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

Abstract

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.

Background

The older population globally is growing at an unprecedented rate, driven by factors such as increased life expectancy and declining fertility rates [1, 2]. This demographic shift in low- and middle-income (LMICs) intersects with the disproportionate occurrence of humanitarian crises which include both natural and man-made disasters. For instance, natural disasters caused $110 billion of losses in the first half of 2023, with the largest share attributed to a major LMIC event, the February Türkiye and Syria earthquakes. In addition, 82% of the global deaths due to weather, climate and water catastrophes occurred in LMICs between 1970 and 2019 [3]. In terms of armed conflicts, analysis of deaths from major armed conflicts between 2000 and 2019 show that all seven conflicts were in LMICs and caused more than 800,000 total deaths [4]. LMICs, especially those grappling with fragility, conflict, and violence possess limited disaster management capacity to respond to large-scale events including both natural and man-made disasters [3, 5].

Older populations (OP) make up to 4% of the United Nations’ Higher Commissioner of Refugees’ (UNHCR)’s overall population of concern, which includes refugees and asylum-seekers, refugees returning home (‘returnees’), the internally displaced and stateless people [6]. OP in humanitarian crises suffer particular types of vulnerability and risk directly impacting their physical, mental, and psychosocial health and well-being. In addition to the normative physical and mental decline in older age, disasters and the highly likely forced displacement puts them at risk of being left behind, injury and disability, mental traumatization and illness, social exclusion and loneliness, loss of economic generation opportunities and assets, as well as a drastic change in social status [7,8,9]. These vulnerabilities are further exacerbated for elderly in LMICs due to the weakened governmental systems and absence of equitable safety nets [3].

A notable challenge in addressing the health and well-being needs of older populations in humanitarian settings is the scarcity of evidence, dedicated funding streams, and tailored programming to their unique needs [7, 10,11,12,13,14,15,16,17,18]. Despite growing recognition of the importance of addressing the needs of older populations in humanitarian contexts, there has been limited effort to systematically map the existing literature on the different dimensions of their health and well-being, particularly in LMIC [18,19,20,21]. The absence of comprehensive reviews hinders the understanding of the scope, depth, and gaps in existing knowledge, thereby impeding efforts to develop evidence-based interventions and advocate for greater inclusion of older individuals in humanitarian policies and programs that affect their well-being.

An initial exploration of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews, the Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports was performed, revealing no ongoing or recently completed scoping reviews or systematic reviews addressing the specified topic. This review was conducted to map and characterize the existing primary peer-reviewed published literature on the health and well-being of older populations affected by humanitarian crises in LMICs in terms of some bibliometric characteristics and the themes explored and their respective findings. It ultimately aims to inform researchers on knowledge gaps pertaining to older populations in humanitarian crises, and policy makers and humanitarian actors on the vulnerabilities of OP is disasters to be addressed in programming interventions.

Review questions

The overarching research question for this review is: “what is the breadth of peer-reviewed published research on older populations affected by humanitarian crises, their main findings in terms of vulnerabilities and needs, access to humanitarian services, and gaps and opportunities to advance existing knowledge and improve programming?”

Methods

This scoping review followed the guidelines outlined by Arksey and O’Malley [22], Levac, Colquhoun and O’Brien [23] and the Joanna Briggs Institute [24]. The reporting of this review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) guidelines [25].

Eligibility criteria

Inclusion criteria

Studies were included if they met the following criteria: [1] primary research study in a peer-reviewed journal written in English, Arabic or French languages; [2] conducted in LMICs as classified by the World Bank country classifications [26], [3] the study period was during or after a humanitarian crisis, defined as including natural (e.g., earthquakes, volcanoes, floods, …) and man-made (e.g., armed conflicts and wars, explosions, …) disasters [27], or a compilation of both; [4] no age cut-off was set as an inclusion criterion defining older age; a population was considered elderly if defined as such by the paper authors; [5] the study population was civilian elderly affected by humanitarian crises, and [6] the study tackled one or more types of the health and well-being of OP, namely: physical health, mental health, and psychosocial health. The difference between mental health and psychosocial health as far as this review is concerned is in the scope. Psychosocial health is framed as a subordinate concept of mental health [28], it is framed in this review as the well-being associated with disaster and displacement-associated social issues and how these affect OP’s experiences, such as coping, adaptation, resilience, social integration, among others. Mental health is framed as the issues and conditions that OP may face on more individual levels. The review also included studies tackling multi-dimensional concepts of health or well-being, such as Quality of Life (QoL) [29]. QoL is defined as “an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns” [30]. This concept includes multiple health-related dimensions such as physical, emotional, social, material, and developmental wellbeing sub-constructs [31], making it an encompassing concept of other wellbeing concepts such as psychosocial wellbeing.

