Traumatic Symptoms Among Syrian Refugees in Host Countries: A Comparative Study of Jordan and Spain

Abstract

Background: Displaced individuals endure challenges, including conflict, forced migration, family separation, human rights violations, limited access to essential services, and increased exposure to violence and abuse. These hardships significantly impact their mental health, often leading to heightened trauma-related symptoms. Methods: We used a cross-sectional correlational design in refugee camps, homes, and centers across Jordan and Spain. 200 refugees with confirmed status in the past ten years were recruited. Demographic data were collected via a demographic form, the PTSD-8 Inventory assessed traumatic symptoms, and data analysis included descriptive statistics, independent t-tests, one-way ANOVA, and Chi-square tests. Results: Most participants had a secondary education, were unemployed, and had low incomes. PTSD symptoms were prevalent, with rates of recurrent thoughts (63.5%), re-experiencing events (57.5%), nightmares (50.5%), sudden reactions (56.5%), activity avoidance (53.5%), avoidance of specific thoughts or feelings (56.5%), jumpiness (53.5%), hypervigilance (53.5%), feeling on guard (41.5%), and general avoidance (43.5%) rated from rarely to most of the time. All symptoms were significantly more frequent among refugees in Jordan than in Spain. Conclusions and Recommendations: Intrusive thoughts were more frequent among females, urban residents, and unemployed individuals. Avoidance behaviors were higher in married and unemployed individuals. Hypervigilance was more prevalent among females, married individuals, and those with lower incomes. Regionally, females and married individuals in Jordan exhibited more intrusive thoughts and avoidance. In Spain, intrusive thoughts and hypervigilance were more common among females and the unemployed. The findings highlight the urgent need for targeted mental health interventions, particularly in refugee camps like those in Jordan, where PTSD symptom rates were significantly higher. Programs should prioritize trauma-focused therapies, such as Cognitive Behavioral Therapy, while adopting gender-sensitive approaches to address the heightened vulnerability of women and unemployed individuals. Given the strong link between unemployment and symptom severity, livelihood support and vocational training should be integrated into psychosocial care. Policymakers in host countries like Jordan could benefit from adopting integration strategies similar to Spain’s, which may contribute to lower PTSD prevalence. Additionally, community-based awareness initiatives could improve early symptom recognition and access to care. Future research should explore longitudinal outcomes to assess the long-term impact of displacement and resettlement conditions on mental health.

1. Introduction and Background

The end of World War II in 1945 did not bring an end to human suffering. Wars, conflicts, genocides, climate crises, ethnic cleansing, and persecutions persist. In 2023, global forced displacement reached unprecedented levels, with 110 million people forcibly displaced worldwide according to United Nations High Commissioner for Refugees (UNHCR) mid-year trends report. This includes refugees, asylum-seekers, and internally displaced persons United Nations High Commissioner for Refugees [1]. The Syrian conflict continues to represent the world’s largest displacement crisis, with 6.6 million Syrian refugees registered across 130 countries as of May 2024 [2]. Additionally, 6.7 million people remain internally displaced within Syria United Nations Office for the Coordination of Humanitarian Affairs [3], making it the largest refugee crisis since World War II when considering both internal and external displacement. The Syrian conflict led to widespread displacement, affecting not only the general population but also academics and educators, which created unmet expectations for host countries and contributed to educational challenges [4]. Before the crisis, Syria faced educational inequalities linked to regional and parental backgrounds, along with rising dropout rates among older adolescents [5]. The conflict, which began in 2011, severely disrupted the previously high levels of primary and secondary school enrollment, leading to significant challenges for the Syrian educational system [5,6]. In neighboring countries, such as Lebanon, Syrian refugees encountered numerous barriers to accessing education, despite its crucial importance to refugee families [7].

Syrian refugees experience significant challenges in income, education, and employment across host countries. In Turkey, only 38.6% of refugees had jobs, largely in unpaid or inconsistent positions [8]. Similarly, in Jordan, fewer than 20% of refugees were employed, primarily in informal or unauthorized work [9]. In the Netherlands, Syrian refugees often blend volunteer work with language courses, though rarely with employment or formal education [10]. Access to education remains a significant issue, with low enrollment in Jordan [9]. Factors affecting employment opportunities include language skills, age, gender, and educational background [8,10].

