https://orcid.org/0000-0001-5442-7147
Figures
Abstract
Background
Frailty and disability often emerge with ageing and affect quality of life. Older adults residing in Rohingya refugee camp in Bangladesh are particularly susceptible to frailty and disability due to adverse physical and social environment along with limited health and social care services available in the camp. This study aimed to investigate the prevalence and factors associated with frailty and disability among Rohingya older adults living in Bangladesh.
Methods
This cross-sectional study was conducted among older adults aged ≥60 years residing in the Rohingya refugee settlement in Bangladesh. The primary outcomes were frailty and disability, explored using the ‘Frail Non-Disabled (FiND) questionnaire. Data were collected face-to-face during November-December 2021, using a semi-structured questionnaire. A multinomial logistic regression model was used to identify the factors associated with frailty and disability.
Results
The majority of participants (n = 864) were aged 60–69 years (72.34%), male (56.25%), married (79.05%), and without formal education (89.0%). The study revealed a high prevalence of frailty (36.92%) and disability (55.21%) among the participants. The multinomial regression analysis showed that the likelihood of experiencing disability was significantly higher among participants who were aged 70–79 years (RRR = 2.65, 95% CI: 1.25, 5.66) and ≥80 years (RRR = 8.06, 95% CI: 1.05, 61.80), were female (RRR = 3.93, 95% CI: 1.88, 8.1.9), had no formal education (RRR = 4.34, 95% CI: 2.19, 8.63), were living in a large family (RRR = 1.82, 95% CI: 1.05, 3.18) and were suffering from non-communicable diseases (RRR = 2.36, 95% CI: 1.32, 4.22) compared to their respective counterparts. The regression analysis also revealed that frailty was significantly higher among participants who were female (RRR = 2.82, 95% CI: 1.34, 5.94), were suffering from non-communicable diseases (RRR = 2.28, 95% CI: 1.27, 4.09), and had feeling of loneliness (RRR = 2.16, 95% CI: 1.11, 4.22).
Conclusions
The findings underscore the need for long-term care and health promotion activities to alleviate the burden of frailty and disability among older adults in humanitarian settings. Efforts should particularly target the most vulnerable groups- older individuals (≥80 years), women, those without formal education, those living in large families, and those with non-communicable diseases.
Citation: Anwar A, Parvez M, Azim F, Yadav UN, Ghimire S, Parray AA, et al. (2026) Frailty and disability among older adults residing in Rohingya refugee camp in Bangladesh. PLoS One 21(1): e0341499. https://doi.org/10.1371/journal.pone.0341499
Editor: Thalía Fernández, Universidad Nacional Autonoma de Mexico, MEXICO
Received: June 2, 2024; Accepted: January 8, 2026; Published: January 23, 2026
Copyright: © 2026 Anwar et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its Supporting Information files.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Ageing populations are steadily growing worldwide, representing a substantial demographic shift. The World Health Organization (WHO) predicts that the world population of older adults aged 60 years and above will increase from 1 billion in 2020 to 2.1 billion by 2050 [1]. Simultaneously, another global demographic shift has been observed through the increased forced migration worldwide [2]. An estimated 123.2 million people were forcibly displaced due to persecution, conflict, violence, and human rights violations [2]. Low- and middle-income countries (LMICs), which already have fragile health and social systems [3] host approximately 73% of the refugees and people in need of protection [4]. Older refugees comprise 4% of the overall refugee population around the globe [5]. Older adults face unique challenges, such as limited access to health care services, reduced social network and quality of support, and limited economic and livelihood opportunities [5,6] in the context of a humanitarian emergency. These challenges are further compounded by age-related physical and physiological phenomena, such as reduced functional ability [7], frailty and disability [8], and cognitive decline [9], which collectively lower the quality of life [10]. Moreover, being overlooked in a humanitarian context, weakened governmental systems, and the absence of safety nets exacerbate the suffering of the older refugees [11]. Bangladesh hosts nearly one million Rohingya refugees from neighboring Myanmar who contribute to the ongoing challenge to the fragile health, economic, social, and environmental system of Bangladesh [12].
Frailty is a multifaceted geriatric syndrome characterised by diminished physiological reserves, decline in cognitive performance and nutritional status, and increased vulnerability to adverse health outcomes [13,14]. Fried and colleagues defined frailty as meeting at least three of the five phenotypic criteria of shrinkage (weight loss), exhaustion, weakness, slow gait speed, and poor physical activity [15]. Disability, on the other hand, refers to difficulties encountered in one or more of the following areas of functioning: impairments (issues with body structure and function), activity limitations (difficulties an individual has performing activities), and participation restrictions (difficulties an individual may encounter when participating in life situations) [16]. Frailty refers to instability and risk of loss of function, while disability indicates loss of function and can often be assessed based on difficulty or dependency in performing activities necessary to live independently [17,18]. Although frailty and disability emerge naturally, their consequences are more severe for older adults in humanitarian contexts due to scarce resources, limited care, and environmental constraints [11].
The Rohingya population, who were forcibly displaced from Myanmar, have experienced state-sponsored persecution, violence, and military attacks in their homeland [19,20]; which has led to waves of mass displacement and forced them to seek refuge in neighboring countries, including Bangladesh [21]. Around one million Rohingyas are currently living in the refugee camp of Cox’s Bazar, Bangladesh, with 52% being children, 44% adults, and 4% older adults [22]. The Rohingya refugee camp is highly populated. As many as 40,000 people live per square kilometer in some areas, making the living standard of the inhabitants one of the worst in the world [23]. The camp’s poor water, sanitation, and hygiene (WASH) condition exacerbate the situation. There is a single communal toilet for every 20 camp residents, often resulting in long waiting times for toilet use [23]. Besides, many toilets are located on higher ground and often lack security lighting, making it difficult for women, children, and older people to access these facilities, especially at night [24]. In line with the ageing population elsewhere, Rohingya older adults experience progressive age-related functional and cognitive decline [7,25]. Rohingya older adults face multifaceted challenges living in Rohingya refugee camp. Evidence indicates that the Rohingya older adults face an array of barriers and challenges in accessing healthcare services [26,27]. Furthermore, the Rohingya older population relies mostly on humanitarian assistance to meet their basic needs, including health and well-being requirements [27,28]. Previous research further provides evidence on the burden of geriatric malnutrition and selected comorbidities among them [29]. The evidence further suggests that displacement-related stressors, such as inadequate access to food, water, shelter, insecure and/or overcrowded living conditions [30], lack of livelihood opportunities [31], and aid dependency [7]` can worsen their quality of life [10] and mental well-being [32]. All these environmental, social, and economic vulnerabilities [33] can exacerbate the onset and consequence of the frailty and disability experience among the Rohingya older adults.
