Structural racism and diminished health returns on education among Palestinian refugees in Lebanon

Drawing on structural racism, eco-social, and weathering theories, we examined whether the association between education and health is diminished among Palestinian refugees in Lebanon (PRL) who live under conditions of structural gendered racism. The study utilized data from a national household survey of PRL conducted by a humanitarian organization in December 2022. In a subsample of 7872 PRL 18 years and older, we assessed the association between education and diabetes, hypertension, and cardiovascular disease (CVD). Adjusted risk-ratios (aRR) were calculated to compare the proportions of the outcomes between each gender and education group of interest, adjusting for age, area of residence, and self-reported socioeconomic status. Analyses were conducted on the entire sample and a subsample of those 55 years and older. Among PRL women, increasing education resulted in a sequential decrease in aRR for diabetes, hypertension, and CVD, although not all estimates were statistically significant. This pattern did not persist in the sub-sample of women 55 years or older. Conversely, increasing education level among men showed no differences in risk. For example, compared to men with elementary or less education, men with university education or higher have a higher aRR of 1.12 (95% C.I. 0.83-1.50) for the outcome of diabetes. This trend persisted when comparing outcome risk in the sub-sample of those 55 years of age and older. The findings reveal a gendered association between education and chronic disease risk that is reflective of structural gendered racism. Whilst PRL women demonstrated a typical overall inverse association, PRL men exhibited a pattern of diminished health return on education. PRL men encounter racialized structures in the Lebanese mainstream economy, which stymies the health benefits they may accrue from education and access to other tangible resources.