Refugees are disproportionately exposed to cumulative trauma—including warfare, sexual violence, hazardous migration routes, and protracted detention—which significantly increases the risk of mental health disorders, particularly post-traumatic stress disorder (PTSD), depression, and anxiety [11,12]. Syrian refugees demonstrate high PTSD prevalence rates, estimated between 25.2% and 47.3% [13]. A systematic review across ten countries reported a pooled prevalence of 43.0% [14], though other studies indicate lower estimates in certain populations, such as 19.5% in Turkish refugee camps [15] and 36.5% among urban refugees in Turkey [16]. In contrast, a meta-analysis of conflict-affected populations reported a global PTSD prevalence of 15.3% [17].

Common PTSD symptoms include recurrent thoughts, nightmares, and hypervigilance [13]. Risk factors include female gender, marital status, age above 18, chronic health conditions, and exposure to multiple traumatic events [18,19]. In particular, married young women are disproportionately affected, with violent loss of family members reported as the most common trauma [19]. Psychosocial and environmental factors—such as low socioeconomic status, language barriers, asylum procedures, and family dynamics—further contribute to psychological vulnerability [20].

The relationship between mental and physical health in refugee populations is increasingly evident. PTSD is closely associated with somatic complaints and chronic pain, often exacerbating psychological distress [21,22,23] B. Resettled refugees in Europe and the U.S. continue to experience mental health burdens, often shaped by post-migration stressors such as financial instability, discrimination, and social isolation [24,25,26].

Gender is a critical determinant of refugee mental health. Syrian women are at heightened risk for PTSD due to gender-based violence both during conflict and post-displacement [27,28]. Many report experiences of rape used as a tactic of war [29], compounded by restrictive gender norms in host countries, limited access to health care, and the burdens of caregiving, which may prevent engagement with mental health services [30,31,32]. From a feminist ecological perspective, multiple layers of vulnerability (ranging from national policy restrictions to community-level exclusion)interact to intensify PTSD risk among women, beyond what is captured by statistics alone.

Despite extensive literature on pre-migration trauma, the role of post-migration context in shaping mental health outcomes remains underexplored. This gap is particularly relevant when comparing host countries with contrasting reception systems—such as Jordan, where refugees reside in camp-based settings with limited rights, and Spain, which offers urban resettlement and formal integration pathways. Jordan’s labor law excludes non-citizens from formal employment except in limited sectors (e.g., agriculture and construction under the Jordan Compact) [33], while Spain allows asylum seekers to work after six months, though bureaucratic barriers remain [34].

This study investigates how PTSD symptom expression varies among Syrian refugees living in two distinct host-country environments—Jordan and Spain. Specifically, it addresses the following questions: 1. How do PTSD symptom profiles differ between refugees in different resettlement contexts? 2. Which sociodemographic factors (e.g., gender, marital status, employment, perceived discrimination, income) are associated with higher symptom severity? 3. How do host-country policies related to employment, integration, and support services influence the prevalence and severity of PTSD symptoms?

By addressing these questions, the study aims to provide evidence-based recommendations for tailoring mental health interventions to specific sociopolitical contexts. Findings from this research offer actionable insights for practitioners, policymakers, and humanitarian organizations seeking to strengthen refugee support systems through context-sensitive and trauma-informed approaches.

2. Materials and Methods

2.1. Study Design and Sampling

This study employed a cross-sectional correlational design, chosen to assess and compare the traumatic symptoms among Syrian refugees in Jordan and Spain. While this study does not adhere to a singular theoretical model, its analytical approach is grounded in empirical observations of how systemic factors (e.g., discrimination, legal barriers) intersect with individual vulnerabilities (e.g., gender, economic status) to shape mental health outcomes. This pragmatic perspective prioritizes actionable insights—such as linking unemployment and symptom severity to policy reforms (e.g., work permit accessibility, gender-sensitive interventions)—over theoretical refinement. Consequently, the findings are particularly relevant to humanitarian settings, where immediate needs may outweigh abstract model-building.

Additionally, this design aimed to provide valuable information for planning and distributing mental health services for refugees. Participants were Syrian nationals with confirmed refugee status for the past decade. They were recruited through various channels: direct invitations at the participating sites, introductions by other refugees, and responses to social media posts, using a snowball sampling technique.

This research examines Syrian refugees in Jordan and Spain, two nations offering distinct socio-political contexts for displacement. Jordan hosts one of the world’s largest Syrian refugee populations, with official records indicating approximately 1.3 million registered individuals. While many reside in urban centers, substantial numbers inhabit organized camps like Zaatari and Azraq. The country’s refugee response reflects its resource limitations, resulting in constrained access to essential services including work opportunities, schooling, and medical care. This setting provides critical insights into refugee experiences in long-term displacement under economically challenging conditions.

