Predicting intention to vaccinate against COVID-19 in older Syrian refugees in Lebanon: findings from a multi-wave study
Authors: Salibi Noura , Abdulrahim Sawsan , Haddad Maria El , Zeid Berthe Abi , Alawieh Marwan F. , Ramadan Zeinab , Ghattas Hala , McCall Stephen J. 
Published: July 2022

AbstractIntroductionCOVID-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.MethodA 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.ResultsOf 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)).ConclusionThis 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.What is already known on this topicDespite global efforts towards more inclusive national deployment vaccination plans, vaccine coverage and uptake among migrants and refugees remains low. Refugees and migrants, the majority of whom live in low and middle income countries, bear the double burden of vaccine inequity and face several challenges and barriers to vaccination including low vaccine supply, inability to access health services, fear of arrest and deportation, lack of accessible information as well as other language, and economic barriers. Research on COVID-19 vaccine intentions among refugees in the region has been limited. Understanding intentions and predictors to vaccinate among refugees, and addressing barriers to vaccine acceptance and registration, is crucial to ensure equitable vaccination and coverage, reduce the spread of COVID-19 and achieve herd immunity.What this study addsThis study is one of the first to develop and internally validate a model of intention to refuse vaccination against COVID-19 in older Syrian refugees. Predictors of intention to refuse the vaccine include age, education, living outside informal tented settlements, sex, perceiving COVID-19 as not a serious infection and vaccines as not safe or effective, and using social media as a source of information on COVID-19. The primary reasons for vaccine refusal were: preference to follow preventive measures, concerns that the vaccine is too new, and belief that the vaccine is not essential. Registration on the national platform to receive the vaccine was low and the reasons for not registering included: being unsure about how to register, and not wanting to receive the vaccine.How this study might affect research, practice or policyThis study highlights the need for targeted interventions to enhance vaccine acceptance and uptake among older Syrian refugees, and address barriers to vaccine registration. Predictors of COVID-19 vaccine refusal among older Syrian refugees will inform humanitarian programming and public health campaigns, and guide resource allocation and deployment planning. Findings inform future research to better understand the predictors of vaccine refusal.