{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T18:06:57Z","timestamp":1790878017743,"version":"4.1.0"},"reference-count":46,"publisher":"Public Library of Science (PLoS)","issue":"10","license":[{"start":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T00:00:00Z","timestamp":1790812800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"ELRHA\u2019s Research for Health in Humanitarian Crisis (R2HC) Programme"},{"name":"UK Foreign, Commonwealth and Development Office (FCDO),","id":[{"id":"https:\/\/ror.org\/037wke960","id-type":"ROR","asserted-by":"crossref"}]},{"DOI":"10.13039\/100004440","name":"Wellcome","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100004440","id-type":"DOI","asserted-by":"publisher"}]},{"name":"the UK National Institute for Health Research","id":[{"id":"https:\/\/ror.org\/0187kwz08","id-type":"ROR","asserted-by":"crossref"}]},{"name":"the University Research Board","award":["104258"],"award-info":[{"award-number":["104258"]}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>Older refugees, exposed to a cluster of biological and social vulnerabilities, are more susceptible to infectious disease outbreaks and their complications. This study developed a predictive model estimating self-reported COVID-19 infection risk among older Syrian refugees in Lebanon using social determinants of health. Additionally, it described the barriers to diagnostic testing among those who reported having had COVID-19 infection at least once.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>This prediction modeling analysis uses data from a longitudinal study conducted between September 2020 and March 2022. Syrian refugees aged 50 years or older living in households that received assistance from a humanitarian organization were interviewed by phone. Self-reported occurrence at least one COVID-19 infection was the outcome of interest. The predictors were identified using adaptive lasso regression. The apparent model performance and discrimination were presented using the calibration slope and the Area Under the Curve (AUC).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Of 2,886 participants (median [IQR] age: 56 [52 \u201362]; 52.9% males), 283 individuals (9.8%) reported a COVID-19 infection at least once. Six predictors of\u00a0at least one COVID-19 infection were identified: living outside informal tented settlements, having elementary and preparatory education or above, having chronic conditions, not receiving cash assistance, being water insecure and having unmet waste management needs. The apparent model had modest discrimination (AUC\u2009=\u20090.621 [95%CI: 0.587 to 0.655]) and good calibration (c-Slope\u2009=\u20091.004 [95%CI: 0.704 to 1.304]). Nearly half of the cases were diagnosed through testing. The main reasons for not testing were perception that the tests were unnecessary (n\u2009=\u200991 [63.6%]) or inability to afford them (n\u2009=\u200946 [32.2%]).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec004\">\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>The identified predictors provide insight into characteristics associated with higher predicted risk of COVID-19 infection among Syrian refugees. However, given the\u00a0model\u2019s\u00a0modest predictive performance and reliance on lasso tuning, further validation and refinement in other populations and settings are needed before implementation. Awareness campaigns, screening measures, and cash assistance may be associated with reduced risk of infection in future pandemics.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pone.0359272","type":"journal-article","created":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T17:34:26Z","timestamp":1790876066000},"page":"e0359272","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["Predicting COVID-19 infection among older Syrian refugees in Lebanon: A multi-wave survey"],"prefix":"10.1371","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2007-5574","authenticated-orcid":true,"given":"Berthe","family":"Abi Zeid","sequence":"first","affiliation":[{"name":"Arnold School of Public Health, University of South Carolina","place":["Columbia, United States of America"],"department":["Department of Health Promotion, Education, and Behavior"]},{"name":"American University of Beirut","place":["Beirut, Lebanon"],"department":["Center for