, incentives, and research interpersonal skills and physician endorsement to participate). The results suggested a dynamic interaction among the identified factors, forming two intersecting axes, with a four-quadrant configuration. The y- and x-axes represented personal factors and contextual factors, respectively. Individuals positioned on the lower-left quadrant were the least likely to participate; those on the upper-right quadrant were the most likely to participate; while those on the upper-left and lower-right quadrants were indecisive. Study characteristics seemed to affect the decision of pregnant women to participate situated in any of the four quadrants. Specific recommendations to improve participation were also identified. CONCLUSIONS: Our findings suggested an interaction of personal factors, contextual factors, and study characteristics affecting subjects' participation. This interaction integrates factors into a novel dynamic framework that could be used in future studies. The recommendations identified may help improve participation of pregnant women in health research hence enhancing the quality and generalizability of research findings in LMIC.

Anaphylaxis management: a survey of school and day care nurses in Lebanon.

OBJECTIVE: Children are at a high risk of developing allergic reactions. Since they spend lots of time at the school or day care, the odds of having an allergic event in this setting is high, hence placing the onus of properly managing their event on nurses. In Lebanon, little is known whether a standardised policy for managing allergic and anaphylactic reaction exists, leaving children unsafe and the school personnel liable. Thus, the aim of this study is to describe the current practices in the management of severe allergies and anaphylaxis by Lebanese nurses working in schools and day cares and to explore the perceived need for a protocol to manage anaphylaxis reaction. METHODS: A cross-sectional survey with nurses working at schools and day cares in Lebanon was conducted. RESULTS: A total of 59 school and day care nurses participated. Eighteen of the school and day care nurses reported having a written policy describing the management steps. Only 12 had witnessed an anaphylactic event. Of those, 10 reported administering an antihistamine medication orally instead of epinephrine intramuscular. Most respondents (56) believed that a standardised guideline for the management of anaphylaxis was essential, and 9 indicated being hesitant to give the epinephrine intramuscular even in the presence of a policy. Finally, 55 stated the need for training nurses in identifying and managing anaphylaxis as a must. CONCLUSION: Currently, the management of anaphylaxis reaction in schools and day cares is suboptimal. Hence, there is a need for a standardised nursing guideline and training for nurses in these settings.