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Table 2 Detailed results on vulnerability factors

From: Health needs of older populations affected by humanitarian crises in low- and middle-income countries: a systematic review

Author, date, (reference), [quality score*]

Context (definition of older age)

Outcome of interest/study design (analysis)

Comparison group

Vulnerability factors

Mental Health Outcomes

Ardalan et al., 2010. [25] [9/10]

Iran/earthquake

(60+)

Older people’s perceptions of needs post disaster/qualitative - focus-group and interviews (content analysis).

NA (qualitative)

Feelings of insecurity: Not being able to protect oneself or belongings from thieves due to frail physical state and fear of being targeted for this reason. Emotional distress: many still very emotionally upset due to trauma during earthquake even years later. Difficult to adjust to new life after earthquake. Causes of distress: losing children, close relatives and friends, experiencing hopeless days, witnessing the destruction of historic parts of the city and losing valued documents and memorabilia.

Ardalan et al., 2011[a] [26] [7/10]

Iran/earthquake (60+)

Psychological state/quality of Life (WHOQOL-BREF)/quantitative - cross-sectional (multivariate)

Earthquake affected vs. non-earthquake affected

Within earthquake-affected sample (regression coefficients): higher age (−0.113, p = 0.003); female gender (−1.169, p = 0.016); urban residence (−1.043, p = 0.044); being unmarried (−1.144, p = 0.018); history of earthquake related injury (−1.542, p = 0.028); dissatisfaction with quality of current living place (−2.718, p < 0.001); functional dependence (ADL) (1.151, p = 0.004).

Comparison with non-earthquake-affected populations: survivors had lower psych. State scores (mean 11.88 12.80, p = 0.03)

Cao et al., 2014 [29] [5/10]

China Earthquake (60+)

Psychological distress (SRQ-20/quantitative survey - cross-sectional (bivariate)

None

Older men: loss of family members (OR 1.32–31.53, p = 0.02); displacement from residence (OR 1.08–32.33, p = 0.04).

Older women: higher educational level (OR 0.09–0.77 p = 0.02); chronic illness (OR 1.11–13.78 p = 0.03); loss of family members (OR 2.87–76.51 p = 0.00); displacement from residence (OR 3.37–37.18 p = 0.00).

Chaaya et al., 2007 [30] [7/10]

Palestian.refugee, Lebanon/(60+)

Depression (GDS)/quantitative - cross-sectional (multivariate)

None

Regular religious attendance (OR 0.41, p = 0.041); sufficient income (OR 0.42, p = 0.003); ADL difficulties (OR 2.05, p = 0.015); Illness during last year OR 2.89, p < 0.001).

Chan et al., 2009[a] [31] [4/10]

Pakistan Earthquake (45+)

Psychosocial (SRQ)/quant. Cross-sectional (bivariate)

Rural vs. urban

Rural more likely to experience feeling depressed/helpless (72% vs. 44%, p < 0.001).

Rural more likely to experience sleeplessness (65% vs. 45%, p < 0.001).

Chen et al., 2012 [33] [8/10]

China Earthquake (60+)

PTSD (CAPS for DSM)/quantitative - cross-sectional (multivariate)

None

Female gender (OR 1.592 [95% CI 1.236–2.057]); aged 81 years or older (OR 1.557 [95% CI 1.057–2.292]); widowed (OR 1.464 [95% CI 1.281–1.660]); low education level (OR 1.395 [95% CI 1.073–1.804]); low monthly income (OR 1.670 [95% CI 1.401–1.992]); suffering bodily injury (OR 2.468 [95% CI 1.863–3.246]); bereavement OR 2.064 [95% CI 1.363–3.994]); low social support (OR 1.826 [95% CI 1.054–3.162].

Goenjian et al., 1994 [36] [4/10]

Armenia Earthquake (59+)

PTSD (PTSD Reaction Index) /quantitative - cross-sectional (bivariate)

Older vs. younger

Within older population: living in high impact zone: higher PTSD scores (p < 0.05)

Comparison with younger: older people had lower PTSD score re-experiencing (2.1 vs. 2.5, p < 0.05); older people had higher PTSD score arousal (2.7 vs. 2.4, p < 0.05).

