Introduction

Since 2013, economic challenges in Venezuela have led to declining production and shortages of basic goods (1). These factors precipitated severe hyperinflation, the deterioration of the healthcare system, widespread migration and displacement, and social and political unrest [1,2,3]. By February 2023, this scenario resulted in more than 7.2 million migrants and refugees from Venezuela [4]. Those remaining in the country faced significant challenges meeting basic needs, including access to utilities, food, and medicines. According to the National Living Conditions Survey (Encuesta Nacional de Condiciones de Vida, ENCOVI, 2019–2020), the self-reported poverty rate increased from 48% in 2014 to 96.2% in 2019–2020 [5], with food insecurity affecting 80% of households in 2017 [6, 7]. In 2022, the severity of the Venezuelan crisis was assessed as “Very High (4.2/5)” by the INFORM Severity Index, a composite measure and comparison tool for assessing humanitarian crises where five represents the highest severity and extreme humanitarian conditions [8]. Compared with other complex crisis, Venezuela ranks higher than Myanmar (3.5) but lower than Libya (4.2), Yemen (4.6), and Syria (4.7) [8]. Public services in Venezuela also have deteriorated significantly, resembling situations observed in other countries affected by wars or natural disasters [9]. In this context, the availability of official government epidemiological data in Venezuela has been limited or non-existent [1, 3].

Social vulnerability - external stressors negatively affecting communities - has been associated with increased mortality, disability [10], and multimorbidity [11]. In other countries in crisis, women, elders, the poorest, and least educated have been identified as vulnerable groups [12], but in Venezuela it is unknown which population groups are most vulnerable to the crisis. The Venezuelan Study of Cardiometabolic Health (Estudio Venezolano de Salud Cardiometabolica, EVESCAM 2014–2017) was the first national population-based cohort study to assess cardiometabolic risk factors and behaviors in Venezuelan adults [13, 14], Using the data from the EVESCAM follow-up evaluation (2018–2020), this study aims to characterize the Venezuelan crisis using seven key indicators to identify the most vulnerable populations for cost-effective, targeted population-based interventions.

Materials and methods

Study design, population, and sampling

The EVESCAM was conducted as an observational cohort study initially aimed to measure the prevalence of cardiometabolic risk factors in a nationally representative sample of Venezuelan adults. EVESCAM 1, the baseline study, was performed between 2014 and 2017 and EVESCAM 2, the cohort’s follow-up was performed between 2018 and 2020. Details regarding the baseline study design and sampling methodology have been published elsewhere [14]. Briefly, between July 2014 and January 2017, 4,454 subjects were enrolled through a multi-stage stratified sampling method using parishes as the primary sampling units. All subjects aged ≥ 20 years were invited to participate and enrolled at the household resulting in 3,420 participants evaluated with a 76.7% response rate. Exclusion criteria included pregnancy and inability to stand or communicate. Between October 2018 and January 2020, 1,257 (37%) participants enrolled at baseline were evaluated by the study staff for follow-up obtaining similar measurements and questionnaires than baseline and adding additional indicators. This report is a secondary analysis of data collected during the follow-up EVESCAM 2 study. Low response rate in the follow-up study was conditioned by transportation and gasoline limitations, mass migration, and declining communication services, which are frequent challenges in conducting research during a humanitarian crisis [9]. Thus, EVESCAM 2 could not maintain the national representativeness that was achieved in EVESCAM 1.

Variable definitions

Seven “a priori” selected crisis indicators were analyzed: food insecurity, stressful life events, family separation, and access disruption to utilities, medicines, transportation, and education. These indicators are widely used in constructs that measure vulnerability of populations in crisis situations [9]. The distribution of these indicators was analyzed across five subgroups: age, sex, ethnicity, socioeconomic status (SES), and education. We hypothesized that elders, women, certain ethnicities, and those of low SES and education levels are the most vulnerable populations during the crisis environment in Venezuela. Variable definitions are provided in Table 1.

Table 1 Variable definitions and categories
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Data analysis

All analyses were conducted using the survey package in R version 4.1.2. The national prevalence of crisis indicators and their distribution across each exposure domain was reported as percentage and 95% confidence intervals (95% CI). Multivariate logistic regression adjusted by the other socio-demographic variables was used to analyze associations among variables. Variables included in the multivariable analysis were age, sex, ethnicity, SES, and education. The primary sampling unit of the survey design was specified for all analyses. Some variables such as disruption in access to utilities/medications and stressful life events were analyzed more in-depth. A p-value < 0.05 was considered statistically significant.

