Predictors and barriers to vaccination among older Syrian refugees in Lebanon: a multi-wave survey
Authors: Zeid Berthe Abi , Khoury Tanya El , Ghattas Hala , Alawieh Marwan F. , Ramadan Zeinab , Anouti Sirine , Abdulrahim Sawsan , McCall Stephen J. 
Published: December 2022

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[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.

Funding

The study was funded by ELRHA’s Research for Health in Humanitarian Crisis (R2HC) Programme. R2HC is funded by the UK Foreign, Commonwealth and Development Office (FCDO), Wellcome, and the UK National Institute for Health Research (NIHR).

Research in context

Evidence before the study

We searched PubMed and Google Scholar for studies published up to September 29, 2022, that target COVID-19 vaccine hesitancy and uptake among older Syrian refugees in the region. We used the following combinations of keyword in our search: “COVID-19 vaccine hesitancy”, “COVID-19 vaccine uptake”, “vaccine literacy”, “vaccine acceptance”, “Syrian refugees”, “predictors”, and “education”. Previous evidence has shown that Syrian refugees have a high risk of severe morbidity and death from COVID-19 infection. Vaccine hesitancy among this vulnerable group in Lebanon is high, and there is a paucity of data available about vaccine uptake in refugee populations. In addition, older Syrian refugees have faced multiple barriers to accessing healthcare. Hence, measuring actual COVID-19 vaccine uptake and understanding the predictors influencing vaccine uptake among older Syrian refugees is critical to improving vaccination access and strategies related to COVID-19 in Lebanon.

Added value of the study

To our knowledge, no studies have examined predictors of COVID-19 vaccine uptake and measured the rate of vaccination among older Syrian refugees. Out of 2,906 participants, 1,235 (42.5%) received at least one dose of COVID-19 vaccine, and 806 (27.7%) received two doses of the COVID-19 vaccine. From the available data from the Ministry of Public health in Lebanon, the reported rate of vaccination among this group is low compared to the Lebanese population. In addition, this study developed a predictive model and identified five predictors of receiving at least one dose of COVID-19 vaccine among older Syrian refugees: age, sex, residence (inside or inside informal tented settlement), education and intention of vaccination.

Implications of all the available evidence

These findings suggest an ongoing need to address vaccine acceptance and uptake among older Syrian refugees by spreading awareness about the importance of the COVID-19 vaccine and enhancing the national system for faster vaccine coverage and response in future crises. Focusing on vaccine intention through tailored interventions and targeting hard-to-reach populations will improve vaccine uptake among Syrian refugees.