Physical Injuries and Burns among Refugees in Lebanon: Implications for Programs and Policies

Abstract

Background: Refugees are prone to injury due to often austere living conditions, social and economic disadvantages, and limited access to health care services in host countries. This study aims to systematically quantify the prevalence of physical injuries and burns among the refugee community in Western Lebanon and examine injury characteristics, risk factors, and outcomes.
Methods: We conducted a cluster-based population survey across 21 camps in the Beqaa region of Lebanon from February to April 2019. A modified version of the ‘Surgeons Overseas Assessment of Surgical Need (SOSAS)’ tool (Version 3.0) was administered to the head of the refugee households and documented all injuries sustained by family members over the last 12 months. Descriptive and univariate regression analyses were performed to understand the association between variables.
Results: 750 heads of households were surveyed. 112 (14.9%) households sustained injuries in the past 12 months, 39 of which (34.9%) reported disabling injuries that affected their work and daily living. Injuries primarily occurred inside the tent (29.9%). Burns were sustained by at least one household member in 136 (18.1%) households in total. The majority (63.7%) of burns affected children under 5 years and were mainly due to boiling liquid (50%). Significantly more burns were reported in households where caregivers cannot lock children outside the kitchen while cooking (25.6% vs 14.9%, p-value=0.001). Similarly, households with unemployed heads had significantly more reported burns (19.7% vs 13.3%, p-value=0.05). Nearly 16.1% of the injured refugees were unable to seek health care due to the lack of health insurance coverage and financial liability.
Conclusions: Refugees severely suffer from injuries and burns, causing substantial human and economic repercussions on the affected individuals, their families, and the host healthcare system. Resources should be allocated toward designing safe camps as well as implementing educational awareness campaigns specifically focusing on teaching heating and cooking safety practices.

Full text

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Physical Injuries and Burns among Refugees in
Lebanon: Implications for Programs and Policies
Samar Al-Hajj (  sh137@aub.edu.lb )
American University of Beirut
Moustafa Moustafa
University of Virginia
Majed El-Hechi
Harvard Medical School
Mohamad A. Chahrour
American University of Beirut Medical Center
Ali A. Nasrallah
American University of Beirut Medical Center
Haytham Kaafarani
Harvard Medical School
Research Article
Keywords: Refugee, Injury, Burn, Prevention, Lebanon
Posted Date: September 16th, 2022
DOI: https://doi.org/10.21203/rs.3.rs-2062219/v1
License:   This work is licensed under a Creative Commons Attribution 4.0 International License. 
Read Full License

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Abstract
Background: Refugees are prone to injury due to often austere living conditions, social and economic
disadvantages, and limited access to health care services in host countries. This study aims to
systematically quantify the prevalence of physical injuries and burns among the refugee community in
Western Lebanon and examine injury characteristics, risk factors, and outcomes.
Methods: We conducted a cluster-based population survey across 21 camps in the Beqaa region of
Lebanon from February to April 2019. A modied version of the ‘Surgeons Overseas Assessment of
Surgical Need (SOSAS)’ tool (Version 3.0) was administered to the head of the refugee households and
documented all injuries sustained by family members over the last 12 months. Descriptive and univariate
regression analyses were performed to understand the association between variables.
Results: 750 heads of households were surveyed. 112 (14.9%) households sustained injuries in the past
12 months, 39 of which (34.9%) reported disabling injuries that affected their work and daily living.
Injuries primarily occurred inside the tent (29.9%). Burns were sustained by at least one household
member in 136 (18.1%) households in total. The majority (63.7%) of burns affected children under 5
years and were mainly due to boiling liquid (50%). Signicantly more burns were reported in households
where caregivers cannot lock children outside the kitchen while cooking (25.6% vs 14.9%, p-value=0.001).
Similarly, households with unemployed heads had signicantly more reported burns (19.7% vs 13.3%, p-
value=0.05). Nearly 16.1% of the injured refugees were unable to seek health care due to the lack of
health insurance coverage and nancial liability.
Conclusions: Refugees severely suffer from injuries and burns, causing substantial human and economic
repercussions on the affected individuals, their families, and the host healthcare system. Resources
should be allocated toward designing safe camps as well as implementing educational awareness
campaigns specically focusing on teaching heating and cooking safety practices.
Background
Injury is the leading cause of death and disability in people under the age of 44 (1, 2). While high-income
countries (HICs) demonstrated a steady decrease in the rate of injuries with time, low- and middle-income
countries (LMICs) showed an increasing trend (3). This can be attributed to multiple reasons, particularly
due to the absence of safety regulations and injury prevention strategies in many LMICs (4).
The Eastern Mediterranean Region (EMR) has the highest rate of injuries related to deaths and disability-
adjusted life years (DALYs) among LMICs, particularly injuries related to road trac crashes and violence
(5–7). According to the Global Burden of Disease (GBD 2019), injury-related deaths in the EMR were
estimated at 56.2 per 100,000, ranking 4th compared to global rates (8). Wars and regional conicts have
exacerbated injury prevalence in many EMR countries and rendered the provision of healthcare services
limited, if not, scarce, particularly in war-affected regions (9). The recent Syrian conict has resulted in