Human ethics and consent to participate declarations

The EVESCAM protocol was approved by the Venezuelan National Bioethics Committee. The EVESCAM follow-up protocol was approved by the Ethics Committee of the Universidad Centroccidental Lisandro Alvarado, Barquisimeto, Venezuela and was conducted in accordance with the Declaration of Helsinki. Signed informed consent was obtained from all study participants.

Results

Participant characteristics

1,257 participants were included in the analysis of follow-up data, of which 71.8% were female, 67.0% older than 50 years, 52.3% from low SES, and 80.2% self-identified as Mixed ethnicity. Additionally, 38.2% had completed up to secondary education and 30.9% had completed university education (Table 2).

Table 2 Socio-demographic characteristics of studied population in EVESCAM 2 study (2018–2020)*
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Prevalence of crisis indicators

The most prevalent crisis indicator was the disruption in access to utilities such as water, electricity, gas, or sanitation, with 77.3% of subjects reporting disruption of at least one of four utilities. Subsequently, disruption of transportation was reported by 70.4%, high stressful life events by 67.2%, food insecurity by 60.2%, family separation by 49.2%, disruption to medication access by 43.8%, and disruption to education by 11.5% (Table 3). Compared with the youngest (age 20–34 years) and Afro-Venezuelans, family separation was more frequent in those older than 50 years and Hispanic whites, respectively. Food insecurity was higher in the low SES group (66.8% [61.3–71.9]) compared to those in the high SES group (48.6% [40.0-57.3]). The disruption in access to at least two of four utilities was more than twice as prevalent among those in the low SES group (41.2% [31.1–52.2]) compared to those in the high SES group (17.6% [11.6–25.7%]), and in those with less education (44.7% [33.2–56.8]) compared to those with university or higher education (21.1% [14.8–29.1]). Lack of access to medicines, transportation, and education as well as stressful life events was similarly prevalent across socio-demographic subgroups (Table 3).

Table 3 Prevalence of crisis indicators according to socio-demographic factors*
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Association of crisis indicators with socio-demographic subgroups

Multivariable analysis showed that the odds of experiencing food insecurity was similar among the age, sex, ethnicity, and education subgroups but were 2.17 (1.5–3.3) higher in those with low SES compared to those with high SES. The odds of reporting stressful life events were similar among the five subgroups. Family separation was between two to three times more likely in subjects 50–64 years old and greater than 65 years old compared to subjects 20–34 years old (OR 1.96 [1.20–3.19], OR 2.84 [1.68–4.81], respectively). Additionally, the odds of experiencing family separation were higher in women than in men (OR 1.73 [1.43–2.09]) and less likely in Afro-Venezuelans than those of Mixed ethnicity (OR 0.62 [0.39–0.97]). Family separation was not associated with SES or education level. Disruption in access to utilities was more likely reported by females than males (OR 1.46 [1.08–1.98]) and by those with primary or no education compared with those with a university degree (OR 2.03 [1.27–3.23]). Lack of access to medications was similar across all the subgroups. Lack of access to transportation was more likely reported by female than males (OR 1.36 [1.10–1.67]) and less likely reported by those of Hispanic White ethnicity than those of Mixed ethnicity (OR 0.60 [0.42–0.87]). The odds of experiencing disruption in children education was lower in older than younger participants, similar between sexes, higher in those of Amerindian ethnicity than Mixed ethnicity, higher in those of low SES compared to those of high SES, and higher in those with lower education than higher education levels (Table 4).

Table 4 Association of crisis indicators and individual- and household-level socio-demographic factors*
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Sub-analysis of crisis indicators

Disruption in access to utilities

In total, 77.3% of subjects reported disruptions/lack of access to one of the four utilities, and 31.7% to two or more of the four utilities. Electricity was the most prevalent utility disruption (70.2%), and its prevalence did not differ across SES. Similarly, lack of access to domestic gas (27.3%) and to poceta or latrine (3.4%) were not different among SES categories. Living in a household without access to at least 7.5 L of potable water per day was reported by 16.9% of participants overall, more frequently reported in those of low SES (23.9% [16.1–33.9%]) than high SES (6.0% [3.2–11.2%]) (Fig. 1).

