The prevalence of health challenges among widows is increasing due to the emotional distress resulting from the loss of their life partners. This distress is primarily driven by psychological factors, which serve as the main contributors to the health challenges they face. A combination of these factors, along with stressful life events such as the loss of a loved one, divorce, financial loss, and violent assault, can significantly increase the risk of suicidality among widows in low-and middle-income countries (LMICs) (Polanco-Roman et al., 2016). The loss of a spouse is a significant and distressing life event (Adena et al., 2023). Research indicates that the death of a spouse can have a detrimental impact on the health and wellbeing of widows, especially older ones (Golden et al., 2009) (Williams et al., 2012). Widowhood in old age is often associated with negative implications for health and well-being ((Agrawal & Arokiasamy, 2010);(Das, 2012); (Perkins et al., 2016)).

Widows often experience physical and emotional pain following the loss of their life partners, leading to the development of various health challenges (Das, 2012) (Golden et al., 2009) (Williams et al., 2012). In general, health challenges are defined as diseases, mental illnesses, or environmental conditions that pose risks to one's health. However, this review defines health challenges as a disease, medical ailment, or environmental condition that poses the risk of disease or medical problems. Chronic diseases such as heart disease, stroke, cancer, type 2 diabetes, obesity, and arthritis, as categorised by the Centres for Disease Control and Prevention (CDC), are common among widows (Centers for Disease Control and Prevention (CDC, 2016). The Centres for Medicare and Medicaid Services (CMMSs) also include a broader list of 19 chronic diseases, including Alzheimer's disease, depression, and Human Immunodeficiency Virus (HIV)/ Acquired immunodeficiency syndrome (AIDS) infection (Centers for Disease Control and Prevention (CDC, 2016). Additionally, mental health disorders, including depression, anxiety disorders, and addictive behaviours, significantly affect many widows (Jiang et al., 2023).

The leading cause of health challenges among widows is often psychological, as they face significant emotional distress following the loss of a spouse (Das, 2012) (Golden et al., 2009) (Williams et al., 2012). Psychological factors such as grief, depression, anxiety, and social isolation can severely impact their mental health as the primary health challenge faced by the majority of widows worldwide ((Avison et al., 2007); (Zheng & Yan, 2024)). The stress of widowhood can lead to a range of mental issues, such as anxiety, anger, depression, irritability, and memory loss ((Avison et al., 2007); (Zheng & Yan, 2024)). Research by (Cheng et al., 2014) indicates that the absence of children is closely linked to depression among widows. It is also reported that health challenges experienced by widows can be attributed to various psychological factors, including exposure to neglect, sexual abuse, violence, and isolation ((Agrawal & Arokiasamy, 2010); (Kansra & Khadar, 2023)). Additionally, role transition, financial stress, and cultural stigmas contribute to their psychological burden, leading to further health complications. In certain cultures, widows are often seen as belonging to their late husband's family, which can lead to them being perceived as a burden by family members (Das, 2012). Also, psychological factors such as physical and mental health (Nseir & Larkey, 2013), as well as poverty ((Lloyd-Sherlock et al., 2015); (Tshaka et al., 2023)), are associated with the outcomes of health challenges facing widows worldwide.

As in other parts of the world, widows in LMICs encounter various challenges such as limited health care access, property rights issues, lack of social support, and harmful traditional practices, all of which can impact their well-being in multiple ways ((Lloyd-Sherlock et al., 2015)). According to the World Bank classification, these countries have a GNI per capita falling between $1,136 and $4,465, according to the data for 2022. The issues of healthcare, employment creation, and income inequality are prevalent in these countries ((Hamadeh & Rompaey, 2023)). Cultural beliefs, legal obstacles, resource limitations, lack of awareness, and the complex interaction of these factors make it challenging to provide effective interventions for widows (Das, 2012) (Holm et al., 2019). The interplay of these psychological factors not only affects their emotional well-being but also has tangible effects on their physical health, underscoring the critical need for supportive interventions that address both mental and physical health in this vulnerable population. To address these challenges, providing coping mechanisms such as family and friend support can play a crucial role in reducing feelings of loneliness among widows (Vries et al., 2014). In light of these challenges, it is essential to explore empirical studies conducted in LMICs to identify the various health challenges affecting widows, particularly those related to psychological factors that contribute to these health issues. Understanding these factors can help develop targeted interventions and support systems to address the unique needs of widows in these contexts.

