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RESEARCH THEME 13: POLITICAL
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www.jogh.org • doi: 10.7189/jogh.11.17001 1 2021 • Vol. 11 • 17001
Samar Al-Hajj1,
Mohamad A Chahrour1*,
Ali A Nasrallah2*,
Lara Hamed1, Ian Pike3
1
Health Management and Policy
Department, Faculty of Health
Sciences, American University of
Beirut, Beirut, Lebanon
2
Department of Surgery,
American University of Beirut
Medical Center, Beirut, Lebanon
3
Department of Pediatrics,
Faculty of Medicine, University
of British Columbia. BC Injury
Research and Prevention Unit,
BC Children’s Hospital Research
Institute, Vancouver, BC, Canada
*Joint equal contributions.
Correspondence to:
Samar Al-Hajj
Assistant Professor of Public Health
Faculty of Health Sciences
American University of Beirut
Van Dyck Hall
PO Box 11-0236
Riad El-Solh
Beirut 1107 2020
Lebanon
sh137@aub.edu.lb
Physical trauma and injury: A multi-
center study comparing local
residents and refugees in Lebanon
Electronic supplementary material:
The online version of this article contains supplementary material.
© 2021 The Author(s)
JoGH © 2021 ISoGH
Background Refugees are susceptible to various types of injury mechanisms associat-
ed with their dire living conditions and settlements. This study aims to compare and
characterize the emergency department admissions due to physical trauma and inju-
ries among local residents and refugees in greater Beirut.
Methods This epidemiological study analyzes injury incidence and characteristics of
patients presenting to Emergency Departments of 5 sentinel hospitals between 2017
and 2019. Using the WHO Injury Surveillance Guidelines and Pan-Asia Trauma Out-
comes Study form, an injury data surveillance form was designed and used in hospital
settings to collect data on injuries. Chi-square test analysis was performed to determine
differences in injury characteristics between local residents and refugees. Regression
models were constructed to assess the effect of being a refugee on the characteristics of
injuries and outcomes of interest.
Results A total of 4847 injuries (3933 local residents and 914 refugees) were reported.
87.4% of the total injuries among refugees were sustained by the younger age groups
0-45 years compared to 68.8% among local residents. The most common injury mech-
anism was fall (39.4%) for locals and road traffic injury (31.5%) for refugees. The most
injured body part was extremities for both populations (78.2% and 80.1%). Injuries
mostly occurred at home or its vicinity (garden or inside the camp) for both popula-
tions (29.3% and 23.1%). Refugees sustained a higher proportion of injuries at work
(6%) compared to locals (1.3%). On multivariate analysis, refugee status was associated
with higher odds of having an injury due to a stab/gunshot (odds ratio (OR) = 3.392,
95% confidence interval (CI) = 2.605-4.416), having a concussion injury (OR = 1.718,
95% CI = 1.151-2.565), and being injured at work (OR = 4.147, 95% CI = 2.74-6.278).
Refugee status was associated with increased odds of leaving the hospital with inju-
ry-related disability (OR = 2.271, 95% CI = 1.891-2.728)]
Conclusions Injury remains a major public health problem among resident and refu-
gee communities in Beirut, Lebanon. Refugees face several injury-related vulnerabilities,
which adversely affect their treatment outcomes and long-term disabilities. The high
prevalence of occupational and violence-related injuries among refugees necessitates
the introduction of targeted occupational safety and financial security interventions,
aiming at reducing injuries while enhancing social justice among residents.
Cite as: Al-Hajj S, Chahrour MA, Nasrallah AA, Hamed L, Pike I.
Physical trauma and injury: A multi-center study comparing local
residents and refugees in Lebanon. J Glob Health 2021;11:17001.
Injury represents a leading cause of death and disability globally [1,2]. Annually, inju-
ry is responsible for over 5 million deaths, accounting for nearly 9% of global deaths
[3]. Each year, millions of people sustain non-fatal injuries that require emergency de-
partment (ED) visits and hospitalizations, impacting individuals’ health and exerting
Al-Hajj et al.
