Background Understanding and overcoming barriers to vaccine acceptance is essential to achieve COVID-19 herd immunity worldwide.This is paramount for displaced populations who are disproportionately affected by underlying disease syndemics.Studies on COVID-19 vaccine acceptance among immigrants and refugees are limited.This study aimed to determine the prevalence and factors associated with COVID-19 vaccine refusal in older Syrian refugee beneficiaries of a humanitarian organization in Lebanon.

Methods The findings come from an ongoing rotating 4-wave panel study aiming to track older Syrian refugees’ vulnerability to COVID-19. The sampling frame was a beneficiaries list of a humanitarian organization in Lebanon and included a probability sample of Syrian refugee households with at least one adult aged 50 years or older. 3,838 individuals agreed to participate in a phone survey. The present findings are limited to a sample of 1,037 from the first panel who were interviewed between January-February, 2021. Intention to vaccinate against COVID-19 was assessed through unadjusted logistic regression models to examine associations between COVID-19 vaccine refusal and socio-demographic factors, adherence practices, and vaccine and COVID-19 related perceptions using Stata/SE13.1.

Results Out 1,037 beneficiaries, 29% (95%CI:0.26–0.32) reported no intention to vaccinate and 5.2% didn’t know. Among those not willing to vaccinate, the reasons were: newness of the vaccine (35%); preference to maintain precaution measures (21%); belief that COVID-19 vaccine is not essential (21%); and other reasons (23%). COVID-19 vaccine refusal was statistically significantly higher outside informal tented settlements (ITS) than inside ITS (Odds ratio (OR):1.36; 95%CI:1.03–1.81). The odds of vaccine refusal were six and seven times higher among older Syrian refugees who did not agree that vaccines are safe (OR:5.97; 95%CI:4.03–8.84) or effective (OR:6.80; 95%CI:4.44–10.42) than those who agreed. Refugees aged 70 years and older and those reporting chronic conditions did not significantly differ from younger participants or those without chronic conditions in their vaccine acceptance. Self-reported adherence to COVID-19 public health measures and perceptions of susceptibility to and severity of COVID-19 were not associated with vaccine acceptance.

Conclusion This study highlights important directions towards enhancing vaccine acceptance among Syrian refugees to reach herd immunity and ensure equitable vaccination. Practical approaches to increase vaccine acceptance include disseminating accurate, accessible, and culturally appropriate information about vaccine safety and effectiveness. Whilst this large study was representative of the beneficiaries of a humanitarian organization and not of all Syrian refugees in Lebanon, it is the first to present evidence on vaccine acceptance among refugees.