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Ethnicity & Health
ISSN: 1355-7858 (Print) 1465-3419 (Online) Journal homepage: http://www.tandfonline.com/loi/ceth20
Self-rated health disparities among disadvantaged
older adults in ethnically diverse urban
neighborhoods in a Middle Eastern country
Abla Mehio Sibai, Anthony Rizk & Hiam Chemaitelly
To cite this article: Abla Mehio Sibai, Anthony Rizk & Hiam Chemaitelly (2016): Self-rated health
disparities among disadvantaged older adults in ethnically diverse urban neighborhoods in a
Middle Eastern country, Ethnicity & Health, DOI: 10.1080/13557858.2016.1244736
To link to this article: http://dx.doi.org/10.1080/13557858.2016.1244736
Published online: 15 Oct 2016.
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Self-rated health disparities among disadvantaged older
adults in ethnically diverse urban neighborhoods in a Middle
Eastern country
Abla Mehio Sibai
a
, Anthony Rizk
a
and Hiam Chemaitelly
b
a
Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of
Beirut, Beirut, Lebanon;
b
Infectious Disease Epidemiology Group, Weill Cornell Medicine-Qatar, Qatar
Foundation, Education City, Doha, Qatar
ABSTRACT
Objectives: This paper examines differentials in self-rated health
(SRH) among older adults (aged 60+ years) across three
impoverished and ethnically diverse neighborhoods in post-
conflict Lebanon and assesses whether variations are explained by
social and economic factors.
Design: Data were drawn from the Older Adult Component (n=
740) of the Urban Health Survey, a population-based cross-
sectional study 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. The role of the
social capital and economic security constructs in offsetting poor
SRH was assessed using multivariate ordinal logistic regression
analyses.
Results: Older adults in Nabaa fared better in SRH compared to
those in Hey El-Sellom and Burj El-Barajneh, with a prevalence of
good, average, and poor SRH 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%, and 43.5% in Burj El-Barajneh. The economic
security construct attenuated the odds of poorer SRH in Burj El-
Barajneh as compared to Nabaa from 2.57 (95% confidence
interval, CI: 1.89–3.79) to 1.42 (95% CI: 0.96–2.08), but had no
impact on this association in Hey El-Sellom (odds ratio, OR: 2.12,
95% CI: 1.39–3.24). The incorporation of the social capital
construct in the fully adjusted model rendered this association
insignificant in Hey El-Sellom (OR: 1.49, 95% CI: 0.96–2.32), and led
to further reductions in the magnitude of the association in Burj
El-Barajneh camp (OR: 1.18, 95% CI: 0.80–1.76).
Conclusions: The social context in which older adults live and their
financial security are key in explaining disparities in SRH in
marginalized communities. Social capital and economic security,
often overlooked in policy and public health interventions, need
to be integrated in dimensions of well-being of older adults,
especially in post-conflict settings.
ARTICLE HISTORY
Received 5 March 2015
Accepted 5 July 2016
KEYWORDS
Self-rated health; ethnicity;
displacement; older adults;
urban health; conflict;
Lebanon
© 2016 Informa UK Limited, trading as Taylor & Francis Group
CONTACT Hiam Chemaitelly hsc2001@qatar-med.cornell.edu Infectious Disease Epidemiology Group, Weill
Cornell Medicine-Qatar, Qatar Foundation –Education City, P.O. Box 24144, Doha, Qatar
Supplemental data for this article can be accessed at 10.1080/13557858.2016.1244736.
ETHNICITY & HEALTH, 2016
http://dx.doi.org/10.1080/13557858.2016.1244736
Introduction
As countries undergo rapid demographic transitions, population aging presents the chal-
lenge of mitigating the rising burden of co-morbidities, the pervasive lack of age-appropri-
ate support services, and the growing health inequalities in later life (Bloom et al. 2015).
The need to inform policy led to the development of various indicators to characterize
health among older adults including quality of life and well-being, and to assess determi-
nants of health inequalities in old age. While the West is spearheading efforts in geriatric
research, the epidemiology of aging remains poorly understood in other settings including
Arab countries of the Mediterranean region. Here, population aging is doubly challenged
by chronic political and economic instability, waves of displacement caused by the recent
regional turmoil, and socioeconomic disparities across sectarian and ethnically diverse
populations.
Located at the heart of the Middle East, Lebanon is a middle-income country that con-
tinues to be heavily affected by over 16 years of armed conflict and instability from 1975
until 1992. Among Arab countries, Lebanon has the highest percentage of older people
aged 65 years and above (8.4%) (United Nations Population Division 2012). Close to
87% of the population, estimated at around 4 million people, are clustered in urban
areas and a substantial proportion reside in the outskirts of the capital, Beirut (United
Nations Population Division 2011). The aim of this work is to characterize older adults’
self-perception of health across three underprivileged ethnically diverse urban commu-
nities affected by displacement waves in Lebanon and to explore whether differential in
access to social and economic resources can mitigate health disparities.
Self-rated health: a comprehensive measure of well-being
A well-established quality of life indicator among older adults is self-rated health (SRH) –it
has been described in the literature as a robust and universal measure of an individual’s
current and future health status that encompasses the physical, mental, and social dimen-
sions of well-being (Jylha 2009; Abdulrahim and El Asmar 2012; Mavaddat et al. 2014b).
Beyond its ability to reflect on an individual’s quality of life, SRH is also key in predicting
mortality, even after controlling for age, gender, socioeconomic status, and comorbidities
(Idler and Benyamini 1997; DeSalvo et al. 2006; Mavaddat et al. 2014a; Stenholm et al.
2015).
Determinants of SRH: theoretical perspective
Building on Bourdieu’s theoretical approach, better SRH in old age appears to be largely
determined by access to psychosocial and material resources as well as the characteristics
of the places in which older people live (Berkman 2000; Carpiano 2006; Kim and Kawachi
2006; Eriksson 2011). Bourdieu’s social capital theory emphasizes ‘the collective resources
of groups that can be drawn upon by individual group members for procuring benefits and
services in the absence or in conjunction with their own economic capital’(Carpiano
2006), which in turn appear to be linked to better health outcomes (Berkman 2000;
Kim and Kawachi 2006; Eriksson 2011). Social capital resources include the structural
characteristics of a neighborhood (neighborhood’s socioeconomic conditions, perceived
2A. M. SIBAI ET AL.
satisfaction with features and services), social connectedness (networks’formation,
strength of social ties, and social participation), social norms (trust and reciprocity),
and social support (resources that can be mobilized to promote an individual’s well-
being) (Carpiano 2006; Linden-Bostrom, Persson, and Eriksson 2010). Additionally, econ-
omic capital has been suggested to play a role in facilitating access to social capital
resources since the ability to acquire services or amenities, such as a phone, or a car,
may as well promote social connectedness (Kawachi et al. 1997; Kawachi, Subramanian,
and Almeida-Filho 2002).