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financial pressure on health care systems [3]. The interplay of multiple intrinsic factors (eg, age, gender,
education, socio-economic status) and extrinsic factors (eg, external environment, available and accessible
health care service) strongly impact the frequency and severity of individual injuries [4-8]. Major discrep-
ancies in the distribution of the global burden of injury-related mortality and morbidity are noted, with
a substantial human and economic impact in low- and middle-income countries (LMICs) [9]. Due to the
lack of injury preventive measures and sub-optimal health care services in these jurisdictions, over 90% of
injury-related deaths occur in LMICs [10].
The Eastern Mediterranean Region (EMR) claims one of the highest global rates of unintentional fatal inju-
ries among LMICs and the second leading cause of disability adjusted life years (DALYs) for youth aged 15-19
years [11,12]. Lebanon, an upper middle-income country in the Eastern Mediterranean region sustain a large
toll of injury burden, as injury ranks 3rd among leading causes of death and 5th in the leading causes of DALYs
for the period 2000 to 2012 [13]. Additionally, regional wars and conflicts have exacerbated the injury pro-
file in EMR countries including Lebanon, and presented additional factors that increase individual morbidity
and mortality. The EMR, with its history of protracted political instability and regional wars, has witnessed the
internal displacement of millions of families and individuals seeking refuge in neighboring countries. Leba-
non endured frequent political unrest and conflicts, and reported high rates of injury morbidity and mortali-
ty [14,15] throughout its history. Recent regional war in neighboring Syria created an influx of refugees who
crossed into Lebanon and settled in camps and informal settlements across the country, accounting for almost
1/3 of the population residing in Lebanon in 2015 - the highest number of refugees per capita in the world [16].
Refugee status represents a pivotal determinant in increasing individual exposure to injuries, particularly
throughout their journey and settlements [17,18]. Review of existing literature demonstrates a discrepancy in
the frequency and nature of injuries sustained by refugees compared to local residents [4,19-24]. In Lebanon,
recent reports show that refugees sustain higher rates of injuries. For instance, in 2015, injuries accounted
for almost 19.8% of hospitalization among Syrian refugees, compared to 14.9% among the local community
[16]. Multiple interconnected factors aggravate refugee conditions and increase the risk of exposures to inju-
ries, namely overcrowded living conditions, unsafe cooking, heating and lighting sources, lack of resources
and poverty, and limited access to health care services. The literature is lacking a proper understanding of how
refugee status is linked to increased vulnerability and affinity towards various types of injuries, particularly in
the MENA region and Lebanon.
This study aims to understand the epidemiology and associated risk factors for injury among local and refu-
gee communities in Beirut. It further aims to compare the rates of ED admissions due to injuries among local
residents and refugees in greater Beirut, Lebanon. The generated evidence is essential to prioritize and adapt
data driven injury prevention programs and policies.
METHODS
Study design
This study is a descriptive epidemiological analysis of injury cases that presented to the ED of 5 sentinel hos-
pitals across the city of Beirut during the study period, June 2017 to May 2018. Sentinel hospitals expressed
willingness to collaborate and provide timely injury data, and each hospital was selected based on its location
in high population catchment areas. Participating hospitals were a mix of private and publicly funded, and each
was in a distinct geographic location relative to other hospitals. The study population included all people who
sustained an injury, whether intentional or unintentional, including poisoning, presenting at the participating
study hospitals. Within the context of this study, local residents refer to patients with a Lebanese nationality
while refugees refer to patients with a Syrian nationality.
