Development of Prediction Models of COVID-19 Vaccine Uptake among Lebanese and Syrians in a district of Beirut, Lebanon: a population-based study (preprint)

ImportanceVaccines are essential to prevent infection and reduce morbidity of infectious diseases, and vulnerable populations may lack access to vaccination campaigns. Previous evidence has shown that migrants and refugees are particularly vulnerable to exclusion, stigma and discrimination, and low COVID-19 vaccine intention and uptake were observed among refugees globally. ObjectiveTo develop and internally validate prediction models of COVID-19 vaccine uptake by nationality. DesignThis is a nested prognostic population-based cross-sectional analysis. SettingData was collected between June and October 2022 in Sin-El-Fil, a district of Beirut, Lebanon. ParticipantsAll Syrian adults and a random sample of other adults from low-socioeconomic status neighborhoods were invited to participate in the study (n=3,138). A telephone survey with consenting participants (n=2,045) was conducted. ExposuresCandidate predictors of COVID-19 vaccine uptake identified from the literature were collected. Main Outcome and MeasuresThe main outcome was uptake of COVID-19 vaccine. Predictors of COVID-19 vaccine uptake were assessed using LASSO regression for Lebanese and Syrian nationalities, respectively. The models discrimination capabilities are presented using the AUC, and their calibration are presented using the calibration slopes. ResultsOf 2,045 participants, 79% were Lebanese, 18% Syrians and 3% of other nationalities. COVID-19 vaccination uptake was higher among Lebanese (85% (95%CI:82-86) compared to Syrians (47% (95% CI:43-51)) (P<0.001); adjusted odds ratio (aOR) 6.8 (95%CI:5.5-8.4). Predictors of uptake of one or more vaccine dose for Lebanese were older age, presence of an older adult in the household, higher education, greater asset-based wealth index, private healthcare coverage, feeling susceptible to COVID-19, belief in the safety and efficacy of vaccines and previous receipt of flu vaccine. For Syrians they were older age, male, completing school or higher education, receipt of cash assistance, presence of comorbidities, belief in the safety and efficacy of vaccines, previous receipt of flu vaccine, and legal residency status in Lebanon. Conclusions and RelevanceThese findings indicate barriers for vaccine uptake in Syrian migrants and refugees, including legal residency status. They call for urgent action to enable equitable access to vaccines by raising awareness about the importance of vaccination and the targeting of migrant and refugee populations through vaccination campaigns. FundingInternational Development Research Centre (IDRC) - Canada Key PointsO_ST_ABSQuestionC_ST_ABSWhat are the context-specific differential predictors of vaccine uptake among the resident population by nationality in Lebanon? FindingsThis is a nested population-based cross-sectional analysis that examined predictors of COVID-19 vaccine uptake among Lebanese and Syrians living in low-socioeconomic neighborhoods in 2022. Socioeconomic, demographic and health risk perceptions were identified for both Syrians and Lebanese, while additional barriers identified in Syrian refugees included legal residency status in the country. MeaningDespite the availability of vaccines to all residents, there were inequalities in vaccine uptake between Syrians and Lebanese which need to be addressed.

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.

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.

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.