Needs assessment with elder Syrian refugees in Lebanon: Implications for services and interventions

Health needs of older people and age-inclusive health care in humanitarian emergencies in low-income and middle-income countries: a systematic review

Health needs of older people in humanitarian settings are poorly documented, negatively affecting the appropriateness of health services they receive. This Review identified the major health needs of older people across humanitarian contexts, including non-communicable diseases and mental health conditions (eg, psychological distress and depression). Barriers to health care of older people included inaccessibility of health-care services; shortage of appropriate health care; insufficient availability of medications and medical equipment; poor geriatric expertise of health-care staff, health policy makers, and health authorities; and age discrimination by health-care personnel. Individual factors included low mobility, poor health literacy, dependence on others for access to care, and self-directed ageism. The participation of older people in shaping health-care services was highlighted as a facilitator of age-inclusive care. Several understudied areas related to the health needs of older people in humanitarian emergencies in low-income and middle-income countries were exposed. We urge governments, academic institutions, humanitarian organisations, and other health-care providers to focus their response and research efforts on the health needs of older people in conflict settings; the health needs of older people in humanitarian emergencies in understudied regions; and on neglected issues such as communicable diseases, cancer, neurocognitive disorders, sexual and reproductive health, genitourinary conditions, and nutrition. The participation of older people in the design, implementation, and evaluation of health-care services is essential to ensure accessibility, appropriateness, and acceptability of care.

Health and well-being of older populations affected by humanitarian crises in low- and middle-income countries: a scoping review of peer-reviewed literature

BACKGROUND

The convergence of global demographic changes and rising humanitarian crises in low- and middle-income countries (LMICs) has raised the number of affected older people (OP). These individuals face the challenges of aging and the adverse conditions of disasters, particularly pronounced in LMICs. This review aims to explore literature on the health and well-being of older populations during humanitarian crises in LMICs.

METHODS

This scoping review included primary studies on the health and well-being of older populations in humanitarian crises in LMIC. A search was conducted in five bibliographic databases last updated in 2023. A numerical summary and thematic analysis of study characteristics and themes were executed and findings were narratively synthesized.

RESULTS

A total of 84 eligible studies were included. The majority of studies were quantitative (n = 56), followed by qualitative (n = 22) and mixed-methods (n = 6). Most literature focuses on the high burden of mental health conditions and their determinants, such as depression, anxiety, and Post-Traumatic Stress Disorder (PTSD). The second most common theme is physical health, discussing high levels of mortality, disability, some non-communicable diseases, and limited evidence on the poor nutritional status. OP lack access to routine healthcare due to cost barriers. The key gaps in the literature are in mental and psychosocial health, especially pertaining to vulnerabilities and risk factors, and to contextualized interventions. Physical health research is relatively narrow lacking a wider range of chronic diseases while no research was performed on communicable diseases other than COVID-19.

CONCLUSIONS

Findings show the complex vulnerabilities of OP in humanitarian crises which exacerbate their physical, mental, and psychosocial health outcomes. There is a need to strengthen evidence on the effectiveness of interventions, and to investigate determinants of health, especially mental and psychosocial health, across different contexts. Research should also explore cross-cutting issues like gender, access to livelihoods, and equitable access to humanitarian assistance.

By the numbers and in their own words: A mixed methods study of unmet needs and humanitarian inclusion of older Syrian refugees in Lebanon

