Correlates of Sexually Transmitted Infections among Syrian Refugee Women and Girls in Lebanon: Knowledge, Symptoms, and Health-Seeking Behaviors

Correlates of Sexually Transmitted Infections among Syrian Refugee Women and Girls in Lebanon: Knowledge, Symptoms, and Health-Seeking Behaviors | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Correlates of Sexually Transmitted Infections among Syrian Refugee Women and Girls in Lebanon: Knowledge, Symptoms, and Health-Seeking Behaviors Dalia Sarieddine, Zahraa Chamseddine, Hady Naal, Asmaa El Dakdouki, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6609236/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 08 Oct, 2025 Read the published version in BMC Women's Health → Version 1 posted 17 You are reading this latest preprint version Abstract Background Syrian refugee girls and young women in Lebanon face a disproportionate risk of poor Sexual Reproductive Health (SRH) outcomes, especially Sexually Transmitted Infections (STIs). However, limited research has explored key risk and protective factors that shape SRH vulnerabilities. This study examined key associations between sociodemographic and clinical characteristics, and experiences of STI symptoms, health-seeking behaviors, and knowledge of AIDS. Methods This cross-sectional study is part of the Self-Efficacy and Knowledge (SEEK) Trial, which aims to improve SRH and Family Planning (FP) among Syrian refugee women and girls in humanitarian settings. Baseline data (n = 485) were collected from two primary healthcare centers in the Bekaa in Lebanon, using the PAPFAM tool during November and December 2023. Results Findings highlight some factors that align and other that contradict previous literature as discussed in the manuscript. In general, findings suggest that poorer experience of STI symptoms was significantly associated with lower participant age, financial barriers to healthcare access, and use of FP methods (all ps < 0.05). Better knowledge of AIDS was significantly associated with higher education of participants, higher age of spouse, and use of FP methods (all ps < 0.05). Knowledge of AIDS transmission was also significantly associated with higher spouse age, higher education of participants, and use of FP methods (all ps < 0.05). Conclusion This study highlights the role of key protective risk factors in influencing STI symptoms, knowledge of AIDS, and health-seeking behavior. Findings suggest that age, education, economic barriers, and use of family planning methods should be considered in targeted interventions aiming to improve SRH outcomes among this population. Refugees Sexual Reproductive Health HIV/AIDS Lebanon STI Family Planning Introduction Sexually transmitted infections (STIs) remain a major public health challenge, with over one million new infections acquired each day, contributing to a substantial global burden of disease (1–3). Common STIs, such as chlamydia, gonorrhea, syphilis, trichomoniasis, Human Papillomavirus (HPV), genital herpes, and Human Immunodeficiency Virus (HIV)/acquired immunodeficiency syndrome pose serious threats to Sexual and Reproductive Health (SRH), especially among women. These infections can lead to severe complications, including mother-to-child transmission, pelvic inflammatory disease (PID), cervical cancer and infertility (4). Despite their significant impact on SRH, the urgency of addressing STIs and HIV/AIDS is often overlooked in humanitarian responses, particularly for marginalized populations like refugees (5). This is especially true for adolescent girls and young women refugees, who make up a substantial majority (6, 7), and whose SRH needs remain largely unmet, increasing their vulnerability to HIV and other STIs (8). Several displacement-related factors contribute to this heightened vulnerability, including unsanitary living conditions in refugee camps, insecurity, socioeconomic deprivation, sexual abuse, multiple partners, transactional sex, stigmatization, and limited access to preventive and educational resources (4, 5, 9, 10). Since the onset of the Syrian crisis in 2011, more than 6 million people have been forced to seek refuge in neighboring countries (11). Lebanon hosts the highest number of refugees per capita globally, with an estimated 1.5 million Syrian refugees (12, 13), and 51.7% are below the age of 18 with an overall similar distribution between males and females (14) In particular, Syrian refugee young women live in extreme poverty and precarious conditions (15, 16), facing limited access to education, social and cultural opportunities, restricted mobility, and a high prevalence of early marriage (4, 17). These factors further increase Syrian refugee women’s susceptibility to poor SRH outcomes (15, 18), including reproductive tract infections, irregular menstruation, and severe pelvic ache, among others (19, 20). Adolescent Syrian refugee girls in Lebanon, in particular, are disproportionately affected and face an elevated risk of poor SRH outcomes such as STIs (9). Despite facing significant SRH challenges, many Syrian refugee women do not seek care due to a range of barriers, including financial constraints, transportation difficulties, lack of female healthcare providers, fear of mistreatment, security risks, poor SRH literacy and lack of awareness of available SRH services (6, 18, 19) .Sociocultural barriers, religious norms and pervasive stigma around STIs also play a major role in limiting refugee populations’ access to SRH knowledge and services, restricting awareness of STIs and limiting open discussions on these issues (4, 21–23). In particular, studies on Syrian refugee young women in Lebanon revealed significant gaps in STI knowledge, with 54.2% unable to identify any STIs and 20.5% unaware of associated symptoms (6). These gaps are also largely attributed to reliance on informal sources of SRH information such as their peers, early marriage that disrupts access to SRH education, and stigma, all of which increases their vulnerability to SRH problems and reduces their overall health-seeking behaviors (9, 24–26). Despite the growing recognition of SRH challenges faced by Syrian refugee women and girls in Lebanon, there remains a significant gap in the literature on factors influencing their experience of STIs, knowledge, and health-seeking behaviors (9, 27). This study examined the risk and protective factors for STI symptoms experienced, knowledge of STIs, particularly HIV/AIDS, and health-seeking behaviors for STIs among Syrian adolescent girls and young women refugees in Lebanon. Methodology SEEK Trial This study is conducted as part of the broader Self-Efficacy and Knowledge (SEEK) trial (protocol paper and retrospective trial registration under review at the time of submission), which is a community-based Randomized Controlled Trial (RCT) that aims to enhance Family Planning (FP), SRH, and overall well-being in humanitarian settings. The trial involved developing, implementing, and evaluating the effectiveness of a WHO low-intensity/low-resource integrated intervention package on SRH, FP, and Mental Health (MH), specifically among Syrian adolescent girls and young women refugees aged 15 to 24 in the Bekaa valley, Lebanon. This cross-sectional study focuses on assessing the associations with baseline SRH characteristics of the recruited participants collected during November and December 2023, with a particular emphasis on STIs and HIV/AIDs. SEEK was conducted at two Primary Healthcare Centers (PHCs) in the Beqaa governorate of Lebanon, which hosts the largest proportion of Syrian refugees in the country, accounting for approximately 39% (28). These two PHCs were selected based on the study’s eligibility criteria. Further details on the study’s target