**1. Introduction**

During the 21st century, the world experienced a considerable increase in the number of individuals who were forced to migrate due to conflicts, civil disorder, expulsion, and assault. The number of refugees and asylum seekers escalated from 17 to 34 million between 2000 and 2020, with half of it being composed of women and girls [1]. In 2021, 25% of the global refugees come from Syrian Arab Republic. Most of Syrian refugees are hosted by neighboring countries, where 19 out of 20 live in urban regions [2]. Lebanon is one of those countries, which hosts the worldwide highest number of refugees per capita [3]. The Lebanese Government did not allow the creation of camps as formal settings for Syrian refugees, who as a consequence became scattered across the country and inhabiting rented rooms, apartments, garages, and informal tented settlements (ITSs) [4–6]. Furthermore, 89% of Syrian refugee families in Lebanon live below the survival minimum expenditure basket (SMEB) defined in the country and experience distressing living conditions [7,8].

The armed conflict in Syria, which continues since 2011, did not only create a public health catastrophe within the country, but also critical public health challenges in the neighboring countries which received refugees [9]. The Lebanese healthcare system is inequitable, in large shares privatized, and is based on out-of-pocket payments [10,11].

**Citation:** Korri, R.; Froeschl, G.; Ivanova, O. A Cross-Sectional Quantitative Study on Sexual and Reproductive Health Knowledge and Access to Services of Arab and Kurdish Syrian Refugee Young Women Living in an Urban Setting in Lebanon. *Int. J. Environ. Res. Public Health* **2021**, *18*, 9586. https:// doi.org/10.3390/ijerph18189586

Academic Editors: Lillian Mwanri, Hailay Gesesew, Nelsensius Klau Fauk and William Mude

Received: 13 July 2021 Accepted: 9 September 2021 Published: 11 September 2021

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**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

With the arrival of Syrian refugees, the system became additionally strained with an excessive demand since its coverage had also to cope with disadvantaged Lebanese individuals, Lebanese citizens returning from Syria, Palestinian refugees that had to give up their settlements in Syria, and in general with an already pre-existing refugee population in the country consisting mainly of Palestinian refugees that arrived in the aftermath of the conflicts of 1948 and 1967 [12]. As a result, the refugees were left with restricted, insufficient, and hard to access services [10,13].

Previous research showed that young people and women experience additional hardships during conflicts and emergencies that lead to health deterioration [14,15]. Women and girls living in humanitarian settings tend to suffer from poor sexual and reproductive health (SRH) outcomes, which put them at increased risk of morbidity and mortality [16–19]. Furthermore, Syrian refugee women in Lebanon experience difficulties when seeking SRH services because of high service costs, absence of female healthcare providers, and discriminatory attitudes from providers [20,21]. A needs assessment has shown that only 32% of Syrian women within the reproductive age in Lebanon consider SRH services easily accessible, while 38% think that these services are practically unavailable and 17% are unaware that these services even exist [22]. Moreover, a situation analysis conducted in 2013 by the United Nations Population Fund (UNFPA) on youths in Lebanon, who are affected by the Syrian crisis, found that only 31% of refugee participants received health services, and 56% of those found the services satisfactory. The analysis also showed that Syrian youths had insufficient knowledge on SRH issues. For instance, only 45% of refugee youths self-declared knowledge of contraceptive methods, of whom one quarter indicated withdrawal as one of the methods [23].

