Impact of COVID-19 Pandemic on Mental Health among the Population in Jordan

Background: Mental health is a key indicator for public health measures. Jordan is one of the countries that has a high prevalence of mental illness and disorders. The COVID-19 pandemic has affected all health services in the country with a high refugee population. The aim of this review is to assess the impact of the pandemic on mental health in Jordan and identify key factors affecting it, in addition to addressing lessons learned from the pandemic. Methods: A systematic search was conducted on Medline Plus, Embase, Web of Science, EBSCOHost Psycinfo and Cinhal, following the PRISMA guidelines. Articles were selected based on predefined inclusion and exclusion criteria. Data were extracted and synthesized using narrative descriptive analysis. Results: The pandemic had a significant impact on PTSD, psychological distress, anxiety, depression and stress. Predictors of a higher impact on mental health were related to gender, socio-economic status and comorbidities. The healthcare workers group was the most affected by mental disorders. Conclusions: The COVID-19 pandemic’s impact on mental health was associated with high levels of PTSD, anxiety, depression and stress. In a country with a high prevalence of mental disorders, prompt and quick measures are needed to support the health system to absorb the effect of the pandemic and be responsive to dealing with the existing high prevalence.


Introduction
Mental health is a key indicator for public health measures in any country. The global burden of mental disorders and illnesses has been increasing proportionally and is estimated to have increased by 48.1% from 1990 to 2019 [1]. Health systems in all countries are facing challenges to address this mental disorder burden. Despite this, mental health services are not prioritized and are given the least support from policy makers [2].
Jordan has a high prevalence of mental disorders, around 26.1%, putting the country on the higher end of the world range, which is between 5.0% to 27.0% [3]. The country is still in the early phase of service provision for this. In 2010, the World Health Organization (WHO) selected Jordan as one of six countries to pilot the implementation of the mental health gap action program; a program that supports and enables countries to strengthen their mental health services [4].
It is also known that Jordan hosts around 3 million refugees from neighboring countries due to conflicts and wars. Around 600,000 refugees have entered Jordan since the beginning of the Syrian conflict in 2011, resulting in the second largest refugee camp in the world [5]. This has put a huge strain on the health system and elevated the burden of mental health disorders, as it is well recognized that such a burden increases within post-emergency response areas and their displaced population [6].
The COVID-19 pandemic reached the entire world by 2021, making it the worst health crisis that humans have faced in recent history, especially in terms of mental health [7]. Jordan took stringent measures to combat the pandemic, and the population faced total HCWs. This inclusion ensured a comprehensive outcome of the effect of the pandemic on the whole population. (2) All types of study designs were included. (3) The review included all articles since the beginning of the pandemic, i.e., from March 2020 to May 2022, the date of the final search.
This research excluded the following: (1) any article that did not include only Jordan or a specific sample for Jordan; (2) literature review articles; (3) Arabic language articles. This bias of language choice did not affect the final research outcomes since health research publishing and education in Jordan is in the English language [19].

Screening
Rayyan.ai software was used for screening as it is considered an application of significance and supports the process of data management during the systematic review process [20]. During the first phase of screening, duplicates were removed. The remaining articles were then screened on the basis of the title and abstract. The full-text articles of the remaining records were then uploaded on Rayyan. A final screening for the remaining fulltext articles was conducted rigorously to ensure compliance with the review key elements, inclusion and exclusion criteria.
Both phases of screening were conducted by two independent reviewers (GS and RK), and a third reviewer (DM) resolved any conflicting decisions to ensure proper selection of eligible studies and non-selection bias [21].

Data Extraction
A data extraction form was created and included the following data: (1) title, (2) lead author and year of publication, (3) population group, (4) study design, (5) sample size, (6) sample characteristics, (7) assessment tools, (8) outcomes and (9) prevalence of symptoms of depression/anxiety/post-traumatic stress disorder (PTSD)/psychological distress/stress. Key elements of the data extracted included the following: (1) the population group to be able to categorise the different studies per the population groups in Jordan, (2) the assessment tools used to determine the prevalence of mental disorders and (3) the prevalence of symptoms of depression/anxiety/ PTSD/psychological distress/stress.

