*3.3. SRH Knowledge and Sources of Information*

The participants approached multiple people when seeking information on SRH issues. The majority of them reached to female relatives other than their mother and sister (*n* = 92), followed by friends (*n* = 77), partner or husband (*n* = 65), mother (*n* = 64), sister (*n* = 53), doctor or nurse (*n* = 40), educational provider (*n* = 2), and male relative (*n* = 1). Only eight participants wished to reach to someone else. A total of 134 out of 297 (45.1%) participants also looked for similar information through different online channels, such as YouTube (*n* = 89/134; 66.5%), Google (*n* = 35/134; 26%), and social media (e.g., Facebook and Instagram; *n =* 10/134; 7.5%).

We evaluated the knowledge of participants on different SRH topics: STIs, symptoms of STIs, methods of contraception, and danger signs of pregnancy. A total of 161 out of the 297 participants (54.2%) were not able to identify any STI, while 61 out of the 297 participants (20.5%) were not able to name any symptom associated with STIs. Among participants who were knowledgeable about these two issues, HIV/AIDS (*n* = 136/136; 100%) and genital itching (*n* = 167/236; 70.7%) were the most STI and related symptom mentioned. The vast majority of Syrian refugee young women (284; 95.6%) knew at least one method of contraception. Birth control pills (*n* = 268/284; 94.3%), IUD (*n* = 266/284; 93.6%), and withdrawal (*n* = 257/284; 90.5%) were the three most identified methods by the knowledgeable young women. Most of the participants (*n* = 231; 77.7%) could name at least one danger symptom which is associated with pregnancy. Vaginal bleeding (*n* = 199/231), intense abdominal pain (*n* = 123/231), and fever (*n* = 116/231) were the three most known symptoms. An overview of the young women's SRH knowledge is presented in Table 3 and a detailed demonstration of that knowledge on the four topics is enclosed in supplementary (Tables S1–S4).

In bivariate analyses using Fisher's exact test, no association was found neither between the overall knowledge on SRH and age (*p*= 0.387) nor between the same overall knowledge and duration of stay in Lebanon (*p*= 0.90). However, the overall knowledge on SRH issues was found to be associated with the type of setting in which the Syrian refugee young women lived before being displaced to Lebanon (*p* < 0.001) in addition to their level of education (*p* < 0.001). Participants coming from Syrian urban areas were more likely to have a higher overall knowledge on SRH issues compared to participants who inhabited rural areas. Furthermore, Syrian refugee young women who acquired an education below secondary level tended to have a poorer knowledge on SRH topics compared to the ones who completed an education above secondary level.


**Table 3.** Sexual and Reproductive Health Knowledge of Participants.

#### *3.4. Access to SRH Services*

We assessed the medical check-ups and procedures received by the participants during their stay in Lebanon. The majority of the young women had at least one general check-up by a gynaecologist (*n* = 233; 78.5%) and one blood test (*n* = 197; 66.3%). Only 27.6% (*n* = 82) of them had at least one check-up by a general practitioner and 15.5% (*n* = 46) of them received at least one vaccination. Very few participants (*n* = 26; 8.8%) reported that they had at least one pap smear during their stay in Lebanon. A total of 28 out of the 297 participants (9.4%) did not receive any medical check-up or procedure during their displacement to Lebanon. Most of the participants (*n* = 240; 80.8%) visited at least once a health facility in Lebanon to receive SRH services. They knew about it through a friend (*n* = 108/240; 45%), a relative (*n* = 106/240; 44.2%), a healthcare provider (*n* = 15/240; 6.2%), or an NGO worker (*n* = 9/240; 3.7%). Only two young women could not remember how they came to know about the facility and its offered services. The last visit for the majority of participants was for receiving pregnancy care and delivery (*n* = 156/240; 65%), followed by STIs treatment and counselling (*n* = 33/240; 13.75%), family planning services (*n* = 21/240; 8.75%), and education or counselling regarding different SRH topics (*n* = 11/240; 4.6%). In addition, 19 out of the 240 participants (7.9%) visited lately a health facility to receive other SRH services such as hormonal therapy and infertility treatment. All the young refugee women talked to a medical doctor, except one participant who talked to a midwife. A female healthcare provider delivered the needed SRH service for the majority of participants (*n* = 174/240; 72.5%). The young women described the healthcare provider as friendly and helpful (*n* = 195/240; 81.3%), unfriendly and disrespectful (*n* = 22/240; 9.2%), friendly but unhelpful (*n* = 19/240; 7.9%), and unexperienced (*n* = 4/240; 1.6%). The biggest percentage of young women (*n* = 177/240; 73.7%) would return again to the health facility. The reasons for not returning for the rest of them are presented in Figure 2.