population, eligibility criteria, sampling strategy, recruitment process, data collection tools and procedures are reported elsewhere (paper currently under review), however they are accessible as supplementary material attached within this manuscript. This cross-sectional study primarily reported findings on STIs, knowledge of AIDS and its transmission methods, and health-seeking behaviors for STIs as key outcomes, while also examining influencing factors from other sections. Four variables were considered as outcomes of interest: Experience of any STI Symptoms (categorized into Yes and No), Healthcare-Seeking Behaviors (categorized into Yes and No); Previous knowledge of AIDS (categorized into Yes and No), and Knowledge of AIDS transmission methods (knows all, some, or none of the methods). Statistical analysis Data was collected and coded into an Excel sheet and exported for analysis using Stata SE version 18. Categorical data are presented using frequency and percent. Four variables were considered as outcomes of interest: Experience of any STI Symptoms (categorized into Yes and No), Healthcare-Seeking Behaviors (categorized into Yes and No); Previous knowledge of AIDS (categorized into Yes and No), and Knowledge of AIDS transmission methods (knows all, some, or none of the methods). Bivariate analysis was used to explore the percentage of suboptimal outcomes vis-à-vis each of the independent variables. Independent variables were grouped by demographics. Differences in proportions were tested using Pearson’s chi-square. Three multivariable logistic regression models were built, one per outcome variable, using the stepwise method and including all independent variables with p ≤ 0.05 at bivariate analysis in the initial model. Results are reported as odds ratio (OR) and 95% confidence interval (CI). Analyses were carried out at a significance level of 0.05. Ethical considerations Ethical approval was sought and obtained from the Institutional Review Board (IRB) at the American University of Beirut. In line with these ethical guidelines, adolescent girls and young women refugees who displayed symptoms of distress were provided with a referral list of Non-Governmental Organizations (NGOs) that offer free mental health services. Results Socio-Demographics Characteristics Descriptive results on the sociodemographic and clinical characteristics of the sample have been documented elsewhere (paper currently under review; however, they may be accessible through the attached supplementary material). Bivariate Analyses Women’s age was associated with experiencing STI symptoms, with younger women (under 18 years) reporting a higher prevalence of STI symptoms (88.9%), compared to older women (83.9%) ( p = 0.021). However, for their spouses, higher age was associated with a higher level of knowledge about AIDS and its transmission methods, with spouses older than 25 years having a higher percentage of knowledge about AIDS (74.8%) compared to those with younger spouses (46.6%) ( p < 0.001). Similarly, for AIDS transmission, the percentage of women who knew some or all methods of AIDS transmission was higher among those with older spouses. In terms of education, women with lower levels of education (illiterate) had the lowest percentages of seeking care (30%), knowledge of AIDS (48.3%), and knowledge of AIDS transmission, whereby only 6.7% reported that they know all methods compared to women with intermediate or secondary education. As for spouse education, it was only associated with knowledge of AIDS, whereby participants whose spouses had secondary level education (75.6%) had higher knowledge than those whose spouses were illiterate (53.1%) (p = .044). Experiencing any STI symptoms and knowledge of AIDS transmission were associated with having multiple wives. All of the women whose spouses had multiple wives experienced STIs ( p = .034). Also, the percentage of those who had some knowledge of AIDS transmission methods was higher among those whose spouses have more than one wife (59.3%) ( p = .011). The barriers to treatment of transportation and embarrassment had varied impacts, with embarrassment being linked to a higher likelihood of seeking professional care among those who felt embarrassed, but having little impact on overall knowledge. Women who reported having financial barriers to seeking healthcare also reported higher prevalence of STI symptoms (88.5%) (p = 0.004). However, women who faced financial barriers had higher knowledge of AIDS than those who did not (55.5%) (p = .034). Women with better family planning access showed better knowledge of AIDS transmission, with 67.1% reporting some knowledge and 31.6% having more comprehensive knowledge, compared to those without access (54.6% and 30.7%, respectively). [Insert Table 1 ] Multivariable logistic regression Experiencing STI Symptoms In the multivariable logistic regression model, which included all variables with significant bivariate associations, older age of women emerged as a significant predictor for experiencing STI symptoms, with those over the age of 18 having 42% lower likelihood of experiencing STI symptoms compared to younger women (OR = 0.58, 95%CI= [0.25,0.84], p = 0.025). Reporting financial barriers to seeking healthcare was significantly associated with nearly twice the odds of experiencing STI symptoms (OR = 1.99, 95% CI = [1.07, 3.69], p = 0.028). Additionally, the present use of family planning methods, mainly protected sex methods, was significantly associated with higher odds of experiencing STI symptoms (OR = 1.88, 95%CI= [1.01,3.51], p = 0.045). Knowledge of AIDS Women whose spouses were older than 25 years had significantly higher odds of having previous knowledge of AIDS (OR = 3.08, 95%CI= [1.97, 4.83]). Wife’s education was also a significant factor, as those with intermediate education were twice as likely to have heard of AIDS compared to illiterate women (OR = 2.12, 95% CI = [1.08, 4.11], p = 0.028). Financial barriers to healthcare were significantly associated with previous knowledge of AIDS, with women facing such barriers being more likely to have prior knowledge (OR = 1.668, 95% CI=[1.06–2.60], p = 0.024). Additionally, FP use was associated with increased odds of prior knowledge of AIDS (OR = 1.604, 95% CI=[1.01, 2.52], p = 0.042). Knowledge of AIDS Transmission Methods Similar patterns were observed regarding knowledge of AIDS transmission methods. Having a spouse older than 25 years was significantly associated with increased odds of knowing all AIDS transmission methods (OR = 2.62, 95% CI=[1.46, 4.70], p = 0.001). Women’s education also played a significant role, with those having secondary education being nearly four times more likely to have full knowledge of AIDS transmission as compared to illiterate women (OR = 3.99, 95% CI = [2.33, 5.64], p = 0.000). Additionally, women whose spouses had multiple wives had a higher likelihood of knowing about some transmission methods of AIDS, showing a threefold increase in odds (OR = 3.92, 95% CI = [1.41, 10.84], p = 0.008). Furthermore, use of family planning was strongly associated with knowledge of AIDS transmission methods, with women using family planning methods having significantly higher odds of knowing all transmission methods (OR = 3.21, 95% CI [1.63, 6.33], p = 0.001). [Insert Table 2 ] Discussion This study examined the associations between STI symptoms experienced, health-seeking behaviors, and knowledge of AIDS with the sociodemographic and clinical correlates among Syrian adolescent girls and young women refugees in Lebanon. Given the limited data on this issue, these findings provide crucial insights into key associations, and highlight related vulnerabilities to inform research, practice, and policy aiming to improve