Exclusion criteria

Accordingly, papers were excluded if [1] they were conducted on military or veteran military populations [2], older populations in the study had experienced a crisis at a younger age [3], studies on all-age populations showing age as a risk factor but not focusing specifically on older populations [4], studies on migrants, and displaced populations due to development projects such as housing rehabilitation and not humanitarian crises, or [5] Studies not tackling any health or well-being constructs.

Information sources

A search was conducted in five bibliometric databases of health and well-being publications: Medline, CINAHL, Embase, PsychInfo, and Global Health. The search was not restricted to a time-frame so all studies ever published on older populations affected by disasters are retrieved. Search strategies across the different databases were constructed using a comprehensive list of keywords and MeSH terms for the following search blocks: “older people”, “humanitarian crises” and “LMICs”. The search strategies for the five databases are included as Additional file 1. The search strategy was run in July 2021 and updated in December 2023. In addition, forward and backward hand-searching¹ of each of the included studies, as well as of the relevant retrieved reviews was conducted to increase the sensitivity of the search.

Selection of sources of evidence

We imported all records retrieved from the electronic search into an electronic citation and reference management tool (EndNote) [32], and all duplicates were removed. The study selection was done over two steps: title and abstract (TA) screening, followed by full-text review. In both steps, the inclusion criteria guided the decisions. At the level of the TA screening, papers were retained if the study included older populations in the context of a humanitarian crisis in any LMIC. The process was more inclusive than exclusive. At the level of the full-text screening, the focus was on excluding papers where older populations were not the focus of the study, or where the humanitarian crisis has occurred in earlier ages, or for an extended period of time that the population has suffered from it before entering older age (Fig. 1). In both steps, screening was performed in duplicate such that two independent reviewers performed each of the screening steps and any discrepancies were resolved by consensus or by a third member of the research team.

Data charting process & data items

We conducted a data charting process to extract the information relevant to our review including bibliometric information (publication date, affiliation of first and corresponding authors, funding sources), the study context and design (research objectives, date and location of the study, disaster name and date, size and characteristics of the sample included in the study in terms of age, gender and nationality composition, migration status, cut-off for older age definition, study design and sampling method), and the concepts explored (health and well-being types). A charting form was created to extract these fields and was pilot-tested on 10 random papers and edits were made where necessary. Next, an online version of the form was created using KoboToolbox [33] and four extractors used it for the charting. Raw data were then retrieved from the online form and validation of the extracted data was conducted on all the charted full-texts by an independent team member (the first author).

Synthesis of the results

First, the extracted bibliometric and methodological characteristics data are presented quantitatively using numeric summaries in Table 1, and summarized narratively in the results section. Next, we present the results summarizing the findings of the 94 included studies in tabular format for each of the papers (Additional file 2²). In addition, we used narrative synthesis by thematically summarizing paper findings using pre-determined deductive codes categorizing the studies’ main themes of inquiry such as ‘physical health and well-being’, ‘mental health and well-being’, and ‘psychosocial health and well-being’ [34]. We also employed inductive codes generated through reading and pooling study findings under main themes and sub-themes of focus. This depiction of results is followed by an in-depth reflection and discussion of the review findings. This serves to describe the breadth, depth, and gaps of the literature on OP’s health and well-being in humanitarian crises in LMICs, and to inform future research agendas and suggest recommendations to improve humanitarian policy and practice.

Table 1 Characteristics of included studies

Patient and public involvement

Because this study is a scoping review, it was not appropriate or possible to involve patients or the public in the design, or conduct, or reporting, or dissemination plans of our research.

Results

The screening and selection procedure is shown in the PRISMA flowchart in Fig. 1. Electronic database searching resulted in 34,294 records after removing duplicates. A total of 123 records were included in the screening of the two search instances, of which 84 were excluded at full-text screening phase for not meeting the eligibility criteria. In addition, 45 records were identified and included from the forward and backward citation searching of the 39 included papers from the database search. Hence, a total of 84 studies were included.