Therefore, the primary gap in the existing review on the health challenges widows in LMICs face lies in the insufficient exploration of the specific psychological factors contributing to these health challenges. While previous studies have acknowledged the importance of grief and loss, they often fail to comprehensively address how interconnected psychological factors such as depression, anxiety, social isolation, role transition, financial stress, and cultural stigmas collectively influence both mental and physical health outcomes among widows.

This review distinguishes itself from previous studies by taking a holistic approach to understanding the psychological landscape of widowhood. Therefore, instead of focusing solely on individual factors, it aims to examine the interplay between multiple psychological dimensions and their cumulative impact on health challenges. Additionally, this study emphasises the context of LMICs, where cultural, social, and economic factors uniquely shape the experiences of widows. By integrating retrieved research studies, this review provided a more nuanced perspective on how these psychological factors contribute to health challenges among widows, ultimately informing targeted interventions that address their specific needs. This comprehensive understanding is essential for improving this vulnerable population's support systems and health outcomes.

The eligibility criteria for this review encompass research articles published in English-language peer-reviewed journals from 2012 to 2024, specifically including crosssectional, cohort, and qualitative studies. The keywords employed include widow, widowhood, psychological factors, health challenges, and chronic diseases. Excluded from consideration are conference papers, proceedings, editorial reviews, letters of communication, commentaries, systematic reviews, and randomised trial studies. Additionally, research articles published prior to 2011 or after 2024 and those published in languages other than English were not included in the selection process. A systematic review was conducted to investigate the existing evidence regarding the health challenges faced by widows in LMICs (Moher et al., 2009).

The search strategy utilised the following search terms: widow OR "widowhood" AND health OR "health challenge*" AND LMICs*. Boolean operators enhanced the search, accounting for plurals, database variations, and spelling (AND/OR). The identified key terms were then entered into CADIMA (Collaboration for the Development of the Internet-based Methodology for Systematic Reviews) for screening purposes (Kohl et al., 2018). This platform assisted in systematically evaluating the relevant literature, ensuring a thorough and organised review process (Kohl et al., 2018).

Electronic searches were conducted across various databases, including Web of Science (WoS) (8,152), Scopus (8,286), PubMed (774), Taylor and Francis [LRTF] (84,477), and Google Scholar (200) for the period spanning January 2024 to June 2024. The last search was conducted on December 6, 2024. A total of 101,889 research articles were retrieved and assessed for eligibility, including 16 research articles. The selection procedures adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (Figure 1) guidelines (Moher et al., 2009). The primary author (NFM) extracted the data and conducted multiple extract reviews to identify relevant descriptions of the health challenges facing widows in low- and middle-income countries (LMICs). Themes were identified through inductive coding. NFM synthesised the extracted data, and the second author (PN) reviewed the initial synthesis, leading to a consensus on the themes reached by both authors.

The primary author (NFM) extracted the data and conducted multiple extract reviews to identify relevant descriptions of the health challenges facing widows in low- and middle-income countries (LMICs). Themes were identified through inductive coding. NFM synthesised the extracted data, and the second author (PN) reviewed the initial synthesis, leading to a consensus on the themes reached by both authors. Data addressing similar issues were categorised and grouped until the themes were clearly described. Crafting suitable formulations proved time-consuming due to the similarities within the data (Sandelowski, 2010). Table 1 provides the characteristics of selected studies.

Quality Assessment

The studies selected for this review were evaluated following the Critical Appraisal Skills Programme (C.A.S.P., 2014). CASP is a widely used framework that assists researchers and practitioners in critically assessing the quality of research studies, particularly in health and social care. It provides tailored checklists for various study types, including qualitative research, cross-sectional studies, cohort studies, randomised controlled trials, and systematic reviews (Kolaski et al., 2023). Table 2 presents the assessment conducted on the selected studies using CASP, outlining the quality evaluation for each study and highlighting key aspects such as methodological rigor, clarity of aims, appropriateness of study design, and data analysis. The CASP assessment ensures that the included studies meet high research quality standards, thereby enhancing the validity and reliability of the review findings.