outcomes, including STIs, healthcare access, and prevention among this population (18, 29). The study population was characterized by limited education, low employment among women, and significant barriers to healthcare access, primarily due to financial constraints and transportation challenges. Our findings indicate a high prevalence of STI symptoms experienced among participants (details reported in a separate manuscript currently under review), exceeding the reported rate of 50.2% among Syrian women who migrated to Turkey (26). We found that women of higher age were significantly less likely to experience STI symptoms, consistent with previous research suggesting that adolescent Syrian refugee girls often face higher risks of poor SRH outcomes, including STIs, due to forced displacement, disruption of education and early marriage (6, 9, 18). Financial barriers to accessing healthcare were significantly associated with a greater likelihood of experiencing STI symptoms, in line with the literature showing that extreme poverty and limited access to SRH services increase STI vulnerability among Syrian refugee women in Lebanon (6, 29). Additionally, our study found that FP use, particularly protected sex methods, was significantly associated with higher odds of experiencing STI symptoms. While uncommon in the literature, this finding may reflect the complex dynamics of FP use in refugee contexts. Women using FP are more likely to be sexually active, which may increase their exposure to STIs. It is also possible that those experiencing STI symptoms may have more frequent contact with the healthcare system, potentially prompting discussions on FP between them and their clinicians. However, the study’s cross-sectional design limits causal interpretation, highlighting the need for further investigation. Several socio-demographic variables predicted knowledge of AIDS among study participants. Participants with higher education levels and whose spouses were older than 25 years were more likely to know about AIDS. However, no significant association was found with women’s age, partially contradicting existing literature, which shows a strong association between older age and higher education levels with HIV/AIDS knowledge among Syrian refugee girls in Lebanon (9). This contradiction and lack of association may be explained by the relatively young age of women in our sample. Women facing financial barriers to healthcare were significantly more likely to have heard of AIDS, which contradicts literature findings suggesting that such barriers to accessing SRH services often limit knowledge on SRH issues (8). This finding may reflect the unique dynamics in humanitarian contexts, whereby these women and girls may have increased exposure to humanitarian campaigns specifically targeting underserved populations to promote SRH awareness. Using FP methods was strongly associated with better knowledge of AIDS, possibly because women engaged in FP have greater knowledge and access to SRH services. This aligns with research showing that limited access to health services leads to poor SRH knowledge among migrant and refugee women (23). Women with spouses older than 25 demonstrated better knowledge of AIDS transmission methods, contradicting existing literature that found no significant association between husband’s age and refugee women’s knowledge of HIV transmission methods (30). This may be explained by the possibility that older spouses have greater awareness of health issues, such as AIDS, and may share their knowledge with their wives. Additionally, women with higher education levels were more likely to know all transmission methods, similar to findings from a cross-sectional study on Rohingya refugee women in Bangladesh, where formal education was linked to better knowledge of AIDS transmission methods (30). Higher education may improve access to health information and enhance knowledge, however, given that most women in our sample had low education levels, overall awareness of transmission methods may have been limited. Women who used FP methods were significantly more aware of all transmission methods as well, which could be attributed to their increased access to healthcare services. This aligns with existing literature where availability of healthcare services was associated with better knowledge of AIDS transmission among refugee women (30). Limitations This study includes several limitations. First, the cross-sectional design limits the ability to establish causal relationships between the identified factors and outcomes. Second, reliance on self-reported data on sensitive topics, including STIs and HIV/AIDS, may introduce social desirability and recall biases, impacting data precision and the accuracy of reported information. Also, some underreporting or misreporting may still have occurred due to stigma surrounding these topics. Furthermore, the study was conducted only in two primary healthcare centers in the Bekaa governorate in Lebanon, which compromises external validity and limits the ability to extrapolate these findings to other settings. Finally, the lack of qualitative data limits the ability to capture nuanced perspectives and contextual factors that might influence the reported outcomes. Future research, including a more representative sample and incorporating qualitative components, is needed to better understand STI correlates among refugee populations. Conclusion This study examined sociodemographic and clinical associations with STI symptoms, health-seeking behaviors, and knowledge of AIDS among Syrian refugee adolescent girls and young women in Lebanon. This study highlights several important associations. For instance, higher age of women is associated with less experiences of STI symptoms, whereas use of FP methods and financial barriers are associated with poorer STI symptoms. Similarly, higher age of spouse, higher education among participants, and use of FP methods were associated with better knowledge of AIDS and its transmission methods. Abbreviations ELRHA Enhancing learning and research in humanitarian assistance HPV Human papilloma virus FP Family planning NGO Non-governmental organization PHC Primary healthcare center PID Pelvic inflamatory disease RCT Randomized controlled trial STI Sexually transmitted infection STD Sexually transmitted disesases SRH Sexual reproductive health WHO World health organization Declarations Ethics approval and consent to participation : This work received approval from the Institutional Review Board at the American University of Beirut and from the World Health Organization Ethics Committee in accordance with the declaration of Helsinki. Clinical Trial Number: Not Applicable Consent for publication : All participants enrolled in this study were required to sign an informed consent form. For participants under 18, their guardians were required to sign one on their behalf. Availability of data and materials : The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests : None Funding : This work was funded by ELRHA and partially funded by the World Health Organization Department of Sexual and Reproductive Health. Author contributions : This study was conceived by DS, HN, AED, ZC, and SS. DS, HN, AED, ZC, wrote different sections of the manuscript. ZC and HT led on data analysis with support from all authors. TB, GHA, FF, SI, ZAS, and SS provided critical revisions. All authors approved the final version of the manuscript. Acknowledgements : Not applicable References (WHO) WHO. Sexually transmitted infections (STIs) 2024 [Available from: https://www.who.int/news-room/fact-sheets/detail/sexually-transmitted-infections-(stis). Ma W, Chen Z, Niu S. 