Syrian Refugees In Lebanon Research Articles

Refugee Networks, Cooperation, and Resource Access

Without formal avenues for claims-making or political participation, refugees must find their own means of securing services from state and non-state providers. This article asks why some refugee communities are more effective than others in mitigating community problems. I present a framework for understanding how refugees’ social networks shape the constraints and capabilities for collective action. I analyze a field experiment where I organized community meetings with Syrian refugees in Lebanon and Jordan, randomly assigning the recruitment method for meetings to introduce exogenous variation in network structure. During meetings, participants were tasked with resolving collective action problems. I examine the dynamics of subsequent group discussion. Results show that although densely networked refugee groups exhibit more cooperation, they suffer from a resource diversity disadvantage. Group diversity facilitates access to resources that may help refugee communities confront community problems. The novel experimental design allows for separately identifying group-level and individual-level mechanisms.

Evaluation of a digital intervention for depression among Lebanese&Syrian refugees in Lebanon

Abstract Background Lebanon is a low-to-middle-income country, hosting more than 1.1 million Syrian refugees, with 90% mental health treatment gap. The National Mental Health Programme (NMHP) in Lebanon along with the World Health Organization (WHO) launched the Step-by-Step (SbS) e-mental health intervention for adults with depression. Step-by-Step is a 5-sessions, self-help, minimally guided digital program for adults with depression. Two Randomized Controlled Trials (RCTs) assessed its effectiveness and cost-effectiveness in the local setting. Methods Participants (n = 569 Syr, n = 680 Leb) were recruited online and randomly allocated to Step-by-Step (n = 283 Syr, n = 331), or Enhanced Care as Usual (n = 286 Syr, n = 349). The ECAU group received one-page psychoeducation and a referral list to services. Online assessments were administered at baseline, post-assessments at eight weeks after enrolment, and follow-up assessments at 20 weeks after enrolment. Primary outcomes were the Patient Health Questionnaire-9 and World Health Organization Disability Assessment Scale 2.0 scores at all post-assessments. Results Intention-to-treat analyses showed significant effects on depression scores (standardized mean differences, SMD: 0.71; 95% CI: 0.45 to 0.97 for Lebanese, and SMD: 0.48; 95% CI: 0.26; 0.70 for Syrians). Significant results were maintained on all secondary outcomes and at follow-up assessments. Conclusions SbS proved effective for depressive and functionality symptoms. Subsequently, it was adopted by MoPH as an official, free-of-charge, and first-line service for depression. A global version of SbS is currently being developed by WHO to be replicated and used in several settings worldwide. Key messages • This landmark study provided unique evidence on the effectiveness of guided-e-mental health interventions for the Lebanese and Syrian refugees affected by adversity in Lebanon. • This study guided the scaled-up of SbS into a widely accessible service among the general population.

Fungal Exposure and Shelter Assessment in Syrian Refugee Settlements in Lebanon

Over 1 million Syrian refugees have fled war to seek asylum in Lebanon. The population has been placed in substandard conditions which could lead to adverse health effects, particularly in vulnerable subgroups, notably due to evident chronic dampness and inadequate ventilation potentially leading to indoor mold growth. To investigate whether the types and conditions of Syrian refugee shelters influence indoor mold populations, a cross-sectional indoor environmental study was performed in 4 provinces of Lebanon. Accordingly, a total of 80 refugee households and 20 host population households (baseline) were selected. Mold air sampling and moisture measurements of shelter material were performed in residential, non-residential, and non-permanent shelters. Results revealed that although non-residential shelters had the highest mean total indoor count (1112 CFU/m3), Aspergillus, Stachybotrys, and Penicillium spp. were strongly associated with non-permanent shelters (p < 0.001). Additionally, occupancy was found to be strongly associated with Cladosporium (p < 0.05), Ulocladium (p < 0.05), and Stachybotrys spp. (p < 0.001). As for shelter conditions, the highest total indoor count (1243 CFU/m3) was reported in unfinished structures. These findings suggest that shelter category, condition and occupancy significantly influence indoor mold concentrations, increasing respiratory health risks for Syrian refugees in Lebanon.