Frailty and disability pose a serious concern among the older population, particularly among migrants and refugees. A study found that immigrants born in low-income countries (LICs) demonstrated a higher frailty index compared to natives and immigrants born in high-income countries (HICs) [34]. Migrants were also found to be frailer than non-migrants in a similar study conducted on 95,635 older adults aged ≥ 50 years living in Europe [35]. The prevalence of frailty among older adults was significantly higher in neighborhoods where a higher proportion of internal migrants reside in Colombia [36]. A three-year follow-up study conducted in 1999 among 534 adult Bosnian refugees originally living in a refugee camp in Croatia revealed that almost half of the older adults had disabilities [37]. Evidence in Africa also suggests that the prevalence of disability is relatively higher among internally and forcibly displaced people [38].
Understanding the unique factors contributing to frailty and disability in this marginalized group is important for developing targeted interventions, improving healthcare provision, and advocating for policy changes that address their specific needs. However, there is a dearth of evidence on frailty and disability among older adults residing in the Rohingya refugee camp in Bangladesh. One study so far found that approximately one in four older adults has limited functional ability [25]. Addressing frailty and disability among the older Rohingya population requires culturally sensitive and context-specific interventions that can account for their unique challenges. Without substantial evidence, designing context-specific interventions targeting this potentially vulnerable Rohingya population would be difficult. The current study, therefore, aimed to examine the prevalence of frailty and disability among the older adults living in Rohingya camp in Bangladesh and to identify factors associated with these conditions.
Materials and methods
Study design and participants
This study adopted a cross-sectional design and was conducted between 1 November and 20 December 2021. Data were collected from participants aged ≥60 years who resided in five selected sub-camps in the Rohingya refugee camp in Bangladesh, where a national non-governmental organisation (NGO) operates. The sample size (n = 973) was calculated based on a 50% prevalence (unknown), a margin of error of 5%, a confidence level of 95%, a test power of 80%, and an anticipated 25% non-response rate. Out of the 973 individuals who were initially approached, a total of 864 participants provided their consent to actively participate in this study, yielding a response rate of 88.8%. The NGO had access to a comprehensive registry listing all beneficiaries aged 60 years and above residing within the designated five sub-camps. This exhaustive registry served as the sampling frame for the study. A simple random sampling technique was employed using this sampling frame to select the targeted number of participants. The age of the participants was verified using the SMART cards, which were issued to individuals residing within the camp by the United Nations High Commissioner for Refugees (UNHCR). The inclusion criteria were having aged 60 years and above. Exclusion criteria were suffering from any adverse mental health conditions, i.e., clinically diagnosed schizophrenia, bipolar mood disorder, dementia/cognitive impairment, and inability to communicate.
Measures
Outcome measure.
The primary outcomes of interest were frailty and disability, measured using the ‘Frail Non-Disabled (FiND) questionnaire’ [39]. This questionnaire was previously used among the older adults in Nepal [14], showcasing its relevance and applicability in the South Asian context. However, the FiND questionnaire has not been previously validated in the Rohingya population. For this study, the instrument was translated into the local language used in the camp to ensure comprehension. No additional cultural adaptation or population-specific validation was performed; scoring and classification followed the developers’ algorithm.
The FiND questionnaire comprises five items encompassing a comprehensive evaluation of various facets. The first two questions are on mobility and belong to the disability, and the latter three questions are on weight loss, exhaustion, and physical activity, and belong to the frailty. Each item is coded as “0” for negative responses and “1” for affirmative responses. Participants who respond affirmatively to at least one of the two disability items are classified as “disabled”, respond negatively to both disability questions but affirmatively to at least one frailty question are classified as “frail”, and respond negatively to each of the five items are classified as “robust”, indicating the absence of both frailty and disability. Cronbach’s α was calculated to determine the internal consistency and reliability of the FiND questionnaire within the targeted study population. The calculation produced a Cronbach’s α value of 0.75, indicating an acceptable level of reliability [40].
Explanatory variables.
The explanatory variables were selected through an extensive review of pertinent literature [14,35,41–43]. Age in years was stratified into three distinct categories: 60–69, 70–79, and ≥80, allowing for a comprehensive examination of age-related nuances. Sex was dichotomously classified as male or female, enabling an exploration of potential gender disparities. Marital status was categorised into two groups: currently married or without a partner, providing insights into the influence of intimate relationships on the outcomes. The variable of formal education was dichotomized as no or yes, providing an understanding of the potential impact of educational attainment. Family size was also dichotomised as ≤4 or >4, allowing for an exploration of the influence of household composition on the outcomes. Monthly family income was categorized as living with aid only, < 5000 BDT, and ≥5000 BDT, while occupation was classified as eployed or unemployed/retired. Participants were also categorized as either having a self-repoted memory or concentration problems or not. Living arrangements were categorised as either living alone or with family, shedding light on the potential consequences of available familial support. Level of physical activity was categorized as either ‘having regular physical activity’ or ‘none or mainly sedentary’. The information on the presence of non-communicable diseases was collected through asking the participants if they have ever been diagnosed with arthritis, hypertension, heart disease, stroke, hypercholesterolemia, diabetes, chronic respiratory diseases, chronic kidney disease, or cancer by a heathcare provider. Participants were then categorized as either suffering from any non-communiable diseases or not.