Data collection
Data were collected for individuals presenting with an injury at any of the participating hospitals within the
12-month period, from June 2017 to May 2018). The Pan-Asia Trauma Outcomes Study (PATOS) guided the
design and development of a one-page injury data collection form for use in the ED at each of the hospitals
to capture and quantify the characteristics of presenting injuries in this study [25]. The one-page PATOS data
collection form was pilot tested at the primary site (American University of Beirut Medical Center) to ensure its
feasibility prior to the full-scale data collection at the 5 participating sites. Data collectors were trained on the
data collection form, and trained on ethics in Human Subjects Research (HSR) via the Collaborative Institu-
tion Training Initiative (CITI). At each hospital, patients’ ED medical records were filtered, and sampled based
Physical trauma and injury in Lebanon
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on the hospital monthly injury prevalence (number of injured cases/total ED visits) with a design precision of
5%-10% and a 95% confidence interval. Data were retrospectively reviewed, abstracted from patient charts
by the trained data collectors, and entered electronically into a secure-password database that is accessed and
managed only by authorized study investigators using RedCap electronic data capture tools [26]. All injury
cases meeting the study criteria were de-identified, included and assigned a unique identifier, precluding the
need for gathering any personal information. Injuries resulting in ED treatment and release, as well as those
resulting in death (at ED arrival or shortly after presenting to ED) were all captured from ED patient records.
Information collected included patients’ nationality, socio-demographic characteristics, injury epidemiology
(intent, mechanism, location, nature, place, activity at time of injury), risk factors (alcohol, substance, seat-
belt use), pre-hospital, ED, and hospital care, and injury outcome (death, hospitalization, treatment and dis-
charge from ED).
Statistical analysis
Statistical analyses were performed using the IBM SPSS statistical package (version 26, IBM Corp, Armonk NY,
USA). Continuous data were reported as means and standard deviations, and comparisons were made using
the independent t test. Categorical data were reported as counts and proportions with comparisons made using
the chi-square test, or the Fisher exact test, as appropriate. Multivariable logistic regression models were con-
structed to assess the effect of refugee status on the characteristics of injuries and outcomes of interest, while
adjusting for age, gender, intent and mechanism of injury. The results were presented as odds ratio (OR) and
95% confidence interval (CI). P < 0.05 was used to indicate statistical significance.
RESULTS
A total of 4847 injuries were reported at the 5 participating hospitals during the period June 2017 to May
2018. More males (63%) than females sustained injuries that required an ED visit. This difference was great-
er among refugee males (68.7%) and females. The average age among Lebanese and Syrian patients was 35.1
(±23.9) and 27.0 (±17.7), respectively. Nearly eighty-eight percent (87.4%) of all injuries among refugees were
sustained by the younger age groups (0-45 years) compared to 68.8% among Lebanese residents (P < 0.05),
while 31.2% of injuries reported among Lebanese and significantly fewer (12.6%) among Syrian refugees were
aged those 45+ years (P < 0.05). Table 1 presents baseline characteristics of the patient population included.
Table 1.
Baseline characteristics of patients presenting to the emergency department with injury, stratified by refugee status
Variable Number (%) P-value
Overall Lebanese Refugees
Patients 4847 3933 (81.1) 914 (18.9)
Age
Mean (SD) 33.6 (23.1) 35.1 (23.9) 27.0 (17.7) <0.001
Median (IQR) 28 (17-49) 29 (17-52) 25 (15-35) <0.001
0-<1 70 46 (1.2) 24 (2.6)
<0.001
1-<15 999 809 (20.6) 190 (20.8)
15-<25 1007 772 (19.6) 235 (25.7)
25-<45 1429 1079 (27.4) 350 (38.3)
45-60 734 658 (16.7) 76 (8.3)
>60 608 569 (14.5) 39 (4.3)
Gender Female 1789 1503 (38.2) 286 (31.3) <0.001
Male 3058 2429 (61.8) 629 (68.7)
Marital status
Married 909 829 (21.1) 80 (8.8)
<0.001Single 2363 1969 (50.1) 394 (43.1)
Unknown 1575 1135 (28.8) 440 (48.1)
Smoking status
Smoker 756 654 (16.6) 102 (11.2)
0.004Non-smoker 2219 2003 (50.9) 216 (23.6)
Unknown 1872 1276 (32.4) 596 (65.2)
Insurance status
Self 672 518 (13.2) 154 (16.8)
<0.001Private 2769 2475 (63.0) 289 (31.6)
Public/NGO 1406 935 (23.8) 471 (51.5)
Hospital type Public 4028 3554 (90.4) 474 (51.9) <0.001
Private 819 379 (9.6) 440 (48.1)
SD – standard deviation, IQR – interquartile range, NGO – non-governmental organization
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A significant difference was found in the hospital accessed for injury treatment and the insurance status be-
tween the two populations. Almost 90% of injured Lebanese sought treatment at private hospitals compared
to almost half that proportion (51.9%) among refugees. The proportion of refugees treated at public hospitals
(48.1%) was almost 5-fold higher than local residents (9.6%). This was similar for insured individuals, where
63% of the Lebanese population had private insurance compared with only 31.5% of Syrian refugees, who
were mostly covered by funds made available through the United Nations High Commissioner for Refugees
(UNHCR) and local and international NGOs (51.5%).