*Int. J. Environ. Res. Public Health* **2021**, *18*, x FOR PEER REVIEW 9 of 16

**Figure 2.** Reasons for not returning to the health facility. **Figure 2.** Reasons for not returning to the health facility.

When asked about their preferred sex of service provider, 52.2% (*n =* 155) of the total participants favoured females and 1.3% (*n =* 4) favoured males. A noticeable percentage of the young women (*n =* 138; 46.5%) did not have any preference. When asked about their preferred sex of service provider, 52.2% (*n* = 155) of the total participants favoured females and 1.3% (*n* = 4) favoured males. A noticeable percentage of the young women (*n* = 138; 46.5%) did not have any preference.

Only half of the participants (*n =* 148; 49.8%) knew a health facility in Bourj Hammoud that provides SRH services. There was no significant association between familiarity with a SRH care provider on the one hand and number of years lived in Bourj Hammoud, bearing head of household position, income level or healthcare decision making power on the other hand. When being asked about the type of services available at the facility, 36.4% (*n =* 54/148) of the young women did not have any answer. We examined the awareness of the participants regarding the availability and accessibility of five different categories of SRH services in Bourj Hammoud and its neighbouring urban areas. More than half of the participating young women knew where to access health services that are related to general medical diagnosis, information on SRH issues, methods of contraception, STIs treatment, and antenatal care. The results are presented in Figure 3. We tested for significant differences in existing knowledge on service availability between the five SRH categories using the Chi-square test. That allowed us to check in case the difference is statistically significant. The participants indicated significantly higher knowledge on the service categories of general medical diagnosis (*p* = 0.006) and antenatal care (*p* < 0.001), in contrast to information on SRH issues (*p* = 0.270), methods of contraception (*p* = 0.685), or STIs treatment (*p* = 0.92). Only half of the participants (*n* = 148; 49.8%) knew a health facility in Bourj Hammoud that provides SRH services. There was no significant association between familiarity with a SRH care provider on the one hand and number of years lived in Bourj Hammoud, bearing head of household position, income level or healthcare decision making power on the other hand. When being asked about the type of services available at the facility, 36.4% (*n* = 54/148) of the young women did not have any answer. We examined the awareness of the participants regarding the availability and accessibility of five different categories of SRH services in Bourj Hammoud and its neighbouring urban areas. More than half of the participating young women knew where to access health services that are related to general medical diagnosis, information on SRH issues, methods of contraception, STIs treatment, and antenatal care. The results are presented in Figure 3. We tested for significant differences in existing knowledge on service availability between the five SRH categories using the Chi-square test. That allowed us to check in case the difference is statistically significant. The participants indicated significantly higher knowledge on the service categories of general medical diagnosis (*p* = 0.006) and antenatal care (*p* < 0.001), in contrast to information on SRH issues (*p* = 0.270), methods of contraception (*p* = 0.685), or STIs treatment (*p* = 0.92).

#### *3.5. Experiences of Pregnancy*

A total of 236 out of the 297 young refugee women (79.5%) reported their experience of pregnancy during their stay in Lebanon. The median number of pregnancies was two (IQR: 1–3). Furthermore, 89 out of the 236 participants (37.7%) stated to have suffered a miscarriage, where 18 reported more than one miscarriage. Almost all participants who experienced pregnancy in Lebanon (*n* = 227/236; 96.2%) received antenatal care. The majority of them (*n* = 172/227; 75.8%) had three or more antenatal visits during their last pregnancy. For the same last pregnancy in Lebanon, 53.8% (*n* = 127/236) of the young women wanted to become pregnant then, 33.9% (*n* = 80/236) preferred to wait longer before becoming pregnant, 11.9% (*n* = 28/236) did not want to become pregnant anymore, and one participant had no response to the question.

**Figure 3.** Awareness of the participants on available and accessible health services in Bourj Hammoud and its neighbouring urban areas. **Figure 3.** Awareness of the participants on available and accessible health services in Bourj Hammoud and its neighbouring urban areas.