Handicap Int. & HelpAge Int, 2014 [37] [4/10]

Syrian refugees in Lebanon & Jordan/war (60+)

Psychological distress(SRQ)/ quantitative survey - cross-sectional (bivariate)

Older vs. younger

Older age populations 3 times more likely than non-elderly to show signs of psychological distress.

(no p-value or exact figures reported)

Havelka et al., 1995 [38] [3/10]

Croatia/war (60+)

Psychosomatic Disorders (SSPD)/quantitative survey- cross-sectional (bivariate)

Older vs. younger

Older age a risk factor for often experiencing the following outcomes related to psychosomatic feelings (older vs. non-elderly):

Persistent memory of stressful event: 81.5% vs. 55.2%, p 0.001; depression 80.6% vs. 52.9%, p = 0.001; insomnia 53.4% vs. 34.3%,p = 0.005; nightmares 33.0% vs. 13.8%, p = 0.001; distraction 32.0% vs. 14.6%, p = 0.001; forgetfulness: 30.1% vs. 11.3%, p = 0.001; emotional numbness 12.6% vs. 6.7%, p = 0.039; fear: 22.3% vs. 10.5%, p = 0.010)

Being older protective against often experiencing the following outcomes (older vs. non-elderly):

Bitterness and resentment towards others 18.4% vs. 36.4%, p = 0.001; aggressive behaviour 6.8% vs. 11.7%, p = 0.014.

Jia et al., 2010 [39]

[8/10]

ChinaEarthquake (60+)

PTSD (PCL-C), psychiatric morbidity (GHQ-12)/quant. - cross-sectional (multivariate)

Older vs. younger

PTSD: older age versus non-elderly (OR 3.56, p = 0.002).

General psychiatric morbidity: older age vs. non-elderly (OR 2.14, p = 0.005).

Johns Hopkins & Policy Studies, 2012 [40] [6/10]

IDPs in Georgia/war (60+)

Depression (GDS), anxiety (GAI)/quantitative - cross-sectional (bivariate)

Long-term(20 years) IDP vs. short-term (4 years) IDP

Depression: Females higher depression scores than males (p < 0.01) (no mean depression score reported).

Anxiety: short-term IDP higher prevalence than long-term IDP (76% vs. 70.3%, p < 0.02).

Females higher scores than males (p < 0.01) (no mean scores reported).

Kohn et al., 2005 [41] [7/10]

Hondurashurricane (60+)

Psych. distress (SRQ); alcohol misuse (SRQ); depression (DSM-IV/ICD-10); PTSD (CIDI; IES)/quantitative - cross-sectional (multivariate)

Older age vs. younger

Risk factors for all psychopathology (except severity of PTSD avoidance subscale) in older age: Exposure inventory (exposure to hurricane); prior “nerves”

Risk factors for PTSD and psychological distress: living in high impact area

Older age vs. non-elderly: none (no p-values or effect measures available).

Li et al., 2011 [42] [7/10]

China, earthquake (55+)

Depressive symptoms, stress reaction (Impact of Event Scale), sense of community (SoC Index)/quantitative – cross-sectional (multivariate)

None

High event impact, a reduced sense of community, and social support were associated (P < 0.05) with higher rates of depression.

Nomura et al., 2010 [44] [7/10]

Sri Lankatsunami (60+)

PTSD (IES-R)/quantitative - cross-sectional (multivariate*)

None

Increasing age by 10-year interval (coef. -0.27, p = 0.04) Loss of or injury to family members due to the tsunami (coef. 6.12, p < 0.001).

Prueksaritanond et al. 2007 [48] [2/10]

Thailand, tsunami (60+)

Depression (Zung Self-Rating Depression Scale)/Quantitative – cross-sectional /quantitative (descriptive)

None

Factors associated with increased symptoms of depression were female (odd ratio [OR] 2.81; 95% confidence interval [CI] 0.73–10.77, p = 0.12), aged of 65 years old and over (OR 2.0; 95% CI 0.52–7.7, p = 0.25), living alone such as single, divorce, or separation (OR 1.47; 95% CI 0.35–6.13, p = 0.44), no income was generated after the tsunami (OR 1.26; 95% CI 0.34–4.75, p = 0.5), hypertension (OR 1.25; 95% CI 0.34–4.59, p = 0.5) and loss of family members (OR 1.14; 95% CI 0.31–4.20, p = 0.56).