A significant difference was present in the mechanism of injury among local and refugee communities. The most
common injury among Lebanese residents was fall-related injury (39.4%); higher than those reported among
Syrian refugees (27.5%). Road traffic injuries (RTIs) were similar in both populations - 30.1% (Lebanese) and
31.5% (Syrian refugees). The majority of the injuries sustained by both communities were unintentional. The
prevalence of assault (interpersonal violence) among refugees was 2.1%, almost double that sustained by res-
idents (1.1%). Stab or gunshot injuries were significantly higher in the refugee population compared to locals
(12.6% and 3.7%, respectively). Both populations experienced high frequencies of upper and lower extrem-
ity injuries (78.2% and 80.1%) followed by head and facial injuries (24.5% and 23.2%). Local residents and
refugees experienced significantly different rates of injuries to the abdomen (1.9% and 3.6%, respectively).
Table 2.
Injury characteristics, stratified by refugee status
Variable Number (%) P-value
Overall Lebanese Refugees
Intent of
injury
Unintentional 4635 3783 (96.2) 852 (93.2) <0.001
Assault 61 42 (1.1) 19 (2.1) 0.014
Intentional self harm 66 56 (1.4) 10 (1.1) 0.438
Others 85 52 (1.3) 33 (3.6)
Mechanism
of injury
Fall 1797 1546 (39.3) 251 (27.5) <0.001
Fire, flame or heat 114 100 (2.5) 14 (1.5) 0.069
Stab or gun shot 262 147 (3.7) 115 (12.6) <0.001
Road traffic injury 1470 1182 (30.1) 288 (31.5) 0.388
Physical overexertion 373 319 (8.1) 54 (5.9) 0.024
Others 357 264 (6.7) 93 (10.2) <0.001
Unknown 474 375 (9.5%) 99 (10.8)
Body part
injured
Head 574 468 (11.9) 106 (11.6) 0.799
Face 601 495 (12.6) 106 (11.6) 0.414
Neck 102 90 (2.3) 12 (1.3) 0.064
Thorax 201 169 (4.3) 32 (3.5) 0.277
Abdomen 109 76 (1.9) 33 (3.6) 0.002
Spine 183 145 (3.7) 38 (4.2) 0.501
Upper extremity 1889 1520 (38.6) 369 (40.4) 0.336
Lower extremity 1921 1558 (39.6) 363 (39.7) 0.955
Skin 45 37 (0.9) 8 (0.9) 0.852
Other non-anatomical 25 12 (0.3) 13 (1.4) <0.001
Injury type
Fracture 1126 947 (24.1) 179 (19.6) 0.004
Strain/sprain 1211 1033 (26.3) 178 (19.5) <0.001
Cuts/bites/open wound 1205 871 (22.1) 334 (36.5) <0.001
Bruise 1225 1042 (26.5) 183 (20) <0.001
Burn 122 105 (2.7) 17 (1.9) 0.159
Concussion 156 119 (3) 37 (4) 0.115
Organ system 147 102 (2.6) 45 (4.9) <0.001
Other 11 7 (0.2) 4 (0.4) 0.137
Location
Home/garden/building 1362 1151 (29.3) 211 (23.1) <0.001
School/sports area 327 297 (7.6) 30 (3.3) <0.001
Street 537 433 (11) 104 (11.4) 0.749
Industrial/construction/work 107 52 (1.3) 55 (6) <0.001
Others 193 167 (4.2) 26 (2.8) 0.051
Activity
Work 305 192 (4.9) 113 (12.4) <0.001
Education/school 15 14 (0.4) 1 (0.1) 0.227
Sports 299 270 (6.9) 29 (3.2) <0.001
Leisure 2340 2033 (51.7) 307 (33.6) <0.001
Others 358 272 (6.9) 86 (9.4) 0.009
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Table 3.