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what has been classied as the worst humanitarian crisis in history (10), with millions of individuals
displaced internally or seeking refuge in bordering countries (11).
Lebanon has taken in the highest number of Syrian refugees relative to its population, estimated at nearly
30% of its current population (12). The refugee crisis has strained the already fragile Lebanese healthcare
system. Several studies have demonstrated a high prevalence of communicable disease (10, 13–15), and
injuries of varying etiologies among the refugee community (i.e. camp burns secondary to open-ame
cooking) (16, 17).
Few studies have examined the physical trauma and injury burden sustained by refugee communities,
particularly in the EMR (15, 18). Global health has traditionally focused on communicable diseases with
limited attention dedicated to injuries (19). The main objective of this study is to quantify and describe
the injury burden among a refugee community in the Northern Beqaa region of Lebanon and offer
insights into the injuries' characteristics, extent, risk factors, and outcomes. Understanding the frequency
and severity of refugees’ injuries is vital to the planning of injury prevention programs, mitigation of injury
impact on the refugee community, and for reducing the strain on the Lebanese healthcare system.
Methods
Study Design and Tool adopted
The study was designed as a cross-sectional cluster-based population survey. The Surgeons Overseas
Assessment of Surgical Need (SOSAS) tool (Version 3.0) (www.surgeonsoverseas.org) was used to
collect data from 21 refugee camps across the Beqaa Valley in Lebanon. This survey is a validated,
cluster-based, cross-sectional tool designed based on the Demographic and Health Surveys (DHS)
guidelines and the World Health Organization (WHO) guidelines for conducting community surveys for
injuries and violence to determine the burden of surgical conditions within a community (20–24). Minor
modications were applied to contextualize the tool, tailor it to the Syrian refugee population and expand
it to collect specic data on physical injuries and burns. For this study, a burn injury was captured
independently and not considered under the umbrella of physical injuries.
Data Collection
The survey was administered to the head of the refugee household here all injuries sustained by family
members over the last 12 months were recorded. A total of 750 households were conveniently sampled
by selecting the 4th residence along the most accessible major routes. If the tent was vacant or absent of
adults, the next residence along the route was selected. Participants provided verbal informed consent
prior to their participation.
Four bilingual research assistants familiar with the local geography, culture, and Arabic language were
recruited and trained to administer the SOSAS questionnaire. The training of data collectors was
conducted over a period of two weeks and included simulated practice sessions with role-playing