Quality Appraisal
The Critical Appraisal Skill Program (CASP) tool was chosen for randomized clinical trials (RCT). For cross-sectional (CS) studies, the AXIS tool was used. A final analysis was created, and the scores were recorded. All studies on mental health in Jordan eligible in this review were included, with no exclusion after appraisal.

Data Synthesis
The narrative descriptive analysis method was chosen for data analysis. In order to exclude any bias, a well-informed and structured process of analysis was performed using the guidelines from the Cochrane consumers and communication review group on data synthesis and analysis [22].

Search Results
In total, 260 publications were identified from searching the databases (Figure 1). Out of the 260, n = 106 publications were initially removed due to duplication. The remaining n = 154 publications were screened on a title and abstract basis. Ninety-five publications were excluded after the title and abstract screening. The agreement rate in the title and abstract phase screening between the first and second reviewer was 86%. Then, the third reviewer (DM) resolved the conflict, resulting in a final agreement of 59 records. The remaining articles were assessed for eligibility based on full-text screening.
Out of the 59 publications, n = 26 was excluded according to the exclusion criteria. Publications removed were as follows: n = 15 were excluded for studying different outcomes and results. Nine publications (n = 9) were excluded for having a different population group than Jordan. Two publications (n = 2) were removed due to non-retrieval. One publication (n = 1) was removed for being a review paper. One publication (n = 1) was removed for being a commentary paper. The overall agreement rate for the full-text screening phase between the first and second reviewer was 80% before the final conflicts were resolved by the third reviewer, resulting in 95% agreement. abstract phase screening between the first and second reviewer was 86%. Then, the third reviewer (DM) resolved the conflict, resulting in a final agreement of 59 records. The remaining articles were assessed for eligibility based on full-text screening.

Figure 1.
Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) study selection flow diagram [18].
Out of the 59 publications, n = 26 was excluded according to the exclusion criteria. Publications removed were as follows: n = 15 were excluded for studying different outcomes and results. Nine publications (n = 9) were excluded for having a different population group than Jordan. Two publications (n = 2) were removed due to non-retrieval. One publication (n = 1) was removed for being a review paper. One publication (n = 1) was removed for being a commentary paper. The overall agreement rate for the full-text screening phase between the first and second reviewer was 80% before the final conflicts were resolved by the third reviewer, resulting in 95% agreement. Table 1 summarises the extracted study characteristics. The sample size of the 31 studies ranged from 26 to 6157 participants, with a total of 42,357 participants. A variety of population groups was studied, including (1) refugees and vulnerable communities (one RCT study and the other CS) with a total of 3721 participants; (2) university students with seven CS studies and a total of 12,750 participants, and one CS study with 382 university teachers; (3) HCWs with five CS studies and a total of 3104 participants and (4)  Table 1 summarises the extracted study characteristics. The sample size of the 31 studies ranged from 26 to 6157 participants, with a total of 42,357 participants. A variety of population groups was studied, including (1) refugees and vulnerable communities (one RCT study and the other CS) with a total of 3721 participants; (2) university students with seven CS studies and a total of 12,750 participants, and one CS study with 382 university teachers;