The assessment of loneliness was undertaken utilizing the 3-item UCLA Loneliness Scale [44], a well-established tool previously employed among the Bangladeshi population [45]. This scale comprises three distinct items, each evaluated through a yes/no format. The three items encompass the following aspects: (i) the frequency of experiencing a lack of companionship, (ii) the frequency of feeling left out, and (iii) the frequency of feeling isolated from others over the preceding two-week period. Each item within the scale was measured using a 3-point Likert response scale: hardly ever (1 point), some of the time (2 points), and often (3 points). Participants were subsequently classified as experiencing loneliness if they responded with “some of the time” or “often” to any of the items [46].
Data collection tools and techniques
A semi-structured questionnaire was employed to collect pertinent information. Data were collected using the SurveyCTO mobile application (https://www.surveycto.com/) and was executed by twenty-two local enumerators. These individuals, hailing from the local community, displayed profound fluency in Rakhine dialects and had prior experience in proficiently executing health-related surveys using electronic platforms. Before starting data collection, the enumerators were trained thoroughly by the research team to acquaint them with data collection tools and techniques.
The English version of the questionnaire was translated into the Rakhine language, and then back-translated into English to check if the intricacies of the source items were properly preserved. Two local NGO personnel proficient in English and the Rakhine languages assisted in this process. After developing the Rakhine version through cross-checking and resolving minor disagreements about the translation, the draft Rakhine instrument was piloted with a small sample (n = 10) of Rohingya older adults from the camp. The pilot administration of the instrument helped further refine the language in the final version of the questionnaire. The data was collected using this final tool through face-to-face interviews of the participants. Each interview took approximately half an hour to complete. The English version of the final questionnaire is provided as S1 File.
Statistical analyses
Descriptive analyses (i.e., frequency and percentage) were performed to explore the distribution of the participants in terms of sociodemographic variables. Considering the fact that outcome variable is categorical with more than two unordered responses, a multinomial logistic regression model was performed [47] to identify the factors independently associated with frailty and disability while controlling for important confounders. The covariates to be included in the final regression model were determined using a backward elimination approach guided by the Akaike information criterion (AIC) [48]. The initial model included all potential covariates outlined in Table 1. In the next step, variables were sequentially removed based on their AIC value and concomitant statistical significance to achieve the final sets of variables for a parsimonious model. The final regression model was performed, including these variables. The Relative Risk Ratio (RRR) and its corresponding 95% confidence interval (95% CI) for the “disabled” and “frail” categories are provided with reference to the “robust” category in Table 2. As the multinomial regression model estimates probabilities rather than odds, and that odds ratio could overestimate the associations, as the outcomes were common, we used RRR instead of odds ratio (OR) to measure association [47]. All statistical analyses were conducted using the Stata software package (Version 14.0).
Ethics approval and consent to participate
The study was approved by Jashore University of Science and Technology’s institutional review committee (Ref: ERC/FBST/JUST/2020–61). As participants were recruited from a forcibly displaced, vulnerable population, additional considerations were taken to ensure the participation of the older adults. Participants were thoroughly apprised of the study’s objectives in their preferred languages before seeking their informed consent. It was also ensured that their consent and participation were not influenced by the aid providers. Participation was voluntary, and participants did not receive any compensation for their time.
Results
Characteristics of the participants
The sociodemographic profiles of the study participants are outlined in Table 1. A substantial proportion of the respondents were within the age range of 60–69 years, accounting for 72.34% of the sample, 21.99% were between 70–79 years old, and 5.67% were aged 80 years or above. Male respondents were a notable majority, representing 56.25% of the participants. Most participants (79.05%) were married and 56.94% resided in households comprising four or more individuals. A large portion of the participants (67.13%) relied solely on external assistance for sustenance. Approximately 89.00% of the participants were unemployed or retired, demonstrating the prevalence of reliance on aid alone and the lack of employment opportunities. Most individuals (90.51%) in the sample indicated that they lived with family, and most (89.00%) had no formal education.
More than half of the participants exhibited diminished memory or concentration, amounting to around 58.00% of the sample, while half (50.12%) suffered from non-communicable diseases, signifying the prevalence of such health conditions within the population under investigation. Additionally, a majority of the sample, encompassing 65.86% of the participants, reported a lack of regular physical activity. Remarkably, a staggering 81.13% of the participants reported experiencing feelings of loneliness, emphasizing the prevailing sense of isolation among the sampled individuals.
Prevalence of frailty and disability
Table 2 outlines the prevalence of non-disabled frailty and disability across different characteristics of the participants to provide descriptive context and identify crude patterns that inform the specification of our multivariable models. Data revealed that a substantial portion (36.92%) of the entire cohort (n = 864) exhibited frailty, while an even higher portion (55.21%) of them grappled with a disability, leaving a mere 7.87% classified as robust. Notably, the prevalence of frailty was relatively higher among individuals aged 60–69 years compared to those aged 80 years and above (40.32% versus 14.29%). Conversely, the prevalence of disability significantly affected the latter group, plaguing 83.67% of those aged 80 years and above compared to 50.40% among their counterparts aged 60–69 years. Furthermore, bivariate analysis revealed that males demonstrated a higher incidence of frailty (38.68%) compared to females (34.67%), whereas females showed a higher rate of disability (62.17%) compared to males (49.79%).
The bivariate analysis also suggested that respondents who did not have any formal education had a higher prevalence of disability (58.00%) than frailty (35.63%) and participants with some formal schooling demonstrated a higher prevalence of frailty (47.37%) compared to disability (32.63%). In addition, participants who had four or fewer family members had a slightly higher prevalence of disability (46.51%) compared to frailty (45.43%), while participants with more than four family members had relatively higher prevalence of disability (61.79%) than frailty (30.49%).
Factors associated with frailty and disability
Table 3 illustrates the independent factors associated with frailty and disability in the multinomial logistic regression model. The analysis revealed compelling evidence that the likelihood of experiencing disability was markedly higher among participants in the age bracket of 70–79 years (RRR = 2.65; 95% CI: 1.25, 5.66) and those aged 80 years or older (RRR = 8.06; 95% CI: 1.05, 61.80), as well as among females (RRR = 3.93; 95% CI: 1.88, 8.19), those deprived of formal education (RRR = 4.34; 95% CI: 2.19, 8.63), those from families consisting of four or more members (RRR = 1.82; 95% CI: 1.05, 3.18), and those suffering from non-communicable diseases (RRR = 2.36; 95% CI: 1.32, 4.22), as compared to their respective counterparts.