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followed by a supervised data collection process at campsites for the initial phases of the study. Data
collection took place over three months between February - April 2019.
The study was approved by the American University of Beirut Institutional Review Board (SBS-2018-
0561).
Statistical Analysis
The Statistical Package for Social Sciences (SPSS) (version 24) (IBM Corp., Armonk NY, USA) was used
for data management and analyses. A descriptive analysis was performed. Continuous data were
reported as means with standard deviations, and comparisons were made using the independent t-test.
Categorical data were reported as counts with proportions and comparisons reported using the Chi-
Square test, or the Fisher's exact test, as appropriate. A two-sided p-value < 0.05 was used to indicate
statistical signicance.
Missing data was encountered secondary to an incomplete response rate for all questions. Only collected
data were analyzed, and no imputation techniques were used for any missing responses. The percentage
of missing data for each variable is underlined in the footnote of its respective table.
Results
Demographics
A total of 750 heads of households were surveyed. The mean number of individuals per
household/informal tented settlement (ITS) was 6.4. The mean age of individuals in each household was
20.4 years (Fig. 1). Syrian governorates of origin were diverse with Aleppo (31.7%) and Raqqa (30.0%)
being the most highly represented region, followed by Homs (12.2%), Idleb (11.3%), and Hama (7.5%).
The average length of stay in Lebanon was 5 years (+/- 2.5). The majority of refugees were illiterate
(59.0%) and nearly (72.2%) were unemployed.
Prevalence of Physical Injury
A total of 112 households (14.9%) reported sustaining an injury within the past year. Of these, 18 (16.1%)
reported being unable to seek healthcare services due to a lack of nancial means.
Injuries were sustained at multiple locations with the highest being inside the tent (29.9%) and on the
road (28.6%) (Table 1). Twenty-two (19.6%) injuries were classied as occupational. Road trac injuries
(RTI) were sustained in 19 households (17%), as mostly (73.7%) were due to a motorcycle crash. None of
the injured refugees were adopting any safety measures while driving.


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Table 1
Injury distribution in distinct locations.
Location Number (%)
On camp (Inside Tent) 23 (29.9)
On camp (Outside Tent) 10 (13)
Road 22 (28.6)
Field 3 (3.9)
Other 19 (24.7)
The long-term effect of injuries varied, with 70 (62.5%) injuries reported as non-disabling, 39 (34.9%)
injuries affected individuals’ work and daily living, and 3 (2.7%) injuries were reported as having a
psychological impact (i.e. feeling ashamed) (Fig. 2).
Prevalence of Burns
A total of 136 households (18.1%) reported a burn to one of the household/tent members. Of those
suffering from burns, 67 (53.6%) were males and 58 (46.4%) were females. The mean age of the injured
individual was 8.2 years (± 12.4) and the majority (63.7%) of burns were incurred by children less than 5
years. Burns affected different body parts, with the highest rate affecting the hand/arm (50%), leg
(19.4%), and face (11.3%) (Table 2).

Table 2
Burns distribution on body parts.
Body Part Number (%)
Hand 36 (29)
Face 14 (11.3)
Arm 26 (21)
Leg 24 (19.4)
Foot 13 (10.5)
Multiple 11 (8.9)
*12 burns unknown 
Half of the burns (49.6%) were caused by direct contact with a boiling liquid, 30.9% by contact with hot
objects, and 13.8% by contact with an open ame. The mode and location of cooking varied amongst
households. While 78.4% of households use propane for cooking, 21.6% use an open ame. Most
cooking occurred inside tents (77%). The chi-squared test showed signicance when examining ‘Burn’
and ‘No Burn’ among refugees’ households. There was no signicant association between the mode or

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location of cooking and sustaining a burn injury (Table 3). Of the 750 households, 227 (30.3%) reported
the inability of child lockout while cooking. Those tents had signicantly higher reported burn cases
(25.6% vs 14.9%, p = 0.001). Households with an unemployed head member were more likely to sustain
more burns (19.7% vs 13.3%, p-value = 0.05), compared to employed households (Table 3).