Older people constitute an overlooked vulnerable population in humanitarian crises. Lebanon is a small country that hosts the largest number of refugees per capita in the world. With exacerbating socioeconomic conditions, exclusionary policies against refugees, and a fragmented humanitarian system, the status of older Syrian refugees (OSRs) requires special attention. This study aimed to explore OSRs' unmet needs, coping strategies, available humanitarian services, and some indicators of the humanitarian inclusion standards focusing on the shelter, health, nutrition and food security, and water, sanitation and hygiene sectors. We conducted a convergent mixed-methods study between December 2021 and March 2022 in the North and Bekaa, including a cross-sectional survey with 461 participants and 14 semi-structured interviews. Results show that OSRs lived in inappropriate shelters (cold, leaking rainwater), especially in informal tented settlements. High rent prices pushed refugee households with elderly to prioritize paying rent at the expense of other needs such as food and medication, particularly when food cash transfer is the sole source of income, jeopardizing food security and intake. Access to dignifying and accessible bathing facilities was compromised in ITSs with shared facilities. Substantial medical costs hindered OSRs access to healthcare such as surgeries. Due to the crisis, chronic medications are not always available in dispensaries for subsidized cost, pushing OSRs to non-compliance and selling food assistance to buy medications. Soaring fuel prices hindered OSRs access to heating and transportation to receive healthcare. No efforts were reported in collecting data on OSRs' needs, targeting them with information on services, or soliciting feedback for programming, especially in the absence of any age-tailored interventions. Findings shed light on the precarious living conditions of OSRs in Lebanon and add to the body of evidence documenting their invisibility to the humanitarian response. An age-inclusive response is needed through holistic, tailored, and sustainable interventions.

Neurological Care of Refugees and Other Forcibly Displaced Persons

There are more than 100 million forcibly displaced persons (FDPs) in the world today, including a high number of people who experience neurologic symptoms and presentations. This review summarizes the conceptual frameworks for understanding neurological health risks and conditions across the migration journey (premigration, migration journey, and postmigration) and life span, including special attention to pediatric FDPs. The interaction with psychiatric illness is discussed, as well as the available published data on neurologic presentations in FDPs in the medical literature. A social determinant of health lens is used to provide ways in which forcible displacement can influence brain health and neurological outcomes. Priorities and future needs for the neurological care of refugees and other FDPs are suggested.

Multisystemic Resilience and Psychosocial Wellbeing among Older Refugees: A Systematic Review with Implications for Mental Health and Psychosocial Support (MHPSS)

Older refugees experience poor mental and emotional health outcomes compared to younger counterparts. Although older adults are instrumental in family/community adjustment in postmigration settings, little is known about how to enhance psychosocial resilience in this population. The aim of this systematic review is to glean deeper insight into the protective factors and processes associated with older refugees' resilience and positive psychosocial health in postmigration settings. We searched eight electronic health and social science databases. Twenty-three articles met the criteria for inclusion; we analyzed these using a multisystemic resilience lens. Studies spanned 1991 to 2022; importantly, 15 of the 23 articles were published in the past decade, indicating growing attention to the mental and psychosocial health of older refugees. Only six of the included articles focused on older refugees living in low- and middle-income countries, revealing a contrast between where most of the world's refugees reside and where the majority of mental health and psychosocial support (MHPSS) research is conducted. We found tremendous variation in determinants of psychosocial resilience based on the politico-historical contexts of migration; sociocultural backgrounds of refugees; and distinct postmigration needs, resources, and settings. Broadly, macrosystem determinants of resilience included security, access to basic services, and maintenance of culture and spirituality. Mesosystem factors were related to social support from families, ethnic communities, religious networks, and host country nationals. Finally, microsystem determinants of older refugees' resilience included language acquisition, cognitive reappraisal, and sense of optimism. Our findings suggest the importance of interdisciplinary, multilevel research designs to highlight how multiple ecosystems interact to promote psychosocial resilience among older refugees. Taken together, this systematic review offers important insight into multilevel protective factors and processes to enhance culturally and contextually meaningful MHPSS for older refugees.

Exacerbated inequalities: A scoping review of the experiences of older persons during conflict situations

BACKGROUND

We conducted the first known comprehensive literature review to (1) identify, categorize, and summarize the existing knowledge about the experiences of older persons and their caregivers during conflict situations; (2) identify the support needs of older persons and their caregivers, and; (3) identify gaps in the literature and understanding that may inform future research.

METHODS

A scoping review methodology of academic peer-reviewed and gray English language literature was employed using six academic literature databases and one gray literature database. We further performed comprehensive searches of relevant search engines and organization websites and bibliographic hand searches to identify additional academic and gray literature. Two authors screened for eligibility of identified studies and documents. One reviewer extracted data regarding authors, article type, geographic origin, key participant characteristics, aims, study design and data collection method, results, conclusions and limitations. Data were analyzed thematically.