Fig. 1
Fig. 1
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Disruptions in access to each utility by socioeconomic status (SES). Results are reported as percentages and 95% confidence intervals. Definitions: Disruptions in access to each utility are defined by individuals living in households with no access to at least 7.5 L of potable water per day (water), no electricity or at least weekly interruptions in electricity (electricity), no access to gas (domestic gas), and no “poceta” or latrine (sanitation)

Disruption/lack of access to medications

The flowchart of the lack of access to medications is presented in Fig. 2. Overall, 60.1% of the participants reported needed at least one medication in the last 3 months. Of those subjects, 43.8% were not able to obtain prescribed medications (specifically, 20.9% did not find the medications and 31.1% stated that the required medications were not affordable) and 63.1% reported that they had to use expired medications. Of those able to obtain medications, 84.6% reported obtaining their medications from non-governmental donations and 60.0% from the pharmacy. In those who needed medications, 68.7% obtained them in an establishment outside the sector in the same city, 16.2% outside the city, and 11.3% outside the country. Only 20.9% were able to obtain their medicines in the sector where they live.

Fig. 2
Fig. 2
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Overview of access to medications, source of medications, and reasons reported for disruption/lack access to medications. * Answering more than one option was allowed

Stressful life events

While 67.2% (95% CI: 63.4–71.0) of participants experienced at least one stressful life event in the last year (Table 3), financial difficulties, death of a close family member, and health problems were the three most frequently reported to occur both once or more than once. In addition, 24% of participants reported witnessing another person being injured by a firearm or knife at least once within the past 12 months (Appendix 1). Stressful life events (SLE) affected similarly to populations in various socio-demographic categories (Table 4).

Discussion

Based on a national sample, the main finding of this study was that the Venezuelan humanitarian crisis significantly affects adults, with high proportions experiencing disruptions in access to utilities (77.3%) and transportation (70.4%), stressful life events (67.2%), food insecurity (60.2%), family separation (49.2%), lack of medication access (43.8%), and disruption to education (11.5%). Moreover, the most vulnerable populations were elders, women, certain ethnicities, and those of low SES and education levels. Compared to their respective counterparts (young individuals, men, Mixed ethnicity, high-SES individuals, and those with university education): women were more affected by family separation (73% higher), lack of utilities (46% higher), and transportation disruptions (36% higher); elders experienced 2.8 times more family separation; Afro-Venezuelans had lower rates of family separation, Whites had lower rates of transportation disruptions, while Amerindians experienced more disruptions of education; low SES participants faced 2.2 times more heightened food insecurity and 2.4 times higher lack of at least two of four utilities; and participants with the lowest education level had twice the lack of utilities and a 57% higher likelihood of having disruptions of education in children living in their homes.

Food insecurity - a household-level economic and social condition of limited or uncertain access to adequate food [15] - is a crucial indicator of population vulnerability. In the United States, food insecurity has been found in 10.5–14% of the population [19] with higher rates among Hispanics (15.6–22.4%) [19]. In this study, including the moderate and severe categories, food insecurity affected 60.2% of the population, but only severe food insecurity affected 23.5% (19.3–28.0%) and it was even higher in the low SES group (29.5% [26.2–33.1%]). A previous report in Venezuela (ENCOVI, 2017) indicated even higher levels of food insecurity at 80% [6]. As a comparison, Yemen - a country facing civil war, famine, multiple diseases, and lack of essential services, termed the world’s worst humanitarian crisis by the United Nations - reported that 66% of the population suffered from hunger in 2020, with 30% experiencing severe food insecurity [20].