Mechanisms linking social capital and economic capital to health
Social capital through its various constructs has been shown to attenuate the impact of
adverse life circumstances on poor health outcomes including SRH through both direct
and indirect pathways (Kawachi, Subramanian, and Almeida-Filho 2002; Kim and
Kawachi 2006; Linden-Bostrom, Persson, and Eriksson 2010; Eriksson 2011; Mavaddat
et al. 2014b; Chen et al. 2015). Specifically, social connectedness, reciprocity, and social
support were noted to have a direct impact on maximizing access to resources and addres-
sing individuals’unmet needs (Kawachi, Subramanian, and Almeida-Filho 2002; Pollack
and von dem Knesebeck 2004; Kawachi, Subramanian, and Kim 2008; Eriksson 2011).
More specifically, higher levels of trust have been also associated with lower rates of car-
diovascular and cerebrovascular conditions, cancers, injuries, and even mortality
(Berkman, Leo-Summers, and Horwitz 1992; Kawachi et al. 1997). Social participation
has been shown to activate cognitive systems and promote positive feelings of meaningful-
ness and belonging, and more generally mental health (Eriksson 2011). The impact of
social capital on health may also follow indirect pathways. Studies have demonstrated
that individuals with higher levels of social capital are less likely to engage in risky beha-
viors such as smoking, poor dietary intake, and physical inactivity, which are pre-dispos-
ing factors for many chronic conditions (Kawachi, Subramanian, and Kim 2008). The link
between lower levels of social capital among older adults and poor SRH has also been
established (Pollack and von dem Knesebeck 2004; Nummela et al. 2009) with multilevel
analyses reaching similar findings (Subramanian, Kim, and Kawachi 2002; Kim and
Kawachi 2006).
Similarly, the association between economic security and better health outcomes
including SRH is well documented (Smith 1999; Subramanian, Kim, and Kawachi 2005;
Subramanyam et al. 2009). Besides the affordability of higher living standards and the
ability to seek improved care for various health conditions, a capital of economic
resources, has been associated with a sense of financial security –a buffering factor
against physical and emotional stress, especially among older adults (Smith 1999;
Kawachi, Subramanian, and Almeida-Filho 2002; Grundy and Sloggett 2003; Huisman
et al. 2013; Chemaitelly et al. 2013).
The limited data available from the Middle East and North Africa region suggest a posi-
tive association between lack of community services, poor housing quality, a derelict infra-
structure, and the prevalence of chronic illness (Habib et al. 2009,2011). Some studies
have gaged the accumulated burdens of unemployment and unpaid domestic labor, as
well as shrinking social networks, on the health of older persons (Habib et al. 2006;
Webster et al. 2015). Others portrayed the gendered dimensions of poor SRH among
ETHNICITY & HEALTH 3
older persons in urban and informal neighborhoods (Ahmad et al. 2013; Chemaitelly et al.
2013). However, the impact of successive displacement waves on the well-being of older
adults and on the social dynamics and economic security among displaced populations
remains unexplored.
Setting and context
This research was conducted in three neighborhoods in Lebanon located in the ‘poverty
belt’surrounding the capital city, Beirut: an eastern suburb (Nabaa) and two southern
suburbs (Hey El-Sellom and Burj El-Barajneh). Our choice of neighborhoods was
informed by their historical trajectory as their formation is, in part, the result of displace-
ment waves caused by local and regional conflicts. These neighborhoods are geographi-
cally defined, and differ not only with respect to their infrastructure, but also with
respect to their ethnic and sectarian make-up which renders social interactions across
these communities highly unlikely. In this work, we define ethnicity as a socially con-
structed identity based on factors inherent to a group such as background, culture, and
religion which dictate social standing, political power, and access to services (Abdulrahim
and Khawaja 2011).
Nabaa is an established formal neighborhood that used to be home for Lebanese with
mixed religious backgrounds. Following years of civil strife, Nabaa became largely inhabited
by Lebanese Christian families who were either among the original residents of the neigh-
borhood or displaced from other areas (Makhoul, Ghanem, and Ghanem 2003). The neigh-
borhood benefits from developmental plans for that area and a large number of churches,
schools, and commercial and industrial institutions can be also found in its vicinity.
On the other hand, Hey El-Sellom is an agricultural land that slowly became an infor-
mal settlement largely inhabited by Lebanese Muslims moving from rural villages in the
South of Lebanon to seek employment in the capital or to flee war and conflict. Although
settlements in Hey El-Sellom evolved from tin huts to more concrete structures, these
settlements are still considered illegal by the government and lack the appropriate infra-
structure to serve its growing population. Residents of Hey El-Sellom are also unique in
that they tend to have their extended family living in their original remote villages
rather than within the neighborhood (Makhoul 2003; Khawaja et al. 2006).
Unlike Nabaa and Hey El-Sellom, Burj El-Barajneh was formed as a temporary settle-
ment to house Palestinian refugees following the 1948 exodus. The Lebanese State has
withheld major development of Burj El-Barajneh camp’s infrastructure, and thus it has
remained largely neglected in terms of infrastructure and basic public services. Palestinian
refugees in Lebanon also face legal restrictions in terms of work and travel, and conse-
quently, are at an economic disadvantage compared to the Lebanese population.
Study objectives
This study comes to fill a gap in the aging literature for Arab countries and aims to con-
tribute 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,
4A. M. SIBAI ET AL.
and the prevention of isolation, marginalization, and the costly option of unwanted insti-
tutional care (World Health Organization 2007).
The study addresses three specific research questions and hypotheses. Firstly, are there
differentials in SRH among older adults across the three communities, Nabaa, Hey El-
Sellom, and Burj El-Barajneh? We hypothesize that older adults in Nabaa, a formal com-
munity, will express better SRH than older adults residing in the informal settlement of
Hey El-Sellom or in the Palestinian refugee camp of Burj El-Barajneh. Secondly, how
do the three communities vary in terms of social capital and economic security? We
hypothesize that social capital will be highest in Nabaa, followed by Burj El-Barajneh
camp, and subsequently Hey El-Sellom, while economic security will be higher in
Nabaa and in Hey El-Sellom than in Burj El-Barajneh camp. And finally, can variations
in social capital and economic security explain differences in SRH across the communities
and what is the contribution of each of these constructs to SRH? We hypothesize that
social capital and economic security contribute separately to SRH of older adults across
the three communities under study, net of the effect of potential confounding factors.