Evaluation of the Early Adolescent Skills for Emotions (EASE) intervention in Lebanon: A randomized controlled trial

BackgroundThere is a need for scalable evidence-based psychological interventions for young adolescents experiencing high levels of psychological distress in humanitarian settings and low- and middle-income countries. Poor mental health during adolescence presents a serious public health concern as it is a known predictor of persistent mental disorders in adulthood. This study evaluates the effectiveness of a new group-based intervention developed by the World Health Organization (Early Adolescent Skills for Emotions; EASE), implemented by non-specialists, to reduce young adolescents' psychological distress among mostly Syrian refugees in Lebanon. MethodsWe conducted a two-arm, single-blind, individually randomized group treatment trial. Adolescents aged 10 to 14 years who screened positive for psychological distress using the Pediatric Symptom Checklist (PSC) were randomly allocated to EASE or enhanced treatment as usual (ETAU) (1:1.6). ETAU consisted of a single scripted psycho-education home-visit session with the adolescent and their caregivers. EASE consists of seven group sessions with adolescents and three sessions with caregivers. The primary outcome was adolescent-reported psychological distress as measured with the PSC (internalizing, externalizing, and attentional symptoms). Secondary outcomes included depression, posttraumatic stress, well-being, functioning, and caregivers' parenting and distress. All outcomes were assessed at baseline, endline, and 3 months (primary time point) and 12 months follow-up. ResultsDue to the COVID-19 pandemic and other adversities in Lebanon at the time of this research, the study was prematurely terminated, resulting in an under-powered trial sample (n = 198 enrolled compared to n = 445 targeted). We screened 604 children for eligibility. The 198 enrolled adolescents were assigned to EASE (n = 80) and ETAU (n = 118), with retention rates between 76.1 and 88.4% across all timepoints. Intent-to-treat analyses demonstrated no between-group differences on any of the outcome measures between the EASE and ETAU. We did observe a significant improvement on the primary outcome equally in the EASE and ETAU groups (−0.90, 95% CI: −3.6, 1.8; p = .52), − a trend that was sustained at three months follow-up. Sub-group analyses, for those with higher depression symptoms at baseline, showed ETAU outperformed EASE on reducing depression symptoms (difference in mean change = 2.7, 95% CI: 0.1, 5.3; p = .04; d = 0.59) and internalizing problems (difference in mean change 1.0, 95% CI: 0.08, 1.9; p = .03; d = 0.56) . ConclusionNo conclusions can be drawn about the comparative effectiveness of the intervention given that the sample was underpowered as a result of early termination. Both EASE and single session psycho-education home visits resulted in meaningful improvements in reducing psychological distress. We did not identify any indications in the data suggesting that EASE was more effective than a single session family intervention in the context of the COVID-19 pandemic and other crises in Lebanon. Fully powered research is needed to evaluate the effectiveness of EASE.

A Self-reflexive Positionality to Navigate the Invective Latency of Ethnographic Relations: Insights From Lebanon and Germany

Positionality has become increasingly important in ethnographic and autoethnographic research. The recent “reflexive turn” in migration studies has encouraged scholars to discuss the concept from different perspectives (e.g., gender, ethnicity, and class). Yet, positionality is relational: It is the result of ongoing interactions between how researchers present themselves in the field and how research participants perceive these presentations. Because self-positioning and positioning of others are mutually bound to each other, positionality reflects a continuous negotiation between actors who may be motivated by different interests. For this reason, it is necessary for researchers to analytically reflect upon the implications of these mutual positionings to more fully understand how to navigate research fields. This is especially important for sensitive research fields—like migration and forced migration—characterized by inequalities, hierarchical structures, and unequal power relations. The present article uses insights from fieldwork conducted among Syrian refugees in Lebanon and Germany between 2017 and 2019 to show how configurations of “humanitarian paternalism” and researchers’ false expectations to save the world can frame positionality as a meta-invective action. Positionality informed by self-reflexivity can help to explore the invective latency of field relations and let contradictions, discomfort, and disharmonic elements emerge. This does not mean that field relations will become more equal and that power structures and inequalities will be reduced as a result. However, being aware of these invective elements offers the opportunity to explore a level of analysis that is often overlooked and make steps toward decolonizing research methodologies and knowledge production.