Disposition outcomes of patients presenting with injury, stratified by refugee status
Variable Number (%) P-value
Overall Lebanese Refugees
Disposition
Treated and discharge 4022 3311 (84.2) 711 (77.8) 0.562
Admitted to hospital 469 404 (10.3) 65 (7.1) 0.018
Transferred to another hospital 29 23 (0.6) 6 (0.7) 0.684
Left AMA 161 110 (2.8) 51 (5.6) <0.001
Dead 21 (0) 1 (0.1) 0.301
GOS at
Discharge
Recovering 3550 2951 (79.9) 599 (74.8) <0.001
Moderate/severe disability 935 734 (19.9) 201 (25.1) 0.014
Vegetative/dead 87 (0.2) 1 (0.1) 0.941
AMA – against medical advice, GOS – Glasgow Outcome Score
The most common injury types sustained by locals were bruises/superficial injury and sprains/strains with
26.5% and 26.3% respectively compared to 20% and 19.5% among refugees. Similarly, fractures constituted
a larger proportion of injuries among locals (24.1%) than among refugees (19.6%). Refugees had a significant-
ly higher proportion of cuts/bites/open wounds and organ system injuries with 36.5% and 4.9% respectively
compared to 22.1% and 2.6% among locals.
Home/garden/building (inside camps in the case of refugees) were the most common site of injury in both
communities yet with slightly different proportions for locals (29.3%) compared to refugees (23.1%). Locals’
injuries occurred more often during leisure and sports-related activities (51.7% and 6.9% respectively), com-
pared with refugees (33.6% and 3.2% respectively). Refugees, however, had a noticeably higher proportion
of occupational injuries (12.4%) occurring at work sites; almost 2.5 times more than locals (4.9%). Table 2
presents the difference in injury characteristics for the two populations.
A significantly higher proportion of locals (10.3%) were admitted to hospitals compared with refugees (7.1%),
while a larger proportion of refugees (5.6%) left Against Medical Advice (AMA) compared with locals (2.8%).
While the majority of both locals (79.9%) and refugees (74.8%) left the hospital with no disability, the pro-
portion of refugees (25.1%) leaving with moderate/severe disability was higher compared to the local popula-
tion (19.9%). Table 3 presents the differences in outcomes for the two populations.
Multivariable logistic regression adjusting for age, gender, and intent of injury showed that refugee status was an
independent risk factor for sustaining gunshot or stab injuries (odds ratio (OR) = 3.392, 95% CI = 2.605-4.416,
P < 0.001), and a protective factor for sustaining a fall injury (OR = 0.701, 95% CI = 0.595-0.826, P < 0.001).