Study Characteristics
(3) HCWs with five CS studies and a total of 3104 participants and (4) older adults 60+ with three CS studies and a total of 1019 participants. The remaining studies were non-specific and included the general population.
The sample characteristics between studies varied; the main characteristics extracted were the age and male-to-female (m/f) ratios. For the refugees and vulnerable communities, one RCT study had a mean age of 40.4, and the other study targeted adolescents living in camps or tented settlements within hosting communities aged 10-17 years. For the university student population subgroup, age ranges were between 18 and 24, with a higher female ratio mostly across all studies in this subgroup. For the HCWs subgroup, the mean age varied but mostly represented younger age groups, with an m/f ratio that varied across the studies. For the older adults subgroup, the first study had an age range between 60 and 68, the second a mean age of 72.4 and the third a mean age of 67.6; m/f ratios were mostly comparable.
The rest of the studies that researched the general population have a variation of the mean ages but mostly the mean age falls within the younger representation, while the m/f ratio is comparable in general.
The outcomes varied among the different studies. Most of the studies included measures of anxiety, depression and stress, with different measuring tools. These amounted to a total of 22 studies. Four studies measured symptoms of PTSD, while two studies assessed psychological distress. It was observed that three studies did not include direct measures of the prevalence of mental health disorders: one study measured death anxiety/spiritual well-being/religion coping in older adults related to COVID-19; another study looked for gender-based disparities by checking psychiatric illness and how gender is a predictor of depression; the final one evaluated the Arabic version of the Fear of COVID-19 Scale (FCV-19S)

Quality Appraisal
The results of the quality appraisal for all the CS studies using the AXIS tool are presented in Table 2. The overall quality of the included studies was moderate, with scores varying from twelve to twenty points (out of a possible twenty points). There were two studies with a red flag since there was no information on funding or ethical approval. Two additional studies had a low score, one with twelve; this score was due to a lack of information about the targeted sampling reference and the lack of sufficient information on the statistical methods used. The other low-scoring study of thirteen was due to a lack of consistency of results and the limitations of the study being presented.
The moderate scoring range is between fourteen and seventeen for a total of eighteen studies. Most of the studies within this range have basic research requirements and information. The lack of proper justification of sample size, measure of addressing nonresponders and the response rates related to it, were the reasons for a moderate scoring.
The scoring for the remaining studies was as follows: four studies with a score of eighteen and three studies with a score of nineteen, and this was due to further information on the non-responders and response rates. One study scored twenty, but this was exceptional since it had all the elements covered within the AXIS critical appraisal tool. The study was funded by the research and evaluation division of the UK Foreign Commonwealth and Development Office for the Gender and Adolescence: Global Evidence (GAGE) longitudinal study [23]. The study was part of the response to the Syrian refugee crisis in Jordan to evaluate the situation and build a more resilient program.
The one RCT study appraised using the CASP RCT tool for critical appraisal showed moderate quality. The study participants were not blinded, changes from the baseline group were also noticed, and p-values were reported but the confidence intervals (CI) were not. In general, the study provided vital information and results related to mental health within a very high-risk population setting.

