Understanding Mental Health Status of Syrian Refugee and Jordanian Women: Novel Insights from a Comparative Study

(1) Background: War and displacement are well-known predictors of negative mental health outcomes among affected populations. This is especially relevant for refugees of war, particularly women, who often repress their mental health needs due to family responsibilities, social stigma, and/or cultural pressures. In this study, we compared the mental health status of urban Syrian refugee women (n = 139) with local Jordanian women (n = 160). (2) Methods: Psychometrically validated Afghan Symptom Checklist (ASC), Perceived Stress Scale (PSS), and Self-Report Questionnaire (SRQ) examined psychological distress, perceived stress, and mental health, respectively. (3) Results: According to independent t-tests, Syrian refugee women scored higher than Jordanian women on the ASC [mean score (SD): 60.79 (16.67) vs. 53.71 (17.80), p < 0.001], PSS [mean score (SD): 31.59 (8.45) vs. 26.94 (7.37), p < 0.001], and SRQ [mean score (SD): 11.82 (4.30) vs. 10.21 (4.72), p = 0.002]. Interestingly, both Syrian refugee and Jordanian women scored higher than the clinical cutoff in the SRQ. Regression analyses indicated that more educated women were less likely to score high on the SRQ (β = −0.143, p = 0.019), particularly in the anxiety and somatic symptoms subscale (β = −0.133, p = 0.021), and were less likely to exhibit symptoms of ruminative sadness (β = −0.138, p = 0.027). Employed women were more likely to exhibit high coping ability than unemployed women (β = 0.144, p = 0.012). (4) Conclusions: Syrian refugee women scored higher than Jordanian women in all used mental health scales. Access to mental health services and enhancing educational opportunities would help mitigate perceived stress and may enhance stress-coping abilities.


Introduction
The Syrian war, which began in 2011, is one of the world's largest humanitarian crises in modern history and has resulted in the displacement of more than 6.7 million Syrians [1]. An estimated 1.4 million Syrians live in Jordan, of whom over 680,000 are registered refugees [2]. Since the average Syrian family size is 5.6, the estimated number of Syrian women refugees in Jordan is around a quarter of a million. In Jordan, Syrian refugees are allowed to work, with a majority of them working on a valid work permit and living on a government-issued residence permit [3,4]. In addition, most of the Syrian refugees in Jordan have access to education and health services, which are mainly offered by the UNHCR [5]. However, competing resources often fail to meet the complex health needs of this vulnerable group [2]. It is well-known that war-related displaced communities are often subjected to increased risks of persecution, discrimination, violence, resettlement, and adaptation problems in host communities [6,7]. This is not surprising considering that postmigration social stressors, including the complex asylum-seeking process, social support, and social

Subject Recruitment
Upon approval of the study protocol by the UH-IRB and JUST-IRB Committees, Syrian refugee and Jordanian women residing in the Ar-Ramtha area of northern Jordan were recruited to participate in the study using convenient and snowball sampling methods through the local Jordan community networks, including community organizations, charitable trusts, and social media groups. Snowball sampling was achieved by asking the recruited women to refer three potential subjects from their social network. Recruitment continued until the target number (about 300 participants) was achieved. Ar-Ramtha is a small city in the northern part of Jordan, which includes 7 small villages with a population of about 240 thousand people. The exact number of Syrian refugees who have settled in Ar-Ramtha is not known, but it is estimated that more than 40,000 Syrians currently reside in this area [31]. All Syrian refugees in the Ar-Ramtha area live within the local community. Both Syrian refugee women and Jordanian women were recruited from the same residential areas. The basic criteria for inclusion were adults, 18 years of age or older, Syrian refugee

Online Survey
The Arabic versions of the survey questionnaires were uploaded on the REDCap platform, which enables the secure building and management of online surveys. The study team used the survey link to access the questions while interviewing the participants. The research team obtained the participants' consent electronically via a REDCap survey link. Participants had the option to complete the survey questionnaire either independently or with one-on-one guidance from the postdoctoral fellow or the student researcher. The study team explained the questions if the participants asked for clarification. Upon survey completion, each participant received a $14 (10 Jordanian Dinars) gift card.