When adjusting for age, gender, intent of injury, and mechanism of injury, refugee status was significantly
associated with higher likelihood of sustaining cuts/bites/open wounds (OR = 1.304, 95% CI = 1.074-1.582,
P = 0.007), concussion (OR = 1.718, 95% CI = 1.151-2.565, P = 0.008) and organ system injury (OR = 1.769, 95%
CI = 1.161-2.695, P = 0.008) as well as lower odds for presenting with a bruise (OR = 0.741, 95% CI = 0.609-
0.901, P = 0.003). Refugee status was associated with higher odds of injuries sustained at industrial/construc-
tion/work site OR = 4.147, 95% CI = 2.74-6.278), P < 0.001) and lower odds of being injured at school or sports
areas OR = 0.393, 95% CI = 0.265-0.584, P < 0.001). As for outcomes, refugee status was associated with an
increased likelihood of leaving the hospital with some form of disability (OR = 2.271, 95% CI = 1.891-2.728,
P < 0.001). Figure 1 shows a summary of the multivariable logistic regression analysis.
DISCUSSION
This study compares injury characteristics, clinical disposition and risk factors among Lebanese and refugee
communities in the capital city of Beirut, Lebanon. Evidence from this study reveals distinct and relatively het-
erogeneous patterns of injuries and outcomes between residents and refugees. This disparity provides insights
into understanding the injury exposure and types of injuries sustained by both communities and allows for
the design of tailored injury prevention and safety programs.
Consistent with existing studies, a predominance of male injuries in both resident and refugee communities
was noted, with a slightly larger proportion of injuries among male refugees (68.7% vs 61.8%) [7,27]. The
refugees’ male workforce exposure to hazardous occupations in industrial or construction sites may increase
their vulnerability to injuries. Refugees had more than 4 times higher odds of presenting at an emergency de-
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partment with an injury sustained at the workplace compared with locals. Refugee’s harsh working conditions
and lack of proper training at workplaces have been reported as major contributing factors to this notable
disparity [28]. In particular, refugees mostly work as construction workers in Lebanon, with hazardous work
environments and an evident lack of proper safety measures adopted at construction and industrial sites [29-
32]. Similar evidence has been noted in a recent Canadian study indicating that refugees and recent immi-
grants have a higher risk of occupational safety hazards as they are less likely to receive information on safety
and health or undergo formal job training [7]. Refugees typically performed more physically demanding jobs
without the use of proper safety protection gears, which increase their risk for injury [24]. Similarly, in Germa-
ny, Spain, and France, the incidence of work-related injuries is higher among migrants compared to citizens,
particularly in jobs in industrial, construction, and agricultural sectors [33]. Refugees’ higher odds of present-
ing with concussion or organ system injury noted in this study may be traced to the severe injuries occurring
at construction sites, and result from such things as falling from a height. Higher prevalence of traumatic brain
injury (TBI) has been previously documented in refugee populations [18] in Denmark and the United King-
dom, leading to severe outcomes and long term disabilities [34,35].
A considerable variation in injury cases by age group and activities existed among residents and refugees. While
residents experienced a more diverse pattern of injury, distributed evenly across all age groups, refugees sus-
tained a high burden of injuries in age groups that might be considered productive, with a limited number of
injuries reported among the geriatric population. Refugees younger than 25 years of age experienced the larg-
er proportion of injuries, in line with previous studies indicating that the rate of unintentional injuries among
children and youth was 20% higher in refugees compared to non-refugees [7]. This trend may be explained
by refugees’ poor living conditions, overcrowded housing and inappropriate child care [27].
A significant difference between the refugees and local community was present in the access to care at public
vs private hospitals. Compared to public hospitals, Lebanese private hospitals typically maintain adequate
resources and infrastructure, reflecting enhanced patient services and provision of care [36]. Only 9% of
locals in the cohort sought care at public hospitals compared to almost 50% of the refugee population. As
refugees more often lack the means for out-of-pocket expenses to cover medical services, they are forced to
seek health care services at public hospitals and selected health care facilities subsidized by UNHCR and lo-
cal NGOs [37]. This highlights the issue of limited availability and accessibility of health care services among
refugees. With the limited public health care system in Lebanon, refugees’ increased rates of non-communi-
cable diseases and larger burden of injury places substantial strain on local system resources and often ex-
hausts its capacities [38,39].
