Discussion
This study showed that poor mental health among older Syrian refugees was very common during the COVID-19 pandemic in Lebanon. We developed a predictive model of poor mental health that included younger age, household food insecurity, household water insecurity, lack of legal residency documentation, irregular employment, higher intensity of bodily pain, having debt and having multiple chronic illnesses. This research provides insight into specific socioecological vulnerabilities faced by older Syrian refugees (online supplemental figure 2).
Older Syrian refugees in Lebanon faced distress and had depressive and anxiety symptoms during the pandemic, as shown by the MHI-5 items; this finding is similar to the results of the previous surveys.3 10 Experiencing daily stressors could have a significant negative impact on mental health3 as refugees faced distressing circumstances compounded by social adversity, the economic crisis and the pandemic.1 2 Syrian refugees have referred to environmental and structural stressors as the main cause of their emotional distress, which they considered as a normal collective result of pressure accumulation.23 These factors are not necessarily recognised by all mental health service providers, though some do recognise that referral to mental health services is sometimes premature considering basic needs are not being sufficiently addressed.23
Older Syrian refugees without legal residency documentation have higher odds of experiencing poor mental health compared with those with a regularised legal status, which is consistent with other findings.24 In Lebanon, legal residency permits are required to be renewed on annual basis and the associated fees may be prohibitive to refugees. Undocumented refugees may face a higher burden of mental health disorders due to a fear of deportation, lack of social protection and barriers to access healthcare services.24 25 A longitudinal study conducted on 387 migrants in Switzerland demonstrated that regularisation had a direct positive impact on reducing the severity of depression.25 This indicates that the precarity of legal status needs to be addressed in the context of Syrian refugees in Lebanon.
Food and water insecurity are two distinct but interconnected predictors of poor mental health identified in this study. These types of resource insecurities are well-known stressors, linked to worry, distress and increased depressive symptoms, which could affect individuals’ well-being and are both basic needs that intersect.26 When experienced together, water and food insecurities have reciprocal effects, leading to potentially additive and even multiplicative deterioration in mental health status.27 It is, therefore, important for humanitarian interventions aiming to improve mental health in such settings to ensure that refugees receive basic needs support that can alleviate food and water insecurities.
Other predictors for poor mental health that emerged from this study were the intensity of bodily pain and having multiple chronic illnesses. The relationship between mental health disorders and pain and chronic illnesses, such as hypertension and diabetes, are well established in the literature.28 29 For instance, complex biological, psychological and social factors interact and may lead to and exacerbate pain and disrupt individuals’ daily life activities,28 which increases the need to access healthcare services and use medication. In particular, older Syrian refugees in Lebanon have reported difficulties in accessing necessary healthcare and medication, and previous studies have shown these factors were associated with poor mental health among migrants and refugees.4 30
Indebtedness and lack of engagement in regular work are stressors that are related to financial status, which may contribute to poor mental health. These stressors are likely to be evident among older Syrian refugees who rely on humanitarian cash assistance as a primary source of income.4 Refugees associate emotional well-being with secure employment and the absence of general economic worries.31 For instance, Syrian refugees in Lebanon have a lack of employment opportunities at all ages and this is likely to be exacerbated among older adults.
In the context of the pandemic, mental health interventions for older refugees are necessary and need to be linked to the provision of other essential humanitarian services including but not limited to social safety net programmes that alleviate food insecurity (e.g., cash interventions and food assistance), water and sanitation interventions and legal and protection services. Predictive models of mental health could be applied to target individuals at high risk of poor mental health with interventions that aim to reduce vulnerabilities.
This study is one of the largest studies to explore the mental health status of older Syrian refugees in Lebanon, with a response rate higher than 85%. The sample of older Syrian refugees was obtained from a single humanitarian organisation’s list of beneficiaries, which limits the generalisability of these results. Nevertheless, this humanitarian organisation (Norwegian Refugee Council) is one of the largest providers of assistance in Lebanon. Similar to the 2021 VASyR (a nationally representative survey of Syrian refugee households in Lebanon),32 which surveyed all ages, the study population had the highest percentages of refugees from the Bekaa region and northern Lebanon (as described elsewhere).17 Additionally, there were comparable proportions of households with family debts (92% in both surveys) and those who received eviction notices (29.6% in the study population vs 21% in VASyR, 2021).32
Furthermore, this study has added to the literature since there have been calls to concurrently collect data on water security and food security, along with mental health outcomes, to understand the risk each poses to health.26 33 Several variables rely on self-reported indicators and MHI-5 was dichotomised into binary variables. While dichotomisation eases the interpretation of results, it has some disadvantages. These include losing the range of outcome variability and considering individuals at the cut-off point as markedly different rather than quite similar.34 Moreover, other potential predictors for poor mental health were identified in the literature, but not included in our model, such as experiencing trauma during their life course, loss of family members or friends, personal or family history of mental health issues, which could improve the discrimination of our model. In particular, we acknowledge the role of social support as a protective factor for mental health. Nevertheless, social support variables were excluded from the model due to their negative impact on the model’s performance.
Future research should evaluate the feasibility and face validity of the proposed predictive tool through qualitative methods, in collaboration with refugees and NGO workers. In addition, the model will be tested and externally validated in future studies conducted with refugees in Lebanon. We also plan to investigate factors associated with the deterioration of mental health over time to improve the predictive value of these models. Longitudinal studies are important because there are a lack of studies examining the causal connections between food and water insecurity, and their intersection with mental health outcomes.33