Fig. 1

PRISMA flowchart

Bibliometric characteristics

The distribution of the included papers by bibliometric characteristics is displayed in Table 1. Primary peer-reviewed publications per year have increased over time from just one in 1989 to a maximum of 11 in 2022 (Fig. 2). This upward trajectory is further accentuated by the 34 studies (40%) of studies published only between 2020 and 2023 (Table 1).

Fig. 2

Distribution of papers by year of publication (n = 84)

Study characteristics

Study designs and objectives

Out of the 84 included studies, 66.7% were primary quantitative, 85.5% of which were cross-sectional studies. Around 26.2% of the studies were qualitative, with half (50%) not specifying the methodology undertook, while the remaining employed case studies, ethnography, phenomenology, and descriptive methodologies. Only 6 studies employed a mixed approach of quantitative and qualitative methods. In terms of study objectives, almost one third of the included studies (35.7%) primarily adopted descriptive approaches, delving into aspects such as quantifying the prevalence of certain outcomes, or qualitatively exploring perceptions and views. Similarly, 26.2% of the studies sought to explore correlations and relationships between certain predictors and outcomes. Another third of the studies (34.5%) sought both descriptive and correlational aims, while only 3 studies aimed, partially or exclusively, to evaluate humanitarian programs. (Table 1)

Study settings and population features

Natural disasters were the primary focus of 49 of the studies, followed by 40% of the studies that focused on man-made disasters (including armed conflicts), while one study addressed a complex emergency of both man-made and natural disaster. Geographically, the studies originate from a diverse array of 26 countries; China had the largest number of studies (22.6%), followed by Lebanon at 10.7% and Bangladesh and Iran at 9.5% each. Regarding sample composition, the biggest fraction of the studies was conducted with refugee populations (29.7%) of the studies, including one study with hosting communities. On the other hand, studies recruiting internally displaced persons to temporary or permanent shelters, non-displaced affected populations, or a mix of both constitute 16.7%, 14.3% and 16.7% of the studies, respectively. The study population in 15 of the studies was in disaster-struck areas without a clear reference to whether participants were relocated or not from their pre-disaster homes. In 9 of the studies, other stakeholders such as humanitarian workers, caregivers, or experts were recruited and consulted either exclusively (n = 4) or in complementarity with a sample of disaster-affected populations. Studies exclusively focusing on elderly populations constituted 85.7% of the studies (Fig. 3).

Fig. 3

Summary of contexts and populations of included studies. Legend: This alluvial diagram shows a conceptual flow of the studies’ context and sample populations. It begins with study countries and flows to show the type of disaster, the sample composition in terms of displacement status, and the country of origin for refugee populations. The total count number is 84 but corresponds to 83 studies excluding one study that used secondary data analysis. Studies summed up to 84 because one study was conducted in both Lebanon and Jordan and was thus entered in duplicate

Gender composition within the studies on older people (not exclusively with other stakeholders) is predominantly mixed, with around 96.3% comprising both male and female participants while only 3 studies exclusively focused on female elderly. Around 47% of the study samples were composed of a balanced sample (with the proportion of males ranging between 45 and 55%). As for the definition of older age, the lowest cut-off used was 45 and the highest is 65, excluding nonagenarians (93–95 years). The most common age cut-off is 60 years old and above adopted by over half of the studies (54.8%), followed by 50 years and above (10.7%). Seven studies did not define an older age cut-off.

Thematic synthesis of study concepts

Considering the themes of focus explored in the included studies, mental health surfaces as the dominant sector of inquiry, capturing the attention of 33% of the included studies, followed by 30% of the studies focusing on physical health, while 9.5% of the studies explored QoL. Fifteen studies focus on the psychosocial dimension of OP’s experiences in humanitarian crises, the majority of which (n = 8) mainly focused on OP’s responses to disasters in terms of coping, adaptation, and resilience. Eleven studies reported on multi-dimensional assessments of OP’s health and well-being. In terms of the evolution of the themes investigated over time (Fig. 4), it is evident that research on OP in disasters first began focusing on physical health followed by mental health. Mental health research grew exponentially reaching its peak in the last decade, at a rate of 2 studies published per year between 2024 and 2023. Research on the psychosocial health and well-being of OP in disasters emerged more recently in 2015 and seems to grow at an increasing pace.

