[Skip to Content]
[Skip to Content Landing]

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

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
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.

Abstract

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.

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 Credit(s)™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

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.

References
1.
World Health Organization (WHO). ApartTogether survey: preliminary overview of refugees and migrants self-reported impact of COVID-19. Accessed February 18, 2021. https://apps.who.int/iris/handle/10665/337931
2.
Bukuluki  P , Mwenyango  H , Katongole  SP , Sidhva  D , Palattiyil  G .  The socioeconomic and psychosocial impact of COVID-19 pandemic on urban refugees in Uganda.   Soc Sci Humanit Open. 2020;2(1):100045. doi:10.1016/j.ssaho.2020.100045PubMedGoogle ScholarCrossref
3.
Fouad  FM , McCall  SJ , Ayoub  H , Abu-Raddad  LJ , Mumtaz  GR .  Vulnerability of Syrian refugees in Lebanon to COVID-19: quantitative insights.   Confl Health. 2021;15(1):13. doi:10.1186/s13031-021-00349-6 PubMedGoogle ScholarCrossref
4.
Rehr  M , Shoaib  M , Ellithy  S ,  et al.  Prevalence of non-communicable diseases and access to care among non-camp Syrian refugees in northern Jordan.   Confl Health. 2018;12(1):33. doi:10.1186/s13031-018-0168-7 PubMedGoogle ScholarCrossref
5.
Wang  B , Li  R , Lu  Z , Huang  Y .  Does comorbidity increase the risk of patients with COVID-19: evidence from meta-analysis.   Aging (Albany NY). 2020;12(7):6049-6057. doi:10.18632/aging.103000 PubMedGoogle ScholarCrossref
6.
Akik  C , Ghattas  H , Mesmar  S , Rabkin  M , El-Sadr  WM , Fouad  FM .  Host country responses to non-communicable diseases amongst Syrian refugees: a review.   Confl Health. 2019;13:8. doi:10.1186/s13031-019-0192-2 PubMedGoogle ScholarCrossref
7.
Demaio  A , Jamieson  J , Horn  R , de Courten  M , Tellier  S .  Non-communicable diseases in emergencies: a call to action.   PLoS Curr. 2013;5:5. doi:10.1371/currents.dis.53e08b951d59ff913ab8b9bb51c4d0de PubMedGoogle ScholarCrossref
8.
WHO. Adherence to long term therapies: Evidence for action. Published 2003. Accessed February 18, 2021. http://apps.who.int/iris/bitstream/handle/10665/42682/9241545992.pdf;jsessionid=6B7994A65CA1BBDE3B6CB3ACDEDA4F49?sequence=1
9.
Unal  B , Critchley  JA , Capewell  S .  Explaining the decline in coronary heart disease mortality in England and Wales between 1981 and 2000.   Circulation. 2004;109(9):1101-1107. doi:10.1161/01.CIR.0000118498.35499.B2 PubMedGoogle ScholarCrossref
10.
Capewell  S , Beaglehole  R , Seddon  M , McMurray  J .  Explanation for the decline in coronary heart disease mortality rates in Auckland, New Zealand, between 1982 and 1993.   Circulation. 2000;102(13):1511-1516. doi:10.1161/01.CIR.102.13.1511 PubMedGoogle ScholarCrossref
11.
Nelson  MR , Reid  CM , Ryan  P , Willson  K , Yelland  L .  Self-reported adherence with medication and cardiovascular disease outcomes in the Second Australian National Blood Pressure Study (ANBP2).   Med J Aust. 2006;185(9):487-489. doi:10.5694/j.1326-5377.2006.tb00662.x PubMedGoogle ScholarCrossref
12.
Mohamad  M , Moussally  K , Lakis  C ,  et al.  Self-reported medication adherence among patients with diabetes or hypertension, Médecins Sans Frontières Shatila refugee camp, Beirut, Lebanon: a mixed-methods study.   PLoS One. 2021;16(5):e0251316. doi:10.1371/journal.pone.0251316 PubMedGoogle ScholarCrossref