Studies characteristics

Five studies were identified as cross-sectional, three as qualitative, and seven as randomised controlled trials (Table 1). The cross-sectional studies included data collected from 2004 to 2024; however, two articles did not specify when the baseline interviews were conducted (Table 1). Most of these cross-sectional studies utilised self-report questionnaires (Table 1), yet they failed to address how self-reported data might have introduced response bias (Polit & Beck, 2012). Additionally, the design descriptions of many cross-sectional studies were unclear, with five studies lacking a clear focus, potentially leading to exposure and outcome bias.

The review also included cohort studies, which, as noted by Schneider et al. (2007), are generally prospective and use an epidemiological approach to examine the relationship between exposure and outcomes. Cohort studies collect data at two or more time points over an extended period (Polit & Beck, 2012). The long duration of data collection was highlighted in two articles, posing disadvantages related to the costs of time, effort, and resources. Internal validity concerns were raised, including issues of "testing," "mortality" (loss to follow-up), and the influence of confounding variables. Social desirability bias may occur when respondents provide answers they believe align with researchers' expectations. Four cohort studies reported small sample sizes (Table 3), which can increase bias, and two studies did not adequately address strategies to minimise bias ((Agrawal & Arokiasamy, 2010); (Burns et al., 2015)). Conversely, four cohort studies identified critical confounding factors in their design or analysis (Table 1). Descriptions of validity and reliability were present in six cohort studies (Table 1), while one cohort study did not mention generalisation or external validity, constituting a limitation.

Three qualitative studies analysed their data thematically, while one utilised MAXQDA software. The studies were conducted in various countries within LMICs, including India (n=1), Switzerland (n=1), Nigeria (n=5), Benin (n=1), China (n=2), South Africa (n=1), Pakistan (n=1), Iran (n=1), Ethiopia (n=1), Zimbabwe (n=1), and Malawi (n=1). Most of the studies adhered to Braun and Clarke's (2021) six-phase framework. The initial step involves immersing oneself in the data through repeated readings to achieve familiarity. This is followed by the generation of initial codes based on identified meaningful segments. The third phase involves searching for themes by grouping related codes. In the fourth phase, themes are refined to ensure they accurately reflect the data. Each theme is then clearly defined and named, elucidating its scope and relevance. Finally, a coherent narrative is crafted, integrating the themes with the research questions and existing literature. This approach ensures a rigorous, transparent, and interpretive analysis of qualitative data.

The main health challenges and contributing psychological factors affecting widows in LMICs included mental health (i.e., depression, anxiety and post-traumatic stress disorder) and physical health problems such as poor eyesight, arthritis, rheumatism, high blood pressure, diabetes, malaria, typhoid, cough, ulcer, osteoarthritis, chronic headache, and chronic diseases. Prolonged grief and ambiguous loss are significant psychological factors that critically impact widows. Additionally, social isolation is a prominent psychological issue highlighted in this review. The multitude of health challenges faced by widows imposes a considerable burden on both the individuals themselves and their families. It is crucial that we address these issues effectively to alleviate this strain. Table 5 presents findings, including primary health challenges and factors contributing to these challenges.

Health challenges affecting widows

The thematic analysis of the data revealed several key findings regarding the health challenges and contributing psychological factors affecting widows in LMICs. The main health challenges retrieved in this review were divided into two major themes: mental health challenges such as depression, anxiety, and PTSD (Agboeze et al., 2020)(Agrawal & Keshri, 2014)(Akpalaba et al., 2021)(Myroniuk, 2016)(Zhou & Hearst, 2016) The second theme is physical health problems, including chronic diseases and malnutrition (Agboeze et al., 2020)(Agrawal & Keshri, 2014)(Akpalaba et al., 2021)(Myroniuk, 2016)(Zhou & Hearst, 2016).