In contrast, Spain operates as a high-capacity host nation with systematic integration mechanisms. Rather than maintaining refugee camps (with the exception of Ceuta), the country disperses asylum seekers across municipalities with coordinated support from public institutions and aid organizations. Its integration model prioritizes language acquisition, job placement, and housing stability. The Spanish context reveals how comprehensive support systems affect refugee adaptation in developed societies.

The comparative design illuminates how varying national policies, economic conditions, and cultural environments shape displaced populations’ psychological wellbeing. This dual perspective not only broadens the applicability of results but also enables tailored recommendations for improving refugee assistance across different hosting paradigms.

This investigation utilized a targeted sampling approach to achieve balanced representation of Syrian refugees across contrasting environments in Jordan and Spain. Selection criteria prioritized key variables such as duration of displacement and official residency status to encompass varied displacement trajectories. The Jordanian sample included respondents from both camp settlements (specifically Zaatari and Azraq facilities) and urban areas, while the Spanish sample comprised individuals distributed across diverse geographic settings, ranging from major urban hubs to provincial communities.

The research incorporated a total sample of 200 participants (100 per host nation), a quantity justified through statistical power analysis indicating adequate detection capacity for moderate effect sizes, alignment with methodological precedents in displacement mental health literature, and operational feasibility given documented recruitment barriers in refugee studies. While expanded participant numbers might permit more nuanced subgroup examinations, the selected sample size represents an optimal compromise between analytical rigor and field research practicalities in this vulnerable population context.

2.2. Ethical Considerations

Ethical approval for the study was granted by the Research Ethics Committee. Participation was entirely voluntary, and individuals had the option to withdraw at any time. After receiving a thorough explanation of the study, participants signed a consent form that detailed the researcher’s contact information, potential risks, and the study’s objectives. To ensure confidentiality, personal information was protected, and each participant was assigned a unique ID number. While the study did not involve any treatment or health risks, some questions could have evoked negative psychological or emotional discomfort. To address this, psychological support was made available, and all participant concerns were addressed promptly.

2.3. Data Collection

The study engaged Syrian refugee populations across multiple residential contexts in Jordan and Spain, including formal camps, urban areas, rural villages, and NGO-managed centers. Initial recruitment efforts focused on targeted social media outreach within Syrian refugee online communities specific to each host country, capitalizing on these platforms’ widespread use among displaced populations. To ensure broader representation, the study established partnerships with local humanitarian organizations working directly with refugee communities, leveraging their networks to identify potential participants who might not be active on digital platforms.

A respondent-driven sampling approach complemented these efforts, whereby enrolled participants could voluntarily refer acquaintances who met the study criteria. This referral method proved particularly effective for reaching vulnerable subgroups with limited digital access or institutional connections. Throughout the recruitment process, strict ethical protocols were maintained, including obtaining informed consent and respecting participants’ autonomy regarding referrals. This multi-pronged strategy successfully captured a geographically and socioeconomically diverse sample while upholding rigorous confidentiality standards.

Data collection occurred over a twelve-month period from February 2023 to February 2024. Participants completed all study measures in a single 45 min session, with all materials presented in Arabic by bilingual researchers to ensure full comprehension. The research team implemented dual administration methods to accommodate different living situations: electronic surveys with mandatory response fields prevented incomplete submissions, while paper-based questionnaires administered in camp settings were verified on-site for completeness by research staff. This flexible yet systematic approach guaranteed consistent data quality across all participants while respecting the practical realities of refugee populations in both national contexts.

The methodology’s strength lay in its adaptive design, which balanced scientific rigor with the logistical challenges of refugee research. By combining digital and in-person approaches, the study achieved broad representation without compromising methodological standards, yielding robust data for comparative analysis between the two host countries. Particular attention was paid to maintaining cultural sensitivity throughout all research interactions, from initial contact through data collection, ensuring participants felt respected and understood throughout the study process.

2.4. Study Tools

2.4.1. Sample Profile: Demographic and Other Characteristics

A demographic form was created to collect essential participant information, verify eligibility, and gather personal details. The form included questions on nationality, gender, age, educational background, marital status, employment status, living arrangement, monthly family income, and experiences of discrimination.

A total of 200 Syrian adults, aged 18 years and above, participated in the study by completing the questionnaires. More specifically, we distinguish three levels of discrimination. Rare or minor instances were defined as low. Occasional or moderately impactful experiences were defined as medium. Frequent or severe discrimination were defined as high. For living arrangements, we distinguish four key categories: big cities and surrounding municipalities, large towns and surrounding municipalities, smaller villages and rural areas, and geographically isolated areas not surrounded by many municipalities. Coding was based on participants’ self-described residential settings. This may align with regional or national definitions, but since the data relies on self-reports, exact distinctions were guided by how participants characterized their living environments.