Data and methods
Study design and data collection
Data for this study were drawn from the Older Adult Component of the Urban Health
Study (UHS), a large cross-sectional population-based study conducted by the Center
of Research on Population Health of the Faculty of Health Sciences at the American Uni-
versity of Beirut during 2002–2003 in the three neighborhoods of Nabaa, Hey El-Sellom,
and Burj El-Barajneh. Further details related to the design and conduct of the UHS have
been described elsewhere (Khawaja and Mowafi 2006; Jawad, Sibai, and Chaaya 2009).
Briefly, the UHS followed a two-stage sampling design, where a sample of 3300 households
was initially selected using a probability sampling proportional to population size. Older
adults aged 60 years and over, regardless of religion or legal status, were subsequently
invited to participate in the Older Adult Component survey. Institutionalized individuals,
migrant workers, and those residing in abandoned buildings were not approached. Out of
852 eligible older adults, 740 (86.8%) completed the face-to-face interview. There were
minor variations in response rate between communities: 85.8% in Nabaa, 83.1% in Hey
El-Sellom, and 90.4% in Burj El-Barajneh camp. Non-response was mainly attributed to
residential change and no contact following three unsuccessful attempts. The interview
took around 75 min to be completed. Less than 1% of older adults had missing or incom-
plete information and those were excluded from further analyses. The original UHS study
and its various components were reviewed and approved by the Institutional Research
Board of the American University of Beirut.
Data for the Older Adult Component of the UHS were collected using an interview
schedule that comprehensively assessed a range of socio-demographic, health, social,
and economic indicators. The tool was constructed in Arabic and pilot-tested prior to
its administration by trained university-level interviewers selected from the different com-
munities. Consistency and quality control checks were performed at multiple levels of the
data collection and data entry phases. Data were entered using CSPro software where
automatic skips and further validity and consistency checks were applied. Questionnaires
ETHNICITY & HEALTH 5
with detected inconsistencies were returned to the field for re-interview. The validity of the
data was further ascertained through a systematic re-interview of 10% of the sample.
Measures
Our dependent variable, SRH, was assessed using a 5-point Likert scale ranging from very
good, good, average, poor, and very poor health. Informed by the frequency distribution of
the 5-point measure for SRH across the three communities and other scholarly work (Wen
et al. 2003; Mellor and Milyo 2005), we analyzed SRH as an ordinal variable with three
categories. Here, subjects who rated their health as ‘very good’and ‘good’were grouped
as having ‘good’SRH (coded as 0), those who reported ‘average’SRH were considered
as a separate category (coded as 1), whereas those who rated their health as ‘poor’and
‘very poor’were classified as having ‘poor’SRH (coded as 2). Details of a sensitivity analy-
sis performed to assess the robustness of our findings using the trichotomous SRH
measure to that using the original measure are discussed in subsequent sections.
Social capital is a multidimensional construct which was operationalized based on seven
subcomponents including locational capital, social anchorage, social participation, civic
trust, reciprocity, hypothetical social support, and social networks (Lindstrom, Sundquist,
and Ostergren 2001; Harpham, Grant, and Thomas 2002; Travis et al. 2004; Kim and
Kawachi 2006; Carpiano 2006). Items describing these subcomponents (n= 21) are detailed
in Table 2. Briefly, locational capital refers to self-perception of neighborhood characteristics
and was measured by four indicators that described satisfaction with the neighborhood
(‘satisfied’,‘average satisfaction’,and‘not satisfied’) and perception of services in the area
including local schools, local infrastructure, and waste management (‘good’,‘average’,and
‘poor’). Social anchorage, defined as the level of ties with the neighborhood, was assessed
using four indicators that described one’s feeling of belonging (‘yes’and ‘no’), knowing
people in the area (‘the majority’,‘a substantial fraction’,‘afew’,and‘no one’), feeling of
safety walking at night (‘very safe’,‘safe’,‘average safety’,‘unsafe’,and‘very unsafe’), and
exposure to assaults or harassments (‘yes’and ‘no’). The social participation dimension
was assessed by two items, namely belonging to a social/community group (‘yes’and ‘no’)
and attending weekly religious gatherings (‘always’,‘some of the time’,and‘never’). Civic
trust, described as an acquired sense of confidence that emanates from respectful social inter-
actions with others, was assessed in relation to the generalized trust in people in the area
(‘the majority’,‘a substantial fraction’,‘afew’,and‘no one’), trusting merchants
(‘the majority’,‘a substantial fraction’,‘af
ew’,and‘no one’), and vigilance being unnecessary
when dealing with others (‘yes’and ‘no’). Reciprocity, a measure of exchange of voluntary
services with others, was assessed using two indicators, namely perception that a sense of
reciprocity among community members prevails (‘yes’and ‘no’) and engagement in recipro-
cal exchange of favors with relatives, friends, or neighbors in the month preceding the survey
(‘yes’and ‘no’). Hypothetical social support, a measure of the emotional and instrumental
assistance available to the older adult, was assessed using four indicators inquiring about
the self-perceived availability of someone to turn to in case of illness (‘yes’and ‘no’), financial
hardships (‘yes’and ‘no’), personal hardships (‘yes’and ‘no’), and when needing to go out
(‘yes’and ‘no’). Last, social network, a measure of the strength of social ties, was assessed
based on the quality of the social interaction with children (‘yes’and ‘no’) and with relatives,
friends, and neighbors (‘yes’and ‘no’).
6A. M. SIBAI ET AL.
In line with the literature (Kawachi, Kennedy, and Glass 1999; Lindstrom, Sundquist,
and Ostergren 2001; Nummela et al. 2009; Linden-Bostrom, Persson, and Eriksson 2010;
Chemaitelly et al. 2013), indicators describing the different subcomponents of the social
capital construct were dichotomized using a conservative approach for combining
negative outcomes. Favorable outcomes for each indicator were coded ‘1’while negative
outcomes were coded ‘0’. For example, for the ‘satisfaction with the neighborhood’indi-
cator, responses of ‘satisfied’and ‘average satisfaction’were coded 1 and those of ‘not sat-
isfied’were coded 0; for the ‘knowing people in the area’indicator, responses of ‘the
majority’and ‘a substantial fraction’were coded 1 and those of ‘a few’and ‘no one’
were coded 0, and for the ‘feeling of safety walking at night’indicator responses of ‘very
safe’,‘safe’, and ‘average safety’were coded 1 and those of ‘unsafe’and ‘very unsafe’
were coded 0. The responses for the resulting dichotomous indicators were then
summed up to generate a continuous composite score for social capital (range: 0–21;
Cronbach’s alpha: .61).
Economic security was assessed using seven indicators (Table 2): current employment
(‘yes’and ‘no’), a monthly income value exceeding the minimum wage in Lebanon (‘yes’
and ‘no’), having other sources of income from self or spouse (‘yes’and ‘no’), not receiving
monetary assistance from children (‘yes’and ‘no’), charity (‘yes’and ‘no’), or relatives
(‘yes’and ‘no’), and having no dependents (‘yes’and ‘no’) (Clark 2004; Chemaitelly
et al. 2013; National Council on Aging, n.d.). Following the same methodology used to
generate a composite score for social capital, the responses for these indicators were
summed up to generate a continuous composite score for the economic security construct
(range: 0–7, Cronbach’s alpha: .56).