13.
Strong  J , Varady  C , Chahda  N , Doocy  S , Burnham  G .  Health status and health needs of older refugees from Syria in Lebanon.   Confl Health. 2015;9:12. doi:10.1186/s13031-014-0029-y PubMedGoogle ScholarCrossref
15.
DeJong  J , Ghattas  H , Bashour  H , Mourtada  R , Akik  C , Reese-Masterson  A .  Reproductive, maternal, neonatal and child health in conflict: a case study on Syria using Countdown indicators.   BMJ Glob Health. 2017;2(3):e000302. doi:10.1136/bmjgh-2017-000302 PubMedGoogle ScholarCrossref
16.
Doocy  S , Lyles  E , Akhu-Zaheya  L , Burton  A , Burnham  G .  Health service access and utilization among Syrian refugees in Jordan.   Int J Equity Health. 2016;15(1):108. doi:10.1186/s12939-016-0399-4 PubMedGoogle ScholarCrossref
17.
World Health Organization. COVID-19 significantly impacts health services for noncommunicable diseases. Accessed February 28, 2022. https://www.who.int/news-room/detail/01-06-2020-covid-19-significantly-impacts-health-services-for-noncommunicable-diseases
18.
Ahsan  S .  Lebanese health care racked by medicine shortages.   Lancet. 2021;398(10300):568. doi:10.1016/S0140-6736(21)01852-3 PubMedGoogle ScholarCrossref
19.
Altare  C , Kostandova  N , OKeeffe  J ,  et al.  COVID-19 epidemiology and changes in health service utilization in Azraq and Zaatari refugee camps in Jordan: a retrospective cohort study.   PLoS Med. 2022;19(5):e1003993. doi:10.1371/journal.pmed.1003993 PubMedGoogle ScholarCrossref
20.
Women  U . Rapid gender assessments on the socioeconomic impacts of COVID-19. Accessed June 28, 2022. https://data.unwomen.org/rga
21.
Abdulrahim  A , Ghattas  H , McCall  S . Changing vulnerabilities and COVID-19 adherence: older refugees in Lebanon. Accessed February 23, 2022. https://www.elrha.org/project/covid-19-adherence-older-refugees-lebanon/
22.
Jeste  DV , Palmer  BW , Appelbaum  PS ,  et al.  A new brief instrument for assessing decisional capacity for clinical research.   Arch Gen Psychiatry. 2007;64(8):966-974. doi:10.1001/archpsyc.64.8.966 PubMedGoogle ScholarCrossref
23.
Abdulrahim  S , Ghattas  H , McCall  S ,  et al. Tracking adherence of older refugees to COVID-19 preventive measures in response to changing vulnerabilities: a multi-level, panel study to inform humanitarian response in Lebanon, 2021 [survey documentation]. Accessed August 15, 2022. https://scholarworks.aub.edu.lb/handle/10938/22852
24.
Cafiero  C , Viviani  S , Nord  M .  Food security measurement in a global context: the food insecurity experience scale.   Measurement. 2018;116:146-152. doi:10.1016/j.measurement.2017.10.065 Google ScholarCrossref
25.
Young  SL , Miller  JD , Frongillo  EA , Boateng  GO , Jamaluddine  Z , Neilands  TB ; HWISE Research Coordination Network.  Validity of a four-item household water insecurity experiences scale for assessing water issues related to health and well-being.   Am J Trop Med Hyg. 2021;104(1):391-394. doi:10.4269/ajtmh.20-0417 PubMedGoogle ScholarCrossref
26.
Harrell  FE . Multivariable modeling strategies. In:  Regression Modeling Strategies. Springer; 2015:63-102. doi:10.1007/978-3-319-19425-7_4
27.
Sauerbrei  W .  The use of resampling methods to simplify regression models in medical statistics.   J R Stat Soc Ser C Appl Stat. 1999;48(3):313-329. doi:10.1111/1467-9876.00155 Google ScholarCrossref
28.