Fig. 4

Heat map of the primary themes of inquiry of included papers. Legend: The total number of studies in the heat map (n = 87) exceed the total number of included studies because three studies were classified and counted in two different themes

Findings from included studies are synthesized narratively below under eight thematic titles which emerging from the thematic analysis: ‘psychosocial issues and vulnerabilities’, ‘adaptation coping and resilience’, ‘mental health needs and vulnerabilities’, ‘mental health interventions’, ‘physical health needs and vulnerabilities’, ‘COVID-19 knowledge, attitudes and practices’, ‘quality of life’, and ‘the state of humanitarian health response’.

Psychosocial health and well-being

Psychosocial issues and vulnerabilities

Seven studies have illustrated the drastic life changes that OP undergo during and after humanitarian crises [35,36,37,38,39,40,41]. In a study with older Iranian earthquake survivors, the authors describe two change trajectories: re-victimization and post-accident growth. The former includes the physical, mental, functional, social and socio-economic challenges faced by the elderly, which exacerbate pre-existing vulnerabilities [41]. Similarly, another study sheds light on the traumatic losses, ageism and disruption in social routine that OP experience [36]. After disasters, OP face great change in social status and disruption of networks as they are likely to become widowed, live alone, and lose family members and breadwinners [38]. With inherent physical health vulnerabilities and disabilities, the elderly’s need for care, income, and social support is magnified affecting both physical and mental health [37, 38]. These dramatic circumstantial and social regressions pose tremendous repercussions on OP’s self-perceptions and jeopardize their self-esteem [35] self-efficacy, and dignity [40], and may inflict feelings of guilt because of increased economic dependence [42]. They become more prone to social isolation and mental and psychosocial problems, including domestic abuse and neglect [35, 39].

Adaptation, coping, and resilience

A total of 22 studies have discussed, to different extents, aspects OP’s psychosocial responses to cope with their new lives [35, 37, 38, 41, 43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60], with eight having these issues as their primary thematic focus [43,44,45, 48, 49, 51, 55, 56]. For instance, the same study conducted with Iranian Earthquake survivors [41] found that the elderly can go through a growth journey including individual growth, self-regulatory behaviors, and reinforcing the houses. Indeed, one study showed that older disaster survivors had a higher positive MH score than younger ones [53]. Factors that help elderly cope with the trauma and respond with more resilience include both individual and social factors [38]. Individual factors include a positive attitude [45] holding on to cultural identity and leveraging on previous experience [38, 44, 61], seeking self-care both mentally and physically, doing activities for healing [54], religious faith and spirituality [38, 43,44,45, 51, 54, 56, 58], coping with new activities, roles and place [43], self-esteem and self-efficacy [54, 56], and good health status [55]. Social factors include social support and family relations and connectedness [38, 44, 47, 48, 51, 55, 56]. Indeed, OP may resort to maladaptive responses after disasters; they may lose motivation to search for relief supplies, become overly dependent, and socially isolated [35, 43, 57]. When OP relocate away from home, they attempt to combine practices from the past and adapt them to the present context; however, feelings of helplessness [47] and uncertainty about the future and return may prevail [59], and elderly may feel insecure [46]. Only one study showed the relationship between elderly refugees and host communities in South Africa, and revealed a nuanced depiction of reality. While some locals are compassionate towards their needs, others are hostile and perceive them as economic competitors, especially the socio-economically disadvantaged [60]. As for sociocultural adaptation and integration of elderly, it is mainly affected by language [37, 52], temporary protection, and exposure to exclusion, social networks, common religion, and poverty [52]. In one study, older Rohingya refugees in Bangladesh reported that they wish to return to their country after the crisis is resolved despite being relatively satisfied with their lives in Bangladesh [50].

Elderly women in particular were found, in one study, to have unique views on resilience focused on embracing culture, immersing in present actions and roles such as farming and childcare, and spirituality [49]. In another study, it was shown that some factors in the pre-disaster context nurture the capacity for resilience such as economic generation and assets, good health status, while prevailing social norms and gendered stereotypes constrain women’s dignity [51].

Mental health and well-being

Mental health needs and vulnerabilities

The main focus of the extracted papers was mental health conditions and their correlates, tackled by 25 studies [46, 54, 57, 62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83]. It is evident that OP may suffer from multiple mental health conditions and issues after disasters [46, 77] as well as general psychiatric morbidity [69] and a variety of conditions such as depression, post-traumatic stress disorder (PTSD) and anxiety.