Table 3
Incidence of burns in association with different tent-related variables.
Variable Number (%)
p-value
Burn No Burn
Tents 136 614
Mode of Cooking Propane 79 (18.2) 356 (81.8) 0.204
Open Flame 28 (23.3) 92 (76.7)
Location of Cooking Indoor 78 (18.2) 351 (81.8) 0.187
Outdoor 30 (23.4) 98 (76.6)
Child Locked Yes 78 (14.9) 445 (85.1) 0.001
No 58 (25.6) 169 (74.4)
Employed Household Yes 24 (13.3) 147 (86.7) 0.05
No 112 (19.7) 457 (80.3)
Literate Household Yes 36 (14.8) 207 (85.2) 0.102
No 100 (19.7) 407 (80.3)
*195 tents have an unknown mode of cooking
*193 tents have an unknown location for cooking
Discussion
This study examined the characteristics, risk factors, and outcomes of injuries affecting the refugee
community in Lebanon. Refugee status increases individuals’ risk of sustaining various injuries,
particularly those associated with overcrowded living conditions and hazardous work environments. This
study provides evidence on the prevalence of injuries and burns among refugees, which in turn helps to
tailor data-driven injury prevention programs and strategies applicable to the context of refugees. These
preventive measures attempt to mitigate the injury burden on the refugee community and reduce the
demand for health and rehabilitation services in host healthcare systems (16, 25, 26).
This study aligns with existing literature and conrms the high prevalence of injuries among the refugee
population in Lebanon (18, 27, 28). A recent local study indicated that a high proportion of medical care

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services provided to adult Syrian refugees are related to injuries, compared to those provided to local
residents in Lebanon (18, 27, 28). Moreover, injuries were the leading cause of hospitalization among
refugees, accounting for nearly 19.8% of hospitalizations compared to 14.9% among the host community
(29). This discrepancy in injury rates has been documented in various countries; a Canadian study
reported an increased rate of motor vehicle injuries, poisoning, suffocation, and overall injury-related
hospitalization and mortality among refugees (27). A similar study conducted in Denmark revealed high
rates of fatal injuries among refugees (30).
Household injuries were mostly reported in this study. Most refugee injuries occurred in tents (29.9%),
further highlighting the refugees’ suboptimal housing conditions, overcrowded households, and
adjacently installed tents. Diminished housing conditions and the absence of safety measures in camps
are major contributors to the high prevalence of injuries among refugees (17). RTI (17%) represented
another major contributor to the refugee injury burden. A similar estimate (19%) of RTI was reported
among Afghan refugees in Pakistan (31). The adoption of safety measures (e.g., wearing helmets, and
safety gear) were nearly absent among injured individuals.
Limited access to healthcare services hinders refugees’ ability to obtain timely care following an injury.
16% of the refugees who reported an inability to afford injury-related treatment underscore refugees’
social and economic disadvantages and their impact on health. Refugees often suffer from a lack of
knowledge on how to navigate the healthcare system in host countries, and how to benet from available
health services, which ultimately adds yet another barrier to healthcare access (32, 33).
With the fragile, highly privatized, and under-resourced healthcare system available in Lebanon, providing
care to the local population is already a challenge that is exacerbated by the refugee crisis (34). This
under-resourced healthcare system, particularly in refugee areas, coupled with refugees’ increased need
for healthcare services beyond that of the local population, worsens the economic burden of refugee
communities on the host healthcare system (35, 36). Refugees are forced to cover their health expenses,
and often resort to borrowing money to cover their out-of-pocket expenditures for injury treatment.
Findings from this study conrm the high prevalence of serious injuries leading to varying levels of
physical impairment that affect refugees’ daily living activities. Many of the reported injuries result in
severe prognoses, which may lead to permanent disabilities. This would limit the integration of refugees
into the workforce and accordingly limit their nancial capabilities, further increasing refugees’ burden on
host countries. A study in war-torn Baghdad found the rates of permanent disabilities following
unintentional injuries were as high as 56% (28). A similar trend was found in the United Kingdom among
a population of refugees and migrants with 38% of head injuries causing persisting disability (37).
Similar to physical injury, burns were also a common health problem among refugees with a prevalence
of over 18%. This rate is comparable to other refugee populations: 11% among Afghan refugees in
Pakistan, 17% among Syrian refugees in Turkey, and 7% among Syrian refugees in Belgium (18, 31, 38).
Refugees’ parental education levels (e.g., illiteracy), cultural practices (e.g., child supervision, cooking
traditions), and housing conditions (e.g. overcrowded, unsafe heating techniques) are known to be risk