Conversely, the odds of frailty were notably higher among females (RRR = 2.82, 95% CI: 1.34–5.94), individuals grappling with non-communicable diseases (RRR = 2.28, 95% CI: 1.27–4.09), and those who experienced a sense of loneliness (RRR = 2.16, 95% CI: 1.11–4.22).
Discussion
This study examined frailty and disability among the older population residing in the Rohingya refugee camp in Bangladesh. The findings revealed that the prevalence of frailty and disability among older adults was 36.9% and 55.5%, respectively. Notably, no previous research reported the frailty and disability among older adults in Rohingya camp in Bangladesh. However, the prevalence of frailty among Rohingya older adults surpasses that of older adults residing in rural Tanzania, as demonstrated by a previous study [49]. It is also higher than another study conducted in the United States, where the prevalence of frailty was 15% among older refugees [50]. A study conducted on forced and internally displaced older adult migrants in Colombia unveiled an alarming prevalence of pre-frailty/frailty, estimated at 80.63% [36]. Another study conducted on Bosnian older refugees reported a disability prevalence of 46% [37] which is close to the estimates found in the present study. The Global AGEing and Adult Health (SAGE) Wave 1 study indicated that both frailty and disability prevalence were highest in India at 55.5% and 93.3% respectively among older adults [41]. A study conducted in Saudi Arabia also unveiled that frailty and pre-frailty affected 21.4% and 47.3% of the population, respectively [51].
The higher prevalence of frailty and disability among Rohingya older adults can plausibly be ascribed to their limited access to fundamental healthcare services, inadequate nutritional support and outcomes, substandard water, sanitation, and hygiene (WASH) provisions, overcrowded living conditions, limited or absent social protection, insufficient care, and meager or absent financial assistance [23,24,52,53]. Moreover, older adults often face exclusion from different services and a dearth of programs specifically tailored to their needs, offered by humanitarian organizations [26,54], which can contribute to this high prevalence. The heightened prevalence of frailty and disability underscores the increased vulnerability of this population to negative health outcomes [55], diminished quality of life [56], and feelings of isolation [57].
The current study highlighted that the prevalence of frailty was higher among individuals aged 60–69, while the occurrence of disability was notably more pronounced in the ≥ 80 age group compared to those in the 60–69 age range. The aging process entails a multitude of physical, psychological, social, and environmental modifications that contribute to the emergence of frailty among older individuals [58]. Consequently, disability, serving as a deleterious consequence resulting from frailty [59], intensifies with advancing age [60,61].
The findings of our research suggest a propensity for heightened levels of frailty and disability in female participants compared to their male counterparts. This finding aligns with comparable research conducted across diverse settings [62–64]. Factors such as longevity, a higher incidence of chronic diseases, and a confluence of social, economic, and health disparities may render females more susceptible to frailty and disability than males [62,64]. The vulnerable position of females within the Rohingya community is accentuated by limited access to crucial health and ancillary services, inadequate provisions for clean water and sanitation, and socio-cultural constraints that curtail women’s ability to access life-saving resources and practices [24,65]. These factors could plausibly account for the increased prevalence of frailty and disability observed among older women within the Rohingya refugee camp.
Our study also found a negative correlation between formal educational attainment and the prevalence of frailty among older adults. This finding mirrors analogous observations made across divergent settings [42,43,66,67]. Formal education, alongside other socioeconomic, cultural, and demographic factors, profoundly influences disease determinants, thereby influencing the onset of maladies throughout one’s lifespan. Education further engenders health-seeking behaviors, care practices, utilization of medical interventions, and the adoption of assistive devices in the face of frailty and disability [68]. Similar to the findings of this study, previous studies also showed that the level of formal schooling is low among older adults [64,69]. In populations with high illiteracy, particularly in refugee camps, formal education may function more as an indicator of early-life socioeconomic advantage than as a direct influence on health-related decision-making [70]. Older adults with some educational attainment may have benefited from better living conditions, nutrition, and healthcare access throughout the life course, factors known to delay vulnerability and frailty [71]. Consequently, the observed protective effect of education may reflect cumulative socioeconomic advantage rather than literacy-related behavioural differences [72]. Moreover, in resource-limited and structurally constrained environments, the capacity to translate education into informed health choices is often restricted by limited service availability and systemic barriers [73,74]. In such settings, material and social resources may play a more decisive role in shaping late-life health outcomes, consistent with life-course frameworks emphasizing the long-term impact of social conditions on ageing and frailty [75,76].
The present study also found that older adults living in a large family had higher levels of disability than those living in a small family. This is probably because large families usually have a higher poverty level [77], and older family members receive less care from family members who are more concerned about their livelihoods [78]. However, while statistically insignificant, prevalence of frailty was lower among older adults from large families, which need to be interpreted cautiously. Conceptually, disability and frailty capture related but distinct constructs, task-specific functional limitation versus physiological reserve. In our setting, larger multigenerational households often co-occur with lower socioeconomic resources and greater caregiving demands. These factors can increase the observed prevalence of disability (e.g., limitations in ADLs/IADLs) through crowding, injury risk, infection exposure, or earlier recognition/reporting of functional limitations by co-residents. At the same time, frailty may be buffered by the greater instrumental and emotional support available in larger families (assistance with meals, mobility, medication management, and social engagement), which can mitigate weight loss, inactivity, and exhaustion—core frailty components—even if some functional disabilities are present. This pattern is consistent with the notion that multigenerational support may ameliorate frailty features even where functional limitations persist or are more readily recognized.
