Investigating Incidence, Correlates, and Consequences of Child Marriage Among Syrian Refugees Residing in the South of Lebanon: A Cross-Sectional Study.

PURPOSE: Research on child marriage has increased in volume but remains scarce in humanitarian settings. This study aimed to investigate rates, correlates, and consequences of child marriage among Syrian refugees in South Lebanon. METHODS: A sample of 1,593 female adolescents and 893 adults was selected using a multistage stratified cluster survey design. We quantified the cumulative incidence of child marriage among age cohorts of female refugees and identified risk factors associated with child marriage using survival methods. We also presented sexual and reproductive health measures among child brides. RESULTS: We found evidence that child marriage was widely practiced among adolescent girls, with Kaplan-Meier curves showing that 32.56% of girls aged 10-19 transitioned to marriage by age 17. Although high, this was lower than rates among women aged 25-29 (p < .005), indicating that child marriage was already widely practiced in prewar Syria. Our Cox models indicated that several factors, which mirror drivers of child marriage in stable settings, are associated with hazard of child marriage in this context. We additionally found important sexual and reproductive health gaps among child brides, such as low levels of knowledge of the dangers of early childbearing and closely spaced births as well as high rates of early and multiple births. CONCLUSIONS: Child marriage is a pervasive practice among Syrian refugees residing in this setting. Our results suggest that a confluence of factors at different levels of the social ecology increase refugee girls' vulnerability to child marriage. They also demonstrate the pressing need for interventions that target refugee child brides.

Multi-purpose cash transfers and health among vulnerable Syrian refugees in Lebanon: a prospective cohort study.

BACKGROUND: Multipurpose cash transfers (MPCs) are used on a widespread basis in the Syrian refugee response; however, there is little to no evidence as to how they affect health in humanitarian crises. METHODS: A prospective cohort study was conducted from May 2018 through July 2019 to evaluate the impact of MPCs on health care-seeking and expenditures for child, adult acute, and adult chronic illness by Syrian refugees in Lebanon. Households receiving MPCs from UNHCR were compared to control households not receiving UNHCR MPCs. RESULTS: Care-seeking for childhood illness was consistently high in both MPC and non-MPC households. An increased proportion of households did not receive all recommended care due to cost; this increase was 19.3% greater among MPC recipients than controls (P = 0.002). Increases in child hospitalizations were significantly smaller among MPC recipients than controls (DiD -6.1%; P = 0.037). For adult acute illnesses, care-seeking increased among MPC recipients but decreased in controls (adjusted DiD 11.3%; P = 0.057); differences in change for other utilization outcomes were not significant. The adjusted difference in change in the proportion of MPC households not receiving recommended chronic illness care due to cost compared to controls was - 28.2% (P = 0.073). Access to medication for adult chronic illness also marginally significantly improved for MPC households relative to controls. The proportion of MPC recipients reporting expenses for the most recent child and adult acute illness increased significantly, as did the [log] total visit cost. Both MPC and control households reported significant increases in borrowing to pay for health expenses over the year study period, but differences in change in borrowing or asset sales were not significant, indicating that MPC was not protective against for household financial risks associated with health. CONCLUSIONS: While MPC may have shown some positive effects, findings were mixed and MPC appears insufficient on its own to address health utilization and expenditures. A broader strategy addressing Syrian refugee health in Lebanon is needed of which MPC should be incorporated, with additional support such as additional conditional cash transfers for health.

A cross-sectional survey on community pharmacists readiness to fight COVID-19 in a developing country: knowledge, attitude, and practice in Lebanon.