Reviewed studies revealed that widows commonly experienced mental health diseases, including stress, post-traumatic stress disorder (PTSD), and depression (Busari & Folaranmi, 2014)(Ezeh, 2022)(Li et al., 2022)(Olawa et al., 2021)(Spahni et al., 2015). Anxiety is the most potent of all the psychological variables constituting widows' stress (Busari & Folaranmi, 2014). (Busari & Folaranmi, 2014) found that frustration, anger, memory, and anxiety independently contributed to widows' stress. (Ezeh, 2022) added that widows are associated with psychological distress, with heightened anxiety and depression. (Li et al., 2022)suggested that widowhood directly influenced depression, regardless of coping styles and perceptions of aging. (Spahni et al., 2015) emphasised that older widows often experienced psychological adjustments, including depression, hopelessness, loneliness, changes in life satisfaction, and perceptions of subjective health following the loss of their spouses.

On the other hand, physical health problems, including poor eyesight, arthritis, rheumatism, high blood pressure, diabetes, malaria, typhoid, cough, ulcer, osteoarthritis, chronic headache, and chronic diseases were identified among widows in LMICs (Agboeze et al., 2020)(Agrawal & Keshri, 2014)(Akpalaba et al., 2021)(Myroniuk, 2016)(Zhou & Hearst, 2016). ( 2021) emphasised that widows in the Nsukka local government of Enugu state faced challenges such as high blood pressure levels at 160.2/100.4 and blood sugar levels at 129.8 Mg/dl. On top of that, many were diagnosed with typhoid and malaria parasites (Agboeze et al., 2020). (Akpalaba et al., 2021) identified six ear, nose, and throat (ENT) diseases, namely cerumen auris, left cerumen auris, otitis externa, otitis media, otitis media with effusion, otomycosis, and pharyngeal trauma, and twelve medical conditions: allergy, chronic headache, chronic ulcer, diabetes mellitus, insomnia, malaria, osteoarthritis, uncontrolled hypertension, and upper respiratory tract infection. (Akpalaba et al., 2021) also found high blood pressure levels of 180/110 mmHg and 250/100 mmHg in two widows. This result can lead to a cardiovascular accident (CVA), popularly called 'stroke', which can also cause sudden death through cardiac arrest (Akpalaba et al., 2021). (Agrawal & Keshri, 2014) highlighted types of chronic diseases such as diarrhoea, gastritis/gastric or peptic ulcer, whooping cough, skin diseases, kidney/ urinary system, tuberculosis, bronchial asthma, hypertension, mellitus diabetes, mental disorders, and eye diseases among older widows. (Agrawal & Keshri, 2014) revealed that the prevalence of communicable diseases was lower among young widows than older widows. (Agrawal & Keshri, 2014) also noted that non-communicable diseases increased significantly with age, as with other diseases. (Zhou & Hearst, 2016) noted that mental illness and chronic diseases were common among widows, with widowers experiencing a decline in physical health after the age of 70. (Myroniuk, 2016) highlighted that widows are at a higher risk of poor health and HIV/AIDS infection. (Ezeh, 2022) discovered a correlation between PTSD in widows and various factors, including partner intimacy, cause of death, and number of surviving children. Additionally, the age of the first child was positively associated with the duration of widowhood, while the age of the last child is positively related to the duration of widowhood (Ezeh, 2022)).

Factors contributing to health challenges among widows

The psychological factors influencing the health and well-being of widows in LMICs are critical in understanding their overall experiences. The current review identified various themes as follows.

The thematic analysis revealed significant health challenges and contributing psychological factors affecting widows in LMICs. Prolonged grief and ambiguous loss were identified as key psychological factors among widows (Busari & Folaranmi, 2014)(Ezeh, 2022)(Kalantari et al., 2023)(Olawa et al., 2021)(Spahni et al., 2015)(Tshaka et al., 2023). The transition to widowhood introduces numerous health challenges, primarily stemming from prolonged grief following the loss of a spouse (Busari & Folaranmi, 2014)(Ezeh, 2022). It was also reported that widows who lost their spouses during the COVID-19 pandemic faced unique challenges due to the absence of traditional mourning ceremonies, compelling them to create their definitions and perceptions of grief (Kalantari et al., 2023). (Tshaka et al., 2023) noted that widows in RMLM experience profound grief and spend considerable time grappling with the emotional and psychological toll of their loss. (Spahni et al., 2015) identified patterns of psychological adaptation to spousal loss in old age. They shed light on the role of intra-and interpersonal resources and contextual factors as discriminant variables in these patterns. On the other hand, (Olawa et al., 2021) highlighted that spousal loss is ambiguous among elderly widows, especially when they are not compensated and supported by the government and nongovernmental organisations, and family and religious organisations.