Several socio-demographic factors and health-related characteristics were assessed as
covariates (Table 1). Socio-demographics included age (‘60–64’,‘65–69’, and ‘≥70’),
gender (‘male’and ‘female’), education (‘any formal schooling’,‘no formal schooling’;
the majority of older adults had only basic reading and writing skills), marital status
(‘married’and ‘not married’), history of displacement (‘yes’and ‘no’), and number of
years lived in the neighborhood. Co-morbidity was measured using self-reported phys-
ician-diagnosed chronic medical conditions including hypertension, diabetes, cardiovas-
cular and cerebrovascular diseases, arteriosclerosis problems, renal problems, and
cancer. Each of these reported medical conditions was dichotomized and coded ‘1’when-
ever the condition was present and ‘0’otherwise. A summative score for chronic con-
ditions was subsequently formed. We further characterized the physical health status of
older adults based on limitations in activities of daily living (‘yes’and ‘no’) as measured
using the Katz Index of Independence in Activities of Daily Living (Katz et al. 1970).
The latter assesses independence in six functions including bathing (‘yes’and ‘no’), dres-
sing up (‘yes’and ‘no’), toileting (‘yes’and ‘no’), transferring (‘yes’and ‘no’), continence
(‘yes’and ‘no’), and feeding (‘yes’and ‘no’). An older adult reporting a limitation in
any of these functions was considered as having a disability. Cigarets and/or narghile
smoking were also reported (‘yes’and ‘no’).
Statistical analysis
Bivariate analyses using Chi
2
and ANOVA tests were performed to examine differentials
in SRH across the three communities, Nabaa, Hey El-Sellom, and Burj El-Barajneh camp,
ETHNICITY & HEALTH 7
and further characterize them based on the socio-demographic and health profile of their
older adults’population (Table 1). Cross-community comparisons in relation to social
capital and economic security indicators and their summative scores were also performed
using respectively, Chi
2
and ANOVA tests (Table 2), as well as bivariate logistic and linear
regression analyses (Table S1 in Supplementary Online Material; SOM).
Four multivariate ordinal logistic regression models were subsequently developed to
explain the perception of poorer SRH expressed by older adults in Hey El-Sellom and
in Burj El-Barajneh camp compared to those in Nabaa (Table 3). The first model exam-
ined the association between community and poorer SRH adjusting for the effect of socio-
demographic and health-related factors that were either identified as significant in the
bivariate analysis (Table 1) or known as established correlates of poor SRH. Models 2
and 3 assessed, respectively, the individual contribution of each of the economic security
and social capital constructs to the association between community and poorer SRH net of
the effect of socio-demographic and health-related factors. The relative contribution of the
economic security and social capital constructs (incorporated simultaneously in the
model) was assessed in Model 4. To examine the magnitude of the differences between
Hey El-Sellom and Burj El-Barajneh with respect to poorer SRH, supplemental multi-
variate ordinal logistic regression analyses were performed applying the models described
above while using Burj El-Barajneh as the reference community (Table S2 in SOM). The
results of these multivariate analyses were reported using odds ratios (OR) and 95% con-
fidence intervals (CI).
Sampling weights were applied to all analyses to adjust for cluster sampling effects and
the unequal sampling probabilities from these neighborhoods. Statistical analyses were
performed using STATA/SE version 13.0, and p-value ≤.05 was considered significant.
Table 1. Socio-demographic and health-related characteristics of older adults, Urban Health Study,
Beirut, 2003.
Variables
Total Nabaa
Hey El-
Sellom
Burj El-Barajneh
Camp
p-value
N = 740 N = 376 N = 118 N = 246
n%n%n% n %
Self-rated health
Good and better 257 34.8 156 41.5 39 33.3 62 25.2 <.001
Average 244 33.0 139 37.0 28 23.9 77 31.3
Poor and worse 238 32.2 81 21.5 50 42.7 107 43.5
Socio-demographic
Age (years)
60–64 260 35.1 114 30.3 47 39.8 99 40.2 .088
65–69 211 28.5 118 31.4 31 26.3 62 25.2
≥70 269 36.4 144 38.3 40 33.9 85 34.6
Sex (% males) 328 44.3 165 43.9 50 42.4 113 45.9 .790
Marital status (% married) 462 62.4 239 63.6 72 61.0 151 61.4 .810
Education (% any schooling) 307 41.5 182 48.4 28 23.7 97 39.4 <.001
History of displacement (% yes) 510 69.3 223 59.6 84 71.2 203 83.2 <.001
Years living in the house (mean ± SD) 26.5 ± 16.2 23.8 ± 15.3 17.4 ± 12.8 35.3 ± 15.5 <.001
Health-related variables
Chronic conditions
a
(% yes) 510 69.4 261 69.6 84 71.8 165 67.9 .748
Disability (% yes) 237 32.2 79 21.1 27 23.1 131 53.5 <.001
Smoking cigarets or narghile (% yes) 214 28.9 98 26.1 26 22.0 90 36.6 .004
a
Chronic conditions include one or more of the following medical conditions: hypertension, diabetes, cardiovascular and
cerebrovascular diseases, arteriosclerosis problems, renal problems, and cancer.
8A. M. SIBAI ET AL.
Social capital and economic security: mediation tests
Analyses testing whether the social capital and economic security constructs will qualify as
mediators for the association between community and SRH based on Baron and Kenny’s
criteria were also performed (Baron and Kenny 1986). These entailed testing whether (a)
Table 2. Comparison of social capital and economic security indicators across Nabaa, Hey El-Sellom,
and Burj El-Barajneh camp, Urban Health Study, Beirut, 2003.