RESULTS

83 documents met this review's inclusion criteria, including 21 academic documents and 62 from the gray literature. Thematic analysis revealed that conflict situations exacerbate existing inequalities experienced by older persons. Within this overarching theme were three interconnected sub-themes: (1) Older adults are particularly vulnerable during conflict situations; (2) Older persons are inadequately supported in conflict situations; (3) In the face of great challenges, many older adults still manage to endure through conflict situations. We identified 15 recommendations from the reviewed documents to better support older adults in conflict situations.

CONCLUSIONS

Existing inequalities, such as ageism and ableism, targeted discrimination, and poor health outcomes, become exacerbated during conflict situations, resulting in older persons being less able to flee and meet their daily needs with sufficient access to necessities and healthcare. Little is known of the experiences and needs of family caregivers during conflict situations. We identified several opportunities to improve the experience and support of older persons in conflict situations.

The determinants of sustained adherence to COVID-19 preventive measures among older Syrian refugees in Lebanon

INTRODUCTION

Lebanon has battled the COVID-19 pandemic in the midst of an economic crisis. The evolution of the pandemic and a fragile health system have meant that public health policy has had to rely heavily on non-pharmaceutical interventions for disease control. However, changes in disease dynamics, an unraveling economy, and pandemic fatigue have meant that disease control policies need to be updated.

METHODS

Using recent and timely data on older (50 years and above) Syrian refugees in Lebanon, this paper uses multivariate linear probability models to explore the determinants of adherence to two non-pharmaceutical COVID-19 prevention measures (wearing a mask and avoiding social gatherings) among this high-risk subgroup in a vulnerable population. Among respondents who report adhering to these measures, the paper also investigates the determinants of sustained adherence over a period of 6 months.

RESULTS

The findings suggest that no individual-level characteristics were robustly associated with mask wearing. For avoiding social gatherings, education was inversely associated with adherence to this preventive measure. Avoiding social gatherings was also significantly lower for residents of informal tented settlements (ITSs). Among initial adherents, and for both preventive practices, ITS dwellers were also significantly less likely to maintain adherence.

CONCLUSION

Identifying variables associated with adherence to non-pharmaceutical preventive practices, particularly for vulnerable groups, can help inform and refine interventions in the face of changing conditions. The material, physical, administrative and socio-economic constraints of life in an ITS suggest that avoiding social gatherings is hardly feasible. Yet despite the challenging conditions of ITSs, the indication to wear a mask is initially complied with, suggesting that tailoring policies to the limits and constrains of context can lead to successful outcomes even in very adverse settings.

The prevalence and risk factors for anxiety and depression symptoms among migrants in Morocco

Humanitarian migration can result in mental health issues among migrants. The objective of our study is to determine the prevalence of anxiety and depression symptoms among migrants and their risk factors. A total of 445 humanitarian migrants in the Orientale region were interviewed. A structured questionnaire was used in face-to-face interviews to collect socio-demographic, migratory, behavioral, clinical, and paraclinical data. The Hospital Anxiety and Depression Scale was used to assess anxiety and depression symptoms. Risk factors for anxiety and depression symptoms were identified using multivariable logistic regression. The prevalence of anxiety symptoms was 39.1%, and the prevalence of depression symptoms was 40.0%. Diabetes, refugee status, overcrowding in the home, stress, age between 18 and 20 years, and low monthly income were associated with anxiety symptom. The associated risk factors for depression symptoms were a lack of social support and a low monthly income. Humanitarian migrants have a high prevalence of anxiety and depression symptoms. Public policies should address socio-ecological determinants by providing migrants with social support and adequate living conditions.

Evaluation of bio-psycho-social and socio-cultural problems of Syrian elderly living in Turkey

BACKGROUND

Older persons are among the vulnerable groups most affected by war and migration due to physical weakness, illness, social environment, and cultural adaptation difficulties.

AIMS

The aim of this study is to determine the economic, biopsychosocial, and socio-cultural problems of the older Syrians living in Turkey.