The current review identified depression and anxiety as significant psychological factors affecting widows in LMICs. Many widows experience elevated levels of these conditions following the loss of their spouses, with social isolation and economic instability often exacerbating their emotional distress (Agboeze et al., 2020)(Ezeh, 2022)(Li et al., 2022)(Oumer et al., 2024). Half of the study participants exhibited depressive symptoms, highlighting the urgent need for interventions to enhance psychological well-being and address various modifiable risk factors associated with depression in elderly individuals (Oumer et al., 2024). Also, (Li et al., 2022) highlighted that widowhood had a direct and positive influence on depression, regardless of coping styles and perceptions of aging. The same study also indicated that psychological factors played a role in the relationship between widowhood and depression (Li et al., 2022). (Agboeze et al., 2020) added that widowhood had a direct and positive influence on depression, regardless of coping styles and perceptions of aging. Moreover, being widowed was found to be connected to feelings of loneliness in both men and women, with a stronger association observed in men. Social engagement was positively associated with family and nonfamily support in men and women, but it was negatively linked to loneliness, specifically in women (Olawa et al., 2021).

Social isolation is another psychological factor highlighted in this review (Dube, 2022) (Ebulum et al., 2024) (Olawa et al., 2021) (Shafiq et al., 2024). (Shafiq et al., 2024) shared the importance of social assistance for widows, which cannot be overstated, as inadequate support is associated with increased isolation. Many widows actively seek friendships to combat social isolation, and they often express their feelings of depression and the struggle to survive (Shafiq et al., 2024). Moreover, being widowed was found to be connected to feelings of loneliness in both men and women, with a stronger association observed in men. Social engagement was positively associated with both family and nonfamily support in men and women, but it was negatively linked to loneliness, specifically in women (Olawa et al., 2021). (Ebulum et al., 2024) highlighted that widows experienced a lack of social support, which most of the time reduced their sense of belongingness and increased social isolation, hence exposing them to a greater risk of suicide. Stress was also a significant positive predictor of suicidal isolation (Olawa et al., 2021). (Dube, 2022) added that the chronological age of widows is significant as it influences their ability to cope with the stress associated with widowhood, isolation, and restricted mobility. Both young and older widows are susceptible to feelings of isolation, indicating that their challenges are not age-specific (Dube, 2022). Younger widows may struggle with societal expectations and the burden of raising children alone, while older widows may experience increased physical limitations and social withdrawal (Dube, 2022). Another psychological factor identified by this study is financial instability. Losing a partner often meant a significant reduction in household income, leading to economic challenges (Agboeze et al., 2020) (Akpalaba et al., 2021) (Dube, 2022) (Li et al., 2022) (Myroniuk, 2016) (Shafiq et al., 2024) (Tshaka et al., 2023). Many widows reported struggles with basic needs such as healthcare, housing, and food. (Dube, 2022) added that the number of children, lack of education, and financial instability following the death of their spouses contribute significantly to the isolation experienced by widows.

On the other hand, (Shafiq et al., 2024) highlighted that a widow faces new challenges daily. However, opportunities are also available, such as financial assistance and skill development programs offered by government institutions and the private sector. (Tshaka et al., 2023) added that financial instability is significant, as many widows lack support and are often unemployed, leading to a precarious economic situation. (Dube, 2022) also insisted that the death of spouses often spells room for the economic resources of widows in low-resourced communities, in which many widows find themselves unable to access these resources, as they are frequently sidelined by in-laws who seize control of the assets. This exclusion not only undermines their financial stability but also perpetuates their vulnerability within the community, making it increasingly difficult for them to rebuild their lives, therefore, addressing these injustices is crucial to ensuring that widows can reclaim their economic rights and secure a better future for themselves and their families (Dube, 2022). In addition, widows were more likely to receive family support, particularly among women, whereas there was no significant relationship between widowhood and nonfamily support for either gender (Li et al., 2022).

