Process Evaluation of an Integrated Community-Based Trial to Improve Family Planning, Sexual Reproductive Health, and Wellbeing among Syrian Refugee Women and Girls in Lebanon During Active Conflict

Background : This study presents the first process evaluation of an integrated family planning, sexual reproductive health, and wellbeing community-based trial among Syrian refugee women and girls in Lebanon. This intervention, known as the Self-Efficacy and Knowledge (SEEK) trial, was developed by the World Health Organization as a low-resource and low-intensity initiative, and led by trained paraprofessionals (community health workers). Methods : The intervention was implemented between September and December 2024, a period marked by active conflict in Lebanon. A mixed-methods process evaluation was conducted, triangulating data from satisfaction surveys, field observations, and semi-structured interviews with participants, health workers, and program staff. Quantitative data were analyzed using SPSS, and qualitative data were analyzed using qualitative content analysis. Data collection tools assessed satisfaction, feasibility, fidelity to content, logistical and contextual barriers. Results : The evaluation revealed high participant satisfaction, with over 90% of participants rating session quality as good or excellent. Participants valued the program’s relevance, paraprofessionals community alignment, and the inclusion of interactive and visual aids. Paraprofessionals expressed satisfaction with the training and delivery process but, along with attending psychologists and midwives, reported the need for more soft-skills training and presentation skills. Logistical challenges included child care needs, transportation barriers, and the necessity of flexible scheduling. The war on Lebanon posed major implementation hurdles, requiring adaptive strategies such as remote coordination and increased reliance on leadership of local staff. Cultural and gender norms affected engagement, particularly around SRH content, with participants recommending greater involvement of men and household decision-makers. The presence of local women committees, research assistants, and field coordinators was key to maintaining trust, communication, and retention of participants. Conclusions : This evaluation demonstrates that SEEK is feasible, acceptable, and adaptable even in the context of active conflict. Its community-led design supported engagement and delivery, underscoring the importance of flexible and locally grounded implementation strategies in fragile settings. Trial Registration: Retrospectively registered on NIH clinical trials reference# NCT07008950