Predicting COVID-19 Infection Among Older Syrian Refugees in Lebanon: A Multi-Wave Survey (preprint)

BackgroundOlder refugees, exposed to a cluster of biological and social vulnerabilities, are more susceptible to COVID-19 infection and its complications. This study developed and internally validated a predictive model estimating COVID-19 infection risk among older Syrian refugees in Lebanon. Additionally, it described the barriers to PCR testing among those who reported a COVID-19 infection. MethodsThis was a cross-sectional analysis of a five-wave longitudinal study conducted between September 2020 and March 2022. Syrian refugees aged 50 years or older living in households that received assistance from a humanitarian organization were interviewed by phone. Self-reported COVID-19 infection was the outcome of interest. The predictors were identified using adaptive LASSO regression. The model performance and discrimination were presented using the calibration slope and the Area Under the Curve. FindingsOf 2,886 participants (median [IQR] age: 56[52-62]; 52.9% males), 283 individuals (9.8%) reported a COVID-19 infection at least once. Six predictors for COVID-19 infection were identified: living outside informal tented settlements, having elementary and preparatory education or above, having chronic conditions, not receiving cash assistance, being water insecure and having unmet waste management needs. The model had moderate discrimination and good calibration. Nearly half of the cases were diagnosed through PCR testing. The main reasons for not testing were perception that the tests were unnecessary (n=91[63.6%]) or inability to afford them (n=46[32.2%]). InterpretationHigh-risk individuals should be targeted based on predictive models incorporating social determinants. Implementing awareness campaigns, screening measures, and cash assistance may reduce vulnerability in future pandemics. FundingELRHAs Research for Health in Humanitarian Crisis Programme and AUB University Research Board. Research in contextO_ST_ABSEvidence before the studyC_ST_ABSA literature search was conducted in the databases PubMed and Google Scholar for studies published between February 1, 2020, and June 14, 2022, with the objective of developing a predictive model or examining the associated factors of COVID-19 infection among older adults or refugees. Different combinations of the following keywords were used in our research: "COVID-19 infection", "SARS-CoV-2", "Coronavirus", "predictors", "risk factors", "refugees", "migrants", and "Syrian". Previous evidence has shown that displaced populations are considered vulnerable groups highly susceptible to the impacts of COVID-19, due to their exposure to a combination of biological and psychosocial vulnerabilities. In Lebanon, Syrian refugees face an elevated risk of infection and its complications, mainly due to the deterioration of their living conditions resulting from the multiple crises burdening the country. The literature search featured the following potential predictors: age, gender, educational attainment, marital status, housing conditions, socioeconomic status, and presence of chronic illnesses. However, to date, no studies have developed predictive models of COVID-19 infection focusing on Syrian refugees in the MENA region. Additionally, there has been a scarcity of predictive models incorporating social determinants to assess the risk of infection among refugees or older adults in this context. Hence, identifying individuals who are highly susceptible to COVID-19 infection and its severity amongst vulnerable populations is important to inform better targeting of assistance in future outbreaks and to reduce the risk of infection and its complications. Added value of the studyTo the best of our knowledge, this is the first study that exclusively incorporates social determinants into a prediction model of COVID-19 infection among older Syrian refugees. Out of 2,886 participants, 283 individuals (9.8%) reported experiencing COVID-19 infection at least once. Six predictors of COVID-19 infection among older Syrian refugees were identified: living outside informal tented settlements, having elementary and preparatory education or above, having chronic conditions, not receiving cash assistance, being water insecure and having unmet waste management needs. Despite the efforts and the collaboration between UNHCR, several NGOs and the Lebanese Ministry of Public Health to cover the cost of COVID-19 testing and to raise awareness about COVID-19 symptoms and the necessity of testing, only half of the cases were diagnosed through PCR or lateral flow tests. The main reasons for not testing were perceptions that it was unnecessary or inability to afford the tests. Implications of all the available evidenceThe predictors identified in this study could be used to inform targeting efforts by humanitarian organizations to provide assistance to Syrian refugees at higher risk of COVID-19 infection or infections in future pandemics. In addition, it will be important for humanitarian organisations to continue outreach efforts outside of informal tented settlements into the community to reach the most vulnerable to COVID infection with interventions. Furthermore, intensifying awareness campaigns among Syrian refugees about testing availability and the importance of visiting a healthcare professional, and considering the implementation of free testing in primary healthcare centers and pharmacies will be essential to control infectious diseases in future pandemics.

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.

Predictors and barriers for the management of non-communicable diseases among older Syrian refugees amidst the COVID-19 pandemic in Lebanon: A cross-sectional analysis of a multi-wave survey (preprint)

Importance: Older Syrian refugees have a high burden of non-communicable diseases and economic vulnerability. Objective: This study aimed to develop and internally validate a predictive model of the inability to manage non-communicable diseases (NCDs) in older Syrian refugees, and to describe barriers to adherence to NCD medication. Design: A nested cross-sectional study within a longitudinal study. Setting: Lebanon. Population: Syrian refugees aged 50 years or older residing in Lebanon who self-reported having hypertension, diabetes, history of cardiovascular disease (CVD) or chronic respiratory disease (CRD). Methods: All households with refugees aged 50 years or older who received humanitarian assistance from a non-governmental organization were invited to participate in a study examining the impact of COVID-19 on older Syrian refugees. Data were collected through telephone surveys between September 2020 and January 2021. The study outcome was self-reported inability to manage hypertension, diabetes, CVD or CRD. Predictors of inability to manage any NCD were assessed using a logistic regression models. The model was internally validated using bootstrapping techniques, which gave an estimate of optimism. The optimism-adjusted discrimination and calibration of the model were presented using C-statistic and calibration slope (C-slope), respectively. Results: Out of 3,222 older Syrian refugees, 1,893 reported having at least one NCD including 43% who had hypertension, 24% diabetes, 24% history of CVD, and 11% CRD. There were 387 (20%) participants who were unable to manage at least one of their NCDs. Predictors for inability to manage NCDs were age, non-receipt of cash assistance, household water insecurity, household food insecurity, and having multiple chronic diseases. The adjusted C-statistic was 0.65 (95%CI:0.62-0.67) and C-slope was 0.88 (95%CI:0.73-1.03). The prevalence of non-adherence to medication was 9% and the main reasons were unaffordability of medication (41%) and the belief that they no longer required the medication after feeling better (22%). Conclusions: This study identified that the predictors of inability to manage NCDs among older Syrian refugees in Lebanon are mainly related to financial barriers, which aids the targeting of assistance and interventions. Context-appropriate assistance is required to overcome financial barriers and enable equitable access to medication and healthcare.