Managing the various health challenges affecting widows places a significant burden on both the individuals and their families (Akpalaba et al., 2021). Many young families were experiencing substantial stress in providing for their households, and the responsibility of caring for elderly widows only serves to intensify this strain (Akpalaba et al., 2021). Triadically, in line with this concerning trend, elderly widows often find themselves abandoned and neglected by their children, relatives, community, and society at large (Akpalaba et al., 2021). There is also a need for healthcare services that are identified as a psychological factor in this review (Busari & Folaranmi, 2014)(Oumer et al., 2024). (Oumer et al., 2024) added that policymakers and stakeholders should prioritise improving access to mental health services to support this vulnerable population, while widows (Busari & Folaranmi, 2014) highlighted several challenges that widows in LMICs are facing, including poor nutrition, inadequate shelter, lack of access to health care, and vulnerability to violence. Additionally, living conditions and environmental factors, such as residing in swampy areas, further contribute to the deteriorating health of widows (Busari & Folaranmi, 2014). Moreover, widows face an increased risk of becoming inactive, isolating themselves from various community development initiatives (Agboeze et al., 2020).

Morbidity prevalence was higher among older widows aged 70+ (49%) compared to those aged below 70 (31%). The prevalence of morbidity also increased with higher per capita expenditure percentile classes, with 43% of older widows in the highest expenditure class affected (Agrawal & Keshri, 2014). (Spahni et al., 2015) highlighted that factors such as the duration of marriage, spousal support, emotional impact of loss, trait resilience, and other in the literature (e.g., education, marital happiness) are associated with health challenges experienced by widows. Furthermore, considering various dimensions of well-being simultaneously can provide insights into how spousal loss affects an individual's response to this significant life event (Spahni et al., 2015). On the other hand, (Myroniuk, 2016) reported that widows who were forced to remarry were more susceptible to diseases, including HIV and STDs. Lifestyle, behavioural, and environmental factors have been identified as significant contributors to health challenges among older widows (Agrawal & Keshri, 2014). The fear of contracting or transmitting HIV was a common concern expressed by widows in discussions about widow cleansing and inheritance practices (Myroniuk, 2016). Many widows interviewed in both semi-structured interviews and focus group discussions voiced worries about the potential spread of HIV within the community through unprotected sexual activity with inheritors (Agrawal & Keshri, 2014)(Myroniuk, 2016). It is also added that engaging in sexual relations without using a condom with a new partner increases the risk of exposure to HIV, not only for the widows but also for their other long-term partners, such as spouses and fellow widows (Myroniuk, 2016). Rituals performed during mourning, such as cleansing, may lead to diseases among widows, attributed to the stimulation of the brain to produce more earwax, known as cerumen (Akpalaba et al., 2021). (Zhou & Hearst, 2016) noted that widows living with children were particularly vulnerable to mental illness and chronic diseases. (Busari & Folaranmi, 2014) highlighted widows' lack of legal rights as contributing to their challenges. Many widows were unaware of their rights and faced significant barriers to accessing justice systems, such as illiteracy, financial constraints, and the threat of violence. (Busari & Folaranmi, 2014) also mentioned that widows may be at risk of experiencing rape.

This systematic review includes findings from sixteen studies conducted in various LMICs. Two main themes were identified (Table 4): health challenges affecting widows and factors contributing to health challenges among widows. This review is constrained by limitations related to the quality of included studies (Table 1), as many of them have small sample sizes (Table 1) and lack detailed information on methodological characteristics (Table 1). It is crucial to acknowledge that different cultures can significantly influence well-being, which appears to be overlooked in countries like India and China, where factors contributing to health challenges among widows seem to be more emotional and psychological. These cultural variations can pose challenges when comparing studies from diverse regions. In these countries, poor socio-economic status is believed to increase health challenges among widows ((Agrawal & Keshri, 2014); (Halleröd & Gustafsson, 2011)). Comparatively, in African countries such as Benin, Nigeria, and Malawi, factors like poverty, loneliness, and abandonment by late husbands' families were linked to health challenges among widows.

