Adapting to the changing dynamics of COVID-19 in a protracted refugee context

In the context of COVID-19, public health researchers are obliged to adapt flexible research strategies and respond to rapidly changing socio-economic contexts surrounding the pandemic. Shortly following the spread of COVID-19 in Lebanon and the institution of the first lockdown, we set out to conduct a longitudinal study that aimed to track the adherence of older refugees in the country to COVID-19 preventive measures. The study period coincided with unprecedented socioeconomic change and upheaval in the country.

Our study was carried out through an NGO-Academic partnership between the American University of Beirut and the Norwegian Refugee Council in Lebanon, where both parties have an effective and longstanding humanitarian-academic partnership. One that built on our strengths where AUB led the research components and NRC focused on community and local level dissemination and engagement with other NGOs. The good communication practices, formalised partnership agreements and commitment to act together for collective goals were the main contribution to the successful working relationship between NRC and AUB.

In this blog, we describe how our team, working through a successful partnership, conducted responsive high quality research during the rapidly emerging COVID-19 pandemic in communities affected by protracted displacement. We also emphasize the importance of including the voices of vulnerable older refugees both in the research itself and in the programmatic responses of NGOs informed by the research findings.

The study was designed in the early stages of the pandemic to examine changes in COVID-19 knowledge, perceptions, and behavioral prevention measures over time in older Syrian refugees. We focused on this group because of both biological and social vulnerability to adverse COVID-19 outcomes and because refugees in general often face structural barriers to adequate health care. Further, the needs of elderly refugees in Lebanon are still under documented and hence, less addressed by humanitarian responses.

We were interested in how the specific vulnerabilities (social, economic, health, protection) of older Syrian refugees were related to their COVID-19 knowledge, perceptions, and behaviors. In order to do this, we collected data using telephone surveys from three panels of older Syrian refugees living in Lebanon, each at four different time points. This flexible design meant that we were continuously collecting data every month from September 2020 to May 2021. This design proved to be extremely adaptable; as the COVID-19 situation changed in Lebanon and as vaccines were deployed, new research questions regarding vaccine equity and uptake became important to investigate. We therefore incorporated into our survey questionnaire new questions addressed to older Syrian refugees regarding their intentions to receive the vaccine and asking whether or not they registered on the Ministry of Public Health platform. As the vaccination campaign progresses, the flexible design allows us to obtain data on actual vaccine uptake.

The multiple wave study over the 9 month period allowed the survey questions to be adapted to the changing circumstances during the pandemic. During January 2021, it became clear that vaccines may soon be given to the population in Lebanon. As we were preparing to launch wave 3 of data collection at that time, we felt it would be opportune to gather data on whether older refugee study participants intend to receive the vaccine. The vaccine was not yet widely distributed, and therefore we felt that capturing intention to vaccinate would be an important predictor of future behavior. The data from wave 3 were analyzed and shared in real time with NRC who disseminated the findings during regularly scheduled meetings of the humanitarian sector in the country. This has helped the various humanitarian organizations to compare the study results with anecdotal evidence they have been collecting and to devise tailored campaign messages to reach vaccine hesitant older refugees.

The timing of the study’s wave 4 data collection coincided with the launch of the Ministry of Public Health’s national registration system platform; registering on the platform was mandatory to receive the vaccine as the Ministry rolled out vaccination to priority groups in sequence. In response to this new development, we added to the study questionnaire new items to capture registration, practical barriers to registering on the national system. In addition to guiding humanitarian organizations to further refine their COVID-19 vaccine campaigns to reach the most hesitant, wave 4 data present evidence on barriers to registering and later accessing the vaccine among older refugees which NRC and others can address.

The AUB and NRC study partners are currently planning to collect concrete data in a fifth wave in January 2022 to assess who has actually taken the vaccine. These data will allow us to understand whether perceptions about vaccines impacted on vaccine uptake. This study is a good example of how an academic-NGO partnership can be reactive to the changing needs and dynamics of a crisis.

Dissemination of findings has been ongoing, both internally between AUB and NRC and externally to the different humanitarian coordination spaces. The work includes developing communication messages to the refugee community, as well as on interpreting the results to open space for more analysis and new suggestions on the research. Furthermore, the vaccine hesitancy results have informed practice at UN level and multi-agency advocacy documents.

To ensure inclusion of the voices of the community, both NRC and AUB engaged the Syrian refugee community, especially older adults, throughout the duration of the research through the community-based research in refugee settings and the community focal points who are Syrian refugees themselves. Furthermore, different stakeholders from both host and refugee communities were consulted regarding the research, survey design and advocacy needs. The consultations also aimed to double check the validity of topics addressed in the survey, in addition to missing topics that are of value for these stakeholders. Feedback from the community was incorporated in the designed tools and methods.