Assessment Tools
There have been a variety of tools used to measure the prevalence of symptoms of depression/anxiety/PTSD/psychological distress/stress. It was also noticed that there were some additional tools used to measure other related outcomes. Table 3 lists all assessment tools used and shows the results related to the prevalence of symptoms associated with these tools.
The most used assessment tools were the Generalised Anxiety Disorder (GAD-7); it is a reliable measurement tool with a seven-item anxiety scale used for clinical and research needs [24]. This scale was used in six studies. The next most used assessment tool was the 10-item Kessler Psychological Distress Scale (K10), this scale measures the level of anxiety and stress symptoms for participants, it is a self-reported scale and is widely used for mental health assessments [25]. The (K10) scale was used in five studies and one study used the (K6) scale. The Depression, Anxiety and Stress Scale, a 21-item questionnaire (DASS-21), is a set of three self-report scales designed to measure the emotional states of depression, anxiety and stress. It was used in four studies, and in one study it was translated into Arabic. The Fear of COVID-19 Scale (FCV-19S) was developed after the COVID-19 pandemic and has been widely used to assess the fear of COVID-19 infections and anxiety. Its psychometric properties are well studied [26], and it was used in four studies. Finally, the nine-item Patient Health Questionnaire (PHQ-9) assesses depression and its severity [27]. This scale was used in three studies.
A variety of other prevalence of anxiety, stress and PTSD assessment tools were less frequently used among the different studies. Figure 2 illustrates the tools used and their frequency in total. depression/anxiety/PTSD/psychological distress/stress. It was also noticed that there were some additional tools used to measure other related outcomes. Table 3 lists all assessment tools used and shows the results related to the prevalence of symptoms associated with these tools.
The most used assessment tools were the Generalised Anxiety Disorder (GAD-7); it is a reliable measurement tool with a seven-item anxiety scale used for clinical and research needs [24]. This scale was used in six studies. The next most used assessment tool was the 10-item Kessler Psychological Distress Scale (K10), this scale measures the level of anxiety and stress symptoms for participants, it is a self-reported scale and is widely used for mental health assessments [25]. The (K10) scale was used in five studies and one study used the (K6) scale. The Depression, Anxiety and Stress Scale, a 21-item questionnaire (DASS-21), is a set of three self-report scales designed to measure the emotional states of depression, anxiety and stress. It was used in four studies, and in one study it was translated into Arabic. The Fear of COVID-19 Scale (FCV-19S) was developed after the COVID-19 pandemic and has been widely used to assess the fear of COVID-19 infections and anxiety. Its psychometric properties are well studied [26], and it was used in four studies. Finally, the nine-item Patient Health Questionnaire (PHQ-9) assesses depression and its severity [27]. This scale was used in three studies.
A variety of other prevalence of anxiety, stress and PTSD assessment tools were less frequently used among the different studies. Figure 2 illustrates the tools used and their frequency in total. Apart from the prevalence of symptoms of depression/anxiety/PTSD/psychological distress/stress assessment tools used in the different studies, analysis showed that there were other instruments used for assessments to support the different research outcomes. These tools included disability measurement, coping with stress, sleep quality and food insecurity in addition to health and well-being. All of these are related outcome factors to issues that escalated during the COVID-19 pandemic lockdown and post lockdown. Apart from the prevalence of symptoms of depression/anxiety/PTSD/psychological distress/stress assessment tools used in the different studies, analysis showed that there were other instruments used for assessments to support the different research outcomes. These tools included disability measurement, coping with stress, sleep quality and food insecurity in addition to health and well-being. All of these are related outcome factors to issues that escalated during the COVID-19 pandemic lockdown and post lockdown.

PTSD
The prevalence of PTSD was assessed in four out of the thirty-one studies [28][29][30][31]. The first study on the refugee subgroup showed that there was a greater decrease in PTSD severity in people assessed during the pandemic than in those assessed prior to the pandemic. The second study included nurses who worked with COVID-19 patients, and it showed that the prevalence of PTSD was 37.1%, while the majority were at the lowest level of PTSD at 17%. The third study highlighted that 3.1% of the general population was diagnosed with PTSD. The final one was on older adults and indicated that COVID-19 had a moderate impact on symptoms of PTSD, and older adults with comorbidities had higher levels of PTSD symptoms.

Psychological Distress
Two out of the thirty-one studies assessed psychological distress [32,33]. The first study was a CS study across 17 countries among the general population. Jordan demonstrated statistically significant high psychological distress compared to the baseline country, which was Thailand in this study. Concerning the (K10) psychological distress, the low distress ratio was 14.9%, while the moderate to high ratio was 85.1%. The second study assessed the psychological distress among university students. Concerning the (K10) psychological distress scale prevalence, 69.5% were severe, 12.6% moderate, 10.8% mild and 7.1% none. Which also showed significant psychological distress.

