Background Throughout the COVID-19 pandemic, older Syrian refugees in Lebanon faced multiple adverse socio-ecological difficulties, which may have exacerbated their mental health disorders. Identifying predictors of poor mental health provides pathways for humanitarian programming to target interventions. This study aimed to identify socio-ecological predictors of poor mental health amongst older Syrian refugees living in Lebanon during the COVID-19 pandemic.

Methods All Syrian refugee households in Lebanon with members aged 50 years or older that received assistance from a humanitarian organization were invited to participate in a multi-wave telephone survey. A repeated cross-sectional analysis was conducted for three (out of five) data collection waves of a longitudinal survey (wave 1 (September-December 2020), wave 3 (January-April 2021) and wave 5 (January-March 2022)). The main outcome, mental health, was measured using the Mental Health Inventory-5, in which a score equal to or less than 60 indicated poor mental health. All candidate predictors identified from the literature and collected in the survey were included in the model. Using wave 1 data, the model was developed through backward stepwise logistic regression. Bootstrapping was used to internally validate the model and to provide an estimate of optimism. The model’s optimism-adjusted calibration slope (C-slope) and discrimination (C-statistic) of the model were presented. Model performance was assessed in waves 3 and 5.

Results Of 3,229 participants, 47% were female, and the median age was 56 years old [IQR: 53–62]. At wave 1, 76.7% had poor mental health, increasing to 89.2% and 92.7% at wave 3 and wave 5, respectively. Predictors for poor mental health were food insecurity, water insecurity, lacking legal documentation, unemployment, and poor self-reported health. The optimised adjusted C-statistic was 0.69 (95% CI:0.67–0.72) with a C-slope of 0.93 (95% CI:0.84–1.05). The C-statistic was 0.69 (95%CI:0.66–0.72) in wave 3, and 0.73 (95%CI:0.69–0.76) in wave 5, as well as the C-slope were 1.00 (95%CI:0.83–1.17) and 1.00 (95%CI:0.84–1.16), respectively.

Discussion The mental health of older Syrian refugees in Lebanon worsened during the COVID-19 pandemic. Predictors of poor mental health were related to the basic human needs and rights of refugees, which require to be met to improve the health and well-being of this vulnerable population. This study is representative of older Syrian refugees receiving assistance and may not be generalizable to all Syrians residing in Lebanon.