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factors that increase the risk of sustaining injuries among refugees (39, 40). Camps are often used long
beyond their temporary design intention leading to structural failures that often compromise safety.
Results of this study show that unemployment and the inability to keep children away from cooking
areas are associated with a higher prevalence of burns. Notably, the number of burn injuries was higher in
households adopting unsafe cooking practices using open ames instead of propane, however, this
association was not statistically signicant. Similarly, burn case numbers were higher among households
where the head of household claimed illiteracy, but again, this was not statistically signicant.
Based on the study ndings, a series of recommendations to help reduce and control injuries among
refugees can be proposed. First, refugee camps should be designed with high safety standards focused
on avoiding injuries and burns (e.g., a larger lot for each tent to reduce family overcrowding and build
camps away from major highways to reduce RTI). Second, a special focus should be given to the safe
placement of heating and cooking appliances within camps. Tailored training on safe cooking practices
should be considered.
Third, adequate Occupational Health and Safety (OHS) training should be provided, focusing on
industrial and other high-risk work environments. Finally, refugees should be educated on how to access
the local healthcare system and informed of methods for obtaining nancial support for health-related
needs.
To our knowledge, this is the rst study to quantify physical injuries and burns among Syrian refugees in
Lebanon which has the highest Syrian refugee per capita density. The results of our study can be
generalizable to other refugee populations in the Middle East and Northern African (MENA) region, which
share many cultural practices and living conditions. This study has several notable limitations. First, data
is largely self-reported by household members. Recall bias must be considered as the collected
information spans over twelve months. Second, data underreporting is considered another possible
limitation of this study. This, however, might be mitigated by social concerns and fear of the stigma that
may lead to underreporting of injury-related disabilities, particularly those affecting women and children.
Conclusions
Refugees suffer from a high burden of injuries and burns in Lebanon, with substantial human and
economic repercussions on families and the host healthcare system. This study provides ground
evidence for the development injury prevention programs targeting refugees. Education on safety
guidelines and preventive measures should be introduced as standard protocols among the refugee
community. Resources should be allocated for safe camp design, with a special focus on heat appliances
and cooking methods. Further research is needed to understand the circumstances surrounding distinct
types of injuries among refugees.
Abbreviations

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DALYs:
Disability-Adjusted Life Years
DHS:
Demographic and Health Surveys
EMR:
Eastern Mediterranean Region
GBD:
Global Burden of Disease
HICs:
High-Income Countries
ITS:
Informal Tented Settlement
LMICs:
Low- and Middle-Income Countries
MENA:
Middle East and Northern African
OHS:
Occupational Health and Safety
RTI:
Road trac injuries
SOSAS:
Surgeons Overseas Assessment of Surgical Need
SPSS:
Statistical Package for Social Sciences
WHO:
World Health Organization
Declarations
Ethics Approval and Consent to Participate
The American University of Beirut Institutional Review Board approved the study (SBS-2018-0561).
Consent was deemed applicable by the committee. All participants were above 18 and were carefully
briefed about this study. Written informed consent was obtained from all participants. All methods were
performed in accordance with the ethical standards as laid down in the Declaration of Helsinki and its
later amendments or comparable ethical standards.
Consent for Publication
Not applicable.
Availability of Data and Material
The datasets generated during and/or analyzed during the current study are available from the
corresponding author on reasonable request.
Competing Interests

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The authors declare that they have no competing interests.
Funding
This study did not receive funds.
Authors' Contributions
S.A. drafted the manuscript. M.EH., M.C., and A.N. conducted the data analysis and contributed to the
drafting of the manuscript. M.M. and H.K. conceptualized and designed the study, and reviewed and
edited the manuscript.All authors approved the nal manuscript as submitted and agree to be
accountable for all aspects of the work.
Acknowledgements
Not applicable.

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Figures

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Figure 1
Distribution of injury across age, mechanisms, and body parts.

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Figure 2
Distribution of injuries by type and impact on life.