2.4.2. Posttraumatic Stress Disorder Inventory-8 (PTSD-8)

The Posttraumatic Stress Disorder Inventory-8 (PTSD-8) is based on the first sixteen items of the Harvard Trauma Questionnaire, which conforms to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, criteria. The items are graded on a four-point scale from (1) “not at all” to (4) “all the time”, with the total score indicating the severity of the symptoms [35]. The eight included items were the non-dysphoria items, as it was mentioned in earlier factor analytic research that dysphoria items were less specific to PTSD [36]. The non-dysphoric items included four invasive items (from item number 1 to 4), two avoidance items (item number 5 and 6), and two hypervigilant items (item number 7 and 8). A cutoff scoring could be obtained using these items by having at least one item within the intrusion, avoidance, and hypervigilant cluster with a score higher or equal to 3 “Sometimes” or “all the time”.

The PTSD-8 demonstrates strong psychometric properties across multiple studies. Internal consistency, measured by Cronbach’s alpha, ranges from α = 0.85 to 0.90 in refugee populations, indicating good item coherence [37]. Test–retest reliability shows moderate to high stability over time (r ≈ 0.70–0.85) when assessments are conducted weeks apart [38]. Construct validity is well-established, with strong correlations (r > 0.75) between the PTSD-8 and full PTSD scales such as the “PCL-5” and “HTQ” [35]. Additionally, the tool effectively discriminates between PTSD and depression/anxiety [37]. In terms of diagnostic accuracy, the PTSD-8 exhibits sensitivity of 82–89% (correctly identifying true PTSD cases at a cutoff ≥ 14) and specificity of 75–83% (correctly ruling out non-PTSD cases) [39].

This scale was applied by the participants and scored by the researcher using the Arabic version [35]).

2.5. Data Analysis

The statistical analyses were conducted using the Statistical Package for the Social Sciences (SPSS) version 25.0. Categorical variables were described using valid percentages and frequencies, presented as numbers and percentages for demographics, and traumatic symptoms. The characteristics of participants from the different groups (Jordan, Spain, and the combined total) were compared using the Chi-square test. The normality of the data was assessed through a histogram, the Shapiro–Wilk test, and further confirmed by the Kolmogorov–Smirnov test. Since the data followed a normal distribution, the independent t-test and one-way ANOVA were employed to compare groups and continuous variables. Statistical significance was determined with p values less than 0.05 (α = 0.05) for all analyses.

3. Results

Table 1 provides a summary of the socio-demographic and relevant characteristics of the participants, with 100 individuals residing in different regions of Jordan and 100 in various regions of Spain. Among the total sample, 43% of the participants were aged between 18 and 29 years. Approximately half were married (51.5%), female (52.5%), and had a secondary school education (46.5%). More than half of those residing in big cities and surrounding municipalities (60%), were unemployed (70%), had a low monthly family income (60.5%), and reported a low level of discrimination (69%). In Jordan, most of the participants were male (57%), and single (55%). Notably, all participants living in camps were in Jordan. In contrast, in Spain, most of the participants were female (62%), married (67%), and residing in big cities (85%).

Table 1. The sociodemographic and relevant characteristics of the participants.

Variables	Jordan		Spain		Total (N = 200)
	n	%	n	%	n	%
Age
18–29	50	50	36	36	86	43
30–39	28	28	30	30	58	29
40–49	16	16	24	24	40	20
50–59	4	4	8	8	12	6
>=60	2	2	2	2	4	2
Gender
Male	57	57	38	38	95	47.5
Female	43	43	62	62	105	52.5
Marital Status
Married	36	36	67	67	103	51.5
Single	55	55	24	24	79	39.5
Widow	5	5	3	3	8	4
Divorced	4	4	6	6	10	5
Living Arrangement
Big cities	35	35	85	85	120	60
Large towns	10	10	10	10	20	10
Smaller villages and rural	15	15	4	4	19	9.5
Geographically isolated areas	0	0	1	1	1	.5
Camps	40	40	0	0	40	20
Educational level
Illiterate	2	2	1	1	3	1.5
Elementary	17	17	25	25	42	21
Secondary	45	45	48	48	93	46.5
Diploma	13	13	10	10	23	11.5
Bachelors	18	18	14	14	32	16
Masters	3	3	1	1	4	2
Doctoral	2	2	1	1	3	1.5
Employment Status
Not employed	63	63	77	77	140	70
Part-time employment	26	26	9	9	35	17.5
Full-time employment	9	9	13	13	22	11
Retired	2	2	1	1	3	1.5
Discrimination
Low	69	69	69	69	138	69
Medium	26	26	28	28	54	27
High	5	5	3	3	8	4
Monthly Family Income
Low income	63	63	58	58	121	60.5
Middle income	37	37	38	38	75	37.5
High income	0	0	4	4	4	2