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Supplementary Files SupplementaryMaterial.docx Tables.docx Cite Share Download PDF Status: Published Journal Publication published 08 Oct, 2025 Read the published version in BMC Women's Health → Version 1 posted Editorial decision: Revision requested 25 Jun, 2025 Reviews received at journal 04 Jun, 2025 Reviews received at journal 31 May, 2025 Reviews received at journal 28 May, 2025 Reviewers agreed at journal 27 May, 2025 Reviewers agreed at journal 27 May, 2025 Reviewers agreed at journal 27 May, 2025 Reviews received at journal 27 May, 2025 Reviewers agreed at journal 27 May, 2025 Reviewers agreed at journal 27 May, 2025 Reviews received at journal 26 May, 2025 Reviewers agreed at journal 26 May, 2025 Reviewers invited by journal 26 May, 2025 Editor invited by journal 09 May, 2025 Editor assigned by journal 08 May, 2025 Submission checks completed at journal 08 May, 2025 First submitted to journal 07 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6609236","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":462530100,"identity":"4202e69a-49ec-412d-975c-227451bc34a7","order_by":0,"name":"Dalia Sarieddine","email":"","orcid":"","institution":"Global Health Institute, American University of Beirut, Lebanon","correspondingAuthor":false,"prefix":"","firstName":"Dalia","middleName":"","lastName":"Sarieddine","suffix":""},{"id":462530101,"identity":"a40805d3-4d36-4206-9bb5-c51ece987f25","order_by":1,"name":"Zahraa Chamseddine","email":"","orcid":"","institution":"Global Health 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Saleh","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvklEQVRIiWNgGAWjYFACxobDfyoYGAyATAkGBosEIrQwNx7gOQPXIkGMFvbmA7xtpGiR7z/YcEBynl3idgbmg7d5GCTyCGoxuJHYcMBwW3Lizga2ZGuglmLCWiQYGw4kbmNO3HCAx0waqCWxgSiHHZxTD9TC/404LQwHEhsONjYcBtnCRpwWkF8OMxw7bryzmc3Yco4BEX6R7z/++DNDTbXsdvbmhzfeVNgQDjEEYAZbSoKGUTAKRsEoGAW4AQCNKz1SmW2dfAAAAABJRU5ErkJggg==","orcid":"","institution":"Global Health Institute, American University of Beirut, Lebanon","correspondingAuthor":true,"prefix":"","firstName":"Shadi","middleName":"","lastName":"Saleh","suffix":""}],"badges":[],"createdAt":"2025-05-07 07:38:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6609236/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6609236/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12905-025-04036-z","type":"published","date":"2025-10-08T15:57:11+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":93419953,"identity":"f2a0ee88-1eb4-4e9b-964c-0d24c2b6e1f0","added_by":"auto","created_at":"2025-10-13 16:09:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":614216,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6609236/v1/46c36d47-6acd-405d-b29a-b05b8a09613b.pdf"},{"id":83571465,"identity":"7cdbfec6-ac6d-4d67-bcef-2810c0fcaaf3","added_by":"auto","created_at":"2025-05-28 16:57:16","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":20851,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-6609236/v1/b1268b3447be0cd1ae5b49d0.docx"},{"id":83571464,"identity":"6fbf90cc-b592-49ad-bb40-947592005287","added_by":"auto","created_at":"2025-05-28 16:57:16","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":65134,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-6609236/v1/b4cc142ae0c4d080ab183508.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Correlates of Sexually Transmitted Infections among Syrian Refugee Women and Girls in Lebanon: Knowledge, Symptoms, and Health-Seeking Behaviors","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSexually transmitted infections (STIs) remain a major public health challenge, with over one million new infections acquired each day, contributing to a substantial global burden of disease (1\u0026ndash;3). Common STIs, such as chlamydia, gonorrhea, syphilis, trichomoniasis, Human Papillomavirus (HPV), genital herpes, and Human Immunodeficiency Virus (HIV)/acquired immunodeficiency syndrome pose serious threats to Sexual and Reproductive Health (SRH), especially among women. These infections can lead to severe complications, including mother-to-child transmission, pelvic inflammatory disease (PID), cervical cancer and infertility (4).\u003c/p\u003e \u003cp\u003eDespite their significant impact on SRH, the urgency of addressing STIs and HIV/AIDS is often overlooked in humanitarian responses, particularly for marginalized populations like refugees (5). This is especially true for adolescent girls and young women refugees, who make up a substantial majority (6, 7), and whose SRH needs remain largely unmet, increasing their vulnerability to HIV and other STIs (8). Several displacement-related factors contribute to this heightened vulnerability, including unsanitary living conditions in refugee camps, insecurity, socioeconomic deprivation, sexual abuse, multiple partners, transactional sex, stigmatization, and limited access to preventive and educational resources (4, 5, 9, 10).\u003c/p\u003e \u003cp\u003eSince the onset of the Syrian crisis in 2011, more than 6\u0026nbsp;million people have been forced to seek refuge in neighboring countries (11). Lebanon hosts the highest number of refugees per capita globally, with an estimated 1.5\u0026nbsp;million Syrian refugees (12, 13), and 51.7% are below the age of 18 with an overall similar distribution between males and females (14) In particular, Syrian refugee young women live in extreme poverty and precarious conditions (15, 16), facing limited access to education, social and cultural opportunities, restricted mobility, and a high prevalence of early marriage (4, 17). These factors further increase Syrian refugee women\u0026rsquo;s susceptibility to poor SRH outcomes (15, 18), including reproductive tract infections, irregular menstruation, and severe pelvic ache, among others (19, 20). Adolescent Syrian refugee girls in Lebanon, in particular, are disproportionately affected and face an elevated risk of poor SRH outcomes such as STIs (9).\u003c/p\u003e \u003cp\u003eDespite facing significant SRH challenges, many Syrian refugee women do not seek care due to a range of barriers, including financial constraints, transportation difficulties, lack of female healthcare providers, fear of mistreatment, security risks, poor SRH literacy and lack of awareness of available SRH services (6, 18, 19) .Sociocultural barriers, religious norms and pervasive stigma around STIs also play a major role in limiting refugee populations\u0026rsquo; access to SRH knowledge and services, restricting awareness of STIs and limiting open discussions on these issues (4, 21\u0026ndash;23). In particular, studies on Syrian refugee young women in Lebanon revealed significant gaps in STI knowledge, with 54.2% unable to identify any STIs and 20.5% unaware of associated symptoms (6). These gaps are also largely attributed to reliance on informal sources of SRH information such as their peers, early marriage that disrupts access to SRH education, and stigma, all of which increases their vulnerability to SRH problems and reduces their overall health-seeking behaviors (9, 24\u0026ndash;26).\u003c/p\u003e \u003cp\u003eDespite the growing recognition of SRH challenges faced by Syrian refugee women and girls in Lebanon, there remains a significant gap in the literature on factors influencing their experience of STIs, knowledge, and health-seeking behaviors (9, 27). This study examined the risk and protective factors for STI symptoms experienced, knowledge of STIs, particularly HIV/AIDS, and health-seeking behaviors for STIs among Syrian adolescent girls and young women refugees in Lebanon.