BACKGROUND: Lebanon, a developing Middle Eastern country, was hit by the COVID-19 pandemic that occurred amid a severe national economic crisis. Community pharmacists are responsible for dispensing appropriate medications and products in addition to counseling, informing and educating the public, and promoting disease prevention and infection control. OBJECTIVE: This study aimed to assess community pharmacists' knowledge, attitude, and practice towards the COVID-19 pandemic and evaluate behavior changes and safety measures. METHODS: An anonymous and standardized online questionnaire in English was disseminated via social media platforms to Lebanese community pharmacists. The questionnaire consisted of 95 items designed as Likert-scales and multiple-choice questions divided into four different sections: socio-demographic characteristics, knowledge-based, attitude-based, and pharmacy practice questions. Descriptive statistical analysis was used to summarize the demographic characteristics, and indices were created for knowledge, attitude, and practice by computing the correct answers for each section. RESULTS: A total of 310 questionnaires were completed. Around 61% have expressed their fear of getting infected with COVID-19 due to occupational exposure. The respondents were able to answer 80-90% of the knowledge-based questions of the survey. A more careful/anxious attitude, but not knowledge, was associated with overall better practice (p = 0.03). Also, respondents stated that they are dispensing protective equipment items such as masks (87%), gloves (60%), and sanitizers (77%) in small quantities due to limited availability. CONCLUSION: Our findings revealed an adequate level of knowledge and good practice towards COVID-19 among Lebanese community pharmacists. Their fears of contracting the virus and compromising the safety of those around them are justified. However, their supply of protective equipment is limited.

Assessment of the awareness and usages of family planning methods in the Lebanese community.

BACKGROUND: Worldwide, one in three women has unmet family planning (FP) needs because of difficulties in accessing or using contraceptives. In Lebanon, information from the scientific literature on the national prevalence of contraceptive use appears scarce. OBJECTIVE: In view of this, we measured the current Lebanese national prevalence of FP methods' uptake among women and men of reproductive age, and we assessed barriers for potential unmet need. METHODS: We conducted a cross-sectional survey on a nationally representative sample of 825 married women (aged 15-49 years) and men of reproductive age (aged 18+ years). We used the validated Demographic & Health Survey (DHS) data collection tool and analysed data with SPSS Version 22.0 with p values <0.05 considered statistically significant. RESULTS: We found that the current prevalence of contraceptive use is 55.6%, the unmet need is 11.4%, the total demand for FP is 67% and the percentage of satisfied demand for FP is 83%. Despite favourable knowledge of and access to FP methods as well as positive attitudes towards FP; there is a clear stagnation in the rate of contraception use over the past four decades. The identified major factors hindering the use of FP methods in Lebanon appear to be religion, age and lower educational levels. CONCLUSION: We suggest the implementation of effective interventions at the national level to promote and encourage the uptake of modern FP methods among couples. The latter will further promote maternal and child health, as well as empower women to fulfil their equal function in society.

Prevalence, Correlates and Management of Hyperglycemia in Diabetic Non-critically Ill Patients at a Tertiary Care Center in Lebanon.

BACKGROUND: Diabetes Mellitus is a chronic metabolic disease that affects 387 million people around the world. Episodes of hyperglycemia in hospitalized diabetic patients are associated with poor clinical outcomes and increased morbidity and mortality. Therefore, prevention of hyperglycemia is critical to decrease the length of hospital stay and to reduce complications and readmissions. OBJECTIVE: The study aims to examine the prevalence of hyperglycemia and assess the correlates and management of hyperglycemia in diabetic non-critically ill patients. METHODS: The study was conducted on the medical wards of a tertiary care teaching hospital in Lebanon. A retrospective chart review was conducted from January 2014 until September 2015. Diabetic patients admitted to Internal Medicine floors were identified. Descriptive analysis was first carried out, followed by a multivariable analysis to study the correlates of hyperglycemia occurrence. RESULTS: A total of 235 medical charts were reviewed. Seventy percent of participants suffered from hyperglycemia during their hospital stay. The identified significant positive correlates for inpatient hyperglycemia, were the use of insulin sliding scale alone (OR=16.438 ± 6.765-39.941, p=0.001) and the low frequency of glucose monitoring. Measuring glucose every 8 hours (OR= 3.583 ± 1.506-8.524, p=0.004) and/or every 12 hours (OR=7.647 ± 0.704-79.231, p=0.0095) was associated with hyperglycemia. The major factor perceived by nurses as a barrier to successful hyperglycemia management was the lack of knowledge about appropriate insulin use (87.5%). CONCLUSION: Considerable mismanagement of hyperglycemia in diabetic non-critically ill patients exists; indicating a compelling need for the development and implementation of protocol-driven insulin order forms a comprehensive education plan on the appropriate use of insulin.

Prospective evaluation of vancomycin therapeutic usage and trough levels monitoring.