Strong et al., 2015 [52] [5/10]

Syrian & Palestinian refugees Lebanon/war (60+)

Negative emotions (SRQ)/ quantitative - cross-sectional (bivariate).

Palestinian (longer displaced) vs. Syrian refugees (shorter displaced)**

Palestinians (i.e. longer-term displaced): higher prevalence of depression (40% vs. 25%, p = 0.050)Palestinians (i.e. longer-term displaced): higher prevalence of feeling scared (33% vs. 18%, p = 0.036)

Among entire sample (Palestinian and Syrian refugees combined):

Older age (p = 0.017) and higher education (p = 0.023) with feeling depressed. Lower social support (p = 0.006) with anxiety.

Viswanath et al., 2012 [53] [5/10]

Indiatsunami (60+)

Psych. morbidity, adjustment disorder, PTSD, depressive episode, panic disorder, alcohol dependence, phobic disorder, anxiety (ICD-10 criteria)/ quantitative - cross-sectional (bivariate)

Older age vs. youngerDisplaced vs. non-displaced

Total sample: (older age vs. non-elderly): Older people more likely to suffer from adjustment disorder (50% vs. 37%, p = 0.030).Displaced (older age vs. non-elderly): Older people less likely to suffer from depressive episodes (6% vs. 20%, p = 0.019). Non-displaced: (older age vs. non-elderly): Older people less likely to suffer depressive episode (7% vs. 27%, p = 0.002). Elderly more likely to suffer PTSD (18% vs. 8%, p = 0.036). Within older age sample (older age vs. non-displaced): non-displaced more likely to suffer adjustment disorder (61% vs. 17%, p = 0.001). Displaced more likely to suffer depressive episode (44% vs. 7%, p < 0.001) and unspecified anxiety disorder (22% vs. 4%, p < 0.011).

Wu et al., 2015 [56]

[5/10]

China, flooding (60+)

‘Health related quality of life’ (HRQoL), incl. Role limitations due to emotional problems, mental health/ quantitative – cross-sectional (multivariate)

Pre-flood rural older people (from National Health Services Survey 2008)

Self-reported HRQoL lower in those aged 80–99 (vs. 60–79), lower in those who are single (vs. married), lower in those with poor sleep patterns, lower in those with pre-existing chronic diseases, lower if hospitalised within the last year, lower if living alone (vs. with spouse),

Zhang et al., 2012[b] [58] [9/10]

China earthquake (60+)

PTSD (PCL-C); anxiety/dep. (HSCL-25)/ quantitative - cross-sectional (multivariate).

None

PTSD: loss of livelihood (OR 3.06 [95% CI 1.30–7.21]); initial fear (OR 1.74 [95% CI 1.16–2.54]).

Anxiety: female (OR 2.03 [95% CI 1.09–3.39]); bereavement (OR 2.59 [95% CI 1.17–5.77]); injury (OR 2.03 [95% CI 1.03–4.11]).

Depression: Initial fear (OR 1.44 [95% CI 1.03–2.01]).

Zhang et al., 2012(c) (5/10] [59]

China earthquake (60+)

Quality of Life (QoL) score/quantitative – cross-sectional (bivariate)

National average

Lower QoL scores are associated (p < 0.5) with: female gender; age over 70; single; lower income; non-smoker; disability in self or family member, poor family relationship

Physical health outcomes

Andre et al., 2013 [24] [3/10]

Rural Democratic Republic of Congo/war (65+)

Nutritional status (MNA-SF/LF)/quantitative - cross-sectional (bivariate)

None

Differences in nutritional status (normal vs. malnourished): mean age (years) 68.4 (+ − 4.0) vs. 74(+ − 6.7) (p < 0.001); BMI <18.5 15.7% vs. 81% (p < 0.001); smoking 31.4% vs. 2.9% (p < 0.001); physical exercise (1–5/week) 100% vs. 2.9% (p < 0.001); >3 prescription drugs/day 19.6% vs. 68.6 (p < 0.001); ADL limitation 50.9% vs. 87.6% (P < 0.001); IADL limitation 11.8% vs. 94.3% (P < 0.001); history of falls: 35.8% vs. 61% (p = 0.003)