This study has also demonstrated the correlative relationship between non-communicable diseases and an escalated state of frailty and disability. This finding is further supported by the aggregated empirical data originating from diverse geographical contexts across the globe [42,69]. Researchers have recurrently highlighted an elevated occurrence of non-communicable diseases among refugees and asylum seekers, attributable to transformative modifications in their manner of living, such as their dietary inclinations and physical exertion [79–81]. Rohingya older adults, with their inherent vulnerabilities and sociopolitical disadvantages, are predisposed to the manifestation of non-communicable diseases [82]. Prior inquiries into older Rohingya cohorts have corroborated the augmented prevalence of enduring non-communicable diseases in this demographic [25,83], thereby elucidating the amplification of frailty and disability observed amongst older adults. We also found that those who felt lonely had higher frailty. Loneliness imparts negative emotions and distress, interfering with the performance of daily activities [83].
Implications for policy and practice
The findings of this study underscore the imperative for a cohesive and collaborative approach among stakeholders, authorities, and partners in order to safeguard the health and well-being of older individuals dwelling in refugee settings. At every juncture of program design and execution, stakeholders and authorities must duly consider the distinct needs of older adults. While multiple agencies are engaged in the Rohingya refugee camp, only a few organizations such as Young Power in Social Action (YPSA), Help Age International-Bangladesh, Center for Disability in Development (CDD), Handicap International, the International Organization for Migration (IOM), direct their efforts toward the welfare of the older adults [84,85]. Organizations dedicated to the welfare of the older population should unite and pool their resources with a steadfast focus on catering to the specific needs of this demographic. While numerous programs operate on a large scale, encompassing all sub-camps in the Rohingya response in Bangladesh, programs designed specifically for older adults remain limited in scope. Thus, it is incumbent upon donor agencies, implementing organizations, and other pertinent stakeholders to proactively address this high burden of frailty and disability among this vulnerable population.
Strengths and limitations of the study
The current study has several strengths and limitations. No previous study has examined frailty and disability, and the associated factors affecting Rohingya older adults. Thus, our study will contribute to the existing body of literature concerning frailty and disability within the displaced, migrant, and refugee populations. However, this study is not without its limitations. Firstly, implementing a cross-sectional design imparts a momentary glimpse into the subject matter, precluding the establishment of causal relationships. Second, the study was confined to a selected number of sites due to constraints imposed upon the capacity for data collection, which poses the question of its generalization for the entire Rohingya camp. Third, a key limitation is the absence of a formal cultural adaptation/validation of FiND for the Rohingya context beyond language translation. While FiND is designed for brief community screening and has been used in regional settings, population-specific validation (e.g., cognitive interviews, test–retest reliability, and construct validity against clinical assessments) is warranted and planned in future work. Fourth, use of self-reported health-related data can further lead to underreporting or misclassification of the non-communicable diseases, particularly by participants with low educational level, limited access to health care services, and limited health literacy. Some chronic disease symptoms can be misclassified, unrecognized, or under-reported. This can impact the estimation of the true burden of non-communicable diseases. Self-reporting can also induce social desirability bias and recall bias, which are important limitations to consider. Finally, frailty comparisons may have been underpowered after stratification; future work should evaluate these relationships longitudinally and with population-specific validation.
Conclusion
The current study revealed a high prevalence of both frailty and disability among older adults in the Rohingya refugee camp in Bangladesh. Our study findings highlight the vulnerability of older adults to frailty and disability and indicate related vulnerability factors, including higher age, female sex, not having formal education, living in large families, suffering from non-communicable diseases, and loneliness. The implications of this study emphasize the need for collaborative efforts among stakeholders to deliver long-term care and health promotion initiatives to reduce the higher level of frailty and disability among the older population. In accordance with the findings of the research, it is also recommended that these interventions be particularly focused on the most vulnerable segments of the population mentioned above.
Supporting information
S1 File. English version of the questionnaire for data collection.
https://doi.org/10.1371/journal.pone.0341499.s001
(DOCX)
Acknowledgments
We acknowledge the role of Md. Zahirul Islam, Program Associate, ARCED Foundation, and Shakil Al Mamun, Senior Officer, Data Management, ARCED Foundation for their full support in data collection for the study.
References
- 1. World Health Organization. Ageing and Health. 2022 [16/08/2023]. Available from: https://www.who.int/news-room/fact-sheets/detail/ageing-and-health
- 2. United Nations High Commissioner for Refugees. Global Trends Geneva: UNHCR; 2025 [updated 12 June 2025; cited 2025 29 September]. Available from: https://www.unhcr.org/global-trends
- 3. Landry MD, Giebel C, Cryer TL. Health system strengthening in fragile and conflict-affected states: a call to action. BMC Health Serv Res. 2021;21(1):726. pmid:34301243
- 4. United Nations High Commissioner for Refugees. Refugee Data Finder: UNHCR; 2025 [cited 2025 Sept 29]. Available from: https://www.unhcr.org/refugee-statistics
- 5. United Nations High Commissioner for Refugees. Older Persons: UNHCR; 2025 [cited 2025 Sept 29]. Available from: https://www.unhcr.org/au/what-we-do/how-we-work/safeguarding-individuals/older-persons
- 6. Abi Chahine M, Kienzler H. Ageism, an invisible social determinant of health for older Syrian refugees in Lebanon: a service providers’ perspective. Confl Health. 2022;16(1):62. pmid:36434728
- 7. Anwar A, Yadav UN, Huda MN, Rifat MA, Ali AM, Mondal PK, et al. Prevalence and determinants of self-reported functional status among older adults residing in the largest refugee camp of the world. BMC Geriatr. 2023;23(1):345. pmid:37264327
- 8. Dismore L, Hurst C, Granic A, Tullo E, Witham MD, Dodds RM, et al. Why are older adults living with the complexity of multiple long-term conditions, frailty and a recent deterioration in health under-served by research? A narrative synthesis review of the literature. J Frailty Sarcopenia Falls. 2023;8(4):230–9. pmid:38046442
- 9. World Health Organization. Mental health of older adults. 2023 [cited 2025 Oct 2]. Available from: https://www.who.int/news-room/fact-sheets/detail/mental-health-of-older-adults#:~:text=While%20most%20have%20good%20health%2C%20many%20are,they%20require%20some%20form%20of%20long%2Dterm%20care
- 10. Anwar A, Kurt G, Yadav UN, Huda MN, Ghimire S, Bhattacharjee S, et al. Prevalence and determinants of quality of life among Rohingya older adults residing in the refugee camp in Bangladesh. BMC Geriatr. 2025;25(1):698. pmid:40993530
- 11. Omari SA, McCall SJ, Hneiny L, Sibai AM. Health and well-being of older populations affected by humanitarian crises in low- and middle-income countries: a scoping review of peer-reviewed literature. Confl Health. 2024;18(1):73. pmid:39633399
- 12. (Babu) K-E-K. The impacts and challenges to host country Bangladesh due to sheltering the Rohingya refugees. Cog Soc Sci. 2020;6(1).