Concept and indicator
Total
(%)
Nabaa
(%)
Hey El-Sellom
(%)
Burj El-
Bararajneh
(%)
Social capital
Locational capital
Happy living in neighborhood/neighborhood satisfaction
(yes)
74.7 84.8 77.1 58.1**
Perception of services in the area-good local schools (yes) 64.2 77.9 58.5** 45.9**
Perception of services in the area-good local infrastructure
(yes)
49.7 62.8 39.8** 34.6**
Perception of services in the area-good waste
management (yes)
70.3 72.3 48.3** 77.6
Social anchorage
Feeling like you belong here (yes) 66.9 51.9 74.6** 86.2**
Knowing people in neighborhood (yes) 52.8 60.6 18.6** 57.3
Feeling safe walking alone at night (yes) 85.3 88.5 78.8** 83.3
No exposure to physical assaults/ verbal harassment (yes) 84.2 79.8 83.1 91.5**
Social participation
Belong to social/community group/neighborhood union
(yes)
11.8 16.5 2.5** 8.9**
Attendance of weekly religious activities (yes) 32.6 33.7 28.2 33.1
Civic trust
Trusting people in area (yes) 21.0 21.0 7.6** 27.2
Trusting merchants (yes) 56.8 49.7 56.4 67.9**
One need not be vigilant in dealing with others in
community (yes)
21.0 31.4 11.9** 9.4**
Reciprocity
People in this community help each other (yes) 34.5 46.8 17.1** 23.9**
Any exchange of non-financial favors last month (yes) 31.3 41.4 18.8** 21.6**
Hypothetical social support
Can turn to someone in case of illness (yes) 94.2 97.6 82.2** 94.7
Can turn to someone in case of financial hardship (yes) 71.4 79.0 61.9** 64.2**
Can turn to someone for help with personal hardships
(yes)
76.0 83.2 62.7** 71.1**
Can turn to someone if feels like going out (yes) 75.5 85.4 53.4** 71.0**
Social networks
Good relation with children (yes) 92.3 91.7 95.7 91.4
Good relation with relatives/friends/neighbors (yes) 91.6 95.7 88.9** 86.5**
Social capital composite score (mean ± SD)
a
12.6 ± 3.0 13.5 ± 3.0 10.6** ± 2.7 12.1** ± 2.6
Economic security
Current employment (yes) 17.0 16.2 13.6 19.9
Monthly income exceeding 450,000 Lebanese pounds
(yes)
71.2 84.6 79.7 46.8**
Income from self/spouse (yes) 24.9 24.5 25.4 25.2
Income assistance from children (yes) 68.5 68.6 61.5 71.5
Income assistance from charity (yes) 20.0 4.8 1.7 52.0**
Income assistance from relatives or friends (yes) 11.4 11.4 4.3* 14.6
Income dependents (yes) 50.9 42.5 41.5 68.3**
Economic security composite score (mean ± SD)
a
3.6 ± 1.4 4.0 ± 1.1 4.1 ± 1.1 2.9 ± 1.5**
*p-value < .05 (bivariate analyses using Nabaa as a reference category).
**p-value < .01 (bivariate analyses using Nabaa as a reference category).
a
Composite scores for the social capital and the economic security constructs were generated by summing up indicators
describing each of these constructs. Favorable outcomes for each indicator were coded ‘1’while negative outcomes were
coded ‘0’. It bears notice that for certain indicators, the favorable outcome might not have been necessarily used to
describe that indicator in the table.
ETHNICITY & HEALTH 9
the type of neighborhood is significantly associated with each of the social capital and
economic security constructs (Table 2 and Table S1 in SOM), (b) the social capital and
economic security constructs are significantly associated with poorer SRH (data not
shown), and (c) the type of neighborhood is significantly associated with poorer SRH,
and this association becomes attenuated towards the null hypothesis and not significant
after controlling for social capital and economic security constructs (Table 3).
Sensitivity analyses
A sensitivity analysis was performed to assess the robustness of our findings to the use
of a trichotomous measure for SRH instead of the original 5-point Likert scale for that
measure. To this end, we applied our full multivariate ordinal logistic regression model
adjusted for the effects of the socio-demographic, health, economic security, and social
capital variables (Model 4) to the association between community and poorer SRH
using respectively, the trichotomous and the 5-point Likert scale measures (Table S3
in SOM).
Another sensitivity analysis was implemented to assess the robustness of our findings
to an alternative conceptualization of social capital that distinguishes between commu-
nity- and individual-level resources (Table S4 in SOM). A composite score for each of
Table 3. Multivariate ordinal logistic regression analyses for poorer self-rated health, Urban Health
Study, Beirut, 2003.
Variables (reference category)
Model 1 Model 2 Model 3 Model 4
OR 95% CI OR 95% CI OR 95% CI OR 95% CI
Community (Nabaa)
Hey El-Sellom 2.07 1.36–3.16 2.12 1.39–3.24 1.46 0.94–2.23 1.49 0.96–2.32
Burj El-Barajneh 1.72 1.20–2.49 1.42 0.96–2.08 1.45 1.00–2.12 1.18 0.80–1.76
Age (60–64)
65–69 1.46 1.02–2.09 1.34 0.93–1.92 1.39 0.97–2.00 1.27 0.88–1.84
70+ 1.27 0.90–1.80 1.12 0.78–1.60 1.26 0.88–1.79 1.10 0.77–1.59
Sex (female)
Male 0.70 0.50–0.97 0.72 0.51–1.00 0.80 0.57–1.12 0.81 0.58–1.14
Education (formal schooling)
No 1.19 0.86–1.66 1.15 0.83–1.61 1.18 0.85–1.66 1.14 0.81–1.60
History of displacement (none)
Yes 1.18 0.86–1.61 1.18 0.86–1.61 1.24 0.90–1.69 1.22 0.89–1.68
Years living in house 1.00 0.99–1.01 1.00 0.99–1.01 1.01 1.00–1.02 1.01 1.00–1.02
Smoking (no)
Yes 1.25 0.89–1.75 1.25 0.88–1.75 1.16 0.82–1.63 1.16 0.82–1.64
Chronic conditions 1.42 1.29–1.57 1.41 1.28–1.56 1.43 1.29–1.59 1.42 1.28–1.57
Disability (no)
Yes 2.60 1.85–3.65 2.47 1.76–3.48 2.59 1.84–3.65 2.46 1.74–3.47
Economic security score 0.81 0.72–0.92 0.81 0.72–0.92
Social capital score 0.87 0.82–0.91 0.86 0.82–0.91
Model 1: Association between community and poorer SRH adjusting for age, gender, education, history of displacement,
years living in house, smoking, chronic conditions, and disability.
Model 2: Role of economic security in explaining the association between community and poorer SRH after adjusting for
confounders (age, gender, education, history of displacement, years living in house, smoking, chronic conditions, and
disability).
Model 3: Role of social capital in explaining the association between community and poorer SRH after adjusting for con-
founders (age, gender, education, history of displacement, years living in house, smoking, chronic conditions, and dis-
ability).
Model 4: Relative contribution of economic security and social capital to the association between community and poorer
SRH after adjusting for confounders (age, gender, education, history of displacement, years living in house, smoking,
chronic conditions, and disability).
10 A. M. SIBAI ET AL.
the community- and individual-level social capital measures was calculated by summing
up their respective dichotomous indicators. The contribution of the resulting measures
to the association between community and poorer SRH was subsequently evaluated
using the multivariate ordinal linear regression analyses, described earlier (Table S5
in SOM).
Results
Significant differences in SRH were observed across the three communities (Table 1).