Research on Population and Health, Faculty of Health Sciences"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tanya","family":"El Khoury","sequence":"additional","affiliation":[{"name":"American University of Beirut","place":["Beirut, Lebanon"],"department":["Center for Research on Population and Health, Faculty of Health Sciences"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sawsan","family":"Abdulrahim","sequence":"additional","affiliation":[{"name":"American University of","place":["Beirut, Lebanon"],"department":["Department of Health Promotion and Community Health, Faculty of Health Sciences"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hala","family":"Ghattas","sequence":"additional","affiliation":[{"name":"Arnold School of Public Health, University of South Carolina","place":["Columbia, United States of America"],"department":["Department of Health Promotion, Education, and Behavior"]},{"name":"American University of Beirut","place":["Beirut, Lebanon"],"department":["Center for Research on Population and Health, Faculty of Health Sciences"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0078-7010","authenticated-orcid":true,"given":"Stephen J.","family":"McCall","sequence":"additional","affiliation":[{"name":"American University of Beirut","place":["Beirut, Lebanon"],"department":["Center for Research on Population and Health, Faculty of Health Sciences"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,10,1]]},"reference":[{"key":"pone.0359272.ref001","unstructured":"World Health Organization. WHO Coronavirus (COVID-19) Dashboard. Available from: https:\/\/covid19.who.int\/. Accessed 2026 August 13."},{"issue":"4","key":"pone.0359272.ref002","doi-asserted-by":"crossref","first-page":"458","DOI":"10.1038\/s41591-020-0823-6","article-title":"Combating COVID-19: health equity matters","volume":"26","author":"Z Wang","year":"2020","journal-title":"Nat Med"},{"key":"pone.0359272.ref003","doi-asserted-by":"crossref","first-page":"100175","DOI":"10.1016\/j.jmh.2023.100175","article-title":"Prevalence of SARS-CoV-2 infection and associated risk factors among asylum seekers living in asylum centres: a cross-sectional serologic study in Canton of Vaud, Switzerland","volume":"7","author":"K Morisod","year":"2023","journal-title":"J Migr Health"},{"key":"pone.0359272.ref004","doi-asserted-by":"crossref","first-page":"05003","DOI":"10.7189\/jogh.11.0503","article-title":"The multidimensional burden of COVID-19 on Syrian refugees in Lebanon","volume":"11","author":"MS Hajjar","year":"2021","journal-title":"J Glob Health"},{"key":"pone.0359272.ref005","author":"M May","year":"2020"},{"key":"pone.0359272.ref006","unstructured":"UNHCR, UNICEF, WFP. VASyR 2022: vulnerability assessment of Syrian refugees in Lebanon; 2023."},{"key":"pone.0359272.ref007","unstructured":"Human Rights Watch. Lebanon: armed forces summarily deporting Syrians; 2023. Available from: https:\/\/www.hrw.org\/news\/2023\/07\/05\/lebanon-armed-forces-summarily-deporting-syrians#:~:text=In%20a%20letter%20to%20Human,the%20Higher%20Defense%20Council%27s%20decision"},{"issue":"1","key":"pone.0359272.ref008","doi-asserted-by":"crossref","first-page":"15","DOI":"10.26719\/emhj.23.001","article-title":"Access of Syrian refugees to COVID-19 testing in Lebanon","volume":"29","author":"A Ghaddar","year":"2023","journal-title":"East Mediterr Health J"},{"issue":"1","key":"pone.0359272.ref009","doi-asserted-by":"crossref","first-page":"126","DOI":"10.1186\/s12939-020-01242-z","article-title":"A model of disparities: risk factors associated with COVID-19 infection","volume":"19","author":"Y Rozenfeld","year":"2020","journal-title":"Int J Equity Health"},{"issue":"4","key":"pone.0359272.ref010","doi-asserted-by":"crossref","first-page":"1364","DOI":"10.1016\/j.chest.2020.05.580","article-title":"Individualizing risk prediction for positive coronavirus disease 2019 testing: results from 11,672 patients","volume":"158","author":"L Jehi","year":"2020","journal-title":"Chest"},{"key":"pone.0359272.ref011","article-title":"Prediction models for diagnosis and prognosis of covid-19: systematic review and critical appraisal","volume":"369","author":"L Wynants","year":"2020","journal-title":"BMJ"},{"key":"pone.0359272.ref012","doi-asserted-by":"crossref","DOI":"10.1136\/bmj.g7594","article-title":"Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD): the