- 13. Buckinx F, Rolland Y, Reginster J-Y, Ricour C, Petermans J, Bruyère O. Burden of frailty in the elderly population: perspectives for a public health challenge. Arch Public Health. 2015;73(1):19. pmid:25866625
- 14. Yadav UN, Tamang MK, Thapa TB, Hosseinzadeh H, Harris MF, Yadav KK. Prevalence and determinants of frailty in the absence of disability among older population: a cross sectional study from rural communities in Nepal. BMC Geriatr. 2019;19(1):283. pmid:31640571
- 15. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-56. pmid:11253156
- 16. World Food Programme. How to use the ICF - A Practical Manual for using the International Classification of Functioning, Disability and Health 2013 [16/08/2023]. Available from: https://www.who.int/publications/m/item/how-to-use-the-icf---a-practical-manual-for-using-the-international-classification-of-functioning-disability-and-health
- 17. Katz S, Downs TD, Cash HR, Grotz RC. Progress in development of the index of ADL. Gerontologist. 1970;10(1):20–30. pmid:5420677
- 18. Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969;9(3):179–86. pmid:5349366
- 19. Ullah AA. Rohingya Refugees to Bangladesh: Historical Exclusions and Contemporary Marginalization. J Immigr Refug Stud. 2011;9(2):139–61.
- 20. Haar RJ, Wang K, Venters H, Salonen S, Patel R, Nelson T. Documentation of human rights abuses among Rohingya refugees from Myanmar. Confl Health. 2019;13:1–14.
- 21. Islam MS. Communal peace in Bangladesh after Rohingya crisis: An assessment of different approaches to community development. J Prev Interv Community. 2020;48(3):256–71. pmid:31244395
- 22. UNHCR. Joint Government of Bangladesh - UNHCR Population Factsheet as of March 2023. 2023 [16/08/2023]. Available from: https://data.unhcr.org/en/documents/details/100047
- 23. Kamal A-HM, Huda DMdN, Dell DCA, Hossain DSZ, Ahmed SS. Translational Strategies to Control and Prevent Spread of COVID-19 in the Rohiynga Refugee Camps in Bangladesh. Glob Biosecur. 2020;1(4):1-10.
- 24. Oxfam. One Year On: Time to put women and girls at the heart of the Rohingya response 2018 [16/08/2023]. Available from: https://www.oxfam.org/en/research/one-year-time-put-women-and-girls-heart-rohingya-response#:~:text=This%20briefing%20paper%20looks%20at,decisions%20that%20affect%20their%20lives
- 25. Anwar A, Yadav UN, Huda MN, Das S, Rosenbaum S, Ali ARMM, et al. Anxiety and Stress Related to COVID-19 Among the Community Dwelling Older Adults Residing in the Largest Refugee Camp of the World. Community Ment Health J. 2023;59(6):1181–92. pmid:36879112
- 26. Mistry SK, Ali AM, Yadav UN, Huda MN, Ghimire S, Bestman A. Difficulties faced by older Rohingya (forcibly displaced Myanmar nationals) adults in accessing medical services amid the COVID-19 pandemic in Bangladesh. BMJ Glob Health. 2021;6(12):1–10.
- 27. Khan HT, Rahman MA, Molla MH, Shahjahan M, Abdullah RBJA. Humanitarian emergencies of Rohingya older people in Bangladesh: A qualitative study on hopes and reality. Aging Int. 2022;47(1):20–37.
- 28. World Food Programme. Lack of funds forces WFP to cut rations for Rohingya in Bangladesh 2023 [16/08/2023]. Available from: https://www.wfp.org/news/lack-funds-forces-wfp-cut-rations-rohingya-bangladesh
- 29. Alam MM, Das R, Clara AA, Mohsin FM, Rumi MAH, Wahab A, et al. The assessment of geriatric malnutrition, geriatric depression and associated co-morbidities among forcibly displaced Myanmar nationals in Bangladesh. Public Health Nutr. 2023;26(10):2048–55. pmid:37529859
- 30. Miller KE, Rasmussen A. War experiences, daily stressors and mental health five years on: Elaborations and future directions. Intervention. 2014;12(1):33–42.
- 31.
Kiragu E, Rosi AL, Morris T. States of denial: A review of UNHCR’s response to the protracted situation of stateless Rohingya refugees in Bangladesh. Policy Development and Evaluation Service, UNHCR; 2011.
- 32. Anwar A, Akter N, Yadav UN, Ghimire S, Bhattacharjee S, Eusufzai SZ, et al. Assessment of mental well-being and its socio-economic determinants among older adults in the Rohingya refugee camp of Bangladesh. Sci Rep. 2024;14(1):17918. pmid:39095644
- 33. Dzando G, Ward P, Gesesew HA, Tyndall J, Ambagtsheer RC. Prevalence, perceptions, and experiences of frailty among older migrants from Low- and Middle-Income Countries to High Income Countries: A mixed method systematic review. Arch Gerontol Geriatr. 2024;121:105360. pmid:38341959
- 34. Brothers TD, Theou O, Rockwood K. Frailty and migration in middle-aged and older Europeans. Arch Gerontol Geriatr. 2014;58(1):63–8. pmid:23993266
- 35. Walkden GJ, Anderson EL, Vink MP, Tilling K, Howe LD, Ben-Shlomo Y. Frailty in older-age European migrants: Cross-sectional and longitudinal analyses of the Survey of Health, Aging and Retirement in Europe (SHARE). Soc Sci Med. 2018;213:1–11. pmid:30053619
- 36. Rengifo-Reina H, Barrientos-Gutiérrez T, López-Olmedo N, Sánchez BN, Diez Roux AV. Frailty in Older Adults and Internal and Forced Migration in Urban Neighborhood Contexts in Colombia. Int J Public Health. 2023;68:1605379.
