ImportanceOlder Syrian refugees have a high burden of noncommunicable diseases (NCDs) and economic vulnerability.ObjectivesTo 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 ParticipantsThis 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 MeasuresThe 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).ResultsOf 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 RelevanceIn 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.
Background: Access to vaccination is important to prevent morbidity and mortality due to COVID-19 among older Syrian refugees. This study aimed to develop an internally validated predictive model for COVID-19 vaccination amongst older Syrian refugees in Lebanon and understand barriers to vaccination. Methods: This multi-wave longitudinal study was conducted through telephone interviews between September 2020 and March 2022 in Lebanon. Syrian refugees aged 50 years or older were invited to participate from a list of households that received assistance from a humanitarian organization. The outcome was self-reported COVID-19 vaccination status. Logistic regression was used to identify predictors of vaccination uptake. Validation was completed internally using bootstrapping methods. Findings: Out of 2,906 participants (median[IQR] age:58[55-64]; 52.9% males), 1,235(42.5%) had received at least one dose of the COVID-19 vaccine. The main reasons for not receiving the first dose of the vaccine included being afraid of the vaccine side effects (40.1%) or not wanting the vaccine (38.1%). The main reason for not receiving the second or third dose was still waiting for a text message for an appointment (67.1% and 73.5%, respectively). Predictors of receiving at least one dose of COVID-19 vaccine included: age, sex, residence, education and intention of vaccination. After adjusting for optimisation, the final model showed moderate discrimination (c-statistic=0.605[95%CI:0.584 to 0.624]) and good calibration (c-slope=0.912[95%CI:0.758 to 1.079]). Interpretation: There is an ongoing need to address vaccine acceptance and uptake among older Syrian refugees, by improving deployment planning, and raising awareness campaigns about the importance of the vaccine.
Introduction: COVID-19 vaccine acceptance among refugees in the Arab region remains low. This study aimed to examine the prevalence, reasons and predictors of COVID-19 vaccine refusal among older Syrian refugees in Lebanon. Method: A nested cross-sectional study among older Syrian refugees in Lebanon. The sampling frame was a complete listing of beneficiary households of a humanitarian organization with an adult aged 50 years or older. Telephone surveys were completed between September 2020 and May 2021. Logistic regression models were used to identify predictors of COVID-19 vaccine refusal. Models were internally validated using bootstrap methods and the models' calibration and discrimination were presented. Results: Of 3,173 Syrian refugees, 61% intended to receive the COVID-19 vaccine, 31% refused and 7% were undecided. Reasons for vaccine refusal were: preference to follow preventive measures (27%) and belief that the vaccine is not essential (21%). Despite high vaccine acceptance, only 6% of older Syrian refugees were registered on the national platform to receive the vaccine. Reasons for not registering included: being unsure about how to register (36%), and not wanting to receive the vaccine (33%). Predictors of COVID-19 vaccine refusal included: sex (female), older age, education, 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: 0.65 (95% CI:(0.63-0.67)) and good calibration (C-Slope: 0.93 (95% CI:0.82-1.06)). Conclusion: This study developed predictive model for vaccination intention with a moderate discriminative ability and good calibration. Prediction models in humanitarian settings can help to identify refugees at higher risk of not intending to receive the COVID-19 vaccine for public health targeting.
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 and pandemic fatigue have meant that disease control policies need to be updated. Identifying variables associated with adherence to non-pharmaceutical preventive practices, particularly for vulnerable groups, can therefore help inform and refine interventions in the face of pandemic fatigue and changing disease dynamics. Using recent and timely data on older (50 years and above) Syrian refugees in Lebanon, this paper explores 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 identifies the determinants of sustained adherence over a period of 6 months. The findings suggest that older refugees and those less educated are less likely to wear a mask, and refugees living in informal tented settlements are more likely to relent on preventive practices within 6 months. Individuals with chronic diseases who initially report avoiding social gatherings are also likelier to desist than those without chronic illness.The lower continued adherence to mask wearing among residents of informal tented settlements points to factors beyond pandemic fatigue and that should be taken into consideration in devising measures for disease control: the potential for community-based norms to determine individual-level behavior. Recognizing the pivotal effect of community-based norms in settings such as informal tented settlements is essential in adapting current policy and designing future interventions.
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