Ardalan et al. 2011[a] [26] [7/10]

Iran earthquake (60+)

Physical Quality of life (QoL) (WHOQOL-BREF)/ quantitative - cross-sectional (multivariate)

Earthquake affected vs. non-earthquake affected

Within earthquake affected sample (regression coefficients): Higher age (−0.113) (p = 0.001); being female (−1.320) (p = 0.017)Being injured due to earthquake (−2.370) (p = 0.006); dissatisfaction with quality of current living place (−2.411) (p < 0.001); functional (ADL) dependence (−1.963) (p = 0.001)

Ardalen et al., 2011[b] [27] [7/10]

Iran earthquake (60+)

Functioning (ADL and IADL, 2 months, 2 years and 5 years after event)/quantitative - cross-sectional (multivariate)

None

Determinants of functional capacity (regression coefficients, p < 0.05):

Model 1 (controlled for all eligible factors except ADL and IADL scores at preceding time period):1. ADL scores at 2 months after the earthquake: age (−0.60); living with others (−.68); and chronic diseases (−0.66).

2. ADL scores at 5 years after the earthquake: age (−0.64); gender (0.41); living with others (−0.86); and chronic diseases (−0.40)

3. IADL scores at 2 months and 5 years after the earthquake: age (−1.64 & -1.61); education (1.44 and −1.47); study area (1.21 and 1.12); living with others (−1.78 & -1.91).

Model 2 (controlled for all eligible factors including ADL and IADL scores at preceding time period):

1.ADL score at two months after the earthquake: age (−0.42), living with others (−0.49), and ADL before the earthquake (0.81).

2. ADL score at 5 years after earthquake: gender (0.16), living with others (0.12), and ADL at 2 months after earthquake (1.03).

3. IADL score at 2 months after earthquake: age (−0.85); living with others (−0.80); and IADL before the earthquake (0.68).

4. IADL score at 5 years after earthquake: IADL at 2 months after the earthquake (0.99).

Arlappa et al., 2009 [28] [4/10]

Rural India/drought (60+)

Chronic Energy Deficiency (CED) and BMI/quantitative – cross-sectional (descriptive)

None

Age (70+ vs. 60–69): higher CED in both genders (males: 59.2% vs. 47.5%; females: 56.6% vs. 45.8%, P < 0.001).

Age (18–59 vs.60+): higher CED among older adults (males: 51.8% vs.38.1%; females: 48.5% vs. 40.5%,,p < 0.001).

Socio-economic factors: Caste (scheduled caste and scheduled tribe 57% vs. Backward caste and others: 44.2%, (p < 0.001); pension (availing: 55.1%, not availing: 49.7% and not required: 45.8%, p < 0.05); occupation (non-agricultural: 53.4%, Agricultural: 52.1% and others 46.1%, (p < 0.001); total land acres (none: 49.3%, 0.01–2.5: 53.7%, 2.5–5: 52.3% and >5: 43.1%, p < 0.001).

Chan et al., 2009[a] [31] [4/10]

Pakistan earthquake (45+)

Dental, visual, eating, hearing, headaches,dizziness,muscle/ joint pain (all SRQ); health seeking behaviour/health access/quantitative - cross-sectional (bivariate).

Rural vs. urban

Rural prevalence (%) compared to older people in urban areas: β

Dental (100 vs. 25) (p < 0.0001); visual (75 vs. 38) (p < 0.0001); weight loss (75 vs. 50, p = 0.001); eating problem (87 vs. 50) (p = 0.002); hearing (54 vs. 40) (p = 0.043); headache (40 vs. 23, p = 0.043); having known medical problem for which never having had treatment (65 vs. 30, p < 0.001); having known medical problem with treatment discontinued (80 vs. 40, p < 0.001)

Urban – higher prevalence (%) compared to older age in rural areas: β a known underlying medical problem (38 vs. 25, p = 0.02).

Godfrey & Kalache, 1989, [35] [3/10]

Ethiopian refugees in Sudan/war and famine (45+)

Mortality rates; prevalence of disability (SRQ)/quantitative - cross-sectional (descriptive)

None

Age-specific mortality rates estimated since arriving in Sudan 1 year (using population estimate as denominator):

45–49 years: 5/1000 per year (N = 1); 50–59 years: 35/1000 per year (N = 5); 60+ years: 273/1000 per year (N = 3).