Numerous research studies have illuminated both mental and physical health challenges faced by widows, such as poor eyesight, arthritis, rheumatism, high blood pressure, diabetes, malaria, typhoid, cough, ulcers, osteoarthritis, chronic headaches, and chronic diseases ((Agboeze et al., 2020); (Agrawal & Keshri, 2014); (Akpalaba et al., 2021); (Zhou & Hearst, 2016)). High blood pressure emerged as a prevalent health concern in the findings among the reviewed papers ((Agboeze et al., 2020); (Agrawal & Keshri, 2014); (Akpalaba et al., 2021)). (Perkins et al., 2016) observed a high incidence of high blood pressure among widows, particularly those who had recently lost their spouses. Widowhood has been connected to the development and severity of coronary artery disease (Daoulah et al., 2017), as well as a spectrum of significant cardiovascular events (Carey et al., 2014). This increased risk could be linked to the stress associated with bereavement, funeral arrangements, and emotional challenges that often accompany widowhood (Perkins et al., 2016). Furthermore, widowhood has been shown to significantly elevate mortality rates across various population groups, even many years after the loss of a spouse (Carr & Bodnar-Deren, 2009).

Furthermore, mental health challenges are prevalent among widows, with stress, anxiety, mental illness, depression, PTSD, and complicated grief being commonly reported in studies (Busari & Folaranmi, 2014)(Ezeh, 2022)(Li et al., 2022)(Myroniuk, 2016)(Olawa et al., 2021). (Li et al., 2022) highlighted the direct and significant impact of widowhood on depression, irrespective of coping mechanisms and perceptions of aging. Depression and anxiety are illustrated by the descriptions of the emotional pain and suffering that constitute the state of widowhood (Holm et al., 2019). Other results have shown that a considerable number of widows meet the criteria for depression and/or complicated grief disorder, emphasising the emotional toll of widowhood (Burns et al., 2015)(DiGiacomo et al., 2013)(Panagiotopoulos et al., 2013).

The current review identified eight key themes based on psychological factors affecting widows, which contribute to various health challenges. Widows often experience emotional pain associated with the loss of a partner, leading to prolonged grief responses that can impair daily functioning and mental health. (Szuhany et al., 2021) supported the idea that losing a loved one is one of life's greatest stressors. While most bereaved individuals experience a period of intense acute grief that gradually diminishes over time, approximately 10% will go on to develop a prolonged grief condition. This prolonged grief can hinder emotional recovery and significantly affect daily functioning, mental health, and overall well-being (Szuhany et al., 2021). Again, emotional turmoil may also involve ambiguous loss, particularly in cases of sudden death or when the partner suffers from a prolonged illness, complicating the grieving process (Keyes et al., 2014). Early in the 20th century, Freud proposed that grief can resemble conditions such as depression, anxiety, and post-traumatic stress (Gillies & Neimeyer, 2006). Research has shown that bereavement and grief share characteristics, including distress and depressive symptoms, which significantly impact overall health (Jacobsen et al., 2010).

The current review highlights that depression and anxiety are among the psychological factors experienced by widows following the death of their spouse, with these conditions often exacerbated by social isolation and economic instability. The same results were observed in studies (Das, 2012)(Perkins et al., 2016)(Trivedi et al., 2009). (Trivedi et al., 2009) highlighted that older widows appeared to be a significant risk factor for the development of depression symptoms. In addition, it turned out that higher education is a significant protective factor against the development of symptoms of depression (Trivedi et al., 2009). In the early 20th century, Freud suggested that grief might resemble depression, anxiety, and posttraumatic stress (Gillies & Neimeyer, 2006). Bereavement and grief share characteristics such as distress and depression that affect health (Jacobsen et al., 2010). Studies have also indicated that widows often experience physical symptoms like lack of energy, reduced appetite, weight loss, disrupted sleep patterns, and pain (Sekgobela et al., 2020). These psychological challenges can severely impact their overall well-being and quality of life, highlighting the need for targeted support and interventions (Keyes et al., 2014). Social isolation is a significant psychological factor affecting widows in LMICs identified in this review. The death of a partner frequently leads to a reduction in social support systems, which can result in profound feelings of loneliness and abandonment. As widows navigate their grief, they may withdraw from social interactions, either due to emotional pain or perceived stigma associated with widowhood. This isolation not only exacerbates their emotional distress but also hinders their ability to seek help and support from others. Consequently, the lack of social connections can lead to increased vulnerability to mental health issues, highlighting the need for interventions that foster community engagement and support networks for widows in these contexts. However, (Freak-Poli et al., 2022) add that loneliness is a greater challenge of widowhood than social isolation or a lack of social support. They proposed alternative strategies, such as helping the of identity and screening for loneliness around widowhood by healthcare workers, which could be beneficial (Freak-Poli et al., 2022). There are strong beliefs that a widowed person should be isolated because she is thought to carry the spirit of the deceased. cultural beliefs reinforce the social isolation of widows, which can significantly detract from their psychological well-being (Remillard et al., 2022). This enforced separation not only exacerbates feelings of loneliness but also hinders their ability to seek support from their communities, ultimately leading to increased mental health challenges.