METHODS

Convergent mixed design was used within the scope of the research. For the qualitative phase of the research, 19 older persons migrants were interviewed. A semi-structured interview form was used to collect data in the interviews. For the quantitative phase of the research, 432 participants were reached. In order to collect data, Geriatric Depression Scale (GDS-15) and Socio-cultural Adaptation Scale (SCAS-R) were used together with the demographic information form.

RESULTS

The mean age of the participants was 66.2 ± 7.10 (Min: 60; Max: 91), the majority (87%) between the ages of 60 to 74 and 53.2% were male. The mean SCAS-R score of the older Syrians was 2.48 ± 0.88 (Min: 1; Max: 5) and the mean GDS-15 was 2.63 ± 3.84 (Min: 0; Max: 15). About 22.7% of older Syrian participants had mild or severe depressive symptoms. Experienced traumatic events, changing economic situation, and family relationships affected both physical and mental health of the older persons. The socio-cultural adaptation of the older persons was affected by language, temporary protection, and exposure to exclusion. The Older Syrians, who lacked information on social services, were experiencing problems with nutrition, clothing, bill payment, and rent due to economic problems. However, they mostly did not want to return to Syria because their living order in Syria was deteriorating and they were afraid.

CONCLUSION

Syrian elderly immigrants living in Turkey have biopsychosocial, economic, and cultural problems. National and international support programs and policies should be developed for elderly Syrian refugees who are expected to live in Turkey unless a safe living environment is provided.

Ageism, an invisible social determinant of health for older Syrian refugees in Lebanon: a service providers' perspective

BACKGROUND

Older refugees face particular challenges because their health and social needs are largely overlooked in humanitarian programmes, policies and research. The few studies available have shown that older refugees suffer from a high prevalence of non-communicable diseases, including mental health problems, increased social isolation and poverty, and difficulty accessing health and social services. This article aims to provide further in-depth understanding of how service providers perceive health and social challenges of older Syrian refugees living in Lebanon by focusing on (1) their health and social challenges; (2) the available and lacking services; (3) participation; and (4) policy recommendations to improve services.

METHODS

This study is based on a qualitative research approach. Fifteen semi-structured interviews were conducted with health and social workers providing services to older Syrian refugees living in Lebanon. All interviews were digitally recorded, transcribed, coded and analysed using thematic analysis.

RESULTS

Study results clearly show that older refugees face increased marginalisation and neglect, mainly because of ageism. Ageism experienced at aid agency, family and individual levels, impacts negatively on older refugees. They have a sense of social isolation, neglect and feel they are a burden, consequently their social participation decreases, impacting negatively on their physical and mental health as well as their access to social and health care. Linked to experiences of ageism, study participants noted: (1) high prevalence rates of non-communicable diseases and mental health problems; (2) difficulties accessing care, with inadequate services to support the needs of older refugees; and (3) policy recommendations calling for an holistic approach to aid which takes into consideration the specific needs of older refugees as well as their capabilities.

CONCLUDING REMARKS

Ageism is a key determinant of health which negatively impacts the physical, mental and social health, and wellbeing of older Syrian refugees. It pushes them to the margins of society where they are left behind by the humanitarian response, policy makers and researchers, as well as their communities and families. To mitigate this situation, this article calls for directly addressing ageism on social, service and policy levels.

"Older people tend to be invisible": a qualitative study exploring the needs and inclusion of older Syrian refugees in the context of compounding crises in host country, Lebanon

BACKGROUND

Older Syrian refugees in Lebanon are a marginalized population with under-recognized health needs. The inclusivity of this population within the humanitarian response is poorly understood. This study aims to identify the unique needs of older Syrian refugees in the context of recent concurrent crises in Lebanon, and explore the extent to which they are being met and prioritized by local and international aid agencies.

METHODS

We conducted in-depth interviews with a snowball sample of 26 stakeholders from 11 organizations operating in the health, nutrition, and water, sanitation, and hygiene sectors. Data analysis followed principles of thematic analysis.