Psychological distress

Risk factors for psychological distress after exposure to disasters include sociodemographic characteristics such as being female [78, 83], advanced age, and lower educational level [64]. Disaster-related factors such as relocation and the loss of family members during the earthquake are also significant predictors [64, 83]. Physical health factors such as chronic diseases [35, 78] and reduced functional status [64, 78] were also reported risk factors. Another source of psychological distress is OP’s worry about their children’s lives and grieving their loss [54]. One protective factor against psychological distress found in one of the studies was having a sense of community [71].

Anxiety

OP may display symptoms of anxiety after exposure to a disaster like an earthquake [72]. Predictors of anxiety include disaster-related factors such as displacement [57], loss of livelihood, bereavement, injury, initial fear during the earthquake, and personal factors such as female gender and depression [72, 81].

Depression

Exposure to disasters was reported to increase the prevalence of depression in elderly survivors, ranging between 15% and 41% in the extracted studies [37, 65, 70,71,72,73, 76].

The determinants of depression include disaster-related factors such as traumatic human and material losses and injury [76, 79, 81], displacement [57], anxiety [72], low educational level [70], chronic illnesses [62, 70, 73, 76], feelings of loneliness or living alone/ social isolation [70, 73, 76], limitations in activities of daily living and dependence on family for living [70, 73], family history of mental illness [79], malnutrition [62], and being female [73, 76, 79]. Older age was negatively associated with depression in two studies [62, 76]. Depression was also found to increases the risk of mortality (more than double the risk) [84]. Protective factors include social support and family relations [62, 70].

PTSD

In the extracted studies, it was found that PTSD among elderly people ranges between around 18% and 60% [63, 66, 79, 82] and a higher incidence was found in older versus younger displaced tsunami survivors [57]. Chronic PTSD was also found to be in relatively higher rates in elderly compared to younger populations [68, 74]. PTSD is a natural consequence of exposure to traumatic events to self or loved ones including human losses and injuries, witnessing death or injury, and loss of livelihoods [66, 68, 69, 75, 81]. In addition, PTSD was found to be correlated with depression, being female, low education, low monthly income, and low social support [66, 79]. Chronic illnesses and poor self-perceived health [63, 82] and older age was found as a risk factor in one study [69]. PTSD signs were found to diminish over time in a study conducted after the Wenchuan earthquake in China [80]. One study examined a potential mechanism linking existential concerns and core beliefs to PTSD and found that both were linked to increased PTSD symptoms and a mediated path connecting existential concerns to PTSD through core beliefs is significant [67].

Mental health interventions

Only two studies explored mental health interventions [85, 86]. A study in Indonesia showed the scarcity and inadequacy of such interventions, underscoring the need for tailored policies and programs to the needs of elderly in disasters [85]. Art interventions may be promising as shown in a study using art tools with older Syrian refugee women in Turkey showing improved expression of positive feelings [86].

Physical health and well-being

Physical health needs and vulnerabilities

A total of 23 studies addressed physical health issues [62, 76, 77, 87,88,89,90,91,92,93,94,95,96,97,98,99,100,101,102,103,104,105,106]. At the level of physical and medical issues and needs, the published literature shows an elevated risk of trauma-induced mortality in disasters [91, 104] especially compared to younger segments [104], and a high incidence of traumatic musculoskeletal injuries and internal injuries such as acute kidney injury [104, 106]. In a study investigating the impact of long-term wartime stressors on 10-year cardiovascular disease (CVD)-specific mortality in middle-aged and older people during the Lebanese civil war, relocation from pre-war residence led to increased 10-year risk of CVD and mortality. Gender differences in mortality rate were found by object of wartime trauma: higher in women than men for those exposed to traumas to self or family members, and higher in men than women when exposed to property and economic losses [103].

In addition, OP suffer from reduced functional capabilities such as Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) after disasters [77, 88], often forcing them to be left behind [92], and reducing their access to relief items post-disaster [88]. Functional decline increases with age, being female, is associated with living alone and having low memory or concentration [87, 93]. In addition, low ADL was found to be associated with low educational level and income, and enhanced by interpersonal trust [93].

OP were found to be disproportionately affected by non-communicable diseases (NCDs) [77, 97]. In a study on Ukrainian OP, it was estimated using secondary public data that an elderly possesses on average 2–5 chronic diseases [102]. The literature shows a significant burden of cardiovascular disorders such as hypotension and hypertension, diabetes mellitus, and chronic obstructive pulmonary disease [62, 76, 77]. Despite increased rate of healthcare seeking after disaster [105], OP suffer from low access to routine healthcare and NCD management, including eye care [77, 90, 96,97,98], and face difficulties in affording medication [95, 97].