INTRODUCTION: Vancomycin is the cornerstone of parenteral therapy for serious methicillin resistant Staphylococcus aureus infections. Optimal dosing of vancomycin is patient specific due to its narrow therapeutic window. The objective of this study is to evaluate the appropriate use of vancomycin focusing on the indication, dose, and therapeutic level monitoring. METHODOLOGY: A prospective observational study was conducted in a tertiary care hospital over a 3- month period. A data collection form was used to gather information on 93 patients receiving vancomycin. Study outcomes were assessment of the appropriateness of vancomycin indication, dose, and therapeutic trough level. RESULTS: The use of vancomycin both empirically and after culture results was appropriate in 78.5 % of the patients. More than half of the patients (51.6 %) were given an inappropriate dose of vancomycin per actual body weight, creatinine clearance, and  indication. Regarding therapeutic vancomycin monitoring, 69.0 % had inappropriate trough level monitoring. Only 15.7 % of the 166 measured troughs were within the target therapeutic level for the corresponding indication. CONCLUSION: This study demonstrates the high level of inappropriate use of vancomycin. This is mainly attributed to inappropriate dose and trough level monitoring. Interventions to improve vancomycin prescribing and monitoring practices are needed. The presence of an interdisciplinary team may improve the appropriate use of medications with a narrow therapeutic index such as vancomycin.

Misconceptions and Malpractices Toward Antibiotic Use in Childhood Upper Respiratory Tract Infections Among a Cohort of Lebanese Parents.

Antimicrobial resistance is an emerging global health threat. Misuse and abuse of antibiotics are of particular concern in the pediatric population. Since management of childhood illnesses depends considerably on parents' perceptions, the objectives of this study were to report parents' perspectives and assess their practices toward antibiotics used for upper respiratory tract infections (URTIs) in children. Using a cross-sectional design, anonymous structured questionnaires were completed by 1,037 parents in public and private schools across Lebanon's largest governorate. Descriptive statistics were used to report participants' responses. A multivariate analysis was performed to identify factors affecting knowledge and malpractice related to antibiotic use. Significant misconceptions and malpractices were identified among parents. For instance, 33.9% of parents considered that antibiotics are helpful in treating common cold among children and 36.2% believed antibiotics expedite the recovery of their child with common cold infection. Moreover, there was a lack of knowledge concerning antibiotic coverage, since 37.9% of the respondents believed that antibiotics treat viral infections and 21.5% were neutral toward this question. Around 20% of the participants believed they can reduce the dose of antibiotics if the child gets better. Significant factors associated with poor knowledge and misuses were parents' lower educational and socioeconomic levels. Despite extensive evidence on the limited role of antibiotics in URTIs, parents in Lebanon continue to misuse them. More concerted efforts are needed to improve parents' knowledge and practices with regard to the rational use of antibiotics.

Prescription patterns of benzodiazepines in the Lebanese adult population: a cross-sectional study.

This study assessed the profile of benzodiazepine (BDZ) users in Lebanon. Adult patients visiting the pharmacies with prescriptions of BDZs were included in the study. Seven hundred and eighty-six current BDZ users were included, of whom 54.2% were females. Twenty-three percent reported being alcohol consumers and were mostly males. The two most commonly used BDZs were alprazolam (34.6%) and bromazepam (33.6%). The indication for use was mainly anxiety (44.4%), insomnia (22.5%), and depression (15.9%). The prescribing physicians were primarily psychiatrists (43.2%), followed by general practitioners (29.7%). Forty percent had been taking the drug for more than a year. Among those using BDZs for at least 1 month, 35.5% increased the dose with time. Thirty-three percent reported having experienced side effects. Eighteen patients (2.3%) reported taking more than one BDZ concomitantly, while 18.3% were taking drugs that should not be prescribed along with BDZs. In conclusion, the use of BDZs is highest among females, especially for the treatment of anxiety. Moreover, continuous use of the drugs for more than a year as well as significant potential drug interactions was identified.

Herbal Products and Dietary Supplements: A Cross-Sectional Survey of Use, Attitudes, and Knowledge Among the Lebanese Population.