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSEEK Trial\u003c/h2\u003e \u003cp\u003eThis study is conducted as part of the broader Self-Efficacy and Knowledge (SEEK) trial (protocol paper and retrospective trial registration under review at the time of submission), which is a community-based Randomized Controlled Trial (RCT) that aims to enhance Family Planning (FP), SRH, and overall well-being in humanitarian settings. The trial involved developing, implementing, and evaluating the effectiveness of a WHO low-intensity/low-resource integrated intervention package on SRH, FP, and Mental Health (MH), specifically among Syrian adolescent girls and young women refugees aged 15 to 24 in the Bekaa valley, Lebanon. This cross-sectional study focuses on assessing the associations with baseline SRH characteristics of the recruited participants collected during November and December 2023, with a particular emphasis on STIs and HIV/AIDs.\u003c/p\u003e \u003cp\u003eSEEK was conducted at two Primary Healthcare Centers (PHCs) in the Beqaa governorate of Lebanon, which hosts the largest proportion of Syrian refugees in the country, accounting for approximately 39% (28). These two PHCs were selected based on the study\u0026rsquo;s eligibility criteria. Further details on the study\u0026rsquo;s target population, eligibility criteria, sampling strategy, recruitment process, data collection tools and procedures are reported elsewhere (paper currently under review), however they are accessible as supplementary material attached within this manuscript.\u003c/p\u003e \u003cp\u003eThis cross-sectional study primarily reported findings on STIs, knowledge of AIDS and its transmission methods, and health-seeking behaviors for STIs as key outcomes, while also examining influencing factors from other sections. Four variables were considered as outcomes of interest: Experience of any STI Symptoms (categorized into Yes and No), Healthcare-Seeking Behaviors (categorized into Yes and No); Previous knowledge of AIDS (categorized into Yes and No), and Knowledge of AIDS transmission methods (knows all, some, or none of the methods).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData was collected and coded into an Excel sheet and exported for analysis using Stata SE version 18. Categorical data are presented using frequency and percent. Four variables were considered as outcomes of interest: Experience of any STI Symptoms (categorized into Yes and No), Healthcare-Seeking Behaviors (categorized into Yes and No); Previous knowledge of AIDS (categorized into Yes and No), and Knowledge of AIDS transmission methods (knows all, some, or none of the methods). Bivariate analysis was used to explore the percentage of suboptimal outcomes vis-\u0026agrave;-vis each of the independent variables. Independent variables were grouped by demographics. Differences in proportions were tested using Pearson\u0026rsquo;s chi-square. Three multivariable logistic regression models were built, one per outcome variable, using the stepwise method and including all independent variables with p\u0026thinsp;\u0026le;\u0026thinsp;0.05 at bivariate analysis in the initial model. Results are reported as odds ratio (OR) and 95% confidence interval (CI). Analyses were carried out at a significance level of 0.05.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003eEthical approval was sought and obtained from the Institutional Review Board (IRB) at the American University of Beirut. In line with these ethical guidelines, adolescent girls and young women refugees who displayed symptoms of distress were provided with a referral list of Non-Governmental Organizations (NGOs) that offer free mental health services.\u003c/p\u003e \u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003eSocio-Demographics Characteristics\u003c/h2\u003e\n \u003cp\u003eDescriptive results on the sociodemographic and clinical characteristics of the sample have been documented elsewhere (paper currently under review; however, they may be accessible through the attached supplementary material).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eBivariate Analyses\u003c/h2\u003e\n \u003cp\u003eWomen\u0026rsquo;s age was associated with experiencing STI symptoms, with younger women (under 18 years) reporting a higher prevalence of STI symptoms (88.9%), compared to older women (83.9%) (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.021). However, for their spouses, higher age was associated with a higher level of knowledge about AIDS and its transmission methods, with spouses older than 25 years having a higher percentage of knowledge about AIDS (74.8%) compared to those with younger spouses (46.6%) (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Similarly, for AIDS transmission, the percentage of women who knew some or all methods of AIDS transmission was higher among those with older spouses.\u003c/p\u003e\n \u003cp\u003eIn terms of education, women with lower levels of education (illiterate) had the lowest percentages of seeking care (30%), knowledge of AIDS (48.3%), and knowledge of AIDS transmission, whereby only 6.7% reported that they know all methods compared to women with intermediate or secondary education. As for spouse education, it was only associated with knowledge of AIDS, whereby participants whose spouses had secondary level education (75.6%) had higher knowledge than those whose spouses were illiterate (53.1%) (p\u0026thinsp;=\u0026thinsp;.044).\u003c/p\u003e\n \u003cp\u003eExperiencing any STI symptoms and knowledge of AIDS transmission were associated with having multiple wives. All of the women whose spouses had multiple wives experienced STIs \u003cstrong\u003e(\u003c/strong\u003e\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.034). Also, the percentage of those who had some knowledge of AIDS transmission methods was higher among those whose spouses have more than one wife (59.3%) (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.011).\u003c/p\u003e\n \u003cp\u003eThe barriers to treatment of transportation and embarrassment had varied impacts, with embarrassment being linked to a higher likelihood of seeking professional care among those who felt embarrassed, but having little impact on overall knowledge. Women who reported having financial barriers to seeking healthcare also reported higher prevalence of STI symptoms (88.5%) (p\u0026thinsp;=\u0026thinsp;0.004). However, women who faced financial barriers had higher knowledge of AIDS than those who did not (55.5%) (p\u0026thinsp;=\u0026thinsp;.034). Women with better family planning access showed better knowledge of AIDS transmission, with 67.1% reporting some knowledge and 31.6% having more comprehensive knowledge, compared to those without access (54.6% and 30.7%, respectively).\u003c/p\u003e\n \u003cp\u003e[Insert Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eMultivariable logistic regression\u003c/h3\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003eExperiencing STI Symptoms\u003c/h2\u003e\n \u003cp\u003eIn the multivariable logistic regression model, which included all variables with significant bivariate associations, older age of women emerged as a significant predictor for experiencing STI symptoms, with those over the age of 18 having 42% lower likelihood of experiencing STI symptoms compared to younger women (OR\u0026thinsp;=\u0026thinsp;0.58, 95%CI= [0.25,0.84], p\u0026thinsp;=\u0026thinsp;0.025). Reporting financial barriers to seeking healthcare was significantly associated with nearly twice the odds of experiencing STI symptoms (OR\u0026thinsp;=\u0026thinsp;1.99, 95% CI = [1.07, 3.69], p\u0026thinsp;=\u0026thinsp;0.028). Additionally, the present use of family planning methods, mainly protected sex methods, was significantly associated with higher odds of experiencing STI symptoms (OR\u0026thinsp;=\u0026thinsp;1.88, 95%CI= [1.01,3.51], p\u0026thinsp;=\u0026thinsp;0.045).