- 37. Mollica RF, Sarajlic N, Chernoff M, Lavelle J, Vukovic IS, Massagli MP. Longitudinal study of psychiatric symptoms, disability, mortality, and emigration among Bosnian refugees. JAMA. 2001;286(5):546–54. pmid:11476656
- 38. Sanhori Z, Lien L, Hauff E, Ayazi T, Mdala I, Eide AH. Change in Disability Associated with Psychological Distress among Internally Displaced Persons in Central Sudan. Int J Environ Res Public Health. 2022;19(9):5347. pmid:35564742
- 39. Cesari M, Demougeot L, Boccalon H, Guyonnet S, Abellan Van Kan G, Vellas B, et al. A self-reported screening tool for detecting community-dwelling older persons with frailty syndrome in the absence of mobility disability: the FiND questionnaire. PLoS One. 2014;9(7):e101745. pmid:24999805
- 40. Gebremedhin M, Gebrewahd E, Stafford LK. Validity and reliability study of clinician attitude towards rural health extension program in Ethiopia: exploratory and confirmatory factor analysis. BMC Health Serv Res. 2022;22(1):1088. pmid:36008866
- 41. Biritwum RB, Minicuci N, Yawson AE, Theou O, Mensah GP, Naidoo N, et al. Prevalence of and factors associated with frailty and disability in older adults from China, Ghana, India, Mexico, Russia and South Africa. Maturitas. 2016;91:8–18. pmid:27451316
- 42. Chen C-Y, Wu S-C, Chen L-J, Lue B-H. The prevalence of subjective frailty and factors associated with frailty in Taiwan. Arch Gerontol Geriatr. 2010;50:S43–7. pmid:20171456
- 43. Kendhapedi KK, Devasenapathy N. Prevalence and factors associated with frailty among community-dwelling older people in rural Thanjavur district of South India: a cross-sectional study. BMJ Open. 2019;9(10):e032904. pmid:31604789
- 44. Hughes ME, Waite LJ, Hawkley LC, Cacioppo JT. A Short Scale for Measuring Loneliness in Large Surveys: Results From Two Population-Based Studies. Res Aging. 2004;26(6):655–72. pmid:18504506
- 45. Mistry SK, Ali ARMM, Yadav UN, Huda MN, Ghimire S, Saha M, et al. Loneliness and its correlates among Bangladeshi older adults during the COVID-19 pandemic. Sci Rep. 2022;12(1):15020. pmid:36056090
- 46. Perissinotto CM, Stijacic Cenzer I, Covinsky KE. Loneliness in older persons: a predictor of functional decline and death. Arch Intern Med. 2012;172(14):1078–83. pmid:22710744
- 47. Zhang D-Y, An D-W, Staessen JA. Clarifying the use of multinomial logistic regression in analysis: a methodological response. Eur Heart J. 2025;46(38):3792. pmid:40717671
- 48. Chaurasia A, Harel O. Using AIC in Multiple Linear Regression framework with Multiply Imputed Data. Health Serv Outcomes Res Methodol. 2012;12(2–3):219–33. pmid:22879799
- 49. Lewis EG, Coles S, Howorth K, Kissima J, Gray W, Urasa S, et al. The prevalence and characteristics of frailty by frailty phenotype in rural Tanzania. BMC Geriatr. 2018;18(1):283. pmid:30445919
- 50. Bandeen-Roche K, Seplaki CL, Huang J, Buta B, Kalyani RR, Varadhan R, et al. Frailty in Older Adults: A Nationally Representative Profile in the United States. J Gerontol A Biol Sci Med Sci. 2015;70(11):1427–34. pmid:26297656
- 51. Alqahtani BA, Alenazi AM, Alshehri MM, Osailan AM, Alsubaie SF, Alqahtani MA. Prevalence of frailty and associated factors among Saudi community-dwelling older adults: a cross-sectional study. BMC Geriatr. 2021;21(1):185. pmid:33731034
- 52. Islam MM, Nuzhath T. Health risks of Rohingya refugee population in Bangladesh: a call for global attention. J Glob Health. 2018;8(2):020309. pmid:30410735
- 53. Jeffries R, Abdi H, Ali M, Bhuiyan ATMRH, El Shazly M, Harlass S, et al. The health response to the Rohingya refugee crisis post August 2017: Reflections from two years of health sector coordination in Cox’s Bazar, Bangladesh. PLoS One. 2021;16(6):e0253013. pmid:34115800
- 54. Hachem S, Ali S, Al-Omari S, Abi Chahine M, Fahme SA, Mehio Sibai A. “Older people tend to be invisible”: a qualitative study exploring the needs and inclusion of older Syrian refugees in the context of compounding crises in host country, Lebanon. Confl Health. 2022;16(1):61. pmid:36403023
- 55. Murphy A, Fuhr D, Roberts B, Jarvis CI, Tarasenko A, McKee M. The health needs of refugees from Ukraine. BMJ. 2022;377:1–2.