RESULTS

Concurrent political, economic, and public health crises in host country promoted income insecurity among older refugees and increased dependency on younger relatives, leading to food insecurity, neglect, and poor health outcomes, including the sequelae of untreated non-communicable diseases. Mental illness was perceived to be exacerbated by Covid-19 related challenges, including social isolation, uncertainty about the future, and additionally due to feelings of guilt related to economic dependence and fundamental exclusion from labor force participation. Despite their vulnerability, older refugees are overlooked by the humanitarian response, which may be related to a lack of data. Pervasive medication shortages in the setting of the economic collapse, as well as inaccessible physical environments and competing interests were all identified as major barriers to care.

CONCLUSIONS

Older Syrian refugees in Lebanon experience dual vulnerability that is acutely exacerbated in the setting of concurrent crises. Sociopolitical, economic, and cultural barriers promote social exclusion and may confer an increased risk of income and food insecurity in this population, with significant implications for health. Humanitarian aid agencies operating in the context of fragmented, under-resourced health systems are currently unable to sufficiently address multi-faceted needs of this community. We recommend moving away from a donor-dependent model of aid by allocating resources toward strengthening inclusive national health systems that emphasize preventative care. We further call for age-disaggregation of routine data and normalization of data sharing among stakeholders in the academic and public health sectors in order to develop evidence-based initiatives that can meet the needs of this under-served community.

Psychosocial support services provided for Syrian refugees with disabilities: a systematic review and thematic analysis

This study systematically reviewed and thematically analyzed studies that investigated psychosocial support services provided to Syrian refugees with disabilities between 2011 and 2020. Nine studies published in the English language were identified from database searches (Google Scholar, PsychInfo, EBSCOhost, Web of Science, and Scopus). Results showed that the forms of psychosocial support services provided to Syrian refugees with disabilities were varied based on the nature of the study and the disability type. The results also provided detailed information about methods, participants, and findings of the identified studies. The thematic analysis results identified six themes that represent the factors related to the psychosocial support services, which were assessment, mental health, psychological well-being, rehabilitation, social participation, and vulnerability. This study provided a set of recommendations that may improve the quality of mental health and psychosocial support services provided to Syrian refugees with disabilities and their families, which are professional development, researches, and policy reforming.

Prevalence of depression symptoms and associated sociodemographic and clinical correlates among Syrian refugees in Lebanon

BACKGROUND

Since the outbreak of the Syrian war in 2011, close to 6 million Syrian refugees have escaped to Syria's neighbouring countries, including Lebanon. Evidence suggests rising levels of mental health disorders among Syrian refugee populations. Yet, to the best of our knowledge, large-scale studies addressing the mental health of adult Syrian refugees in Lebanon are lacking. We examined the prevalence of depression symptoms, which represent a common and debilitating mental health disorder among Syrian refugee populations in Lebanon, along with their sociodemographic and clinical correlates.

METHODS

A cross-sectional survey design was conducted as part of a collaborative project-"Sijilli"- led by the Global Health Institute at the American University of Beirut (Beirut, Lebanon) across 4 informal tented settlements for refugees (Beirut, Bekaa, North, South) in Lebanon among adult Syrian refugees (≥18), over a period extending from 2018 to 2020. The survey inquired about participants' sociodemographic and clinical characteristics, and screened participants for symptoms of depression through sequential methodology using the Patient Health Questionnaire (PHQ-2 and PHQ-9).

RESULTS

A total of 3255 adult Syrian refugees were enrolled in the study. Of those refugees, 46.73% (n = 1521) screened positive on the PHQ-2 and were therefore eligible to complete the PHQ-9. In the entire sample (n = 3255), the prevalence of moderate to severe depression symptoms (PHQ-2 ≥ 2 and then PHQ-9 ≥ 10) was 22% (n = 706). Further analyses indicate that being ≥45 years of age (OR 1.61, 95% CI 1.13-2.30), a woman (OR 1.34, 95% CI 1.06-1.70), widowed (OR 2.88, 95% CI 1.31-6.32), reporting a neurological (OR 1.73, 95% CI 1.15-2.60) or a mental health condition (OR 3.98, 95% CI 1.76-8.97) are major risk factors for depression.