Effectiveness of the caregiver support intervention on child psychosocial wellbeing among Syrian refugees in Lebanon: Mediation and secondary analysis of a Randomized Controlled Trial

BackgroundWar and violence have a serious negative impact on the wellbeing and mental health of many children. Caregivers play an important role in mitigating or exacerbating this impact. ObjectiveThis study evaluates the impact of the nine session Caregiver Support Intervention on improving children's wellbeing and examines putative mediators of changes in children's psychosocial wellbeing. Participants and setting240 female caregivers were randomly allocated (1:1) to the CSI or a waitlist control comparison condition. The study was implemented in Lebanon, in an area characterized by high levels of poverty and a high number of the Syrian refugees. MethodsA parallel group Randomized Controlled Trial reporting on caregiver-reported child-level wellbeing. We used a combination of the Kid- and Kiddy-KINDL (parent version) for index children ages three to 12. Putative mediators of the CSI on children's psychosocial wellbeing included harsh parenting, caregiver psychological distress, caregiver wellbeing. Measurements were conducted at baseline, post-intervention and 3-months follow-up. ResultsWe demonstrated a statistically significant change in caregiver reported children's psychosocial wellbeing at post-intervention (Mdiff =4.39, 95 % CI = 1.12, 7.65, p < 0.01, d = 0.28) but not at follow-up (Mdiff = −0.97, 95 % CI = -4.27, 2.32, p > 0.05). The proportion of the total effect of the CSI intervention on child psychosocial wellbeing mediated by caregiver distress, caregiver wellbeing and harsh parenting was 77 %. ConclusionThe CSI holds potential for down-stream short-term effect on improving children's psychosocial wellbeing, beyond the previously reported positive caregiver outcomes. This effect was not sustained three months post intervention. The study confirms caregiver wellbeing and parenting support as dual pathways mediating child psychosocial wellbeing.Prospective trial registration: ISRCTN22321773

Employability of Syrian Refugees in Lebanon: The Role of Legal Residency

ABSTRACT The onset of the Syrian crisis in 2011 has led people to flow to neighboring countries seeking protection. Syrian refugees have become a topic of interest for many researchers where studies have highlighted their vulnerability in their host countries, including finding a job. There have been papers addressing the factors influencing Syrian refugees’ employability, but very few have specifically focused on the role of legal residence and legal documentation. In this research, our main objective is to examine the correlation between Syrian refugees’ legal residency and their labor force participation in Lebanon. We use the Vulnerability Assessment of Syrian Refugees in Lebanon (VASyR) dataset and run a Probit model. The main finding of our empirical analysis is that Syrian refugees with legal residency are more likely to be employed in Lebanon. After dividing by educational levels, the results suggest that legal residency is positively associated with a higher probability of finding work among those with a school education or university education as the highest educational attainment. This paper also includes identity documentation factors (identification document (ID), national passport, family booklet) and some demographic factors (gender, marital status, education, age). Finally, the paper provides some policy recommendations regarding this issue.

The determinants of sustained adherence to COVID-19 preventive measures among older Syrian refugees in Lebanon.

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, an unraveling economy, and pandemic fatigue have meant that disease control policies need to be updated. Using recent and timely data on older (50 years and above) Syrian refugees in Lebanon, this paper uses multivariate linear probability models to explore 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 investigates the determinants of sustained adherence over a period of 6 months. The findings suggest that no individual-level characteristics were robustly associated with mask wearing. For avoiding social gatherings, education was inversely associated with adherence to this preventive measure. Avoiding social gatherings was also significantly lower for residents of informal tented settlements (ITSs). Among initial adherents, and for both preventive practices, ITS dwellers were also significantly less likely to maintain adherence. Identifying variables associated with adherence to non-pharmaceutical preventive practices, particularly for vulnerable groups, can help inform and refine interventions in the face of changing conditions. The material, physical, administrative and socio-economic constraints of life in an ITS suggest that avoiding social gatherings is hardly feasible. Yet despite the challenging conditions of ITSs, the indication to wear a mask is initially complied with, suggesting that tailoring policies to the limits and constrains of context can lead to successful outcomes even in very adverse settings.

Religion, Ideology, and Political Parties’ Positions on Refugees in South Asia and the Middle East

Some political parties adopt rhetoric and policy stances favorable to refugees, while others view refugees as a potential economic or security threat or a challenge to the asylum country's predominant identity and push for refugees’ rapid return. We argue that, despite material constraints in asylum countries, like those stemming from the level of economic development, domestic political contestation and differences shape refugee politics and associated outcomes. We further posit that the key element of those domestic political differences is not that leftist parties are systematically more sympathetic to refugees than rightist parties. Rather, our empirical analysis shows that, in the non-Western contexts that we study, parties that emphasize a religious identity shared with most refugees are more likely to view those refugees more favorably than parties that do not emphasize that religious identity or that emphasize a religious identity not shared with refugees. We build on moral foundations theory to explain why religion and politics matter and why rightist parties are not necessarily less favorable to refugees than leftist parties. We carry out a comparative study of party positions toward Syrian refugees in Lebanon and Turkey and toward Rohingya refugees in Bangladesh and explain why party leaders’ choices regarding religion and politics shape refugee politics. While others have questioned the claim that leftists are more likely to favor refugees than conservatives, we contribute to the literature by specifying the conditions under which that is unlikely to be the case, and we develop a theoretically grounded explanation for that pattern.