#### *3.5. Experiences of Pregnancy* **4. Discussion**

A total of 236 out of the 297 young refugee women (79.5%) reported their experience of pregnancy during their stay in Lebanon. The median number of pregnancies was two (IQR: 1–3). Furthermore, 89 out of the 236 participants (37.7%) stated to have suffered a miscarriage, where 18 reported more than one miscarriage. Almost all participants who experienced pregnancy in Lebanon (*n =* 227/236; 96.2%) received antenatal care. The majority of them (*n =* 172/227; 75.8%) had three or more antenatal visits during their last preg-This cross-sectional quantitative study assessed the general SRH status of Arab and Kurdish Syrian refugee young women living in Bourj Hammoud, Lebanon, and determined their knowledge on SRH issues and access to SRH services. Its findings show the Syrian refugee young women limited overall SRH knowledge and insufficient access to needed services within their urban setting of residence specifically and in Lebanon as a host country generally.

nancy. For the same last pregnancy in Lebanon, 53.8% (*n =* 127/236) of the young women wanted to become pregnant then, 33.9% (*n =* 80/236) preferred to wait longer before becoming pregnant, 11.9% (*n =* 28/236) did not want to become pregnant anymore, and one participant had no response to the question. **4. Discussion** This cross-sectional quantitative study assessed the general SRH status of Arab and Kurdish Syrian refugee young women living in Bourj Hammoud, Lebanon, and determined their knowledge on SRH issues and access to SRH services. Its findings show the Syrian refugee young women limited overall SRH knowledge and insufficient access to needed services within their urban setting of residence specifically and in Lebanon as a host country generally. In our study, a low number of participants (46 out of 297) received immunization. A similar finding was reported in 2013 among pregnant Syrian women living in different Lebanese urban areas, where only 8.0% of women were vaccinated against tetanus [45]. Immunization of mothers is key to prevent maternal, neonatal, and young children morbidity and mortality [46,47]. Additionally, vaccination of girls and young women against the human papillomavirus (HPV) prohibits cervical cancer. In 2018, almost 90% of the deaths caused by this disease took place in low- and middle-income countries [48]. A very limited number of participating young women (8.8%) had at least one pap smear during their displacement to Lebanon. According to the Centers for Disease Control and Prevention (CDC), women having the age between 21 and 29 years should receive one pap smear every three years in case of a normal test. This important screening tool, which detects malignant and premalignant lesions of the cervix, allows an early diagnosis of cervical cancer [49].

In our study, a low number of participants (46 out of 297) received immunization. A similar finding was reported in 2013 among pregnant Syrian women living in different Lebanese urban areas, where only 8.0% of women were vaccinated against tetanus [45]. Immunization of mothers is key to prevent maternal, neonatal, and young children morbidity and mortality [46,47]. Additionally, vaccination of girls and young women against the human papillomavirus (HPV) prohibits cervical cancer. In 2018, almost 90% of the deaths caused by this disease took place in low- and middle-income countries [48]. A very limited number of participating young women (8.8%) had at least one pap smear during their displacement to Lebanon. According to the Centers for Disease Control and Prevention (CDC), women having the age between 21 and 29 years should receive one pap smear every three years in case of a normal test. This important screening tool, which detects Among the participants who visited a healthcare facility in Lebanon, 65% accessed SRH services that are related to pregnancy care and delivery. This was also observed in an assessment conducted in Lebanon only a year after the start of the Syrian conflict, where 59.7% of the displaced women never visited a gynaecologist if not for pregnancy care or delivery [22]. The insignificant variance in the presented numbers throughout the prolonged Syrian crisis highlights the need to increase the awareness among refugees on all available SRH services at reduced prices on one hand and their locations of availability on the other hand. Additionally, it is necessary to extend the awareness through refugee's different networks, including social media [50]. Syrian refugee young women living in Bourj Hammoud reported different barriers that limit their access to available SRH services. Mistreatment by staff, high cost, poor quality of services, long waiting times, far distances, and unaffordable means of transport were the obstacles mentioned by participants. Comparable barriers are

observed in Syrian refugee populations in Jordan and Turkey [51,52], in addition to other displaced populations such as refugee adolescent girls in the Nakivale refugee settlement in Uganda [44]. Surprisingly, and in contrary to other studies on Syrian refugee women in Jordan and Turkey [35,53,54], the sex of the healthcare provider was not named as a barrier to SRH services access. Differently, a recognizable percentage of participants (46.5%) did not have any preference concerning the sex of service provider. Some of the participants described healthcare providers by disrespectful, unhelpful, and unexperienced, and expressed their unsatisfaction with the quality of received SRH services. These reports reflect the participants' major concerns regarding the skills of the healthcare provider on one hand and the sufficiency of SHR services on another hand, and not in respect to the sex of healthcare provider. It is true that more than half of the participants knew where to go to receive health services in Bourj Hammoud and its neighbouring urban areas, however the percentage of Syrian young women who do not know where to have this access is still considered elevated (ranged between 39.4 and 48.8%). This emphasizes once more time the necessity to expand the awareness among refugees on available SRH services-such as receiving information on SRH issues, methods of contraception, STIs treatment, and antenatal care. Although there was no significant association between familiarity with a SRH care facility and the healthcare decision making power, it is essential to further examine the effect of the women's dependent decisions on their own SRH status, especially that the majority of participants (34.3%) had to make a joint decision with their husband or partner.