CONCLUSION

Our study suggests that an estimated one in four Syrian refugees in Lebanon shows moderate to severe depression symptoms, and our findings have important public health and clinical implications on refugee health. There is a need to enhance screening efforts, to improve access and referral to mental health services, and to improve post-migration factors among Syrian refugees in Lebanon.

Strengths-based inquiry of resiliency factors among refugees in Metro Vancouver: A comparison of newly-arrived and settled refugees

STRENGTHS-BASED INQUIRY OF RESILIENCY FACTORS AMONG REFUGEES IN METRO VANCOUVER: A comparison of newly-arrived and settled refugees.

OBJECTIVE

To identify the resiliency factors among refugees in the Metro Vancouver area, and compare these factors between newly-arrived and settled refugees.

DESIGN

Semi-structured individual interviews.

SETTING

Vancouver, British Columbia, and surrounding suburban communities.

PARTICIPANTS

13 key informants from resettlement, healthcare, and public education sectors who work closely with refugees, 13 refugees who have resided less than five years in Canada (LTFYRs), and 8 refugees who have resided greater than five years in Canada (GTFYRs). Refugee source countries were Syria, Iraq, Afghanistan, Iran, Kenya, Vietnam, Somalia, and Mexico.

MAIN FINDINGS

Key informants stated that knowledge from this study would help create and improve current supports for refugees, inform policy, increase understanding of refugee perspectives, and promote strengths-based resettlement strategies. Resiliency factors were grouped into themes, which were categorized as internal or external resiliency factors. Internal resiliency factors included fixed characteristics (age at arrival, female gender, and past education/skills), positive coping strategies (acceptance and positivity), proactivity, and integration (personal identity and adaptation). External resiliency factors identified were support systems, employment and finances, living environment, and societal encouragement of refugees. Comparison of responses between LTFYRs and GTFYRs revealed overall consistency in resiliency factors, but with LTFYRs identifying characteristics that assisted with acute integration, such as age at arrival, more often than GTFYRs. Comparison of responses between refugees and key informants revealed that key informants less frequently identified internal resiliency factors.

CONCLUSION

This study qualitatively describes several internal and external resiliency factors of refugees in Vancouver. Awareness and promotion of these resiliency factors in refugee populations, in collaboration with healthcare providers, settlement organizations and education systems, may improve refugee resettlement. These findings will also help generate the groundwork for local interventions that can support refugee resiliency in the population studied.

Enablers of psychological well-being for refugees and asylum seekers living in transitional countries: A systematic review

The purpose of this systematic review was to locate and synthesise existing peer-reviewed quantitative and qualitative evidence regarding enablers of psychological well-being among refugees and asylum seekers living in transitional countries and for whom migration status is not final. Systematic searches were conducted in nine databases: Academic Search Premier, CINAHL, Embase, Emcare, Medline, Psychology and Behavioral Science, PsycINFO, Scopus, and Web of Science. Search terms were related to refugees and asylum seekers, enablers, and psychological well-being. Studies were limited to those conducted in the last 20 years, with participants who were refugees and asylum seekers with no legal residency status, aged 16 years and above, and living in transit host countries without UNHCR resettlement programmes. This systematic review was conducted between March and June 2018 and followed the PRISMA guidelines. Results were screened by two reviewers at two stages: title and abstracts, and full-text. Critical appraisal and data extraction were also completed by two reviewers. Initial database searching yielded 3,133 results. Following the addition of two records from relevant reference lists and the removal of duplicates, a total of 1,624 results were included for screening. A total of 16 articles were deemed eligible for inclusion in this review, reporting on a collective sample of 1,352 participants. Twelve qualitative and four quantitative studies identified eight enablers of psychological well-being: social support; faith, religion and spirituality; cognitive strategies; education and training opportunities; employment and economic activities; behavioural strategies; political advocacy; and environmental conditions. Despite many challenges associated with forced displacement and the transit period, this review highlights multiple factors that promote well-being and suggest areas for intervention development and resource allocation.