Validation of the Arabic version of the refugee health screener-13 among postpartum Syrian refugees in Lebanon

PurposeRefugee mothers are at a significantly increased risk of suffering from postpartum depression. However, available tools to screen for it often use a Western paradigm of mental health, which may not be culturally appropriate, and may not account for the background stress experienced by refugees. The purpose of this study is to test and validate refugee health screener-13 (RHS-13), which was developed by consultation with refugees from different backgrounds among a group of Syrian refugee mothers living in Beqaa’s valley in Lebanon.Design/methodology/approachThe tool was tested on a sample of 103 women. Internal consistency of the items for each subscale was assessed using Cronbach’s alpha. An interitem correlation was performed to examine the most correlated items on the scale. Pearson correlation coefficient was calculated between each subscale and its diagnostic proxy. To find the best fit cutoff point between sensitivity and 1-specificity, ROC curves were used.FindingsRHS-13 is a reliable and valid tool to detect depression and anxiety among postpartum Syrian mothers (internal consistency 0.803, correlation with patient health questionnaire: 0.63 and correlation with generalized anxiety disorder-7: 0.73). The best fit cutoff points were 12, 15 and 25, indicating the severity of symptoms from mild to severe, respectively.Originality/valueRHS-13 is a valid tool among postpartum refugees in Lebanon and can be used by primary care physicians, mental health providers and social workers working with refugees from the Middle East to screen mothers for depression and anxiety.

Cognitive Dissonance Induction to Decrease Vaccine Hesitancy Among Syrian Refugees in Lebanon: A Cognitive Approach Towards the Promotion of Health Seeking Behaviors

Background: The rollout of the COVID-19 vaccine represented more than logistical challenges. Lebanon, despite benefitting from the COVAX initiative that made vaccines more accessible to everyone residing in the country, faced considerable challenges encouraging the Syrian refugee population to register for a vaccine. The reasons behind refugees’ reluctance to get vaccinated were mainly behavioral in nature: fear of side effects, doubts about the vaccine’s effectiveness, and even the belief that the vaccine was unnecessary. Methods: An RCT was conducted in order to test the impact of dissonance induction on the level of willingness of Syrian refugee survey respondents who had not been vaccinated (n=1,569). The survey also collected data on refugees’ knowledge, attitudes, and practices regarding the vaccine. Results: Results revealed that dissonance induction significantly reduced vaccine hesitancy, with more pronounced effects detected among women, middle aged adults. Conclusion: These findings have important implications on rethinking the behavioral aspect of the delivery of public health services to the refugee population in Lebanon and vulnerable populations elsewhere.

Hepatitis B and C: neglected infectious diseases among Syrian refugees in Lebanon

Background Hepatitis B and C are life-threatening infections that can result in liver-associated complications. Lebanon is a country experiencing its worst economic and political crises to date and is considered to be of low endemicity for hepatitis B virus (HBV) and hepatitis C virus (HCV). We aimed to assess the prevalence of HBV and HCV infections among Lebanese and Syrian refugees residing in Lebanon, to describe the current situation beyond statistical scrutiny and identify risks and long-term consequences associated with neglecting these infections. Methods We extracted data on the prevalence of HBV and HCV among the Lebanese population and Syrian refugees residing in Lebanon from 2013 to 2018 and sorted them based on age and gender. We compared the prevalence of HBV and HCV among these groups to the prevalence among the Syrians remaining in Syria, after which we calculated the expected number of HBV and HCV cases in Lebanon based on the total number of registered Syrian refugees in Lebanon. We conducted an extensive literature review using MEDLINE, Google Scholar, and PubMed. Results The prevalence of HBV and HCV in Lebanon from 2013 to 2018 was 1.74% and 0.21%, respectively. 13% of HBV cases and 6% of HCV cases were associated with Syrian refugees. HBV and HCV were more prevalent among men than women for both the Lebanese population and the Syrian refugees. Among the total population, the 20-39 age group represented 40% of HBV and 30% of HCV cases. For the Syrian refugee subgroup, 57% of HBV cases and 28% of HCV cases were reported among individuals aged 20-39 years. The prevalence of HBV and HCV among the total Syrian population in Syria was 5.6% and 2.8%, which was significantly higher than the prevalence among the Syrian refugees in Lebanon for both HBV (0.003%) and HCV (0.001%). The number of HBV and HCV cases recorded among the Syrian refugees in Lebanon was significantly lower than the expected number of HBV and HCV cases. Conclusions Hepatitis B and C are neglected diseases among the Syrian refugee population in Lebanon. Continued neglect can increase the risk of chronic viral hepatitis complications and mortality, further increasing the health and economic burden in Lebanon. Urgent action is needed from the host country and the international community to achieve better surveillance, detection, and linkage to medical care in order to manage and prevent unexpected consequences.