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eKnowledge of AIDS\u003c/h2\u003e\n \u003cp\u003eWomen whose spouses were older than 25 years had significantly higher odds of having previous knowledge of AIDS (OR\u0026thinsp;=\u0026thinsp;3.08, 95%CI= [1.97, 4.83]). Wife\u0026rsquo;s education was also a significant factor, as those with intermediate education were twice as likely to have heard of AIDS compared to illiterate women (OR\u0026thinsp;=\u0026thinsp;2.12, 95% CI = [1.08, 4.11], p\u0026thinsp;=\u0026thinsp;0.028). Financial barriers to healthcare were significantly associated with previous knowledge of AIDS, with women facing such barriers being more likely to have prior knowledge (OR\u0026thinsp;=\u0026thinsp;1.668, 95% CI=[1.06\u0026ndash;2.60], p\u0026thinsp;=\u0026thinsp;0.024). Additionally, FP use was associated with increased odds of prior knowledge of AIDS (OR\u0026thinsp;=\u0026thinsp;1.604, 95% CI=[1.01, 2.52], p\u0026thinsp;=\u0026thinsp;0.042).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eKnowledge of AIDS Transmission Methods\u003c/h2\u003e\n \u003cp\u003eSimilar patterns were observed regarding knowledge of AIDS transmission methods. Having a spouse older than 25 years was significantly associated with increased odds of knowing all AIDS transmission methods (OR\u0026thinsp;=\u0026thinsp;2.62, 95% CI=[1.46, 4.70], p\u0026thinsp;=\u0026thinsp;0.001). Women\u0026rsquo;s education also played a significant role, with those having secondary education being nearly four times more likely to have full knowledge of AIDS transmission as compared to illiterate women (OR\u0026thinsp;=\u0026thinsp;3.99, 95% CI = [2.33, 5.64], p\u0026thinsp;=\u0026thinsp;0.000). Additionally, women whose spouses had multiple wives had a higher likelihood of knowing about some transmission methods of AIDS, showing a threefold increase in odds (OR\u0026thinsp;=\u0026thinsp;3.92, 95% CI = [1.41, 10.84], p\u0026thinsp;=\u0026thinsp;0.008). Furthermore, use of family planning was strongly associated with knowledge of AIDS transmission methods, with women using family planning methods having significantly higher odds of knowing all transmission methods (OR\u0026thinsp;=\u0026thinsp;3.21, 95% CI [1.63, 6.33], p\u0026thinsp;=\u0026thinsp;0.001).\u003c/p\u003e\n \u003cp\u003e[Insert Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study examined the associations between STI symptoms experienced, health-seeking behaviors, and knowledge of AIDS with the sociodemographic and clinical correlates among Syrian adolescent girls and young women refugees in Lebanon. Given the limited data on this issue, these findings provide crucial insights into key associations, and highlight related vulnerabilities to inform research, practice, and policy aiming to improve outcomes, including STIs, healthcare access, and prevention among this population (18, 29). The study population was characterized by limited education, low employment among women, and significant barriers to healthcare access, primarily due to financial constraints and transportation challenges.\u003c/p\u003e \u003cp\u003eOur findings indicate a high prevalence of STI symptoms experienced among participants (details reported in a separate manuscript currently under review), exceeding the reported rate of 50.2% among Syrian women who migrated to Turkey (26). We found that women of higher age were significantly less likely to experience STI symptoms, consistent with previous research suggesting that adolescent Syrian refugee girls often face higher risks of poor SRH outcomes, including STIs, due to forced displacement, disruption of education and early marriage (6, 9, 18). Financial barriers to accessing healthcare were significantly associated with a greater likelihood of experiencing STI symptoms, in line with the literature showing that extreme poverty and limited access to SRH services increase STI vulnerability among Syrian refugee women in Lebanon (6, 29). Additionally, our study found that FP use, particularly protected sex methods, was significantly associated with higher odds of experiencing STI symptoms. While uncommon in the literature, this finding may reflect the complex dynamics of FP use in refugee contexts. Women using FP are more likely to be sexually active, which may increase their exposure to STIs. It is also possible that those experiencing STI symptoms may have more frequent contact with the healthcare system, potentially prompting discussions on FP between them and their clinicians. However, the study\u0026rsquo;s cross-sectional design limits causal interpretation, highlighting the need for further investigation.\u003c/p\u003e \u003cp\u003eSeveral socio-demographic variables predicted knowledge of AIDS among study participants. Participants with higher education levels and whose spouses were older than 25 years were more likely to know about AIDS. However, no significant association was found with women\u0026rsquo;s age, partially contradicting existing literature, which shows a strong association between older age and higher education levels with HIV/AIDS knowledge among Syrian refugee girls in Lebanon (9). This contradiction and lack of association may be explained by the relatively young age of women in our sample. Women facing financial barriers to healthcare were significantly more likely to have heard of AIDS, which contradicts literature findings suggesting that such barriers to accessing SRH services often limit knowledge on SRH issues (8). This finding may reflect the unique dynamics in humanitarian contexts, whereby these women and girls may have increased exposure to humanitarian campaigns specifically targeting underserved populations to promote SRH awareness. Using FP methods was strongly associated with better knowledge of AIDS, possibly because women engaged in FP have greater knowledge and access to SRH services. This aligns with research showing that limited access to health services leads to poor SRH knowledge among migrant and refugee women (23).\u003c/p\u003e \u003cp\u003eWomen with spouses older than 25 demonstrated better knowledge of AIDS transmission methods, contradicting existing literature that found no significant association between husband\u0026rsquo;s age and refugee women\u0026rsquo;s knowledge of HIV transmission methods (30). This may be explained by the possibility that older spouses have greater awareness of health issues, such as AIDS, and may share their knowledge with their wives. Additionally, women with higher education levels were more likely to know all transmission methods, similar to findings from a cross-sectional study on Rohingya refugee women in Bangladesh, where formal education was linked to better knowledge of AIDS transmission methods (30). Higher education may improve access to health information and enhance knowledge, however, given that most women in our sample had low education levels, overall awareness of transmission methods may have been limited. Women who used FP methods were significantly more aware of all transmission methods as well, which could be attributed to their increased access to healthcare services. This aligns with existing literature where availability of healthcare services was associated with better knowledge of AIDS transmission among refugee women (30).