Statistical Analysis
The statistical analyses were conducted using complete case analyses, and the response rates of variables of interest ranged from 96% to 100%. Data were first examined using descriptive statistics. Sample comparisons between Syrian and Jordanian women were performed using an independent t-test or chi-square test for continuous and categorical variables, respectively. An analysis of covariance (ANCOVA) was used to compare the scores on each stress scale between Syrian and Jordanian women while controlling for participants' age, employment status, and relationship status. An ANCOVA was conducted separately for each stress and mental health scale. The effects of participant characteristics on each stress scale were examined using stepwise linear regression to identify predictor variables. Separate regression analyses were conducted for each stress scale. The correlations between perceived stress and mental health measures were also examined using person-correlation analyses. Significance was set at p < 0.05. All analyses were conducted using IBM SPSS statistics (version 29.0).

Results
Data were collected from a total of 139 Syrian refugee women and 160 Jordanian women residing in the Ar-Ramtha area of northern Jordan between July and September 2022. Table 1 depicts the demographic characteristics and socioeconomic circumstances of the participants. Participants' ages ranged from 18 to 77 years (mean = 41.36). The age distribution was comparable among Syrian and Jordanian women (p = 0.207). Education level was significantly different between Syrian refugee and Jordanian women (p < 0.001), with 84.9% of Syrian refugee women not completing high school compared to 48.8% of Jordanian women. While 81.9% of Jordanian women reported having health insurance, only 6.5% of refugee women had health insurance (p < 0.001). Additionally, 97.8% of Syrian refugees had a monthly income below 551 JD (~750 $), which is significantly higher than 81.9% of Jordanians who reported a monthly income below 551 JD (p < 0.001). The percentage of Syrian refugee women who reported living with more than one family in the same house (38.8%) was significantly higher (p < 0.001) than Jordanian women (10.6%). Note. Data were analyzed using chi-square for categorical variables and t-test for continuous variables. JD = Jordanian Dinar; ** p < 0.01; *** p < 0.001.

Perceived Stress and Mental Health Measures
In the PSS, Syrian refugee women scored significantly higher than Jordanian women (p < 0.001), as seen in Figure 1A. Further analysis of positive and negative items within the PSS revealed that Syrian refugee women reported higher scores in the perceived distress subscale, negative items (p = 0.004), and lower scores in the coping ability subscale, positive items (p < 0.001), compared to Jordanian women, as seen in Table 1. The results of the ANCOVA revealed a similar significant difference between Syrian refugee and Jordanian women in the PSS total score when controlling for participants' age, employment status, and relationship status (p < 0.001). Note. Data were analyzed using chi-square for categorical variables and t-test for continuous variables. JD= Jordanian Dinar; ** p < 0.01; *** p < 0.001.

Perceived Stress and Mental Health Measures
In the PSS, Syrian refugee women scored significantly higher than Jordanian women (p < 0.001), as seen in Figure 1A. Further analysis of positive and negative items within the PSS revealed that Syrian refugee women reported higher scores in the perceived distress subscale, negative items (p = 0.004), and lower scores in the coping ability subscale, positive items (p < 0.001), compared to Jordanian women, as seen in Table 1. The results of the ANCOVA revealed a similar significant difference between Syrian refugee and Jordanian women in the PSS total score when controlling for participants' age, employment status, and relationship status (p < 0.001). In the SRQ, Syrian refugee women reported a higher total score compared to Jordanian women (p = 0.002), see Figure 1B. Although both reported above the clinical cutoff score of 7, subscales analysis within the SRQ revealed that Syrian refugees exhibited significantly higher depressive symptoms compared to Jordanian women (p < 0.001). While anxiety and somatic symptoms were comparable between the two groups (p = 0.135), as seen in Table 1, the results of the ANCOVA revealed a significant difference between Syrian refugee and Jordanian women in the total SRQ score when controlling for participants' age, employment status, and relationship status (p = 0.010).
In ASC, Syrian refugees reported a significantly higher total score compared to Jordanian women (p < 0.001), see Figure 1C. Subscales analysis within the ASC measure revealed that Syrian refugees reported higher scores than Jordanian women in the sadness with social withdrawal subscale (p < 0.001) as well as in the ruminative sadness subscale (p = 0.002), but not in the aggression subscale (p = 0.286), as seen in Table 1. An ANCOVA analysis revealed a significant difference between Syrian refugee and Jordanian women in the total ASC score when controlling for participants' age, employment status, and relationship status (p < 0.001).