The participants had limited overall knowledge on four SRH topics: STIs, symptoms of STIs, methods of contraception, and danger signs of pregnancy. Their knowledge on at least one contraception method was the highest (95.6%), followed by at least one symptom of STIs (79.5%), at least one danger sign of pregnancy (77.7%), and at least one STI (45.8%). Although neither age nor duration of stay in Lebanon were found to affect the participants' overall level of knowledge, this knowledge seems to depend on Syrian refugee young women's education level and type of setting in which they lived before being displaced to Lebanon. According to McKay, women cannot have a SRH care decision making power if they are not provided with precise and comprehensive information in the first place [55]. Women from lower social class receive less information because of the healthcare providers' assumption that they are not able to comprehend scientific knowledge [55]. In this study, HIV was found to be the most known type of STI. A similar finding was reported among Syrian refugee mothers in Jordan [56]. The considerable national and international awareness campaigns on HIV, which is not the case for other STIs, could be the cause behind that [56]. Interestingly, participants had acceptable knowledge on STIs symptoms but could not identify most of the STIs. This could be due to the tightly connected social networks of refugees, through which Syrian women exchange information that focus on sharing personal experiences, specially that friends, relatives, and partners or husbands were the main sources of information for the vast majority of participants.

Although almost all participants were knowledgeable of at least one method of contraception, 45.8% of women who experienced pregnancy in Lebanon had low or no desire for their last pregnancy. Thus, there is a gap between the level of knowledge on contraceptive methods on one hand and the actual use of these methods on another hand. Some studies reported a restricted level of contraceptive use within the population of Syrian refugee women in Lebanon, which ranged from 42.3 to 65.5% [22,45]. A qualitative study on Syrian refuge women in Turkey found that participants had sufficient knowledge on modern contraceptive methods but could not identify their efficiency [57]. Therefore, the very high level of knowledge on contraception methods among the participants of this study can be a result of an over-reporting, where women are only aware of the methods' names but not of their functions and effectiveness.

SRH started to be incorporated in the humanitarian responses and programs that tackle different types of crises since the 1990s [58,59]. These programs, and regardless of their application level, should be designed based on the particular context of each country in which they will be implemented [60]. In case of extended crises, such as the Syrian armed conflict that has been lasting for the past 10 years, healthcare systems become fragile which negatively affect the health status of women [13,61,62]. It is essential to describe and recognize the present complex and multi-layered Lebanese context, in order to better understand its impact on the well-being of Syrian refugees in general and the SRH of Syrian refugee women in specific. Lebanon is experiencing several complex crises since October 2019: economic breakdown, political unsteadiness, the COVID-19 pandemic, and the explosion at the Port of Beirut on the 4th of August 2020 [63]. These crises were added to the vulnerable conditions of refugees as a result of the conflict in Syria [63,64].

The economic crisis, which started in October 2019 and its effects were slightly witnessed during the data collection of our study, is considered one of the three worst economic crises worldwide since the mid-19th century [63]. A drastic increase in the unemployment rate, one of the crisis' consequences, was reflected in the findings of the study, where 30 participants have not received any income since October 2019. The protracted financial and political crisis hinders the providing of crucial public services, including health services, and thus impairs the well-being of individuals [63]. According to Médecins Sans Frontières (MSF), the increase in the inflation rate to 133% by November 2020 distressed Lebanese citizens as well as refugees and obstructed their capability to access satisfactory healthcare services [64]. Furthermore, the economic crisis pushed at least half of the Lebanese population under the national poverty line [63]. In an already inequitable, stretched, and remarkably privatized healthcare system, the crisis generates additional obstacles to access healthcare services and cause the health deterioration of already vulnerable groups [64]. These populations will have to put first their family's life saving needs such as food and shelter before their own SRH needs [65]. In a phone survey conducted by the World Food Program (WFP), 36% of households reported barriers in accessing health care between November and December 2020, a percentage that increased from 25% between July and August 2020 [63].

