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.

Help-seeking behaviour in women diagnosed with gynaecological cancer: a systematic review.

BACKGROUND: Identifying what prompts or hinders women's help-seeking behaviour is essential to ensure timely diagnosis and management of gynaecological cancers. AIM: To understand the factors that influence the help- seeking behaviour of women diagnosed with gynaecological cancer. DESIGN AND SETTING: Systematic review and narrative synthesis of studies from high-income settings worldwide. METHOD: Five databases were searched for studies, of any design, that presented factors related to the help-seeking behaviour of women diagnosed with a gynaecological cancer. Data from the articles were extracted and presented using narrative synthesis, which was both inductive and deductive. The COM-B (capability, opportunity, motivation, behaviour) model of behaviour change was used as a framework. RESULTS: In total, 21 studies were included in the review. Inductive synthesis presented three main themes of factors related to the help-seeking behaviour of women diagnosed with gynaecological cancer: patient factors, such as knowledge of symptoms; emotional factors, including previous healthcare experience, embarrassment, and trust; and practical factors, including time and resources. Deductive synthesis demonstrated that capability (namely, symptom knowledge), opportunity (having the required time and overcoming the cultural taboos surrounding gynaecological symptoms), and motivation (believing that seeking help is beneficial) are all required to initiate help-seeking behaviour. CONCLUSION: Although it is a journey of defined steps, the help- seeking behaviour of women with symptoms diagnosed with gynaecological cancer is influenced by personal and societal factors. Interventions to improve help seeking will need to address the specific identified factors, as well as capability, opportunity, and motivation.

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.

COVID-19 vaccine acceptance in older Syrian refugees: Preliminary findings from an ongoing study.

This study assesses COVID-19 vaccine intentions among a sample of older Syrian refugee beneficiaries of a humanitarian organization in Lebanon, and explores factors associated with vaccine refusal. The findings are part of an ongoing rotating 4-wave panel study. The sample was limited to participants from the first panel who completed a phone interview between January-February 2021. Out of 1,037 beneficiaries, almost a third (29%) reported no intention to vaccinate. Reasons for refusal were: newness of the vaccine (35%); preference to maintain precaution measures (21%); belief that the COVID-19 vaccine is not essential (21%); and other (23%). COVID-19 vaccine refusal was significantly associated with perceptions regarding vaccine safety (OR: 5.97; 95%CI: 4.03-8.84) and effectiveness (OR: 6.80; 95%CI:4.44-10.42) but did not differ by age, presence of chronic conditions, self-reported adherence to COVID-19 measures, and perceptions of susceptibility to and severity of COVID-19. Addressing vaccine hesitancy among Syrian refugees in Lebanon necessitates disseminating accurate, accessible, and culturally appropriate information about vaccine safety and effectiveness.

Vulnerability of Syrian refugees in Lebanon to COVID-19: quantitative insights.

Lebanon, a middle-income country with ongoing political turmoil, unstable economic situation, and a fragmented and under-resourced health system, hosts about one million Syrian refugees since 2011. While the country is currently experiencing substantial COVID-19 epidemic spread, no outbreaks have been reported yet among Syrian refugees. However, testing of this population remains limited and exposure levels are high given dire living conditions and close interaction with the host community. Here, we use quantitative insights of transmission dynamics to outline risk and contextual factors that may modulate vulnerability of Syrian refugees in Lebanon to potentially large COVID-19 epidemics.Syrian refugees live in close contact with the host community, and their living conditions are favorable for epidemic spread. We found that the high levels of crowding within Syrian refugee households and among those in informal tented settlements, the inadequate water supply and sanitation, limited use of masks, inadequate access to health care, and inadequate community awareness levels are vulnerability factors that directly impact important parameters of transmission dynamics, leading to larger epidemic scale. Poverty, stigma, and fear of legal consequences are contextual factors that further exacerbate this vulnerability. The relatively high prevalence of non-communicable diseases in this population could also affect the severity of the disease among those infected. Mathematical modeling simulations we conducted illustrated that even modest increases in transmission among Syrian refugees could result in a large increase in the incidence and cumulative total number of infections in the absence of interventions.In conclusion, while the young age structure of the Syrian refugee population might play a protective role against the scale and disease-burden severity of a potential COVID-19 epidemic, the epidemic potential due to several vulnerability factors warrants an immediate response in this population group. Local and international actors are required to mobilize and coordinate efforts to prevent the transmission of COVID-19, and to mitigate its impact amongst the vulnerable refugee populations globally.