Food security in Venezuela faces multiple challenges across three dimensions. Firstly, a staggering 94% of Venezuelans lack sufficient income to afford a basic food basket, with costs and inflation reaching alarming levels [7]. For instance, in 2020, the cost of a family food basket (consisting of 60 essential consumer products) reached $176.9, while the minimum wage was only $3.20 per month. This meant that a family needed 55 minimum wage paychecks to afford a family food basket [21]. Recently, the situation has even further deteriorated, with the cost of the family food basket reaching $482.3 in March 2023, while the minimum wage increased to only $5.3 per month, necessitating three months’ worth of salary to cover a single day’s worth of family food expenses [22]. Not surprisingly, this study found that low SES participants had a 20% higher prevalence of food insecurity than those with high SES, highlighting the disproportionate impact of the economic and nutritional crisis on vulnerable low-income populations. Secondly, food availability has been reduced due to declining production. There was a 67% drop in imports between 2016 and 2017 [23] leading to a decreased intake of high biological value animal protein sources, minerals, and vitamins such as iron, calcium, zinc, vitamin A, vitamin C, and B-complex [7]. Dietary diversity in Venezuela is significantly lower than in other Latin American countries, with an average score of 2.3 out of 8 according to EVESCAM data from 2014 to 2017 [24], while other countries average 5–6 out of 9 [25]. Families in Venezuela restrict purchases to 5 to 7 products, consisting mainly of cereals that prioritize caloric intake and satiety over dietary diversity [7]. Thirdly, the lack of essential services including water, electricity, gas, and transportation further compromises the healthiness and quality of food, exacerbating the challenges with food insecurity. Nutritional deficiencies are exacerbated with food insecurity [26]. According to the Food and Agriculture Organization State of Food Security and Nutrition in the World report (2021) [27], undernutrition in Venezuela increased by 8.4% between 2004 and 2006 and 2018–2020 reaching 27.4% (7.8 million). To address this issue, the Venezuelan government implemented a food delivery program, the Local Supply and Production Committees (CLAP boxes, by its acronym in Spanish) for the most vulnerable individuals [23]. In 2017, 75% of households received CLAP boxes. Still, the distribution was inconsistent with 30% receiving them monthly, 16% bi-monthly, and 54% less frequently [23], which makes this program alone insufficient to meet the nutritional needs of entire families.

In this study, SLE (financial difficulties, accidents, family deaths, health issues, relationship breakdowns, and violence) affected the entire population irrespective of their sociodemographic characteristics. Financial difficulties emerged as the most prevalent SLE, impacting nearly a quarter of participants multiple times within the previous year. The Venezuelan crisis has been widely attributed to economic factors including mismanagement of oil resources and the national budget [28]. Within the span of a decade, Venezuela’s economic landscape has undergone a drastic transformation due to political instability and hyperinflation which led to a significant decline in the population’s purchasing power, an increase in poverty, and a limited ability for basic needs to be met [29]. Personal insecurity has been a significant stressor for Venezuelans in the past two decades. The initial increase in national income per capita since 2000 led to more equitable wealth distribution at the individual level but coincided with a rise in homicide rates and other crimes [30]. While adverse economics remains the main driver of the Venezuelan crisis, personal insecurity also contributed to the exodus of Venezuelans to other countries. A survey of 1,500 Venezuelan migrants in five Colombian cities in 2019 revealed that 26% cited personal insecurity as a reason for leaving the country [31]. Notably, 25% of participants in this study reported witnessing firearm or knife-related injuries within the past year.

Venezuela has experienced one of the largest migrations worldwide Over 7 million people have left the country [4], comparable with Syria (5.2 million) and Ukraine (6.3 million), which has significantly increased family separation. External displacement accounted for the majority, with 4.5 million refugees and asylum seekers, compared to 300,000 internally displaced individuals between 2010 and 2019 [32]. In 2017, 35% of households reported migration of their members [5]. In the present study, family separation reached almost 50%, aligning with reports that 73% of Venezuelan migrant families in Colombia had relatives remaining in Venezuela [33]. About 90% of the Venezuelan migrants were men aged between 15 and 59 years [34], coinciding with the finding of this study that participants ≥ 50 years old and women reported family separation more frequently than younger participants and men, respectively. The male proportion reported in successive evaluations of the EVESCAM cohort decreased from 47.8% (2014–2017) [14] to 28.2% (2018–2020), indicating greater migration among men. In fact, since 2017, the male: female ratio among migrants gradually increased to 1.32 in 2021 [34]. Afro-Venezuelans experienced a lower proportion of family separation compared to individuals of Mixed ethnicity, but the reasons behind this trend (e.g., cultural, economic, or migration pattern) remain unclear due to limited research on the ethnic composition of Venezuelan migrants. Ten percent of participants had school-age children in their households who were not attending school. Official data from the Venezuelan Ministry of Education confirm this, with approximately 850,000 students dropping out of school in 2019 [32]. The situation likely worsened due to COVID-19-related school closures. The negative impact of interrupted education was more pronounced among Amerindians, individuals from low SES, and less educated participants, which emphasizes that school disruptions disproportionately affect vulnerable populations.