Age-specific mortality rates for 2-year period prior to migration (denominator all those reported in Tigray households during this period): 45–49 years: 14/1000 per year (N = 5); 50–59 years: 41/1000 per year (N = 4); 60+ years: 91/1000 per year (N = 8).

Pieterse et al., 1998 [45] [6/10]

Rwandan refugees in Tanzania/war (60+)

BMI, AMA, AFA, MUAC/quantitative - cross-sectional (bivariate)

Older vs. younger

Older higher prevalence of malnutrition (BMI < 18.5): Men (23.2% vs. 15.0%, p < 0.05); women (15.1% vs. 10.9%, p < 0.05)

Older lower mean AMA (important in relation to ability to remain active and independent): Men 50–59, 60–69 and 70+ (34.7, 32.3, 30.9, respectively, p < 0.05); women 50–59, 60–69 and 70+ (35.1, 33.0, 31.5, respectively, P < 0.05).

Pieterse et al., 2002 [46] [8/10]

Rwandan refugees in Tanzania/ war (50+)

Handgrip strength/quantitative - cross-sectional (multivariate)

Older vs. younger

Men: BMI contributes 5.7% to variation in Handgrip strength. (coef 0.262, p < 0.001); AMA contributes 10.2% to variation in handgrip strength (coef 0.303, p < 0.001).Women: BMI contributes 3.5% to variation in handgrip strength (coef 0.188, p < 0.001); AMA contributes 2.8% to variation in handgrip strength (coef 0.153, p < 0.001).

Pieterse & Ismail, 2003 [47] [4/10]

Rwandan refugees in Tanzania/war (50+)

Perceptions of nutritional risk factors by older persons/ qualitative interviews (ranking methodology)

None (qualitative)

Older people’s perceptions of main problems of the less well-off were: physical impairment; no purchasing power, income, tools and utensils; no people to provide assistance and moral support, social isolation. Older people’s perceptions of who were the most vulnerable: widows and widowers; physically impaired and disabled; those living alone, have no children living nearby, have care-giving responsibilities (for example for young children or old spouse).

Ramji &Thoner, 1991 [49] [2/10]

Displaced in Moz- mbique/Zimbab-we/war (45+)

BMI/quantitative - cross-sectional (descriptive)

None

Older women in Mozambique (displaced on average 6 months) had a mean BMI significantly lower than older Mozambique women displaced to Zimbabwe (displaced on average 2 years). BMI 17.3 vs. 21.1 (p < 0.001)

Sibai et al., 2001 [50] [9/9]

Lebanon, war (50+)

Mortality/quantitative – cohort (multivariate)

Participants in a 1983 community-based health survey

Women exposed to human losses had a significant excess risk of both CVD and total mortality (RR 3.37 and RR 2.28 respectively). Exposure to property losses carried a greater mortality risk for men. Positive trend in the rate ratios for mortality endpoints with an increase in the intensity of exposure to a cumulative number of war events.

Sibai et al., 2007 [51] [8/9]

Lebanon/war (50+)

All-cause mortality, cardiovascular mortality (ICD-9)/ quantitative - cohort (multivariate)

None

Cardiovascular mortality: Men: unmarried (RR 2.50 [95% CI 1.28–4.89]); living with ≥3 generations (RR 1.99 [95% CI 1.32–3.00]); living with married child (RR 1.63 [95% CI 1.03–2.57]). Women: none

All-cause mortality: Men: widowed/divorced/separated (RR 1.63 [95% CI 1.06–2.52]); living with ≥3 generations (RR 1.56 [95% CI 1.12–2.15]); living with married child (RR 1.70 [95%CI 1.19–2.43]).Women: living with married child (RR1.55[95%CI1.04–2.32]).

Strong et al., 2015 [52] [5/10]

Syrian & Palestinian refugees inLebanon/war (60+)

Negative emotions (using SRQ), and functional status (Katz Index of Independence in Activities of Daily Living/ quantitative - cross-sectional (bivariate).

