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Development of a Prediction Model for the Management of Noncommunicable Diseases Among Older Syrian Refugees Amidst the COVID-19 Pandemic in Lebanon

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Key Points

Question  What are the predictors and barriers to managing noncommunicable diseases (NCDs) for older Syrian refugees in Lebanon?

Findings  This prognostic study including 1893 refugees with at least 1 NCD (chronic respiratory disease, diabetes, history of cardiovascular disease or hypertension) developed a predictive model for the inability to manage any NCD with a moderate discriminative ability. Predictors of inability to manage any NCD included age, no cash assistance, household water and food insecurity, and having multiple chronic diseases.

Meaning  These findings suggest context-appropriate assistance is required to overcome financial barriers and enable equitable access to health care and medication required to manage NCDs among refugees.


Importance  Older Syrian refugees have a high burden of noncommunicable diseases (NCDs) and economic vulnerability.

Objectives  To develop and internally validate a predictive model to estimate inability to manage NCDs in older Syrian refugees, and to describe barriers to NCD medication adherence.

Design, Setting, and Participants  This nested prognostic cross-sectional study was conducted through telephone surveys between September 2020 and January 2021. All households in Lebanon with Syrian refugees aged 50 years or older and who received humanitarian assistance from a nongovernmental organization were invited to participate. Refugees who self-reported having chronic respiratory disease (CRD), diabetes, history of cardiovascular disease (CVD), or hypertension were included in the analysis. Data were analyzed from November 2021 to March 2022.

Main Outcomes and Measures  The main outcome was self-reported inability to manage any NCD (including CRD, CVD, diabetes, or hypertension). Predictors of inability to manage any NCD were assessed using logistic regression models. The model was internally validated using bootstrapping techniques, which gave an estimate of optimism. The optimism-adjusted discrimination is presented using the C statistic, and calibration of the model is presented using calibration slope (C slope).

Results  Of 3322 older Syrian refugees, 1893 individuals (median [IQR] age, 59 [54-65] years; 1089 [57.5%] women) reported having at least 1 NCD, among whom 351 (10.6% overall; 18.6% of those with ≥1 NCD) had CRD, 781 (23.7% overall; 41.4% of those with ≥1 NCD) had diabetes, 794 (24.1% overall; 42.2% of those with ≥1 NCD) had history of CVD, and 1388 (42.3% overall; 73.6% of those with ≥1 NCD) had hypertension. Among individuals with NCDs, 387 participants (20.4%) were unable to manage at least 1 of their NCDs. Predictors for inability to manage NCDs were age, nonreceipt of cash assistance, household water insecurity, household food insecurity, and having multiple chronic diseases, with an adjusted C statistic of 0.650 (95% CI, 0.620-0.676) and C slope of 0.871 (95% CI, 0.729-1.023). The prevalence of nonadherence to medication was 9.2%, and the main reasons for nonadherence were unaffordability of medication (40.8%; 95% CI, 33.4%-48.5%) and the belief that they no longer required the medication after feeling better (22.4%; 95% CI, 16.4%-29.3%).

Conclusions and Relevance  In this cross-sectional study, the predictors of inability to manage NCDs among older Syrian refugees in Lebanon were mainly related to financial barriers. Context-appropriate assistance is required to overcome financial barriers and enable equitable access to medication and health care.

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Article Information

Accepted for Publication: July 29, 2022.

Published: October 13, 2022. doi:10.1001/jamanetworkopen.2022.31633

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 McCall SJ et al. JAMA Network Open.

Corresponding Author: Stephen J. McCall, DPhil, Center for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon (sm227@aub.edu.lb).

Author Contributions: Dr McCall and Miss Abi Zeid had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Mrs El Khoury and Mrs Salibi contributed equally. Drs Abdulrahim, Chaaya, Ghattas, and Sibai contributed equally as co–senior authors.

Concept and design: McCall, Abdulrahim, Chaaya, Ghattas, Sibai.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: McCall, El Khoury.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: McCall, Salibi, Abi Zeid, El Haddad, Chaaya, Sibai.

Obtained funding: McCall, Abdulrahim, Ghattas, Sibai.

Administrative, technical, or material support: McCall, El Khoury, Alawieh, Abdulrahim, Ghattas.

Supervision: McCall, Abdulrahim, Ghattas.

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was supported by Elrha’s Research for Health in Humanitarian Crisis (R2HC) Programme, which aims to improve health outcomes by strengthening the evidence base for public health interventions in humanitarian crises. R2HC is funded by the UK Foreign, Commonwealth and Development Office, Wellcome, and the UK National Institute for Health Research.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The views expressed herein should not be taken, in any way, to reflect the official opinion of the Norwegian Refugee Council or Elrha.

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