Since data on the SRH of young refugee women living in urban settings in Lebanon are particularly scarce, the general aim of this exploratory study is to assess the SRH status of Arab and Kurdish Syrian refugee young women living in Bourj Hammoud. Its specific objective is to determine the knowledge of refugee young women on SRH issues such as sexually transmitted infections (STIs) and contraceptive methods on one hand and their access to SRH services such as ever visited health facility in Lebanon and healthcare provider characteristics on the other hand. The agenda of the International Conference on Population and Development (ICPD) and the *Inter-Agency Field Manual on Reproductive Health in Humanitarian Settings* (IAFM) by the Inter-Agency Working Group on Reproductive Health in Crises (IAWG) form the framework of the study [17,24]. Its objective and results are in line with the Sustainable Development Goal (SDG) Number Three—*ensure healthy lives and promote well-being for all at all ages*—which also encompasses the necessity to advance reproductive, maternal, and child health [25]. This study complements a qualitative research, conducted previously by our team, in which qualitative insights on knowledge and experiences around SRH of Syrian girls aged between 13 and 17 years also living in Bourj Hammoud were provided [26]. Our findings are aimed at improving and focusing health promotion activities on SRH in refugee populations.

#### **2. Materials and Methods**

#### *2.1. Study Setting*

According to the United Nations High Commissioner for Refugees (UNHCR), 8141 Syrian refugees registered the industrial area of Bourj Hammoud as their place of residence [27]. The area has a history of accommodating refugees since the 1920s, where Armenians arrived after surviving genocide and escaping expulsion by Ottomans [28]. In the present, individuals with lower socio-economic status—including Lebanese citizens, Syrian, Palestinian, and Iraqi refugees, and migrant workers—reside in Bourj Hammoud [29,30]. The suburb, which is one of the most heavily inhabited in the Middle East, suffers from inadequate living conditions such as unsatisfactory infrastructure, hygiene conditions, and supply of electricity and clean drinking water [28,31].

#### *2.2. Study Design*

We employed a cross-sectional survey to explore the SRH knowledge of refugee young women and their experiences in accessing services. The questionnaire consisted of five sections: demographic characteristics (e.g., age, ethnic group, level of education); displacement characteristics (e.g., year of fleeing, reason of fleeing, and duration of stay in Bourj Hammoud); individual agency in displacement (e.g., head of household, healthcare decision making power); SRH knowledge (e.g., sources of information, knowledge on contraceptive methods and STIs); experiences in accessing SRH services (e.g., ever visited health facility in Lebanon for SRH services, healthcare provider characteristics); and experiences of pregnancy (e.g., number of pregnancies and antenatal care visits in Lebanon). The questionnaire's different parts were developed based on two validated tools: Reproductive Health Assessment Toolkit for Conflict-Affected Women, CDC, 2007 [32] and Adolescent Sexual and Reproductive Health Toolkit for Humanitarian Settings, UNFPA and Save the Children, 2009 [33]. The questionnaire was designed in English, translated into Arabic, and piloted before the start of the data collection.

### *2.3. Sample Participants*

We calculated a sample size of 297 and managed to enroll 305 Syrian refugee young women. The sample size was determined based on Cochran's (1963) formula for cross sectional studies with a precision of 5% and a confidence level of 95% [34]. The prevalence of self-claimed knowledge of contraceptive methods among Syrian refugee girls and young women from previous studies was adopted [23,35]. Snowball sampling was used to recruit participants. When conducting research that includes hidden groups such as vulnerable refugee communities, snowball sampling method is found to be the most suitable [36,37].

Five different snowball starting points were applied through five Syrian female community gatekeepers. In order to avoid a homogenous sample and to ameliorate representation, gatekeepers belonging to various age and ethnic groups, coming from different areas in Syria, and having distinct socio-economic characteristics (e.g., education level and monthly income) were chosen. Additionally, we allowed only a limited number of participants from each resulting chain [38,39]. The efficiency of engaging gatekeepers in the recruitment procedure for research on sensitive topics that involve refugee communities as participants has been previously reported [40,41]. The inclusion criteria of respondents were: bearing Syrian nationality, belonging to Arab or Kurdish ethnic groups, age between minimum 18 and maximum 30 years, and date of arrival to Lebanon only after the start of the armed conflict in Syria (set at 15 March 2011). Eight questionnaires were excluded from the study, since their corresponding participants moved to Lebanon before 15th of March 2011. Since snowball sampling was implemented, there is no means to estimate the number of individuals who refused to participate in the study.