Comparing crises across countries is complex because each context is distinct, driven by unique factors such as political instability, armed conflict, or natural disasters, which lead to specific consequences. Furthermore, the equilibrium between vulnerability and resilience varies among crisis-affected populations. Venezuela faces a complex humanitarian emergency arising from economic and political issues. This emergency manifests in widespread food insecurity, hyperinflation, fuel shortages, inadequate basic services like water, gas, and electricity, and a collapsed public healthcare system. Despite this individuality, Venezuela shares similarities with other countries such as Zimbabwe, Argentina, and Greece in economic aspects; with Belarus, Myanmar, and Syria in political aspects; and with Syria, Yemen, and South Sudan in humanitarian aspects as shortages of food and medicine, widespread poverty, and mass migration.

The implications of these findings for population health are significant. A review of cardiometabolic risk factors in Venezuela from 2000 to 2020, including the crisis period, indicates a decline in smoking and obesity but an increase in diabetes, prediabetes, hypertension, and metabolic syndrome [35]. These findings are associated with the cumulative effects of stress on the body, known as allostatic load, which is linked to adverse psychological and physiological health outcomes, including cardiovascular risk factors [36]. Lower SES is linked to higher levels of environmental stressors, physiological stress [37], and unhealthy behaviors such as tobacco use, excessive alcohol consumption, physical inactivity, and poor nutrition [38]. In Maracaibo, the second largest city in Venezuela, residents exposed to frequent electric shortages experienced elevated levels of anxiety, depression, boredom, and poor sleep quality [39]. Food insecurity is also associated with hypertension, coronary heart disease, cancer, and diabetes, contributing to an increased burden of chronic disease among vulnerable populations [40, 41].

The crisis also impacts the health system, leading to the inability to meet demand and provide quality services. Hospitals face reduced bed capacity, shortages in clinical laboratories and radiology services, and unreliable water and electricity supplies [42]. Similar effects of economic collapse on health infrastructure and population health can be observed in the former Soviet Union, Venezuela, and Zimbabwe, including impacts on the healthcare workforce, disproportionate effects on vulnerable populations, and the reemergence of certain infectious diseases [43]. According to EVESCAM data from 2014 to 2017, 67.4% of Venezuelans utilized public healthcare centers, while 21% used private centers (12.5% with insurance coverage and 8.5% paying out of pocket) [14] However, the proportion of out-of-pocket expenses likely increased due to the deterioration of public centers and significant remittances sent by Venezuelan migrants to their families, which amounted to $3.7 billion in 2019 [44].

The data obtained in this study are concerning and there is no evidence to suggest that the impact of the crisis on the vulnerable Venezuelan population has diminished in the past three years. Besides, economic indicators may not reflect improved living conditions or a reduced impact of the crisis on vulnerable populations [45]. To alleviate this situation, in 2019, the United Nations Office for the Coordination of Humanitarian Affairs requested a raise of $223 million from the international community to address urgent needs in health, water, sanitation and hygiene, food insecurity, nutrition, and housing for 7 million people in Venezuela [46]. The effectiveness of these interventions needs to be evaluated.

Limitations of this study include high loss to follow-up due to transportation and gasoline limitations, mass migration, and declining communication services -common challenges when conducting research in crisis contexts [9]. Around 10% of the loss to follow-up was due to participants migrating out of the country. The lack of data on the number of school-age children within each household complicates the interpretation of the education interruption indicator, as respondents may refer to the same children. The study did not include important crisis indicators such as infant mortality and sexual/gender-based violence. However, available data indicate a 1.4-fold increase in the infant mortality rate in Venezuela between 2008 and 2016 [47]. Methodologically, this study’s strengths lie in the follow-up of a national representative sample, as well as collecting essential domains recommended for detecting public health risk factors during a crisis, including population size and composition, food insecurity, nutritional status, physical and mental health, and service availability [9]. By identifying vulnerable populations, the results of this study can be used for advocacy and action, explicitly to design public health interventions in this crisis context.

Conclusion

This study provides the first national analysis of the humanitarian crisis in Venezuela, covering seven indicators of the complex crisis and their distributions over important subgroups. The findings offer valuable insights into vulnerable populations and can inform targeted interventions to address immediate and long-term challenges. Overcoming various barriers, such as deteriorating basic services, transportation and fuel shortages, migration, and communication decline, was crucial for conducting the EVESCAM follow-up. This study highlights the critical impoverishment, high food costs, and inadequate minimum wage that contribute to the Venezuelan crisis. The EVESCAM study provides invaluable information about a population in crisis, and ongoing analysis is examining changes in cardiometabolic health outcomes throughout the crisis and ways to efficiently intervene.