Self-Rated Health Disparities Among Disadvantaged Older Adults in Ethnically-Diverse Urban Neighborhoods in a Middle Eastern Country
Authors: Chemaitelly Hiam 
Published: July 2019

Objectives and Rationale

This paper examines differentials in self-rated health among older adults aged 60 years and more across three impoverished and ethnically diverse neighborhoods in post conflict Lebanon and assesses whether variations are explained by social and economic factors. This study comes to fill a gap in the aging literature for Arab countries and aims to contribute to a better understanding of the social and economic determinants of health inequality in later life. The study is in tandem with the growing literature on ‘Aging in Place’ and the associated policy direction that stresses the importance of reinforcing the social and physical environment to ensure healthy aging in one's home and community, and prevention of isolation, marginalization, and the costly option of unwanted institutional care.

Design

Data were drawn for 740 older adults using a population based cross sectional survey conducted in 2003 in a formal community (Nabaa), an informal settlement (Hey El-Sellom) and a refugee camp for Palestinians (Burj El-Barajneh) in Beirut, Lebanon. Social capital, a multidimensional construct was operationalized using 21 indicators assessing locational capital, social anchorage, social participation, civic trust, reciprocity, hypothetical social support, and social networks. Economic security was assessed using seven indicators that include current employment, a monthly income value exceeding the minimum wage, having other sources of income from self or spouse, not receiving monetary assistance from children, or from charity, or from relatives, and having no dependents. Analyses testing whether the social capital and economic security constructs qualify as mediators for the association between community type and self-rated health based on Baron and Kenny's criteria were also performed. These include contrasting the social capital and economic security indicators and their summative scores across communities using χ2 and ANOVA tests and examining their association with SRH using bivariate ordinal logistic regression models. The role of the social capital and economic security constructs in offsetting poorer self-rated health was assessed using multivariate ordinal logistic regression analyses after controlling for confounders which include age, sex, educational attainment, history of displacement, years living in the house, smoking, chronic conditions, and disability.

Results

Older adults in Nabaa fared better in self-rated health compared to those in Hey El-Sellom and Burj El-Barajneh, with a prevalence of good, average, and poor self-rated health being respectively, 41.5%, 37.0%, and 21.5% in Nabaa, 33.3%, 23.9% and 42.7% in Hey El-Sellom, and 25.2%, 31.3%, 43.5% in Buj El-Barajneh. Nabaa also showed the highest level of social capital, scoring on a 21-points scale, a mean of 13.5 while Burj El-Barajneh camp and Hey El-Sellom followed with mean scores of 12.1 and 10.6, respectively (p–value < 0.001). This was mainly attributed to consistently higher scores on locational capital, social participation, reciprocity, hypothetical social support, and social networks beyond the immediate family in Nabaa. Meanwhile, the economic security assessment suggested significant differentials across the three communities with Burj El-Barajneh camp found to be the most disadvantaged, while Nabaa and Hey El-Sellom exhibited comparable characteristics. On a 7-points scale, we estimated a mean economic security of 2.9 in Burj El-Barajneh (p-value < 0.001) compared to 4.0 in Nabaa and 4.1 in Hey El-Sellom. In addition to their significant association with community, the social capital and economic security constructs were also found to be significantly associated with self-rated health with Odds ratios respectively assessed at 0.84 (95% confidence interval: 0.81–0.89) and 0.70 (95% confidence interval: 0.63–0.78), thus fulfilling the criteria for Baron and Kenny's mediation factors. The economic security construct attenuated the odds of poorer self-rated health in Burj El-Barajneh as compared to Nabaa from 2.6 (95% confidence interval: 1.9–3.8) to 1.42 (95% confidence interval: 0.9–2.1) after adjusting for confounders, but had no impact on this association in Hey El-Sellom (Odds ratio: 2.1, 95% confidence interval: 1.4–3.2). The incorporation of social capital in the fully adjusted model rendered this association insignificant in Hey El-Sellom (Odds ratio: 1.5, 95% confidence interval: 0.9–2.3), and led to further reductions in the magnitude of this association in Burj El-Barajneh camp (Odds ratio: 1.18, 95% confidence interval: 0.8–1.8).

Discussion and Conclusions

The three communities examined in this study share a low socio-economic profile characterized by dense urban livings, economic hardships, displacement, and lack of public services and infrastructure. Despite these similarities, striking differences in self-rated health were revealed and these were explained by differentials in the availability of social and economic resources, largely a reflection of the structural differences across these communities. Older adults in Nabaa, a formal neighborhood, fared better in self-rated health than the older cohort in Hey El-Sellom, an informal settlement, and the Palestinian refugees in Burj El-Barajneh camp. Although older adults in Nabaa and Hey El-Sellom were similar with regard to economic security, Nabaa exhibited higher levels of social capital. The poorer self-rated health among older adults in Hey El-Sellom was shown to be largely determined by social deficiencies in this neighborhood. Meanwhile, the study highlighted the scarcity of social and economic resources in Burj El-Barajneh camp, the result of dispossession of Palestinian refugees. In sum, the social context in which older adults live and their financial security are key determinants of well being that are often overlooked by interventions targeting older adults in deprived post conflict settings. Social capital and economic security should be the focus of public health interventions and policy aiming at promoting the quality of life of older adults in the Arab region.