Fall and road traffic injury were among the leading causes of injuries in both populations with a slight varia-
tion in age group distribution. Lebanese locals were at a higher risk of sustaining fall-related injuries, demon-
strated by the adjusted odds ratio of 0.7 that confirmed the decreased risk of fall-related injuries among ref-
ugees. Further analysis indicates that over 72% of the elderly Lebanese population suffered from fall-related
Mechanism -Stab/Gunshot
Mechanism -Physical Overexertion
Mechanism -Fire/Flame/Heat
Mechanism -Fall
Mechanism -RTI
Type -Orga n System
Type - Concussion
Type -Cut/Bite/Open Wound
Type -Fracture
Type
-Burn
Type -Strain/Sprain
Type -Bruise
Place -Industrial/Construction Site
Place -Street
Place -Home/Garden
Place -School/Sports Area
3.392 (2.605 -4.416)
0.967 (0.825 -1.134)
0.712 (0.527 -0.962)
0.701 (0.595 -0.826)
0.574 (0.325 -1.013)
1.769 (1.161 -2.695)
1.718 (1.151 -2.565)
1.304 (1.074 -1.582)
1.16 (0.94 -
1.432)
0.98 (0.315 -3.046)
0.822 (0.664 -1.019)
0.741 (0.609 -0.901)
2.647 (2.03 -3.452)
0.484 (0.408 -0.575)
0.434 (0.289 -0.65)
0.245 (0.031 -1.929)
01234567
Figure 1.
Forest plot showing adjusted odds ratios and 95% confidence intervals for Syrian refugee status as a risk/protec-
tive factor for each mechanism, type, and place of injury.
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injuries, consistent with current literature which underscores the propensity of older adults to suffer from fall
injuries [40-42]. Road traffic injury represents another major contributor to injuries in both resident and ref-
ugee communities. While this aligns with regional data showing a similar high proportion of emergency vis-
its due to road traffic injuries, it is divergent to studies conducted in China and Canada showing increased
risk for suffering from motor-vehicle accidents and severe traffic injuries in refugee communities compared to
non-refugees, as well as to a study conducted in Turkey showing an opposite higher proportion of road traffic
injuries among locals [7,23,27]. Road traffic injuries, hence, highly depend on the specificities of the local en-
vironment and its built-in safety infrastructure. In Lebanon, the absence of road safety measures coupled with
the lack of compliance and enforcement, represent major contributing factors responsible for the high rates of
road traffic injuries sustained by both local and refugee communities alike [43].
Even though most injuries were unintentional in both populations, assault injuries reported by refugees con-
stituted a 2-fold higher proportion than that sustained by locals. Nonetheless, these numbers could have been
subject to a reporting bias as patients presenting to the emergency department may hide the true intent of
injury to avoid possible police investigations, especially as many refugees seek refuge in Lebanon unlawful-
ly. This could be further delineated by the high proportion of stabbing and gunshot injuries among refugees
constituting 12.6% of all injuries compared to 3.7% among the local population. The increased risk of assault
injuries among refugee communities has been previously documented [21], and may be explained by multi-
ple factors including poverty and possible criminal gang involvement [44,45]. Refugees, having been subject
to trauma, instability and displacement stressors, are exposed to accumulated mental disturbances, leading to
an increased tendency toward assault and violence [46-48].