Van Calster  B , McLernon  DJ , van Smeden  M , Wynants  L , Steyerberg  EW ; Topic Group ‘Evaluating diagnostic tests and prediction models’ of the STRATOS initiative.  Calibration: the Achilles heel of predictive analytics.   BMC Med. 2019;17(1):230. doi:10.1186/s12916-019-1466-7 PubMedGoogle ScholarCrossref
29.
Steyerberg  EW . Overfitting and optimism in prediction models. In:  Clinical Prediction Models. Springer; 2019:95-112. doi:10.1007/978-3-030-16399-0_5
30.
Leijdekkers  JA , Eijkemans  MJC , van Tilborg  TC ,  et al; OPTIMIST group.  Predicting the cumulative chance of live birth over multiple complete cycles of in vitro fertilization: an external validation study.   Hum Reprod. 2018;33(9):1684-1695. doi:10.1093/humrep/dey263 PubMedGoogle Scholar
31.
Harrell  FE  Jr , Lee  KL , Mark  DB .  Multivariable prognostic models: issues in developing models, evaluating assumptions and adequacy, and measuring and reducing errors.   Stat Med. 1996;15(4):361-387. doi:10.1002/(SICI)1097-0258(19960229)15:4<361::AID-SIM168>3.0.CO;2-4 PubMedGoogle Scholar
32.
Fernandez-Felix  B , García-Esquinas  E , Muriel  A , Royuela  A , Zamora  J .  Bootstrap internal validation command for predictive logistic regression models.   Stata J. 2021;21(2):498-509. doi:10.1177/1536867X211025836 Google Scholar
33.
Moons  KG , Donders  ART , Steyerberg  EW , Harrell  FE .  Penalized maximum likelihood estimation to directly adjust diagnostic and prognostic prediction models for overoptimism: a clinical example.   J Clin Epidemiol. 2004;57(12):1262-1270. doi:10.1016/j.jclinepi.2004.01.020 PubMedGoogle Scholar
34.
Chaaban  J , Salti  N , Ghattas  H ,  et al. Multi-purpose cash assistance in Lebanon: impact evaluation on the well-being of Syrian refugees. Accessed August 15, 2022. https://www.nrc.no/globalassets/pdf/reports/camealeon-impact-assessment-of-multi-purpose-cash-assistance-for-syrian-refugees-in-lebanon/camealeon-mpc-impact-assessment.pdf
35.
Ratnayake  R , Rawashdeh  F , AbuAlRub  R ,  et al.  Access to care and prevalence of hypertension and diabetes among Syrian refugees in northern Jordan.   JAMA Netw Open. 2020;3(10):e2021678-e2021678. doi:10.1001/jamanetworkopen.2020.21678 PubMedGoogle Scholar
36.
Lyles  E , Burnham  G , Chlela  L , Spiegel  P , Morlock  L , Doocy  S ; Lebanon Health Access Survey (LHAS) Study Team.  Health service utilization and adherence to medication for hypertension and diabetes among Syrian refugees and affected host communities in Lebanon.   J Diabetes Metab Disord. 2020;19(2):1245-1259. doi:10.1007/s40200-020-00638-6 PubMedGoogle Scholar
37.
Workman  CL , Brewis  A , Wutich  A , Young  S , Stoler  J , Kearns  J .  Understanding biopsychosocial health outcomes of syndemic water and food insecurity: applications for global health.   Am J Trop Med Hyg. 2021;104(1):8-11. doi:10.4269/ajtmh.20-0513 PubMedGoogle Scholar
38.
Jamaluddine  Z , Sahyoun  NR , Choufani  J , Sassine  AJ , Ghattas  H .  Child-reported food insecurity is negatively associated with household food security, socioeconomic status, diet diversity, and school performance among children attending UN Relief and Works Agency for Palestine Refugees schools in Lebanon.   J Nutr. 2019;149(12):2228-2235. doi:10.1093/jn/nxz189 PubMedGoogle Scholar
39.
Omidvar  N , Ghazi-Tabatabie  M , Sadeghi  R , Mohammadi  F , Abbasi-Shavazi  MJ .  Food insecurity and its sociodemographic correlates among Afghan immigrants in Iran.   J Health Popul Nutr. 2013;31(3):356-366. doi:10.3329/jhpn.v31i3.16828 PubMedGoogle Scholar
40.