Predictors and barriers to vaccination among older Syrian refugees in Lebanon: a cross-sectional analysis of a multi-wave longitudinal study

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. 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. 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). 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. ELRHA's Research for Health in Humanitarian Crisis Programme.

The impact of forced displacement: trauma, increased levels of inflammation and early presentation of diabetes in women Syrian refugees.

Forced displacement and war trauma cause high rates of post-traumatic stress, anxiety disorders and depression in refugee populations. We investigated the impact of forced displacement on mental health status, gender, presentation of type 2 diabetes (T2D) and associated inflammatory markers among Syrian refugees in Lebanon. Mental health status was assessed using the Harvard Trauma Questionnaire (HTQ) and the Hopkins Symptom Checklist-25 (HSCL-25). Additional metabolic and inflammatory markers were analyzed. Although symptomatic stress scores were observed in both men and women, women consistently displayed higher symptomatic anxiety/depression scores with the HSCL-25 (2.13±0.58 versus 1.95±0.63). With the HTQ, however, only women aged 35-55 years displayed symptomatic post-traumatic stress disorder (PTSD) scores (2.18±0.43). Furthermore, a significantly higher prevalence of obesity, prediabetes and undiagnosed T2D were observed in women participants (23.43, 14.91 and 15.18%, respectively). Significantly high levels of the inflammatory marker serum amyloid A were observed in women (11.90±11.27 versus 9.28±6.93, P=0.036). Symptomatic PTSD, anxiety/depression coupled with higher levels of inflammatory marker and T2D were found in refugee women aged between 35 and 55years favoring the strong need for psychosocial therapeutic interventions in moderating stress-related immune dysfunction and development of diabetes in this subset of female Syrian refugees.

A multidimensional approach to measuring vulnerability to poverty among refugee populations

AbstractThis study constructs a multidimensional livelihood index (MLI) using data from Syrian refugees in Lebanon to identify households who are currently poor. The MLI is then used to predict households' vulnerability to future poverty using a three‐stage Feasible Generalized Least Squares (FGLS) model. The analysis identifies more precisely which households and geographical locations are vulnerable to experiencing prolonged poverty. This study is among the first to adapt the multidimensional poverty framework to the context of protracted forced displacement. The approach provides insights into how humanitarian and development organizations can more optimally target assistance to alleviate immediate and future poverty.

174. Power Sharing in Community-engaged Research with Syrian Refugees in Lebanon: Using Implementation Science Frameworks to Guide Fit to Context of a Young Adult Community Worker Intervention

174. Power Sharing in Community-engaged Research with Syrian Refugees in Lebanon: Using Implementation Science Frameworks to Guide Fit to Context of a Young Adult Community Worker Intervention

The Dynamics of Refugee Return: Syrian Refugees and Their Migration Intentions

AbstractWe study the drivers of refugees' decision making about returning home using observational and experimental data from a survey of 3,003 Syrian refugees in Lebanon. We find that the conditions in refugee-hosting countries play a minor role. In contrast, conditions in a refugee's home country are the main drivers of return intentions. Even in the face of hostility and poor living conditions in host countries, refugees are unlikely to return unless the situation at home improves significantly. These results challenge traditional models of decision making about migration, where refugees weigh living conditions in the host and home countries (“push” and “pull” factors). We offer an alternative theoretical framework: a model of threshold-based decision making whereby only once a basic threshold of safety at home is met do refugees compare other factors in the host and home country. We explore some empirical implications of this new perspective using qualitative interviews and quantitative survey data.

Access of Syrian refugees to COVID-19 testing in Lebanon.