Anxiety, Depression and Stress
Twenty-two studies out of the thirty-one studies assessed elements of mental health related to anxiety, stress and depression. Most of the studies showed increased levels of anxiety, depression and stress within the different population groups during the COVID-19 pandemic.
Five studies assessed the three elements of anxiety, depression and stress [34][35][36][37][38]. The first study reported the prevalence of depression, anxiety and stress at different levels of 78.7%, 67.9% and 58.7%, respectively. Related predictors of higher levels were associated with home quarantine. A correlation was found between higher levels of depression, anxiety and stress and demographic, health-related factors and lifestyle variables. The second study reported that 49.2% of participants experienced increased anxiety, 72.4% experienced increased worry, 23.1% experienced increased depression and 22.6% experienced increased panic. Females were shown to be more susceptible to emotional and mental stress. In the third study, participants reported 57.5% depression, 42.0%, stress and 59.1% anxiety. This study indicated that risk factors related to increased distress scores were female gender, married people, knowing someone who died from COVID-19 and worrying about COVID-19. The fourth study reported a prevalence of depression of 57.8%, anxiety of 42.4% and stress of 50.1%. Statistically significant risk factors were related to gender, number of dependents and caring for a COVID-19 patient. The fifth study reported symptoms of depression, anxiety and stress at 41.8%, 24.5% and 22.8% to be mild, extreme and severe, respectively, with the increasing levels of symptoms related to the fear of COVID-19 score.
Five studies assessed the prevalence of anxiety and depression [30,[39][40][41][42]. In the first study and in terms of anxiety, 53.0% of the participants reported symptoms: 33.8% mild, 12.9% moderate and 6.3% severe anxiety. Half of the respondents reported depressive symptoms. All these symptoms were related to poor sleep quality among participants. In the second study, 8.9% of participants were diagnosed with anxiety disorder, and 5.6% were diagnosed with depression. Predictors of mental disorders were low monthly income, unemployment and diabetic patients. The third study reported a depression prevalence of 23.8% and an anxiety prevalence of 13.1%. Higher prevalence was noticed among the risk groups of females, divorced people and those having chronic illnesses. The fourth study reported the prevalence of anxiety symptoms at 33.8% mild, 12.9% moderate and 6.3% severe. The prevalence of depression symptoms was as follows: 21.5% highest quartile, 26.8% third quartile, 24.8% second quartile and 26.9% lowest quartile. The fifth exploratory study reported higher level of anxiety and depression among HCW's with high workload and in isolation units.
Two studies assessed stress and depression prevalence [23,43]. The first study, on the refugee population, reported that 19.3% of adolescents presented with symptoms of moderate-to-severe depression, and two-thirds of adolescents reported that household stress had increased during the pandemic. The second study reported an overall increased stress level and an increased feeling of fear and anxiety. This was a phenological method study.

Non-Prevalence
Three studies did not include direct measures or prevalence of mental health [55][56][57]. The first study measured coping with death anxiety/spiritual well-being/religion in older adults in the context of COVID-19. The second study looked for gender-based disparities by checking psychiatric illness and concluded that gender is a predictor of depression. The final study evaluated the Arabic version of the Fear of COVID-19 Scale for use in other research related to mental health and COVID-19 and concluded that the Arabic FCV-19S is a reliable scale.

Clear aims and Objectives
Selection process likely to select participants representing the reference population Using measurement tools for risk factor and outcome variables Response rate raise and non-response bias?   Table 3. Summary of assessment tools and prevalence.

No. Lead Author and Year of Publication Assessment Tools Prevalence of Symptoms of Depression/Anxiety/ PTSD/Psychological Distress/Stress
There was a greater decrease in PTSD severity in people assessed during the pandemic than those assessed prior to the pandemic 2 (Masha'al et al., 2022) [44] • (GAD-7) • (Brief-COPE) 70.6% reported mild to severe anxiety levels upon returning to on-campus learning.
3 (Al-Ajlouni et al., 2020) [39] • (GAD-7) In terms of anxiety, 53% of the participants reported symptoms for mild (33.8%), moderate (12.9%) or severe anxiety (6.3%). Half of respondents reported depressive symptoms. • (GAGE) conceptual framework Jordan demonstrated statistically significant high psychological distress compared to the baseline country, Overall, the study indicated that COVID had moderate impact on symptoms of PTSD, Older adults with comorbidities has higher level of PTSD