Leung  CW , Epel  ES , Ritchie  LD , Crawford  PB , Laraia  BA .  Food insecurity is inversely associated with diet quality of lower-income adults.   J Acad Nutr Diet. 2014;114(12):1943-53.e2. doi:10.1016/j.jand.2014.06.353PubMedGoogle Scholar
41.
Ghattas  H , Sassine  AJ , Seyfert  K , Nord  M , Sahyoun  NR .  Food insecurity among Iraqi refugees living in Lebanon, 10 years after the invasion of Iraq: data from a household survey.   Br J Nutr. 2014;112(1):70-79. doi:10.1017/S0007114514000282 PubMedGoogle Scholar
42.
Seligman  HK , Laraia  BA , Kushel  MB .  Food insecurity is associated with chronic disease among low-income NHANES participants.   J Nutr. 2010;140(2):304-310. doi:10.3945/jn.109.112573 PubMedGoogle Scholar
43.
Barnett  K , Mercer  SW , Norbury  M , Watt  G , Wyke  S , Guthrie  B .  Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study.   Lancet. 2012;380(9836):37-43. doi:10.1016/S0140-6736(12)60240-2 PubMedGoogle Scholar
44.
Kardas  P , Lewek  P , Matyjaszczyk  M .  Determinants of patient adherence: a review of systematic reviews.   Front Pharmacol. 2013;4:91. doi:10.3389/fphar.2013.00091 PubMedGoogle Scholar
45.
Linjakumpu  T , Hartikainen  S , Klaukka  T , Veijola  J , Kivelä  S-L , Isoaho  R .  Use of medications and polypharmacy are increasing among the elderly.   J Clin Epidemiol. 2002;55(8):809-817. doi:10.1016/S0895-4356(02)00411-0 PubMedGoogle Scholar
46.
Ingersoll  KS , Cohen  J .  The impact of medication regimen factors on adherence to chronic treatment: a review of literature.   J Behav Med. 2008;31(3):213-224. doi:10.1007/s10865-007-9147-y PubMedGoogle Scholar
47.
Bambauer  KZ , Soumerai  SB , Adams  AS , Zhang  F , Ross-Degnan  D .  Provider and patient characteristics associated with antidepressant nonadherence: the impact of provider specialty.   J Clin Psychiatry. 2007;68(6):867-873. doi:10.4088/JCP.v68n0607 PubMedGoogle Scholar
48.
Bagchi  AD , Esposito  D , Kim  M , Verdier  J , Bencio  D .  Utilization of, and adherence to, drug therapy among Medicaid beneficiaries with congestive heart failure.   Clin Ther. 2007;29(8):1771-1783. doi:10.1016/j.clinthera.2007.08.015 PubMedGoogle Scholar
49.
Krueger  K , Botermann  L , Schorr  SG , Griese-Mammen  N , Laufs  U , Schulz  M .  Age-related medication adherence in patients with chronic heart failure: a systematic literature review.   Int J Cardiol. 2015;184:728-735. doi:10.1016/j.ijcard.2015.03.042 PubMedGoogle Scholar
50.
Ioffe  Y , Abubakar  I , Issa  R , Spiegel  P , Kumar  BN .  Meeting the health challenges of displaced populations from Ukraine.   Lancet. 2022;399(10331):1206-1208. doi:10.1016/S0140-6736(22)00477-9 PubMedGoogle Scholar
51.
Chew  SM , Lee  JH , Lim  SF , Liew  MJ , Xu  Y , Towle  RM .  Prevalence and predictors of medication nonadherence among older community-dwelling people with chronic disease in Singapore.   J Adv Nurs. 2021;77(10):4069-4080. doi:10.1111/jan.14913 PubMedGoogle Scholar
52.
Nair  KV , Belletti  DA , Doyle  JJ ,  et al.  Understanding barriers to medication adherence in the hypertensive population by evaluating responses to a telephone survey.   Patient Prefer Adherence. 2011;5:195-206. doi:10.2147/PPA.S18481 PubMedGoogle Scholar
Close
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Close
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Close
Close

Lookup An Activity

or

My Saved Searches

You currently have no searches saved.

Close

My Saved Courses

You currently have no courses saved.

Close