Polymerase chain reaction is a well-known method for testing COVID-19 infection, however, refugee populations often face difficulties in accessing testing. Several structural and cultural challenges have hindered access of Syrian refugees to COVID-19 testing in Lebanon, including financial barriers, stigma, and low perception of vulnerability. To explore barriers to accessing COVID-19 testing by Syrian refugees in Lebanon. This qualitative study conducted 10 focus group discussions among Syrian refugees and 21 individual semistructured interviews with healthcare workers. Ethical approval was obtained from the Institutional Review Board of the Lebanese International University, and the study followed the ethical principles of the Declaration of Helsinki. Syrian refugees in Lebanon did not consider COVID-19 testing to be important. Despite the availability of free testing services, psychological, cultural, environmental, and financial barriers hindered them from getting tested. Some of them relied on consultation with pharmacists, who were easy to access and provided symptomatic treatment without the need to test for COVID-19. Fear of stigma, deportation, and isolation were common cultural barriers. Testing was considered unnecessary because of the perception of low disease severity and an attitude of negligence towards preventive practices. The harsh economic and living conditions were of greater concern to the refugees. Findings from this study add to existing literature regarding the social and cultural barriers to COVID-19 testing among Syrian refugees and should be considered when tailoring health promotion campaigns to halt the spread of the COVID-19 pandemic.

Perceived facilitators and barriers to the provision of sexual and reproductive health services in response to the Syrian refugee crisis in Lebanon.

The Syrian crisis has resulted in one of the worst humanitarian disasters in modern history. Inadequate access to and use of sexual and reproductive health services is a prevailing issue among adolescent girls and young refugee women in humanitarian settings. This article aimed to explore and describe the perceived extent of implementation of the different objectives and activities outlined within the minimum initial service package for reproductive health in crisis services in Lebanon, from the perspectives of a diverse set of stakeholders from leading organizations (public, private, primary health centers, nongovernmental organizations) that were directly engaged with the Syrian refugee crisis response. This study is a cross-sectional survey conducted using a standardized and validated questionnaire. Centers that provided sexual and reproductive health services to Syrian refugees in Lebanon were mapped. The study was based on a purposive sampling approach, retrieving 52 eligible organizations to cover most areas in the country. A total of 43 centers accepted to take part in the study. The head of the center was then asked to identify one person in their center who holds adequate knowledge of the explained objectives of the survey. Accordingly, the identified person was asked to fill out the survey. A considerable portion of the respondents had limited knowledge about the specific minimum initial service package objectives and related sexual and reproductive health services. The study found the presence of a leading reproductive health agency, the Lebanese MoPH, as an essential facilitating factor for sexual and reproductive health service provision in Lebanon and has helped in overseeing the overall sexual and reproductive health coordination response for Syrian refugees (76.74% of all respondents). The identified challenges impeding adequate sexual and reproductive health services provision for Syrian refugees included (1) insufficient supplies (46.51%); (2) insufficient funds (39.53%); and (3) shortage of staff (39.53%). The recommendations for improved sexual and reproductive health service provision include the need for (1) enforcing the lead minimum initial service package agency for adequate and effective coordination, reporting, and accountability and (2) increasing funding for training staff and healthcare workers, as well as improving the overall quality of services available with the inclusion of family planning services, purchasing the necessary commodities, supplies and equipment, and covering fees associated with the different sexual and reproductive health services.

Tackling the COVID-19 infodemic among Syrian refugees in Lebanon: Development and evaluation of the "Wikaytek" tool.

The COVID-19 infodemic has been a global public health challenge, especially affecting vulnerable populations such as Syrian refugees with limited internet access and functional, health, digital, and media literacies. To address this problem, we developed Wikaytek, a software to diffuse reliable COVID-19 information using WhatsApp, the preferred communication channel among Syrian refugees. In this paper, we describe the systematic development of the tool. We undertook a pilot study guided by the Humanitarian Engineering Initiative (HEI)'s user-centered design framework, comprising five stages: (a) user research, including needs assessment and desk review of interventions with target users; (b) concept design based on platform and source selection, message format, concept testing, and architecture design; (c) prototyping and implementation, encompassing software development and system operation; (d) user testing (alpha and beta); and (e) evaluation through software analytics and user interviews. We reported a qualitative process evaluation. Wikaytek scrapes validated and reliable COVID-19-related information from reputable sources on Twitter, automatically translates it into Arabic, attaches relevant media (images/video), and generates an audio format using Google text-to-speech. Then, messages are broadcast to WhatsApp. Our evaluation shows that users appreciate receiving "push" information from reliable sources they can trust and prefer the audio format over text. Wikaytek is a useful and well-received software for diffusing credible information on COVID-19 among Syrian refugees with limited literacy, as it complements the texts with audio messages. The tool can be adapted to diffuse messages about other public health issues among vulnerable communities, extending its scope and reach in humanitarian settings.