Linear Regression Analyses
Linear regression analysis indicated that more educated women were less likely to score highly in the SRQ (p = 0,019), particularly in the anxiety and somatic symptoms subscales (p = 0.021), and they were also less likely to exhibit ruminative sadness (p = 0.027). Employed women were more likely to exhibit high coping ability as compared to unemployed women (p = 0.012). Women with health insurance were less likely to report high perceived distress than women without health insurance (p = 0.001). Unmarried, divorced, or widowed women were more likely to report higher scores in the SRQ than married women (p = 0.022). Women with hypertension were more likely to report higher scores than women without hypertension in the PSS. Women with hypertension were also more likely to report high scores in the SRQ (p = 0.018) and the ASC (p = 0.002). Women with irritable bowel syndrome were more likely to report high scores in the SRQ (p = 0.018) than women without irritable bowel syndrome. Women with more children were more likely to report a high aggression score (p = 0.018) than women with fewer children, as seen in Table 2.

Correlation Analyses
Further correlation analysis between mental health measures and PSS total score and subscales showed that perceived stress and perceived distress were positively correlated with SRQ total scores and depression and anxiety subscales, as well as with ASC total score and ASC subscales, as seen in Table 3. Coping ability was negatively correlated with the SRQ total score and the depression and anxiety subscales. Coping ability was also negatively correlated with the ASC total score, particularly with sadness on the social withdrawal subscale, as seen in Table 3.