TRIPOD statement","volume":"350","author":"GS Collins","year":"2015","journal-title":"BMJ"},{"issue":"12","key":"pone.0359272.ref013","doi-asserted-by":"crossref","first-page":"1495","DOI":"10.1016\/j.ijsu.2014.07.013","article-title":"The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies","volume":"12","author":"E von Elm","year":"2014","journal-title":"Int J Surg"},{"issue":"8","key":"pone.0359272.ref014","doi-asserted-by":"crossref","first-page":"966","DOI":"10.1001\/archpsyc.64.8.966","article-title":"A new brief instrument for assessing decisional capacity for clinical research","volume":"64","author":"DV Jeste","year":"2007","journal-title":"Arch Gen Psychiatry"},{"issue":"5","key":"pone.0359272.ref015","article-title":"Predicting depressive and anxiety symptoms among Lebanese and Syrian adults in a suburb of Beirut, Lebanon, during concurrent crises: nested cross-sectional study","volume":"16","author":"CAEP Study Group","year":"2026","journal-title":"BMJ Open"},{"issue":"10","key":"pone.0359272.ref016","doi-asserted-by":"crossref","DOI":"10.1001\/jamanetworkopen.2022.31633","article-title":"Development of a prediction model for the management of noncommunicable diseases among older Syrian Refugees amidst the COVID-19 pandemic in Lebanon","volume":"5","author":"SJ McCall","year":"2022","journal-title":"JAMA Netw Open"},{"issue":"5","key":"pone.0359272.ref017","doi-asserted-by":"crossref","DOI":"10.1016\/S2666-7568(23)00038-7","article-title":"Predictors and barriers to vaccination among older Syrian refugees in Lebanon: a cross-sectional analysis of a multi-wave longitudinal study","volume":"4","author":"B Abi Zeid","year":"2023","journal-title":"Lancet Healthy Longev"},{"key":"pone.0359272.ref018","doi-asserted-by":"crossref","first-page":"146","DOI":"10.1016\/j.measurement.2017.10.065","article-title":"Food security measurement in a global context: the food insecurity experience scale","volume":"116","author":"C Cafiero","year":"2018","journal-title":"Measurement"},{"issue":"5","key":"pone.0359272.ref019","doi-asserted-by":"crossref","DOI":"10.1136\/bmjgh-2019-001750","article-title":"The Household Water InSecurity Experiences (HWISE) Scale: development and validation of a household water insecurity measure for low-income and middle-income countries","volume":"4","author":"SL Young","year":"2019","journal-title":"BMJ Glob Health"},{"key":"pone.0359272.ref020","doi-asserted-by":"crossref","DOI":"10.1007\/978-3-319-19425-7","volume-title":"Regression modeling strategies with applications to linear models, logistic and ordinal regression, and survival analysis","author":"J Harrell","year":"2015"},{"key":"pone.0359272.ref021","article-title":"Calculating the sample size required for developing a clinical prediction model","volume":"368","author":"RD Riley","year":"2020","journal-title":"BMJ"},{"issue":"1","key":"pone.0359272.ref022","doi-asserted-by":"crossref","first-page":"267","DOI":"10.1111\/j.2517-6161.1996.tb02080.x","article-title":"Regression shrinkage and selection Via the Lasso","volume":"58","author":"R Tibshirani","year":"1996","journal-title":"J R Stat Soc Series B Stat Methodol"},{"key":"pone.0359272.ref023","volume-title":"Stata statistical software: release 16","author":"Stata Corp","year":"2019"},{"key":"pone.0359272.ref024","unstructured":"Access Center for Human Rights. The needs and challenges of refugees amid the COVID-19 pandemic. Beirut: Access Center for Human Rights; 2021; Available from: https:\/\/achrights.org\/en\/2021\/07\/30\/12341\/"},{"issue":"4","key":"pone.0359272.ref025","doi-asserted-by":"crossref","first-page":"295","DOI":"10.26719\/emhj.23.038","article-title":"A cross-sectional study of knowledge, attitude, behaviour and preventive measures for COVID-19 infection in Lebanon","volume":"29","author":"F Sakr","year":"2023","journal-title":"East Mediterr Health J"},{"issue":"1","key":"pone.0359272.ref026","doi-asserted-by":"crossref","first-page":"42","DOI":"10.1186\/s12879-022-07031-z","article-title":"SARS-CoV-2 antibody seroprevalence in Lebanon: findings from the first nationwide serosurvey","volume":"22","author":"A Hoballah","year":"2022","journal-title":"BMC Infect Dis"},{"key":"pone.0359272.ref027","doi-asserted-by":"crossref","first-page":"49","DOI":"10.1186\/s13031-020-00295-9","article-title":"Infectious disease outbreaks