- 56. Fusco O, Ferrini A, Santoro M, Lo Monaco MR, Gambassi G, Cesari M. Physical function and perceived quality of life in older persons. Aging Clin Exp Res. 2012;24(1):68–73. pmid:22643307
- 57. Ekoh PC, Iwuagwu AO, George EO, Walsh CA. Forced migration-induced diminished social networks and support, and its impact on the emotional wellbeing of older refugees in Western countries: A scoping review. Arch Gerontol Geriatr. 2023;105:104839. pmid:36343437
- 58. Zhang X, Liu Y, Van der Schans CP, Krijnen W, Hobbelen JSM. Frailty among older people in a community setting in China. Geriatr Nurs. 2020;41(3):320–4. pmid:31959415
- 59. Makizako H, Shimada H, Doi T, Tsutsumimoto K, Suzuki T. Impact of physical frailty on disability in community-dwelling older adults: a prospective cohort study. BMJ Open. 2015;5(9):e008462. pmid:26338685
- 60. Guralnik JM, Fried LP, Salive ME. Disability as a public health outcome in the aging population. Annu Rev Public Health. 1996;17:25–46. pmid:8724214
- 61. Berlau DJ, Corrada MM, Kawas C. The prevalence of disability in the oldest-old is high and continues to increase with age: findings from The 90+ Study. Int J Geriatr Psychiatry. 2009;24(11):1217–25. pmid:19259982
- 62. Zeki Al Hazzouri A, Mehio Sibai A, Chaaya M, Mahfoud Z, Yount KM. Gender differences in physical disability among older adults in underprivileged communities in Lebanon. J Aging Health. 2011;23(2):367–82. pmid:21068395
- 63. Zimmer Z, Korinek K, Young Y, Teerawichitchainan B, Toan TK. Early-Life War Exposure and Later-Life Frailty Among Older Adults in Vietnam: Does War Hasten Aging? J Gerontol B Psychol Sci Soc Sci. 2022;77(9):1674–85. pmid:34637517
- 64. Kim S, Kim M, Han D. Incidence Rates of Disability and Its Associated Factors among Korean Community-Dwelling Older Adults. Iran J Public Health. 2020;49(9):1718–26. pmid:33643947
- 65. Nasar S, Raz S, Parray AA, Hossain MR, Sultana R, Nadim ASM, et al. An assessment of gender vulnerability in the humanitarian crisis in Cox’s Bazar, Bangladesh: Developing a gender-based vulnerability index in the Rohingya and Host community contexts. Int J Disast Risk Reduc. 2022;81:103246.
- 66. Hsu H-C, Chang W-C. Trajectories of frailty and related factors of the older people in Taiwan. Exp Aging Res. 2015;41(1):104–14. pmid:25494673
- 67. Ye L, Elstgeest LEM, Zhang X, Alhambra-Borrás T, Tan SS, Raat H. Factors associated with physical, psychological and social frailty among community-dwelling older persons in Europe: a cross-sectional study of Urban Health Centres Europe (UHCE). BMC Geriatr. 2021;21(1):422. pmid:34247573
- 68. Freedman VA, Martin LG. The role of education in explaining and forecasting trends in functional limitations among older Americans. Demography. 1999;36(4):461–73. pmid:10604075
- 69. Curcio C-L, Henao G-M, Gomez F. Frailty among rural elderly adults. BMC Geriatr. 2014;14:2. pmid:24405584
- 70. Galobardes B, Shaw M, Lawlor DA, Lynch JW, Davey Smith G. Indicators of socioeconomic position (part 1). J Epidemiol Community Health. 2006;60(1):7–12. pmid:16361448
- 71. Lynch J, Smith GD. A life course approach to chronic disease epidemiology. Annu Rev Public Health. 2005;26:1–35. pmid:15760279
- 72. Baker DP, Leon J, Smith Greenaway EG, Collins J, Movit M. The education effect on population health: a reassessment. Popul Dev Rev. 2011;37(2):307–32. pmid:21984851
- 73. Miller KE, Rasmussen A. War exposure, daily stressors, and mental health in conflict and post-conflict settings: bridging the divide between trauma-focused and psychosocial frameworks. Soc Sci Med. 2010;70(1):7–16. pmid:19854552
- 74. Porter M, Haslam N. Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons: a meta-analysis. JAMA. 2005;294(5):602–12. pmid:16077055
- 75. Hoogendijk EO, Heymans MW, Deeg DJH, Huisman M. Socioeconomic Inequalities in Frailty among Older Adults: Results from a 10-Year Longitudinal Study in the Netherlands. Gerontology. 2018;64(2):157–64. pmid:29055946
- 76. Etman A, Kamphuis CBM, van der Cammen TJM, Burdorf A, van Lenthe FJ. Do lifestyle, health and social participation mediate educational inequalities in frailty worsening? Eur J Public Health. 2015;25(2):345–50. pmid:25061232
- 77.
Orbeta AC. Poverty, vulnerability and family size: evidence from the Philippines. Tokyo: Asian Development Bank Institute; 2005.
- 78. Ali I, Azman A, Ahmed MK, Akhtar T, Deceukelier B. Assessment of the Needs of Rural Older People in Bangladesh. Int J Commun Soc Dev. 2022;4(3):317–38.
- 79. Mowafi H. Conflict, displacement and health in the Middle East. Glob Public Health. 2011;6(5):472–87. pmid:21590557
- 80. Mowafi H, Spiegel P. The Iraqi refugee crisis: familiar problems and new challenges. JAMA. 2008;299(14):1713–5. pmid:18398084
- 81. Amara AH, Aljunid SM. Noncommunicable diseases among urban refugees and asylum-seekers in developing countries: a neglected health care need. Glob Health. 2014;10:24. pmid:24708876
- 82. Rahman A, Biswas J, Banik PC. Non-communicable diseases risk factors among the forcefully displaced Rohingya population in Bangladesh. PLOS Glob Public Health. 2022;2(9):e0000930. pmid:36962636
- 83. Mistry SK, Ali ARMM, Irfan NM, Yadav UN, Siddique RF, Peprah P. Prevalence and correlates of depressive symptoms among Rohingya (forcibly displaced Myanmar nationals or FDMNs) older adults in Bangladesh amid the COVID-19 pandemic. Glob Mental Health. 2021;8:1–9.
- 84. Khan HTA, Rahman MA, Molla MH, Shahjahan M, Abdullah RB. Humanitarian Emergencies of Rohingya Older People in Bangladesh: A Qualitative Study on Hopes and Reality. Ageing Int. 2020;47(1):20–37.
- 85. cbm. Supporting people with disabilities in Cox’s Bazar Refugee Camp. 2023 [16/08/2023]. Available from: https://www.cbmuk.org.uk/cbminaction/supporting-people-with-disabilities-in-coxs-bazar-refugee-camp/