Predictors and Barriers to Vaccination Among Older Syrian Refugees in Lebanon: A Cross-Sectional Analysis of a Multi-Wave Longitudinal Study

Background: 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. Methods: 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. Findings: 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). Interpretation: 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.