Nutritional status was found to be poor in terms of undernutrition and malnutrition [62, 76, 77, 100], low arm muscular area (AMA) [100], and chronic energy deficit [89]. Nutritional status was found to be negatively affected by low access to income and basic needs, physical functionality, and psychosocial trauma [99]. Lower age, male gender, body mass index (BMI) and AMA are positively associated with handgrip strength [101].

Oral health was also shown to be affected by disaster reflected in a study by an increased prevalence of periodontitis, which could be linked to unhealthy post-disaster practices such as poor oral hygiene, stress, tobacco abuse, and poor nutritional intake [94].

COVID-19 knowledge, attitudes and practices (KAP)

A total of six studies [107,108,109,110,111,112] investigated COVID-19-related KAP. One study explored the elderly misconceptions about COVID-19 and found that they have an average of five misconceptions, mainly regarding preventive measures [107].

High levels of COVID-19-related anxiety and stress were found in one study among older Rohingya refugees in Bangladesh [108], while the majority were found to have low fear in another study [109]. Negative emotions towards COVID-19 were mainly associated with negative perceptions or experiences with the disease, such as perceived risk, having difficulty getting food or medical care during the pandemic, and knowing a friend or family member who got infected [108, 109].

In practice, the shelter type highly affects adherence to preventive measures – social gatherings and mask-wearing are poorly abided by in camps where residence is crowded and social relations entail physical proximity [111]. On the other hand, getting the COVID-19 vaccine in a study among older Syrian refugees in Lebanon was dependent on lacking misconceptions about its importance and side-effects, and living in camps which are heavily accessed by humanitarian agencies [112]. Another study explored tobacco smoking during COVID-19 showing that a significant proportion of older Rohingya refugees in Bangladesh reported a perceived increase in tobacco smoking during COVID-19, while lower odds were associated with being concerned or overwhelmed by the disease [110].

Quality of life (QoL)

A total of 9 studies discussed OP’s QoL in disasters [37, 64, 105, 113,114,115,116,117,118]. QoL was found to be overall low on the different dimensions after disaster [105, 116]. One study showed that the psychological dimension remains low even long-term post-disaster, while the social relations dimension improves [113]. The main factors reported to improve OP’s QoL in disasters include social support and family function [115, 118], while reduced functional capacity [113, 118], depression [118], female gender [113, 114], and injury [113], low educational status [114, 115], and higher age [113]. Similarly, older survivors in Indonesia after the 2018 earthquake, tsunami and liquefaction reported worse scores on average QoL and its sub-scores [116].

Similarly, health-related QoL (HRQoL) was found to be poor in OP in disasters [117], with its main determinants being relocation from pre-disaster residence [64], advanced age [64, 105, 117], lower educational level [64], the loss of family members during the earthquake [37, 64], traumatic experiences, and changing economic situation [37], the presence of chronic illnesses [64, 105, 117], poor functional status and injury [117]. On the other hand, social support and accessibility of resources positively influence HRQoL [117].

The state of humanitarian health response for elderly

A total of seven studies discussed the state of humanitarian health response to OP in disasters [10, 37, 42, 46, 76, 119, 120]. They shed light on the overarching issue of ageist stereotypes and exclusionary neglect of elderly existing at individual, familial and humanitarian levels. These were found to lead to social exclusion and neglect of elderly, especially in accessing relief, social, or healthcare services. When intersected with disproportionately higher rates of NCDs, diminished functional capacity, and mental health problems, older refugees are at a great disadvantage experiencing low access to basic needs such as nutrition, clothing, paying bills and rent, accessing healthcare, and affronting dignity. This entails the need to holistic and inclusive approaches to humanitarian aid [10, 37, 42, 46, 76, 119]. Unfortunately, a study on medical humanitarianism in Jordan showed that although OP are viewed as ‘vulnerable’ by humanitarians, they are also deemed economically burdensome: they have a limited lifespan, high disease burden, and low economic contribution, making them ‘low value-for-money’ [120].