Nabaa had the highest proportion of older adults reporting good SRH (41.5%), followed
by Hey El-Sellom (33.3%) and Burj El-Barajneh (25.2%). The distribution of average and
poor SRH was, respectively, 37.0% and 21.5% in Nabaa, 23.9% and 42.7% in Hey El-
Sellom, and 31.3% and 43.5% in Burj El-Barajneh camp. The three communities were
comparable in terms of age, gender, and marital status distributions. Older adults in
Nabaa were significantly more likely to have achieved formal schooling (48.4%) than
their counterparts in Hey El-Sellom (23.7%) and Burj El-Barajneh (39.4%). More than
two-thirds of the older adult population across these settings reported a history of displa-
cement (69.3%) with the highest percentage being noted in Burj El-Barajneh (83.2%). The
overall mean number of years lived in the household (±SD) at the time of the survey was
26.5 (±16.2) years with significant differences across the three communities, being highest
in Burj El-Barajneh camp (35.3 years), followed by Nabaa (23.8 years), and Hey El-Sellom
(17.4 years). Close to 70% of older adults reported being diagnosed with at least one
chronic medical condition, and around one-third faced limitations in their activities of
daily living. The latter was significantly highest in Burj El-Barajneh camp (53.5%, p
< .001). Tobacco smoking was also more prevalent in Burj El-Barajneh camp (36.6%)
than in Nabaa (26.1%) and Hey El-Sellom (22.0%).
Table 2 shows the distribution of social capital and economic security indicators com-
pared across the three communities. Overall, Nabaa had the highest level of social capital,
showing on a 21-points score, 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 (F
2,733
= 52.51, p-value
< .001). The higher levels of social capital observed in Nabaa was mainly attributed to con-
sistently higher scores on locational capital, social participation, reciprocity, hypothetical
social support, and social networks beyond the immediate family. However, Burj El-Bar-
ajneh camp appeared to match and, in some instances, exceed Nabaa and Hey El-Sellom in
relation to certain other social capital indicators such as social anchorage and civic trust.
For example, 86.2% of older adults in Burj El-Barajneh expressed strong feelings of
belonging to the community compared to 74.6% in Hey El-Sellom and 51.9% in Nabaa.
Also, stronger feelings of civic trust towards merchants and community members pre-
vailed in Burj El-Barajneh camp (67.9% and 27.2%, respectively) compared to Nabaa
(49.7% and 21.0%, respectively) and Hey El-Sellom (56.4% and 7.6%, respectively). Hey
El-Sellom scored lowest on indicators for hypothetical social support with only about
two-third of older adults reporting that they can turn to someone in case of financial hard-
ships or when in need of help with personal hardships, and slightly more than half report-
ing that they can turn to someone when they feel like going out. Meanwhile, the vast
majority of older adults across the three communities reported having strong social net-
works and excellent relations with their children, relatives, friends, and neighbors.
ETHNICITY & HEALTH 11
In contrast to the above, in examining differentials in economic security across the three
communities, Burj El-Barajneh camp was found to be the most disadvantaged (Table 2),
while Nabaa and Hey El-Sellom exhibited comparable characteristics. On a 7-points
score, we estimated a mean economic security of 2.9 in Burj El-Barajneh compared to 4.0
in Nabaa and 4.1 in Hey El-Sellom (F
2,736
= 69.86, p-value < .001). Significant differences
in economic security were revealed between Burj El-Barajneh camp and each of Nabaa
and Hey El-Sellom. Meanwhile, Nabaa and Hey El-Sellom had comparable economic pro-
files. Indeed, although levels of current employment were not significantly different across
the three communities (17% overall), older adults in Nabaa and Hey El-Sellom were signifi-
cantly more likely to have a monthly earning exceeding the minimum wage than those in
Burj El-Barajneh camp (84.6% and 79.7% vs. 46.8%, respectively, p< .001). Older adults
in Burj El-Barajneh were also more likely than those in the other two communities to be
dependent on others, thus receiving income assistance from charity (52.0% vs. 4.8% and
1.7%, respectively, p-value < .001) and were more likely to financially support other depen-
dents (68.3% vs. 42.5% and 41.5%, respectively, p-value < .001).
Table S1 in SOM shows findings of the bivariate regression analyses examining the
magnitude of the association between the three communities and the various social
capital and economic security indicators as well as their summative scores. Compared
to Nabaa, older adults in Hey El-Sellom and Burj El-Barajneh were significantly less
likely to exhibit neighborhood satisfaction, engage in social activities or reciprocal
exchange of non-financial favors, or to have social support. This translated to older
adults in Hey El-Sellom and Burj El-Barajneh being significantly more likely to have
lower scores on the social capital construct than older adults in Nabaa (β=−2.90, 95%
CI: −3.48; −2.31 and β=−1.45, 95% CI: −1.90; −0.98, respectively). As expected, older
adults in Burj El-Barajneh camp were particularly prone for poorer socioeconomic secur-
ity compared to those in Nabaa (β=−1.12, 95% CI: −1.33; −0.92). Meanwhile, there was
no difference in economic security between older adults residing in Hey El-Sellom and
those residing in Nabaa (β= 0.12, 95% CI: −0.14; 0.38).
Compared to Burj El-Barajneh, older adults in Hey El-Sellom were significantly more
likely to be satisfied with their neighborhood, but less likely to express feelings of social
anchorage and civic trust, to be socially active, and to have someone to turn to in case
of illness or when feeling like going out. Meanwhile, there was no difference between
the two neighborhoods with respect to perception of local infrastructure, feeling safe to
walk at night, engaging in reciprocal exchange of services, getting support in case of finan-
cial and personal hardship, and having a strong social network. However, overall, older
adults in Hey El-Sellom were significantly more likely to have a lower social capital
score than those in Burj El-Barajneh camp (β=−1.45, 95% CI: −2.07; −0.82). Lebanese
older adults in Nabaa and Hey El-Sellom were also significantly more likely to score
higher on the economic security construct than their Palestinian counterparts in the
camp (β= 1.12, 95% CI: 0.92; 1.33 and β= 1.25, 95% CI: 0.97; 1.53, respectively).