\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study includes several limitations. First, the cross-sectional design limits the ability to establish causal relationships between the identified factors and outcomes. Second, reliance on self-reported data on sensitive topics, including STIs and HIV/AIDS, may introduce social desirability and recall biases, impacting data precision and the accuracy of reported information. Also, some underreporting or misreporting may still have occurred due to stigma surrounding these topics. Furthermore, the study was conducted only in two primary healthcare centers in the Bekaa governorate in Lebanon, which compromises external validity and limits the ability to extrapolate these findings to other settings. Finally, the lack of qualitative data limits the ability to capture nuanced perspectives and contextual factors that might influence the reported outcomes. Future research, including a more representative sample and incorporating qualitative components, is needed to better understand STI correlates among refugee populations.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study examined sociodemographic and clinical associations with STI symptoms, health-seeking behaviors, and knowledge of AIDS among Syrian refugee adolescent girls and young women in Lebanon. This study highlights several important associations. For instance, higher age of women is associated with less experiences of STI symptoms, whereas use of FP methods and financial barriers are associated with poorer STI symptoms. Similarly, higher age of spouse, higher education among participants, and use of FP methods were associated with better knowledge of AIDS and its transmission methods.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eELRHA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEnhancing learning and research in humanitarian assistance\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHPV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHuman papilloma virus\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFamily planning\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNGO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNon-governmental organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePHC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePrimary healthcare center\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePID\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePelvic inflamatory disease\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRandomized controlled trial\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSTI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSexually transmitted infection\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSTD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSexually transmitted disesases\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSRH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSexual reproductive health\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld health organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participation\u003c/strong\u003e: This work received approval from the Institutional Review Board at the American University of Beirut and from the World Health Organization Ethics Committee in accordance with the declaration of Helsinki.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number:\u0026nbsp;\u003c/strong\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e: All participants enrolled in this study were required to sign an informed consent form. For participants under 18, their guardians were required to sign one on their behalf. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e: None\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: This work was funded by ELRHA and partially funded by the World Health Organization Department of Sexual and Reproductive Health.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e: \u0026nbsp;This study was conceived by DS, HN, AED, ZC, and SS. DS, HN, AED, ZC, wrote different sections of the manuscript. ZC and HT led on data analysis with support from all authors. TB, GHA, FF, SI, ZAS, and SS provided critical revisions. All authors approved the final version of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e: Not applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003e(WHO) WHO. Sexually transmitted infections (STIs) 2024 [Available from: https://www.who.int/news-room/fact-sheets/detail/sexually-transmitted-infections-(stis).\u003c/li\u003e\n\u003cli\u003eMa W, Chen Z, Niu S. Advances and challenges in sexually transmitted infections prevention among men who have sex with men in Asia. Current Opinion in Infectious Diseases. 2023;36(1):26-34.\u003c/li\u003e\n\u003cli\u003eVos T, Allen C, Arora M, Barber RM, Bhutta ZA, Brown A, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990\u0026ndash;2015: a systematic analysis for the Global Burden of Disease Study 2015. The lancet. 2016;388(10053):1545-602.\u003c/li\u003e\n\u003cli\u003eAl-Maharma D, Safadi R, Ahmad M, Halasa S, Nabolsi M, Dohrn J. Knowledge, Attitudes And Practices Of Syrian Refugee Mothers Towards Sexually Transmitted Infections. Int J Womens Health. 2019;11:607-15.\u003c/li\u003e\n\u003cli\u003eSilveira A. An Evidence Review of Sexually Transmitted Infections in Humanitarian Settings. 2017.\u003c/li\u003e\n\u003cli\u003eKorri 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. International Journal of Environmental Research and Public Health. 2021;18(18):9586.\u003c/li\u003e\n\u003cli\u003eUNHCR. Women [Available from: https://www.unhcr.org/what-we-do/protect-human-rights/safeguarding-individuals/women.\u003c/li\u003e\n\u003cli\u003eIvanova O, Rai M, Kemigisha E. A systematic review of sexual and reproductive health knowledge, experiences and access to services among refugee, migrant and displaced girls and young women in Africa. International journal of environmental research and public health. 2018;15(8):1583.\u003c/li\u003e\n\u003cli\u003eFahme SA, El Ayoubi LEL, DeJong J, Sieverding M. Sexual and reproductive health knowledge among adolescent Syrian refugee girls displaced in Lebanon: The role of schooling and parental communication. PLOS Global Public Health. 2023;3(1):e0001437.\u003c/li\u003e\n\u003cli\u003eNouri S. Effects of conflict, displacement, and migration on the health of refugee and conflict-stricken populations in the Middle East: Institute of Advanced Engineering and Science; 2019.\u003c/li\u003e\n\u003cli\u003eUNHCR. Syria Refugee Crisis Explained 2025 [Available from: https://www.unrefugees.org/news/syria-refugee-crisis-explained/.\u003c/li\u003e\n\u003cli\u003eKnudsen AJ. Syria\u0026rsquo;s refugees in Lebanon: brothers, burden, and bone of contention. Lebanon Facing the Arab Uprisings: Constraints and Adaptation. 2017:135-54.\u003c/li\u003e\n\u003cli\u003eUNHCR. UNHCR Lebanon factsheet - April 2024 2024 [Available from: https://www.unhcr.org/lb/wp-content/uploads/sites/16/2024/05/UNHCR-Lebanon-FactSheet-Q1-2024.pdf.\u003c/li\u003e\n\u003cli\u003eVASyR U. Vulnerability Assessment for Syrian Refugees in Lebanon. United Nations High Commissioner for Refugees, the World Food Programme, United Nations Childrens\u0026rsquo; Fund https://data unhcr org/en/documents/details/90589 Date accessed. 2023;13.\u003c/li\u003e\n\u003cli\u003eKorri R, Hess S, Froeschl G, Ivanova O. Sexual and reproductive health of Syrian refugee adolescent girls: a qualitative study using focus group discussions in an urban setting in Lebanon. Reproductive health. 2021;18(1):130.\u003c/li\u003e\n\u003cli\u003eKukrety N, Al-Jamal S. Poverty, inequality, and social protection in Lebanon. Social justice and development policy in the Arab world. 2016.\u003c/li\u003e\n\u003cli\u003eChahine A, Al-Masri M, Samra S, Abla Z. Situation analysis of youth in Lebanon affected by the Syrian crisis. Lebanon: United Nations. 2014.\u003c/li\u003e\n\u003cli\u003eFahme SA, Sieverding M, Abdulrahim S. Sexual and reproductive health of adolescent Syrian refugee girls in Lebanon: a qualitative study of healthcare provider and educator perspectives. Reproductive health. 2021;18:1-16.\u003c/li\u003e\n\u003cli\u003eReese Masterson A, Usta J, Gupta J, Ettinger AS. Assessment of reproductive health and violence against women among displaced Syrians in Lebanon. BMC women\u0026apos;s health. 