Overview
This review assessed the impact of the COVID-19 pandemic on the mental health of the general population in Jordan. It also explored the related risk and predictive factors. In general, it is well established now that the COVID-19 pandemic had an impact on all areas of health. It is one of the biggest crises that affected the health system globally [58]. Mental health is one of the areas that has been enormously influenced due to the measures that have been taken to combat the global spread of the virus and all the economic consequences thereafter.
The results showed an increased prevalence of PTSD, psychological disorders, symptoms of anxiety, stress and depression among the different population groups in Jordan. Most studies showed an increase in the prevalence of symptoms related to mental health disorders; results varied from a moderate to a severe impact. The effect was not specific for any population group; it was universal among the general population. These results conformed with the global results on the impact of the COVID-19 pandemic on mental health. A study by Yunitri et al. [59] concluded that the COVID-19 pandemic caused a measurable impact on PTSD and mental health-related disorders globally and on the different population subgroups. The results from Jordan also conformed with other lower-middle-income countries (LMICs). In a CS research from Bangladesh by Das et al. [60] (p. 1), the study highlighted that 'the prevalence of loneliness, depression, anxiety and sleep disturbance was estimated at 71%'. However, the results from Jordan were unique and represented strong data since Jordan had one of the most stringent lockdowns worldwide and a nearly zero caseload at the beginning of the pandemic [61].
Overall, the sample size of all studies was acceptable but not all were justified. This was due to the difficulty in collecting surveys during the pandemic period. Most of the surveys conducted were online. During the pandemic this method of sampling was convenient and reliable. However, this may have created some bias in the results of prevalence. Since the recruitment of participants was not stratified, results may not represent the real prevalence rates among the population holistically.
Jordan hosts a good number of refugees and displaced communities; two studies addressed the prevalence of mental disorders in those settings. First, the RCT conducted a pre-and post-pandemic assessment; it showed that pre-existing mental issues might not cause worsened psychological distress post-pandemic. The results were unforeseen yet justifiable as (1) refugees and displaced people are already suffering from forms of PTSD and the effect of this suffering is substantial [62]; (2) Syrian refugees in Jordan live in one of the second largest refugee camps worldwide, and during the strict lockdown period, mobility in and out of the camp was halted to minimise the risk of infections in such a densely populated area. However, these data and results are not enough to generalise.
The HCWs subgroup assessment showed a high prevalence rate, specifically at the beginning of the pandemic and when dealing with patients infected with COVID-19. This risk of high prevalence did not change even after one year of the pandemic. It is clear that HCWs were one of the most affected population subgroups. Being on the frontline of combating the pandemic, shortage of staff, full hospital capacity, and burnouts were all examples of how the pandemic affected the overall health services and system. The results from Jordan were similar to results from other countries. A study by Fournier et al. [63] included 77 hospitals in France and showed that the pandemic made devastating effects on HCWs. Even in a low-caseload country like Cyprus, HCWs reported a high level of mental health issues [64].
From the 31 studies reviewed, 3 reported results from elderly subgroups, with a total sample size of 1019. This confirmed that elderly people were underrepresented. None of the studies investigated the frail elderly group.

Gender Predictors
There was a consistency in results of being female as a predictor for having higher prevalence rates of mental health-related symptoms. Most studies concluded that women were experiencing more mental health problems than men in Jordan. Global research also confirmed that being female has a higher incidence of mental health-related issues. The higher incidence of mental disorders is gender-related and has been confirmed in studies even before the pandemic [65]. This may be due to different socio-economic, genetic and health-related factors. Males tend to have more substance abuse or antisocial disorders.
In LMICs and the refugee setting, this gender predictor can be more evident since females are more exposed to gender-based violence and sexual assault, are paid less for work and get divorced, and other factors. It is well documented that the female population requires health-specific needs apart from general needs. Although the research in this area is still limited, it showed that the effect of the pandemic on females was higher on the mental health front [66].