Findings of our multivariate regression analyses are presented in Table 3. Older adults
residing in Hey El-Sellom and Burj El-Barajneh had higher odds for reporting poorer SRH
outcomes (OR: 2.07, 95% CI: 1.36–3.16 in Hey El-Sellom and OR: 1.72, 95% CI: 1.19–2.49
in Burj El-Barajneh) than older adults residing in Nabaa in the first model adjusted for
socio-demographic and health-related factors (Model 1). The inclusion of the economic
security score in Model 2 explained the variation in poorer SRH for Burj El-Barajneh
12 A. M. SIBAI ET AL.
where the OR was attenuated from 1.72 (95% CI: 1.19–2.49) to 1.42 (95% CI: 0.96–2.08)
after adjusting for confounders but not for Hey El-Sellom (OR: 2.12, 95% CI: 1.39–3.24 in
Model 1 vs. OR: 2.12, 95% CI: 1.39–3.24 in Model 2). However, unlike Model 2, the multi-
variate model assessing the contribution of social capital (Model 3) was able to explain
most of the variation in poorer SRH for older adults in both Hey El-Sellom (OR: 1.46,
95% CI: 0.94–2.23) and Burj El-Barajneh (OR: 1.45, 95% CI: 1.00–2.12). In the fully
adjusted model (Model 4) examining the relative contribution of the social capital and
economic security constructs, further reduction of the OR for only Burj El-Barajneh
camp to 1.18 (95% CI: 0.80–1.76) was noted.
Our supplemental multivariate regression analyses using Burj El-Barajneh as a refer-
ence showed no significant differences in poorer SRH between Hey El-Sellom and Burj
El-Barajneh camp in the first model controlling for basic socio-demographic and health
variables (OR: 1.20, 95% CI: 0.73–1.96), nor in subsequent models controlling for
additional covariates (Table S2 in SOM).
Mediation analysis
Our analyses assessing whether the social capital and economic security constructs fulfill
Baron and Kenny’s mediation criteria (Baron and Kenny 1986) revealed significant associ-
ations between the type of neighborhood and each of the social capital and economic
security constructs (Table 2 and Table S1 in SOM). The social capital and economic secur-
ity constructs were also significantly associated with poorer SRH (OR: 0.84, 95% CI: 0.81–
0.89 and OR: 0.70, 95% CI: 0.63–0.78, respectively; bivariate analyses that are not shown in
tables). In addition, the significant association between type of neighborhood and poorer
SRH (Tables 1 and 3) was rendered non-significant after the inclusion of the social capital
and economic security constructs (Table 3). These analyses affirm the social capital and
economic security constructs as mediators for the association between type of neighbor-
hood and poorer SRH.
Sensitivity analyses
Our sensitivity analysis comparing the outcomes of multivariate ordinal regression ana-
lyses (Model 4) using, respectively, the 3-point and 5-point measures for poorer SRH
yielded similar results with a slightly better R
2
for the model using the trichotomized
outcome (Table S3 in SOM).
We explored the robustness of our findings to an alternative conceptualization of social
capital that distinguishes between community- and individual-level resources (Table S4 in
SOM). On an 8-point score for community-level social capital, Nabaa showed a mean of
5.4, followed by Burj El-Barajneh camp with a mean of 4.2, and Hey El-Sellom with a
mean of 4.1. Similarly, on a 13-point score for individual-level social capital, Nabaa had
a higher score (mean of 8.1) than Burj El-Barajneh (mean of 7.8) and Hey El-Sellom
(mean of 6.5). Incorporating community-level social capital in a multivariate ordinal
regression model reduced the magnitude of the association between community and
poorer SRH from an OR of 2.07 (95% CI: 1.36–3.16) to 1.59 (95% CI: 0.94–2.23) in
Hey El-Sellom and from 1.72 (95% CI: 1.20–2.49) to 1.35 (95% CI: 1.00–2.12) in Burj
El-Barajneh camp, after controlling for socio-demographic and health variables (Table
ETHNICITY & HEALTH 13
S5 in SOM). On the other hand, while it reduced the magnitude of the association between
community and poorer SRH, a model incorporating individual-level social capital did not
fully explain this association among older adults in Hey El-Sellom (OR: 1.71; 95% CI:
1.11–2.64). This model did not also have an impact on the association between Burj El-
Barajneh and poorer SRH (OR: 1.70; 95% CI: 1.18–2.46). However, all three constructs
for economic security, community-level, and individual-level social capital remained sig-
nificant in the full multivariate ordinal logistic model examining the magnitude of the
association between community and poorer SRH. The latter was assessed at an OR of
1.48 (95% CI: 0.96–2.32) in Hey El-Sellom and of 1.16 (95% CI: 0.80–1.76) in Burj El-Bar-
ajneh camp compared to Nabaa.
Discussion
This study extends on previous research on the various roles played by social capital and
economic security in explaining health disparities among older adults within the context
of ethnically diverse underprivileged urban neighborhoods. As a result of years of civil
strife and conflict in Lebanon, the three communities examined in this study share a
low socioeconomic profile characterized by dense urban livings, economic hardships, dis-
placement, and lack of public services and infrastructure. Despite these similarities, strik-
ing differences in SRH were revealed and these were explained by differentials in the
availability of social and economic resources –possibly a reflection of the structural differ-
ences across these communities. Older adults in Nabaa, a formal neighborhood, fared
better in SRH 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. Social and economic deficiencies appeared to contribute equally to the
poorer perception of health among older adults in Burj El-Barajneh camp. Meanwhile,
the poorer SRH among older adults in Hey El-Sellom was largely determined by the
lower levels of social capital in this neighborhood. These findings and the contextual
realizations of these relations are discussed below.
The disparity in SRH between older adults in Burj El-Barajneh camp and Nabaa is not
surprising. Palestinian camps in Lebanon were established as temporary settlements follow-
ing the 1948 Palestinian exodus, and political agreements entailed that the Lebanese govern-
ment has minimal interference in the camps’governance. Six decades past their institution,
the camps are still viewed as temporary arrangements and are often overlooked in the gov-
ernment’s infrastructure renovation plans (Makhoul, Ghanem, and Ghanem 2003). Calls for
granting citizenship to the second- and third-generation Lebanese-born Palestinians have
been continuously rejected out of concerns over upsetting the sectarian balance in the
country (Abdulrahim and Khawaja 2011). Palestinians’participation in the Lebanese
labor force is also largely restricted leading those working in professional jobs to earn sub-
stantially lower wages than their Lebanese counterparts (Abdulrahim and Khawaja 2011).
The lack of adequate social and economic integration programs for Palestinian refugees
makes Burj El-Barajneh camp the most deprived among the three neighborhoods. This dis-
connect may have fostered social ties within the camp and may have led to higher levels of
social support and social anchorage among its residents, despite poor locational capital and
the absence of proper national integration schemes. The environmental and economic
14 A. M. SIBAI ET AL.
disparities between Palestinian older refugees and Lebanese older adults were also reflected
in health differentials, with Palestinians bearing twice the disability burden and significantly
higher smoking levels. Our analysis underscored the role of social capital and economic
resources in shaping poor SRH among Palestinian older adults. These findings appear to
be consistent with reviews and studies conducted among underprivileged refugees and
ethnic minorities elsewhere. Research from Europe and the USA argues that disparities in
health, including a lower perception of health, are a direct outcome of the disadvantage
triad of poor sense of control, social isolation, and deprivation (Lindstrom, Sundquist, and
Ostergren 2001; Nielsen and Krasnik 2010;Wongetal.2011).