Addressing and challenging these beliefs is essential for improving widows' social integration and well-being. Another psychological factor identified by this review is financial instability (Ryu & Fan, 2023). Losing a partner often meant a significant reduction in household income, leading to economic challenges (Ross & Gale, 2021). Many widows reported struggles with basic needs such as healthcare, housing, and food. Many widows took on additional caregiving responsibilities for children or elderly relatives, which added stress and limited their ability to care for themselves (Kansra & Khadar, 2023). Access to health care services was also highlighted as one of the psychological factors in this review. Economic constraints, transportation issues, and cultural norms often hindered widows' access to necessary healthcare services. Many reported difficulty obtaining medical care and medications (Cochran et al., 2022). (Syed et al., 2013) highlighted that transportation barriers create significant obstacles to accessing healthcare, often resulting in delayed and missed appointments and inconsistent medication use. These challenges can severely impact individuals' overall health and well-being, particularly for vulnerable populations facing numerous hurdles in seeking medical care. Addressing transportation issues is essential to improve access to healthcare services and ensure patients receive timely and effective treatment (Syed et al., 2013).

The current review also noted that certain rituals commonly performed by widows during mourning could potentially contribute to their health challenges (Akpalaba et al., 2021). Rituals associated with bereavement, like makgoma observed among the Northern Sotho people of South Africa, also pose health challenges for widows who do not undergo proper cleansing rituals after the death of a family member (Makgahlela & Sodi, 2016). Thus, cultural beliefs surrounding makgoma may lead to symptoms resembling meningitis, further complicating the health and well-being of widows within these communities (Makgahlela & Sodi, 2016).

This review highlights the significant health challenges faced by widows in LMICs, with a particular focus on the psychological factors that contribute to their well-being. The analysis revealed that widows often experience a range of mental health issues, including depression, anxiety, and prolonged grief, exacerbated by social isolation and financial instability. Financial instability emerged as a critical psychological factor, leading to heightened stress and anxiety, which further impacted their overall health. The interplay between economic challenges, social support networks, and psychological well-being underscores the complexity of the issues faced by widows. To address these challenges, it is essential to develop targeted interventions that provide financial support and enhance mental health resources and social integration. Community-based programs that foster resilience and empower widows can significantly improve their quality of life. Future research should continue to explore the diverse experiences of widows in different cultural contexts, focusing on effective strategies to mitigate the psychological and health challenges they face. By understanding and addressing these factors, we can better support support widows and promote their overall well- being in LMICs.

To effectively support widows in LMICs, it is crucial to implement comprehensive interventions that address their mental health, economic stability, and social integration. Mental health services should be made accessible and tailored to the unique needs of widows, providing counselling and support to address issues such as depression and anxiety. Financial assistance programs, job training, and income-generating activities can alleviate economic pressures and empower widows to regain control of their lives. Additionally, community engagement initiatives that foster social connections and combat isolation should be prioritised, creating supportive networks for widows. Policymakers must advocate for the rights and well-being of widows, addressing cultural stigmas and ensuring access to healthcare and social services. Future research should focus on evaluating the effectiveness of these interventions and exploring innovative approaches to improve the quality of life for widows across diverse cultural contexts.