The Lebanese public healthcare system was also stressed due to the increasing number of COVID-19 patients starting of spring 2019. An assessment conducted by the Interagency Sexual and Gender-based Violence (SGBV) before the 4th of August 2020 to study the pandemic's effect on the level of SGBV throughout the country, found that 51% of the participating women and girls, including Syrian refugees, feel less safe and only 30% of them are still accessing health services [66]. Finally, the blast at the Port of Beirut impaired six main hospitals in addition to 23 primary health care centers and caused the loss of medical supplies in different types of healthcare settings: primary, secondary, and tertiary [67]. Since this study's data collection phase took place between January and March 2020, its results do not show the serious effects of the Lebanese multiple crises. All these events might contribute to further worsening the SRH of Syrian refugee women and are expected to continue in doing so.

The combined effect of the several crises on Syrian refugee young women's SRH status, knowledge, and access to available services should be investigated in depth in order to complement the new needs of women who are experiencing an increased vulnerability. The evaluation of the existing services and programs should also be performed to determine their level of suitability and sufficiency vis-à-vis to the necessary requirements to avert poor SRH outcomes, specially that no clear plan is being drafted on the governmental level to resolve the different crises.

We recognize the different limitations of this study. First of all, the researcher was not able to always assert the reported age of participants based on available official documents. Second, the self-reporting conducted by participants might have caused over- or underreporting, especially with the effect of social desirability bias. Moreover, the study's sample is non-representative, since no random sampling method was applied. However, and since the aim of our exploratory study is to have insights into the SRH of refugee young women living in an urban setting, which is overlooked in research, representation was not the preference [68,69]. The study on a sensitive topic such as SRH, participants' anxiety about

the research intentions, and restrictions when building connections and trust within the Syrian refugee community living in Bourj Hammoud presented challenges when recruiting participants and thus limited women's participation and representation. Finally, the crosssectional type of the study did not allow an investigation of the changes in the participants' SRH knowledge and access to services at different points in time during their displacement to Lebanon.

### **5. Conclusions**

Syrian refugee young women residing in Bourj Hammoud have restricted access to SRH services and unsatisfactory overall knowledge on different SRH topics. Thus, it is necessary to expand the awareness among refugee women on all affordable and available SRH services in urban settings and not to only focus on refugees' maternal health. Provision of information on variety of different SRH issues and treatment of STIs are some of those services that are still inadequate. Furthermore, an effective intervention targeting these challenges should always be designed according to the context of the setting in which it will be implemented. Such a design will assure constructive outputs, where refugee women's SRH status is enhanced.

This study provides valuable primary data on the SRH knowledge and access to services among young refugee women living in an urban setting, which makes them a hard-to-reach group. The findings could guide future research on specific SRH components of Syrian refugee women in Lebanon in specific and of other young refugee populations in the extended Middle East and North Africa (EMENA) countries in general. Such research is highly needed in Lebanon in order to shape the work of national, international, governmental, and non-governmental institutions that support this target group through SRH services, especially within a context of multiple crises that are expected to further deteriorate the SRH status of Syrian refugee women and lead to urgent poor SRH outcomes.

**Supplementary Materials:** The following are available online at https://www.mdpi.com/article/ 10.3390/ijerph18189586/s1, Table S1. Identified STIs among Knowledgeable Participants (*n* = 136); Table S2. Identified STIs Symptoms among Knowledgeable Participants (*n* = 236); Table S3. Identified Methods of Contraception among Knowledgeable Participants (*n* = 284); Table S4. Identified Danger Signs of Pregnancy among Knowledgeable Participants (*n* = 231).

**Author Contributions:** R.K., O.I. and G.F. conceptualized and designed the overall study. R.K. was responsible for the data collection and analysis. O.I. and G.F. provided supervision during the processes of data collection and reviewing of results. R.K. drafted the original and following versions of the manuscript, with contributions from O.I. and G.F. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research was funded by a PhD scholarship from Konrad-Adenauer-Stiftung, Germany. The article processing charge was funded by the Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich (LMU).

**Institutional Review Board Statement:** The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Review Boards of Rafik Hariri University Hospital in Lebanon—as per advice of the Lebanese Ministry of Public health—and the Faculty of Medicine at Ludwig-Maximilians-Universität in Munich, Germany (Project Nr. 19-552-27.02.2020).

**Informed Consent Statement:** Informed Arabic written consent was obtained from all participants prior to data collection.

**Data Availability Statement:** The dataset and materials used in this study are available from the first author on reasonable request.

**Acknowledgments:** The authors would like to acknowledge the key role of the gatekeepers in recruiting participants and facilitating the communication between them on one hand and the researcher on the other hand. They would also like to acknowledge the participation of young women, who gave their time to report important information.

**Conflicts of Interest:** The authors declare no conflict of interest. The funder had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.
