Predicting poor mental health amongst older Syrian refugees in Lebanon during the COVID-19 pandemic: a multi-wave longitudinal study (preprint)

BackgroundThe COVID-19 pandemic has worsened pre-existing vulnerabilities among older Syrian refugees in Lebanon, potentially impacting their mental health. This study aimed to identify predictors of poor mental health amongst older Syrian refugees living in Lebanon during the pandemic. MethodsThis study used repeated cross-sectional data from a multi-wave telephone survey (September 2020-March 2022). It was conducted among Syrian refugees aged 50 years or older from households that received assistance from a humanitarian organization. Poor mental health was defined as a Mental Health Inventory-5 score of 60 or less. Its trend over time was assessed using growth curve model; and, its predictors were identified using wave one data, through backwards stepwise logistic regression. The models internal validation was conducted using bootstrapping. FindingsThere were 3,229 participants (median age=56 [IQR=53-62]) and 47.5% were female. At wave one, 76.7% had poor mental health, and this increased to 89.2% and to 92.7% at waves three and five, respectively ({beta}=0{middle dot}52; 95% CI: 0{middle dot}44-0{middle dot}63; p-value<0.001). Predictors for poor mental health were younger age, food insecurity, water insecurity, lack of legal status documentation, irregular employment, higher intensity of bodily pain, having debt, and having chronic illnesses. The final model demonstrated good discriminative ability and calibration. InterpretationMental health predictors were related to basic needs, rights and financial barriers. These allow humanitarian organizations to identify high risk individuals, organizing interventions, and addressing root causes to boost resilience and well-being among older Syrian refugees in Lebanon. FundingELRHAs Research for Health in Humanitarian Crisis Programme. Research in context Evidence before this studyA search was conducted on PubMed and Google Scholar for studies published between February 1, 2020 and June 20, 2023, using the search terms "Syrian Refugees", "Mental Health", and "Prediction Model", including all article types with no time constraints or language restrictions. We found that few previous prognostic models for Syrian refugees have been developed exclusively among participants at high risk of poor mental health, such as widowed women, Syrian refugees with post-traumatic stress disorder, or those who experienced ambiguous loss. Older adults were underrepresented in these studies, which had small sample sizes and focused primarily on inter-relational factors. Therefore, their effectiveness in predicting outcomes for this highly vulnerable group, which faces distinct circumstances, may be constrained due to their development based on incomparable samples and contexts. Furthermore, none were developed during the COVID-19 pandemic. Overall, the search highlighted the need for research into the specific vulnerabilities and risk factors for mental health faced by the community of older Syrian refugees in Lebanon, as the existing models do not appear to be applicable to this group. Added value of this studyThe study developed a prognostic model to predict the risk of poor mental health amongst older Syrian refugees in Lebanon during the COVID-19 pandemic, using predictors that covered economic, social and health factors. Data were collected using a multi-wave panel study. Most participants had poor mental health that increased over the course of the study. Younger age, food insecurity, water insecurity, lack of legal status documentation, irregular employment, higher intensity of bodily pain, having debt, and having multiple chronic illnesses were predictors of poor mental health. These findings are consistent with previous literature on associations between these vulnerabilities and poor mental health amongst refugees. Implications of all the available evidenceThe study provides evidence that the population of older Syrian refugees in Lebanon faces multiple vulnerabilities and were largely at risk for poor mental health, which increased during the COVID-19 pandemic. Vulnerabilities identified in this study as predictors of poor mental health indicate that it will be necessary to engage with humanitarian sectors outside of health such as food assistance, water, sanitation and hygiene (WASH) and legal assistance programs in order to support mental health in older Syrian refugees.

Predictors and barriers to vaccination among older Syrian refugees in Lebanon: a multi-wave survey (preprint)

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.

Predicting intention to vaccinate against COVID-19 in older Syrian refugees in Lebanon: findings from a multi-wave study (preprint)

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.

Too much to mask: determinants of sustained adherence to COVID-19 preventive measures among older Syrian refugees in Lebanon (preprint)

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.