Patient dispositions and outcomes varied considerably between the two populations. Refugees had almost
2.3 times greater odds of being discharged with a Glasgow Outcome Score (GOS) of moderate to severe
disability compared to locals. The increased injury morbidity and mortality among the refugee community
is often shaped by a combination of multiple factors, including unsafe living conditions, hazardous work-
ing environments, and limited access to health care services [49]. While the worse outcomes could be due
to initially more severe injuries, this high proportion raises a major concern regarding the environment in
which refugees live and work, and the quality of health care service they access. The potential discrepan-
cy in severity of injury on presentation could be due to a higher exposure of risky settings and violence, as
well as the lack of access to immediate health care services which exacerbates the injury severity and affects
outcome due to delayed and sub-optimal health care services [50]. In the same context, almost double the
proportion of refugees elected to leave the hospital Against Medical Advice (AMA) compared to locals, fur-
ther elucidating refugees’ limited access to health care and possible inability to afford hospital admission
associated health expenditures [49].
A series of recommendations aiming at decreasing injuries among the refugee community can be presented
based on evidence provided from this study. First and foremost, protective policies and procedures should
be implemented to prevent workplace injuries and to safeguard workers’ occupational health and safety [24].
Second, appropriate work training and injury awareness programs should be integrated to increase safety
at the workplace. Third, concerted efforts should focus on designing safe and appropriately populated refu-
gee camps, in addition to developing and delivering awareness and educational activities at camp sites that
aim to educate refugees and raise awareness about common injuries sustained at camps. Fourth, to ease the
problem of violence and assault within the refugee community, efforts should be focused on mitigating pov-
erty and alleviating mental health problems. Securing job opportunities and providing refugees with finan-
cial support can safeguard them from seeking illegal channels of money, and render them less susceptible
to be involved in violence and assault [51,52]. Similarly, working on refugees’ mental well-being can help
to alleviate the psychiatric conditions that might perpetuate the tendency to engage in violent acts within
refugee communities [53]. Finally, more resources should be secured to ensure refugees’ easy access to the
health care services in the country.
To the best of our knowledge, this study is the first that compares the various factors, characteristics, and out-
comes of injuries sustained by refugees and locals residing in Lebanon. The study, however, is not without
limitations. First, the study is a retrospective and may be hindered by the availability of certain injury-related
variables. Second, a methodological limitation might be introduced with the inclusion of all patients with Syr-
ian nationality under the group of refugees, as a minor proportion of those could have been living in Lebanon
even prior to the onset of the Syrian war. Third, the absence of the injury severity score at ED presentation
limited the ability to accurately assess patients’ treatment outcomes. Moreover, as socioeconomic status may
play a role in injury characteristics and outcomes, having access to household income data may have proved
helpful in further stratifying the analysis, and is encouraged in future studies of this nature. Nonetheless, with
Al-Hajj et al.
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data pooled from 5 public and private hospitals covering all age groups, this study captured a representative
sample of the local citizen and refugee populations, enhancing our understanding of the types and risks of in-
jury, and increasing its generalizability in recommending injury prevention strategies.
CONCLUSION
Injury remains a major public health problem among resident and refugee communities in Beirut, Lebanon.
Refugees face several injury-related vulnerabilities due to their harsh living and working conditions coupled
with their limited access to health care services, which adversely affects their treatment outcomes and long-
term disabilities. The high prevalence of occupational and violence-related injuries among refugees necessi-
tates the introduction of targeted occupational safety interventions, aiming at reducing injuries while enhanc-
ing social justice among residents.
Ethics: This study was approved by the American University of Beirut Institutional Review Board (IRB # 2018-0061) and
by the ethical committee at each participating hospital.
Funding: This study was supported by a fund from the National Council for Scientific Research in Lebanon
Authorship contribution: SA conceptualized the idea; SA, MC, AN and LH contributed to drafting the manuscript; MC,
AN and IP contributed to the data analysis; All authors have contributed to the editing of the manuscript; All authors have
approved the final version of the paper. SA conceptualized the idea; SA, MC, AN and LH contributed to drafting the man-
uscript; MC, AN and IP contributed to the data analysis; All authors have contributed to the editing of the manuscript;
All authors have approved the final version of the paper.
Competing interests: The authors completed the ICMJE Unified Competing Interest Form (available upon request from
the corresponding author), and declare no conflicts of interest.
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