Our findings of a significant differential in SRH between Hey El-Sellom and the baseline
Nabaa community, largely explained by social capital, merits further discussion of the con-
textual factors specific to Hey El-Sellom. Although Lebanese, residents of these communities
have different displacement histories and their social conditions and health are shaped by
differences in background and culture. Residents of Hey El-Sellom are, in the majority, dis-
placed from rural areas in the South of Lebanon, which is perceived as their primary place of
belonging (Makhoul, Ghanem, and Ghanem 2003).Because support systems in Lebanon, as
elsewhere in Arab countries, tend to revolve around the extended family sphere (Rashad,
Osman, and Roudi-Fahimi 2005; Sibai and Yamout 2012), older persons compelled to
remain in urban settlements may find themselves disconnected from their origin and
from extended familial social networks (Connidis 2010; Habib et al. 2011) and, hence,
prone to poorer health. This social disconnect was evident, particularly, through the low
levels of social participation, support, trust, and reciprocity in Hey El-Sellom (Table 2 and
Table S1 in SOM). Older adults displaced from rural areas may also be facing challenges
in adjusting to urban living. Indeed, unlike urban areas, villages tend be less crowded,
have more friendly physical environments for older adults, a slower pace of life, and multiple
opportunities for vibrant social interactions among residents. The nature of informal settle-
ments could have also added other constraints on the involvement of older adults residing in
these neighborhoods in decision-making at community level, thus contributingto their poor
SRH. For instance, electoral rights in Lebanon are defined by the individual’s area of origin
rather than area of residence, which may have contributed to the weakened local ties and a
detachment from community affairs in Hey El-Sellom. These observations were affirmed by
our regression analyses emphasizing social capital as a key determinant of well-being among
older adults even after controlling for economic deprivation (Table 3).
We observed no difference between older adults in Hey El-Sellom and those in Burj El-
Barajneh camp with respect to poorer SRH (Table S2 in SOM). One plausible explanation
to our findings pertains to the type of migration –a factor closely related to self-perceived
health (Sundquist et al. 2000; Sundquist, Johansson, and Sundquist 2009). Indeed, unlike
Nabaa where older adults tend to be voluntary-returns to their community postwar, the
settlement of older adults in Hey El-Sellom and Burj El-Barajneh camp was rather involun-
tary. The context in which these displacements occurred and the resulting sensitivities
between the various ethnicities dictated that individuals displaced from southern villages
reside in informal settlements in the southern suburbs of Beirut and that Palestinian refugees
be confined to their camps. Evidence has linked ‘forced’migration/displacement and the
associated sense of lack of control to poorer health outcomes and poorer SRH (Sundquist
et al. 2000; Sundquist, Johansson, and Sundquist 2009). However, further research is war-
ranted to explore whether there could be other explanations to the observed trend.
ETHNICITY & HEALTH 15
Our alternative conceptualization of the social capital construct highlighted the role of
community-level resources in alleviating poorer SRH among older adults and indicated
that, despite their importance, individual-level resources are not the sole determinants
of older adults’well-being (Table S5 in SOM). These findings are in line with an abundant
literature on ‘Ageing in Place’which highlights the sense of attachment, security, and feel-
ings of autonomy that older adults tend to attribute to their neighborhoods and the health
benefits associated with a positive neighborhood perception (Wiles et al. 2009,2012). Our
findings emphasize the need to advocate for infrastructure development plans that would
maximize the opportunities of older adults in underserved communities to carry comfor-
tably their activities of daily living, engage in age-appropriate recreational activities,
promote their social interaction, and provide them with a positive perception of their
physical environment.
Our study findings need to be discussed in view of certain limitations. The cross-sec-
tional design of the survey renders the temporal evolution of events less evident. For
instance, while low levels of social capital and economic security may have likely con-
tributed to poorer SRH among older adults, there is a possibility that poorer SRH could
have affected not only social capital pillars, but also the motivation to engage in income
generating activities. Furthermore, in the absence of a unique standardized scale for
social capital, our constructs’indicators were adapted from scales that have been
widely used in Western countries. The authenticity of these indicators to the original
measures and their applicability to the Arab context still need to be established using
validation studies. Also, our analytical approach was limited by the various metrics
used to assess the indicators of the social capital and economic security constructs.
This dictated the dichotomization of measures prior to constructs’development
which may have obscured part of the variability captured by those measures, thus poss-
ibly introducing bias to these constructs. A formal mediational analysis for the social
capital and economic security constructs was also not possible given the ordinal
nature of our dependent variable. Finally, it should be mentioned that, although the
findings of this study provide insights into possible determinants of SRH among
older adults, they may not be directly generalizable to older adults in other impover-
ished settings or to the older Lebanese population at large.
Since the date of this survey, the country has witnessed several other conflicts, including
the July 2006 war on Lebanon and the more recent Syrian crisis, yielding an influx of over
1.5 million refugees. The resulting strains on existing social and economic infrastructures
in these neighborhoods are magnified by the prevailing governmental dysfunction hinder-
ing the development and implementation of interventions. While these emerging circum-
stances could have an impact on the magnitude of the association between social and
economic constructs and SRH, they are unlikely to change the directionality of our find-
ings highlighting the importance of these dimensions for well-being at old age.
In conclusion, this study sheds light on the role of social capital and economic security
in explaining disparities in SRH among older adults in marginalized communities. Pro-
grams and policy should focus on addressing these, often overlooked, dimensions of
well-being among older adults especially in post-conflict regions. This is a timely public
health concern in the Arab region in light of the ongoing regional strives and the increas-
ing numbers of displaced communities with various geo-historical trajectories of move-
ments and displacements.
16 A. M. SIBAI ET AL.
Disclosure statement
No potential conflict of interest was reported by the authors.
Funding
This publication was made possible by the partial support provided to authors by the Biostatistics,
Epidemiology, and Biomathematics Research Core at the Weill Cornell Medicine-Qatar. This study
was also part of a larger multidisciplinary research project on urban health supported by grants
from the Wellcome Trust [grant number 061495/Z/00/Z], the Andrew W. Mellon Foundation
[940200692/200200709], and the Ford Foundation [grant number 990-1511-1]. The statements
made herein are solely the responsibility of the authors.
Key messages
(1) Older adults living in a formal neighborhood had better self-rated health than those
living in an informal settlement. Self-rated health among the latter also fared better
than among those living in refugee camps.
(2) Social capital and economic security are key in explaining disparities in self-rated
health among older adults in marginalized communities.
(3) Both community- and individual-level social capital resources contribute to self-
rated health among older adults in disadvantaged communities.
(4) There is a need for integrating social capital and economic security in programs and
policy geared towards promoting older adults’well-being, especially in post-conflict
regions.
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