Discussion

This scoping review maps the literature on the health and well-being of older populations within humanitarian crisis settings in LMICs. In terms of study characteristics, the review found a total of 94 studies published between 1989 and 2023 at an exponentially increasing rate. These studies spanned 30 countries dispersed in 4 continents, and mostly tackled natural disasters. The main communities of OP targeted by the studies were populations who remained in the same disaster-struck area, and almost one third of the studies were conducted with refugees. The review also shows heterogeneity in the age cut-off used in the papers to define older age ranging between 45 and 65 years, with the majority adopting the 60 years threshold, which is the cut-off long adopted by the United Nations [121]. The most commonly employed research designs are quantitative, particularly cross-sectional, while less than a third of the studies utilized qualitative designs, and six papers employed mixed methods.

Regarding study findings, the review highlights five major areas of research on OP’s health and well-being in humanitarian crises: psychosocial health and well-being, mental health and well-being, physical health and well-being, QoL, and health humanitarian response. It found that the biggest body of literature is on mental health, particularly exploring prevalent mental health disaster-related conditions and their correlates, such as psychological distress, depression, anxiety, and PTSD. Determinants were of many types including demographic, such as advanced age and gender, psychosocial such as displacement and social isolation, and physical such as chronic diseases and disabilities. However, limited evidence is found on mental health interventions.

The review also revealed the recent emerging literature on psychosocial health and well-being which mainly discusses the life changes that OP undergo and mechanisms and correlates of their coping, adaptation, and resilience. They show that OP face particular challenges in adapting to the losses incurred post-disasters, including human losses (family members, caregivers, breadwinners, spouses…) and of assets and livelihoods, further exacerbating the vulnerabilities attributed to the normative challenges of ageing.

In addition, it was found that OP face numerous physical health issues in disaster contexts including injury, disability, NCDs, and mortality. Healthcare utilization was investigated in only two studies showing weak access to routine care and low affordability of medication. A few recent studies also investigated OP’s knowledge, attitudes, and practices towards COVID-19, and showed a high prevalence of misconceptions and low abidance to preventive measures. Conflicting findings were revealed regarding negative feelings such as anxiety and fear from COVID-19, which were shown to be affected by OP’s perceptions of the disease.

Findings on mental and physical health are consistent with findings in other reviews. For instance, Massey found that older age, female gender, socio-economic deprivation and rural residency were frequently found as significant determinants of negative physical and mental health outcomes [21]. In addition, the review by Bocker and Hunter found that older people affected by humanitarian crises in Africa suffer from compromised physical health including low functional status, increased mortality rates, increased prevalence of NCDs and communicable disease, and low nutritional status as well as food insecurity [18].

Similarly, the review found jeopardized QoL and HRQoL measures in OP, whose different dimensions are affected by a myriad of demographic, social, and physical health vulnerabilities such as female gender, advanced age, chronic illness and disability, depression, and post-disaster traumas.

Finally, seven studies were found to discuss aspects of the health humanitarian response to OP’s needs in disasters, showing their disadvantage reaching services and information on them, as well as underlying ageist stereotypes at individual, social, and organizational levels. These findings point to limited evidence on a major social determinant of OP’s health in disasters.

Gaps in the literature and directions for future research

The findings of this review recommend that future research should focus on filling gaps across many intersecting dimensions, namely under-researched themes, sub-groups pertaining to gender and disability status, contexts, under-utilized study designs. First, more research is needed across the different dimensions of vulnerability. For instance, while studies mainly focused on mental health conditions and their determinants, more research is needed to substantiate and triangulate the correlates of the different issues and disorders, including psychiatric morbidities and weak social integration and adaptation post-disasters [20, 21]. Because most studies were cross-sectional in nature, the evidence base is not rigorous enough to build concrete interventions. In addition, life course approaches and other longitudinal designs and frameworks are needed to strengthen the evidence on risk and protective factors. For instance, the differential effect of various types of traumatic experiences are not explored enough in older populations, neither are the mechanisms that may lead to psychopathology taking into account historical pre-disaster variables. In addition, gender research in disaster mental health of elderly is shy; future research should aim to explore the different dynamics of psychological and mental health phenomena across older men and women through a culturally sensitive lens looking at the effects of contextual gender and age norms and values, especially in displacement. The absence of any studies focusing particularly on the health and well-being of older men is a major gap, especially as related to the potential effect of social regression and economic losses [103]. Finally, social structures and support systems among OP must be further explored to leverage on and strengthen in resilience and development interventions. For instance, future research should aim to unravel which social relations and networks are eroded, preserved, or newly built, as well as the different types of social support received and given [18]. In addition, more research is needed with host communities to explore their reactions towards older refugees and IDPs, paving the way for effective social cohesion interventions where needed.