Discussion
Forced displacement and migration are well-recognized stressors that often contribute to complex mental health issues among refugees [6,43,44], with a reportedly high vulnerability to mental distress and greater susceptibility to mental illnesses among women refugees [44][45][46][47]. This is not surprising considering the risks, violence, and exploitation that women often face during displacement and resettlement processes [48,49]. While the impact of displacement stressors on women refugees is well documented [50][51][52][53], context-specific factors that contribute to mental distress are not well understood. This study provides important information on context-specific issues of mental stress among a sample of Syrian refugee women resettled in an urban setting in northern Jordan. The levels of perceived stress among Syrian refugee women in our sample are predictive of important mental health outcomes, as discussed below. While pre-migration traumatic stress, such as torture, loss of property, physical assault, and loss of livelihood, is recognized as a key predictor of mental health outcomes in refugees and asylum seekers [54], recent research has focused on the psychological impact of post-migration stressors in the novel environment of resettlement [11]. The post-resettlement experience of Syrian refugees resettled in Jordan is typically characterized by extreme poverty and uncertainty around basic needs such as housing, health care access, education, and employment [55]. The post-migration environment is especially critical for refugee women as they are considered a highly vulnerable group, often with worse trauma-related mental health outcomes [51,56].
In our sample, Syrian refugee women reported high levels of perceived stress compared to the local Jordanian women. Correlation analysis revealed that hypertension was a predictable variable of increased perceived stress. This is concerning, as having no health insurance was also a predictable variable of perceived distress. Considering that approximately 93.5 % of Syrian refugee women were without medical insurance, a lack of health insurance or access is a predictable risk factor for perceived distress and associated mental health outcomes in Jordan-based Syrian refugee women. This is not surprising considering Syrian refugees' lack of access to adequate healthcare in Jordan. The healthcare challenges of Syrian refugees in Jordan are not just about disparities in access and outcomes; they have become an economic, political, and social crisis for the Jordanian government [57]. Furthermore, the coping ability was significantly higher among Jordanian women when compared to Syrian refugee women. Linear regression analysis suggested that coping ability was negatively correlated with having diabetes but positively correlated with having a job. Although the percentages of both predictable variables, employment and having diabetes, are comparable between Syrian refugee and Jordanian women, other factors such as financial hardship may negatively impact coping abilities among Syrian refugee women. It has been reported that low socioeconomic status and income are important determinants of the refugee coping process [58]. Another significant factor affecting coping ability is education. A literature review that focused on East African refugees indicated that education is an important factor that improves refugees' coping abilities and that, through education, young refugees sought hope for a safe, prosperous, and equitable future [59]. The school enrollment rate for Syrian refugees in Jordan is less than 60% [60]. Low enrollment rates also suggest that refugees face challenges in continuing and completing basic education in Jordan [61]. Only a small fraction of refugees (8%) are currently enrolled in higher education in Jordan. As the opportunities for higher education are limited for Syrian refugees and considering the access to these opportunities is unequal, this often results in refugees not being able to see the value of education [62]. This limited opportunity for education is particularly concerning for girls, as early marriage and school dropout are interrelated outcomes that have an enormous impact on refugee girls' vulnerability to adverse mental health outcomes [18]. Mental health stigma remains one of the most acknowledged reasons why refugees fail to access mental health services. Many studies have previously reported the underutilization of mental health services by various refugee groups when compared to the general population [63][64][65]. For example, Afghan refugee women [66,67] in the United States and Syrian refugee women in Lebanon [68], Canada [69], and Germany [70] are reported to have unmet mental health needs and low use of mental health services. Lack of knowledge about mental health is one of the major barriers to seeking mental health, highlighting the significance of refugee education as an empowering tool [71].
We observed that Syrian refugee women exhibited significantly higher scores in the SRQ than Jordanian women, particularly in the depression subscale. Syrian refugee women also exhibited higher scores in ASC than Jordanian women, particularly in the sadness with social withdrawal and ruminative sadness subscales. Pearson's correlation analyses revealed that perceived stress and distress have a significant positive correlation with all mental health outcomes. While pre-migration traumatic stress is recognized as a key predictor of mental health outcomes in refugees, post-migration stressors in the settlement environment are critical determinants of refugee mental health [11]. The stressful postmigration environment is especially concerning for refugee women as a vulnerable group to mental health issues [14,72]. As wives and/or mothers, women bear extra burdens in the process of immigration in order to support family members as they adjust to a new way of life and often undertake the role of protecting and upholding family values, culture, and beliefs [73,74]. It is significant to point out here that both Jordanian and Syrian refugee women scored higher than the clinical cutoff of 7 on the SRQ scale. Women are the primary caregivers in the family and often ignore their own healthcare needs to protect the family, which may partially explain their vulnerability to psychological and mental health symptoms [75]. In fact, mental health is still highly stigmatized in Arab culture [76]. Additionally, only a few mental health institutions exist in Jordan; there are only three mental health hospitals for adults and one specialized psychiatric hospital for children [77,78], with the total number of practicing psychiatrists in Jordan not exceeding 2 per 100,000 residents [79]. Thus, the stigma around mental health combined with the scarcity of mental health care institutions is suggested as the main barrier to seeking mental health care among both Syrian refugees as well as Jordanian women [79].
In our study, the number of children was a predictive variable for women reporting an aggression score. While the prediction of aggression was comparable between Syrian refugees and Jordanian women, the lack of social support, the worrying about family members left behind in Syria, poverty, and the limited resources might exacerbate the coping strategies of Syrian refugee women.

Conclusions
To effectively serve resettlement and facilitate the effective integration of refugees into host communities, mental health professionals and policymakers must be cognizant of the impact of the refugee experience and cultural contexts on psychosocial functioning. Social workers and health professionals should consider designing and implementing targeted programs that address current stressors and rebuild indigenous social support systems to enhance acculturation and reduce mental health problems among Syrian refugee women.

Limitations
Our study has several limitations. First, the reliance on self-report, as opposed to clinical interview; second, the study focused on one city. Therefore, the results cannot be generalized to other similar populations resettling in other cities in Jordan. Third, the cross-sectional nature of our observations mitigates cause-and-effect conclusions. Finally, the questionnaires did not include all the factors that may impact women's mental health.  Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.

Data Availability Statement:
The data presented in this study are available upon request from the corresponding author. The data are not publicly available due to privacy.