Palestinian (i.e. longer-term displaced) vs. Syrian refugees (i.e. shorter-term displaced)**

Palestinians (i.e. longer-term displaced) higher prevalence of: hypertension (86% vs. 53%, p < 0.001); diabetes (81% vs. 38%, p < 0.001); eye disease (28% vs.16%,p 0.002); lung disease (44% vs.11%,p < 0.001); digestive tract disease (23% vs. 9%, p0.010); difficulty walking (65% vs. 39%,p 0.002); impaired vision (70% vs. 13%, p < 0.001); impaired hearing (49% vs. 8%, p < 0.001)

Palestinians (i.e. longer-term displaced) lower prevalence of Arthritis, injury or back pain (7% vs. 31% p 0.007);

Among entire sample (Palestinian and Syrian refugees combined): Older age (p = 0.002) and larger household size (p = 0.003) with worse functional status. Older age and lower educational status with worse self0reported health status. β

Wen et al., 2010 [54] [7/10]

China, earthquake (65+)

Mortality, physical injury/quantitative – cross-sectional (descriptive)

All earthquake-affected patients

Extremities the most common location of trauma in older patient admitted to hospital. Mortality significantly higher in this age group - secondary to e.g. thoracic visceral and craniocerebral injuries. Admission of older age patients peaking on the third, fifth, and eighth days. β

Wong et al., 2015 [55] [5/9]

21 crisis-affected countries (conflict & natural disasters)

Intra-operative mortality & surgical procedure types – retrospective cohort of routine data from 93,385 operative cases (11% were older people) at MSF facilities, June 2008 to Dec 2012 (descriptive)

Younger populations (<50) from same crisis-affected populations

Intra-operative mortality increased with each age stratum from 60 years onwards

Wu et al., 2015 [56] [5/10]

China, flooding (60+)

HRQoL: physical functioning, role limitations due to physical illness, bodily pain, general health perceptions, vitality, social functioning/quantitative – cross-sectional (multivariate).

Pre-flood rural older age (National Health Services Survey 2008)

Self-reported physical health lower in those aged 80–99 (vs. 60–79), lower in those who are single (vs. married), lower in those with poor sleep patterns, lower in those with pre-existing chronic diseases, lower if hospitalised within the last year, lower if living alone (vs. with spouse), lower in those with illness in the last two weeks, lower in females

Zhang et al., 2012[a] [57] [7/10]

China earthquake (65+)

Clinical features and outcomes of crush patients with acute kidney injury, mortality rate/ quantitative - cross-sectional using medical records (multivariate)

Older age vs. younger

Clinical and lab findings: (older age vs. younger): higher systolic pressure (131.9 vs. 115.2, p = 0.001); lower incidence of oliguria (13.2% vs. 41.0%, p = 0.001)

; lower creatinine (220.4 vs. 352.6, p = 0.001); lower potassium (4.1 vs. 5.3, (p < 0.001); lower serum phosphorus (1.2 vs. 1.9, (p < 0.001); lower creatinine (8173.6 vs. 57,423.0, p = 0.001).

Trauma events and medical complications (older age vs. younger): lower % of extremity crush injury (71.1% vs. 88.6%, p = 0.004); higher proportion of thoracic trauma (35.6% vs. 18.7%, p = 0.016); higher proportion of extremity fracture (42.2% vs. 19.9%, p = 0.002); higher proportion of rib fractures (26.7% vs. 7.2%, p = 0.002); higher proportion of vertebral fractures (17.8% vs. 6.7%, p = 0.020); higher proportion of pneumonia (42.2% vs. 25.9%, p = 0.035)

Risk factors for death: older people receiving dialysis had higher mortality rate compared to younger adults (62.5% vs. 10.5%, p < 0.001).

Risk factors for death in older people (controlling for BP, no of injuries, ISS, thoracic trauma, ARDS, sepsis/or dialysis): dialysis (OR 15.14, p = 0.011); sepsis (OR 13.24, p = 0.030).

  1. For studies using both bivariate and multivariate analysis only multivariate factors were extracted. Only significant associations were extracted (p < 0.05) for studies that conducted statistical tests
  2. β Did not include tests for statistical significance
  3. *For detailed results on quality assessment, please email corresponding author
  4. **Length of displacement is an assumption by review authors based on history of Palestinian and Syrian displacement and not explicitly reported by study authors (Strong et al., 2015)