2014;14:1-8.\u003c/li\u003e\n\u003cli\u003eUsta J, Masterson AR. Women and health in refugee settings: The case of displaced Syrian women in Lebanon. Gender-based violence: Perspectives from Africa, the Middle East, and India: Springer; 2015. p. 119-43.\u003c/li\u003e\n\u003cli\u003eBotfield JR, Zwi AB, Rutherford A, Newman CE. Learning about sex and relationships among migrant and refugee young people in Sydney, Australia:\u0026lsquo;I never got the talk about the birds and the bees\u0026rsquo;. Sex Education. 2018;18(6):705-20.\u003c/li\u003e\n\u003cli\u003eKingori C, Ice GH, Hassan Q, Elmi A, Perko E. \u0026lsquo;If I went to my mom with that information, I\u0026rsquo;m dead\u0026rsquo;: sexual health knowledge barriers among immigrant and refugee Somali young adults in Ohio. Ethnicity \u0026amp; health. 2018;23(3):339-52.\u003c/li\u003e\n\u003cli\u003eMetusela C, Ussher J, Perz J, Hawkey A, Morrow M, Narchal R, et al. \u0026ldquo;In my culture, we don\u0026rsquo;t know anything about that\u0026rdquo;: sexual and reproductive health of migrant and refugee women. International journal of behavioral medicine. 2017;24:836-45.\u003c/li\u003e\n\u003cli\u003eEl Ayoubi LEL, Abdulrahim S, Sieverding M. Sexual and reproductive health information and experiences among Syrian refugee adolescent girls in Lebanon. Qualitative Health Research. 2021;31(5):983-98.\u003c/li\u003e\n\u003cli\u003eMourtada R, Schlecht J, DeJong J. A qualitative study exploring child marriage practices among Syrian conflict-affected populations in Lebanon. Conflict and health. 2017;11:53-65.\u003c/li\u003e\n\u003cli\u003eŞahin K, G\u0026uuml;ner P. The Knowledge about Sexuality and Sexually Transmitted Diseases of Syrian Women and Men Immigrated to Hatay-Antakya: A Qualitative Study. Ankara Medical Journal. 2022;22(1).\u003c/li\u003e\n\u003cli\u003eNabulsi D, Abou Saad M, Ismail H, Doumit MA, El-Jamil F, Kobeissi L, et al. Minimum initial service package (MISP) for sexual and reproductive health for women in a displacement setting: a narrative review on the Syrian refugee crisis in Lebanon. Reproductive Health. 2021;18:1-13.\u003c/li\u003e\n\u003cli\u003eUNHCR. UNHCR Field Office in Zahle [Available from: https://www.unhcr.org/lb/where-we-work/unhcr-field-office-zahle#:~:text=As%20of%2001%20January%202023,total%20number%20of%20registered%20refugees.\u003c/li\u003e\n\u003cli\u003eFahme SA, Chehab S, Logie CH, Mumtaz G, Fitzgerald D, Downs JA, et al. Intersecting social-ecological vulnerabilities to and lived experiences of sexually transmitted infections among Syrian refugee women in Lebanon: A qualitative study. PLOS Global Public Health. 2024;4(8):e0003507.\u003c/li\u003e\n\u003cli\u003eKhan MN, Rahman MM, Rahman MM, Islam MM. HIV transmission knowledge among Rohingya refugee women in Bangladesh: a cross-sectional survey. BMJ open. 2021;11(10):e047516.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Refugees, Sexual Reproductive Health, HIV/AIDS, Lebanon, STI, Family Planning","lastPublishedDoi":"10.21203/rs.3.rs-6609236/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6609236/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eSyrian refugee girls and young women in Lebanon face a disproportionate risk of poor Sexual Reproductive Health (SRH) outcomes, especially Sexually Transmitted Infections (STIs). However, limited research has explored key risk and protective factors that shape SRH vulnerabilities. This study examined key associations between sociodemographic and clinical characteristics, and experiences of STI symptoms, health-seeking behaviors, and knowledge of AIDS.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis cross-sectional study is part of the Self-Efficacy and Knowledge (SEEK) Trial, which aims to improve SRH and Family Planning (FP) among Syrian refugee women and girls in humanitarian settings. Baseline data (n\u0026thinsp;=\u0026thinsp;485) were collected from two primary healthcare centers in the Bekaa in Lebanon, using the PAPFAM tool during November and December 2023.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eFindings highlight some factors that align and other that contradict previous literature as discussed in the manuscript. In general, findings suggest that poorer experience of STI symptoms was significantly associated with lower participant age, financial barriers to healthcare access, and use of FP methods (all ps\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Better knowledge of AIDS was significantly associated with higher education of participants, higher age of spouse, and use of FP methods (all ps\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Knowledge of AIDS transmission was also significantly associated with higher spouse age, higher education of participants, and use of FP methods (all ps\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis study highlights the role of key protective risk factors in influencing STI symptoms, knowledge of AIDS, and health-seeking behavior. Findings suggest that age, education, economic barriers, and use of family planning methods should be considered in targeted interventions aiming to improve SRH outcomes among this population.\u003c/p\u003e","manuscriptTitle":"Correlates of Sexually Transmitted Infections among Syrian Refugee Women and Girls in Lebanon: Knowledge, Symptoms, and Health-Seeking Behaviors","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-28 16:49:11","doi":"10.21203/rs.3.rs-6609236/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-25T11:54:36+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-04T05:54:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-31T12:58:25+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-28T20:43:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"103683111642503742227919578687043698867","date":"2025-05-27T13:05:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"31814048385470489540679738330969323524","date":"2025-05-27T12:31:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"246339734806050978546485564211020236712","date":"2025-05-27T09:45:33+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-27T08:32:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"55377325272042382239130972410176877041","date":"2025-05-27T07:44:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"268828062177943489422577067388820018778","date":"2025-05-27T05:34:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-27T02:02:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"22777029595031238932186420829922770139","date":"2025-05-27T01:55:59+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-27T01:04:34+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-09T08:59:23+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-08T06:04:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-08T05:59:26+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2025-05-07T07:23:55+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b7a3170e-2dcb-4114-b03f-d021863c84e3","owner":[],"postedDate":"May 28th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-13T16:06:20+00:00","versionOfRecord":{"articleIdentity":"rs-6609236","link":"https://doi.org/10.1186/s12905-025-04036-z","journal":{"identity":"bmc-womens-health","isVorOnly":false,"title":"BMC Women's Health"},"publishedOn":"2025-10-08 15:57:11","publishedOnDateReadable":"October 8th, 2025"},"versionCreatedAt":"2025-05-28 16:49:11","video":"","vorDoi":"10.1186/s12905-025-04036-z","vorDoiUrl":"https://doi.org/10.1186/s12905-025-04036-z","workflowStages":[]},"version":"v1","identity":"rs-6609236","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6609236","identity":"rs-6609236","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}