among forcibly displaced persons: an analysis of ProMED reports 1996-2016","volume":"14","author":"AN Desai","year":"2020","journal-title":"Confl Health"},{"key":"pone.0359272.ref028","doi-asserted-by":"crossref","DOI":"10.1093\/eurpub\/ckv167.054","article-title":"Stigma and Discrimination towards Migrants in Health Care","volume":"25","author":"O Karadag Caman","year":"2015","journal-title":"Eur J Public Health"},{"key":"pone.0359272.ref029","author":"H Bradby","year":"2015"},{"issue":"8","key":"pone.0359272.ref030","doi-asserted-by":"crossref","DOI":"10.2471\/BLT.20.271080","article-title":"Refugees and COVID-19: achieving a comprehensive public health response","volume":"98","author":"Q Alemi","year":"2020","journal-title":"Bull World Health Organ"},{"key":"pone.0359272.ref031","author":"R Capps","year":"2020"},{"key":"pone.0359272.ref032","article-title":"The stigma surrounding refugee\/immigrant population with COVID-19 status- a scoping review","volume":"21","author":"F Aghajafari","year":"2023","journal-title":"Ann Fam Med"},{"issue":"1","key":"pone.0359272.ref033","doi-asserted-by":"crossref","first-page":"942","DOI":"10.1186\/s12889-022-13370-y","article-title":"Experience of discrimination during COVID-19 pandemic: the impact of public health measures and psychological distress among refugees and other migrants in Europe","volume":"22","author":"M Marchi","year":"2022","journal-title":"BMC Public Health"},{"issue":"6","key":"pone.0359272.ref034","doi-asserted-by":"crossref","first-page":"978","DOI":"10.1111\/phn.12950","article-title":"Barriers related to COVID-19 testing intention","volume":"38","author":"G Shahrour","year":"2021","journal-title":"Public Health Nurs"},{"issue":"2","key":"pone.0359272.ref035","doi-asserted-by":"crossref","first-page":"499","DOI":"10.1111\/nhs.12947","article-title":"Social determinants related to COVID-19 infection","volume":"24","author":"SB Kim","year":"2022","journal-title":"Nurs Health Sci"},{"key":"pone.0359272.ref036","author":"International Labour Organization.","year":"2013"},{"key":"pone.0359272.ref037","author":"M Kattaa","year":"2020"},{"key":"pone.0359272.ref038","doi-asserted-by":"crossref","first-page":"100041","DOI":"10.1016\/j.jmh.2021.100041","article-title":"Clinical outcomes and risk factors for COVID-19 among migrant populations in high-income countries: a systematic review","volume":"3","author":"SE Hayward","year":"2021","journal-title":"J Migr Health"},{"key":"pone.0359272.ref039","unstructured":"World Health Organization. Cholera 2024. Available from: https:\/\/www.who.int\/news-room\/fact-sheets\/detail\/cholera. Accessed 2025 September 4."},{"key":"pone.0359272.ref040","doi-asserted-by":"crossref","first-page":"113715","DOI":"10.1016\/j.ijheh.2021.113715","article-title":"Household water insecurity will complicate the ongoing COVID-19 response: evidence from 29 sites in 23 low- and middle-income countries","volume":"234","author":"J Stoler","year":"2021","journal-title":"Int J Hyg Environ Health"},{"issue":"6","key":"pone.0359272.ref041","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0268851","article-title":"The determinants of sustained adherence to COVID-19 preventive measures among older Syrian refugees in Lebanon","volume":"18","author":"N Salti","year":"2023","journal-title":"PLoS One"},{"issue":"1","key":"pone.0359272.ref042","doi-asserted-by":"crossref","first-page":"13","DOI":"10.1186\/s13031-021-00349-6","article-title":"Vulnerability of Syrian refugees in Lebanon to COVID-19: quantitative insights","volume":"15","author":"FM Fouad","year":"2021","journal-title":"Confl Health"},{"key":"pone.0359272.ref043","doi-asserted-by":"crossref","first-page":"100011","DOI":"10.1016\/j.jmh.2020.100011","article-title":"Tackling COVID-19 in informal tented settlements (Lebanon): an assessment of preparedness and response plans and their impact on the health vulnerabilities of Syrian refugees","author":"P Moawad","year":"2020","journal-title":"J Migr Health"},{"key":"pone.0359272.ref044","unstructured":"REACH UNHCR. Comparative analysis of Syrian refugees staying in and outside camps: Kurdistan region of Iraq multi-sector needs assessment factsheet; 2014."},{"key":"pone.0359272.ref045","unstructured":"UNHCR, UNICEF, WFP. Vulnerability assessment of Syrian refugees in Lebanon. 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