Socio-Economic Predictors
The pandemic imposed economic and social hardship on the population in general. Jordan was already suffering from that hardship pre-pandemic: unemployment, loss of work and youth unable to find work, in addition to limited financial support [67]. On the social level, lockdowns caused physical distancing, more use and addiction to social media, less human interactions and a lack of proper social support. All these socio-economic factors are considered to be predictors for mental health disorders. Most of the reviewed studies indicated a correlation between the increased prevalence of mental health issues and socio-economic situation, as per Gong et al. [68] (p. 11) 'Loneliness, insecurity, anxiety, depression, sleep problems, discrimination, and substance abuse are adverse mental consequences experienced by individuals experiencing economic turmoil during the pandemic'.
This predictor is key since the effect of the socio-economic hardship is still ongoing globally and in Jordan. It is evident that more population groups are in need of financial and social support to be able to overcome the pandemic impact. However, this requires more research and looking into the long-term effects of the pandemic on the affected population groups.

Comorbidities Predictors
Data showed that people suffering from chronic diseases or pre-psychiatric conditions have higher levels of prevalence of mental health symptoms. The combination of clinical or physical illness with a mental disorder is considered a risk factor, and this is an area of big concern [69]. It worsens if comorbidities are affecting the elderly, refugees or vulnerable community members. These results corresponded with other global studies that confirmed that the prevalence of anxiety and depression symptoms and the level of stress were significantly higher among adults with comorbidities [70].

Recommendations and Lessons Learned from the Impact on Mental Health
The impact of the COVID-19 pandemic was an opportunity for elevating and enhancing mental health services. The pandemic had put mental health at the forefront of the public health crises. This may have not been the case if the situation was still pre-pandemic. In Jordan there have been focused efforts in the last period post-pandemic to enhance health services in general and mental health in specific; it is recommended that mental health services be more integrated within primary health services [71].
The pandemic has also been an opportunity to further the research in the field of mental health, which will surely reflect upon the entire research of mental health in the country, but it is also recommended to further advance this research in areas such as refugee settings, elderly population and how to strengthen mental health services within the health system. These focus areas are discussed in the national mental health and substance abuse plan of Jordan [72].
HCWs were one of the most affected groups as the lack of proper mental health training programs and psychiatric educational courses were among the factors that influenced this group, in addition to the shortage of human resources and HCWs specialised in mental health and psychiatric illnesses [73]. It is recommended to increase and advance educational and training services for mental health providers in Jordan.
On the community level, taking the case of university students as an example, this review showed a lack of awareness and educational programs in universities, which has led students to be more likely affected by the impact of COVID-19 on their mental health. The disturbance that occurred due to the dramatic shift to virtual and online education also caused an increasing impact on the mental well-being of students and teachers alike. It is recommended to expand community awareness programs to support the onset of mental health disorders.
On the refugee front, it is recommended to incorporate psychosocial education in schools and universities for elevating awareness and building resilience. Such programs are of great impact on enhancing the resilience of refugees to better incorporate within their communities and cope with mental health issues [74]. Piloting the idea and re-searching it in vulnerable communities would be of great importance.
Finally, on the country policy level, more governance and implementation of mental health and psychological support programs are needed to make sure that the health system is resilient and adaptable to any future crisis.

Strengths
To the best of our knowledge, this is considered the first systematic review conducted for Jordan that addressed the impact of COVID-19 on the mental health of the general population. Moreover, this review addressed the outcomes and predicting factors, while also suggesting recommendations on how to tackle mental health issues at the country level.

Limitations
This review was conducted on a descriptive narrative analysis and not a meta-analysis. This for sure affects the overall assurance of results and the measurement of the real impacts from the reviewed publications. Also, the variances in study subgroups, more representation of some groups such as students, younger age, females and less representation of others such as elderly, adolescents and refugees, have imposed a limitation on generalising the outcomes. Finally, including all studies regardless of quality appraisal outcomes may have created some bias as it did not address comparable studies.

Conclusions
This systematic review assessed the impact of the COVID-19 pandemic on the mental health of the population in Jordan. The results showed a significant correlation between the pandemic and the effect it imposed on mental health. Increased levels of PTSD/ psychological distress/ anxiety, depression and stress were reported among the different population groups. The lessons learned from the impact have shed light on several recommendations on how to address this mental health epidemic to help Jordan overcome the effect and be able to build a more robust strategy for the future.