There has been a marked increase in use of herbal products and dietary supplements (HP/DS) in many developed and developing countries. However, data about consumption patterns and awareness about these products in the Lebanese population is scarce. The present study aimed to examine the determinants of HP/DS use in Lebanese adults, identify potential interactions and safety concerns and assess the knowledge and attitudes of consumers towards the efficacy and safety of these products. A face-to-face, 28-item survey was administered to Lebanese adults (n = 726) in community pharmacies across the country. Thirty-five percent of participants reported to be currently consuming at least one HP/DS including 23 % who were consuming vitamins and/or mineral supplements and 18 % consuming herbal products. Significant safety concerns were identified among consumers in the form of disease-supplement, drug-supplement as well as supplement-supplement interactions. Logistic multivariate regression analysis indicated that use of supplements was positively associated with the female gender and increasing age. The majority of respondents falsely believed that HP/DS pose no risk to the general population and that they must be safe to be sold in Lebanon. Moreover, most participants were consuming these products based on recommendations from friends or relatives rather than from healthcare professionals. Substantial misconceptions about HP/DS exist among Lebanese adults, indicating a need for consumers' education from professional and reliable sources on the efficacy and safety of such products.

Influenza Vaccination: A Cross-Sectional Survey of Knowledge, Attitude and Practices among the Lebanese Adult Population.

BACKGROUND: Influenza is a common preventable infectious disease associated with high mortality and morbidity. Vaccination is the most cost-effective measure to prevent influenza, yet the vaccine uptake is known to be low. No previous studies have assessed the rate of seasonal influenza vaccination use among the Lebanese population, nor examined the knowledge and attitudes towards the influenza vaccine. METHODS: A cross-sectional survey was performed in 30 pharmacies randomly selected across Lebanon. A 19-item questionnaire was used to record influenza vaccination status, knowledge and attitudes towards the influenza vaccine among the Lebanese general population. RESULTS: The survey response rate was 93%. Among the 640 study participants, the overall 2014-2015 seasonal influenza vaccination rate was 27.6%. The majority of participants (72.4%) reported irregular uptake of the vaccine. Results of the multivariate analysis revealed that elderly people (OR = 2.25, CI = 1.08-4.71), with higher education (OR = 1.42, CI = 1.09-1.84), higher physical activity (OR significantly higher than 1 for all categories), and chronic respiratory disease (OR = 3.24, CI = 1.58-6.62) were more regularly vaccinated, while those who visit the doctor "only when needed" (OR = 0.55, CI = 0.34-0.88) and those who consume more than seven drinks/week (OR = 0.24, CI = 0.09-0.65) were less regularly vaccinated. When introducing knowledge and attitude variables to the model, "thinking that the vaccine was not needed" was the only correlate that demonstrated a significant inverse association with regular influenza vaccination (OR = 0.15; p = 0.017). CONCLUSIONS: Suboptimal vaccination rates exist among the Lebanese ambulatory adult population. Clear misinformation on the importance of regular influenza immunization is also highlighted. This evidence underscores a compelling need to raise public awareness regarding the efficacy of the influenza vaccine.

Combined bronchodilators (tiotropium plus olodaterol) for patients with chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD), a respiratory disease characterized by a progressive decline in lung function, is considered to be a leading cause of morbidity and mortality. Long-acting inhaled bronchodilators, such as long-acting ß2 agonists (LABAs) or long-acting muscarinic antagonists (LAMAs), are the cornerstone of maintenance therapy for patients with moderate-to-very-severe COPD. For patients not sufficiently controlled on a single long-acting bronchodilator, a combination of different bronchodilators has shown a significant increase in lung function. Tiotropium, a once-daily dosing LAMA, demonstrated sustained improvements in lung function as well as improved health-related quality of life, reduced exacerbations, and increased survival without altering the rate of decline in the mean forced expiratory volume in 1 second (FEV1) with fairly tolerable side effects. Olodaterol is a once-daily dosing LABA that has proven to be effective in improving lung function, reducing rescue medication use, and improving dyspnea and health-related quality of life, as well as improving exercise endurance with an acceptable safety profile. The combination of olodaterol and tiotropium provided additional improvements in lung function greater than monotherapy with each drug alone. Several well-designed randomized trials confirmed that the synergistic effect of both drugs in combination was able to improve lung function and health-related quality of life without a significant increase in adverse effects. The objective of this paper is to review available evidence on the clinical efficacy and safety of tiotropium, olodaterol, and their combination in patients with COPD.