Furthermore, while many studies explored physical health outcomes, the size of the evidence falls short of reflecting a full picture of OP’s suffering post-disasters [21]. OP disproportionately suffer from non-communicable diseases, many of which are under-researched in contexts of humanitarian crises, namely cancer, diabetes, and CVD, especially in terms of accessing appropriate care. For instance, no studies were conducted on the status of OP needing dialysis post-disaster. OP with disabilities and limited mobility or bed-ridden, as well as those left behind need special attention in researching their physical, mental, and psychosocial health. Gender differences in disease burden and access to care in light of varying social norms and perceptions of the intersection of gender and old age must be further explored. In addition, a small number of studies have addressed OP’s nutritional status. Future research should bring forth a multi-dimensional lens looking into nutrition in elderly, linking it to other under-researched themes such as access to livelihoods and economic generation, poverty, change in household arrangement and headship, and food security. In addition, no evidence is available on the incidence of communicable diseases and their associated mortality in OP, despite the high likelihood of outbreaks in post-disaster settings, and the high vulnerability of OP to severe forms of diseases, namely diarrheal diseases, hepatitis, meningitis, and acute respiratory illnesses [122]. The role of damaged or inappropriate water, sanitation, and hygiene (WASH) systems must be also explored for accessibility and safety, especially in light of the direct effect of poor WASH systems on the propagation of communicable diseases in disaster contexts. In addition, while a handful of studies have explored KAP on COVID-19, more evidence is needed to explore these topics across different locations and contexts in order to contextualize interventions.

Second, research exploring and evaluating health humanitarian interventions for elderly is almost inexistent across the different dimensions of health and well-being. For instance, mental health and psychosocial support interventions must be explored in order to account for the specific contextual, cultural, and individual needs of older affected populations. Furthermore, health programs at institution and community levels must be explored, as well as mapping any interventions at the level of shelter, WASH, and socioeconomic development, including livelihoods programs tailored for elderly. Ideally, quasi-experimental designs are merited, especially in light of the impossibility of randomized trials in disaster settings. Different stakeholders must be consulted for ideal triangulation and substantiation, including policy makers, and humanitarian actors and donors. In this regard, a cross-cutting theme that must be further explored is ageism, its extent, and the magnitude of its effect on OP’s lives, especially in terms of funding, designing, and delivering holistic and inclusive humanitarian services.

Recommendations for humanitarian actors

In addition to the above research recommendations, humanitarian actors and agencies must work to ensure the integration and adoption of inclusive standards and principles in their health interventions [123]. This includes ensuring the collection of age- and gender-disaggregated data on needs, access to services and associated facilitators and barriers, as well as coping strategies. Furthermore, these parties must utilize these data for learning and strengthening a holistic and coherent approach to programming, execution, accountability, and advocacy to receive more funding for OP programs. A study on humanitarian funding worldwide showed that less than 1% was directed to programs addressing the needs of elderly [16]. Traditional humanitarian responses often prioritize the needs of younger demographics, overlooking the distinct vulnerabilities and resilience capacities of older individuals. Consequently, older populations remain underserved and marginalized within humanitarian programming and policy frameworks [7, 15, 17]. Humanitarian agencies must also mainstream training of their staff on age-sensitive conduct and service delivery. A gender-sensitive approach must also be employed to address the intersectional vulnerabilities of older women, building on their capacities.

Limitations

The findings of this review must be read in light of its methodological limitations. The review only targeted published peer-reviewed journal articles, excluding grey literature, which includes knowledge published by humanitarian agencies. However, we aimed to focus on the literature that possesses a certain amount of methodological rigor pertaining to the academic peer-review process, on which stronger conclusions can be made.

Conclusion

The findings from this review suggest a relatively weak body of literature and evidence on the health and well-being of older populations affected by humanitarian crises in LMICs. The breadth and depth of the research on these populations, their needs and vulnerabilities, their liabilities and coping strategies, as well as the relevance, appropriateness, and effectiveness of the interventions addressing their needs must be further expanded. This will aid in informing program donors, program designers, and humanitarian actors to better serve this overlooked population, and ensuring ‘no one is left behind’.