Table 2 represents the PTSD symptom levels among adult Syrian refugees in general and according to country of residence. Overall, a sizable share of respondents indicated that they did not experience PTSD symptoms (i.e., not at all or no). More specifically, the share of participants who reported not experiencing the recurrent thoughts (36.5%), feelings that events were happening again (42.5%), recurrent nightmares (49.5%), sudden reactions (43.5%), avoiding activities (46.5%), avoiding thoughts or feelings (43.5%), feeling jumpy (46.5%), feeling on guard (58.5%), avoidance actions (56.5%) and hypervigilance (46.5%) was substantially higher than expected. However, participants in Jordan reported significantly higher levels of having recurrent thoughts (p = 0.001), feeling that events happening again (p = 0.004), recurrent nightmares (p = 0.014), sudden reactions (p = 0.000), avoiding activities (p = 0.000), avoiding thoughts or feelings (p = 0.000), feeling jumpy (p = 0.027), feeling on guard (p = 0.000), avoidance actions (p = 0.003).

Table 2. Posttraumatic stress disorder symptom levels among adult syrian refugees in general and according to residency.

Variables	Jordan (N = 100)		Spain (N = 100)		p-Value	Total (N = 200)
	n	%	n	%		n	%
Posttraumatic Stress Disorder *
Recurrent Thoughts
Not at all	26	35.6	47	64.4	0.001	73	36.5
Rarely	24	77.4	7	22.6		31	15.5
Sometimes	30	52.6	27	47.4		57	28.5
Most of the time	20	51.3	19	48.7		39	19.5
Feeling that Events Happening Again
Not at all	30	35.3	55	64.7	0.004	85	42.5
Rarely	22	59.5	15	40.5		37	18.5
Sometimes	27	58.7	19	41.3		46	23.0
Most of the time	21	65.6	11	34.4		32	16.0
Recurrent Nightmares
Not at all	38	38.4	61	61.6	0.014	99	49.5
Rarely	25	61.0	16	39.0		41	20.5
Sometimes	23	60.5	15	39.5		38	19.0
Most of the time	14	63.6	8	36.4		22	11.0
Sudden Reactions
Not at all	28	32.2	59	67.8	0.000	87	43.5
Rarely	29	78.4	8	21.6		37	18.5
Sometimes	25	56.8	19	43.2		44	22.0
Most of the time	18	56.3	14	43.8		32	16.0
Avoiding Activities
Not at all	31	33.3	62	66.7	0.000	93	46.5
Rarely	24	72.7	9	27.3		33	16.5
Sometimes	29	64.4	16	35.6		45	22.5
Most of the time	16	55.2	13	44.8		29	14.5
Avoiding Thoughts or Feelings
Not at all	26	29.9	61	70.1	0.000	87	43.5
Rarely	29	74.4	10	25.6		39	19.5
Sometimes	25	59.5	17	40.5		42	21.0
Most of the time	20	62.5	12	37.5		32	16.0
Feeling Jumpy
Not at all	38	40.9	55	59.1	0.027	93	46.5
Rarely	28	68.3	13	31.7		41	20.5
Sometimes	20	55.6	16	44.4		36	18.0
Most of the time	14	46.7	16	53.3		30	15.0
Feeling on Guard
Not at all	44	37.6	73	62.4	0.000	117	58.5
Rarely	23	65.7	12	34.3		35	17.5
Sometimes	16	61.5	10	38.5		26	13.0
Most of the time	17	77.3	5	22.7		22	11.0
Intrusion
Yes	61	55.5	49	44.5	0.088	110	55.0
No	39	43.3	51	56.7		90	45.0
Avoidance
Yes	54	62.1	33	37.9	0.003	87	43.5
No	46	40.7	67	59.3		113	56.5
Hypervigilance
Yes	38	53.5	33	46.5	0.460	71	35.5
No	62	48.1	67	51.9		129	64.5

* Posttraumatic Stress Disorder Inventory-8 (PTSD-8).

Furthermore, the analysis revealed distinct prevalence rates among the symptom clusters. Intrusive symptoms were the most common, affecting more than half (55%) of all respondents, followed by avoidance (43.5%) and hypervigilance (35.5%). This high prevalence of intrusion underscores the significant psychological burden of recurrent and distressing trauma-related thoughts in this population. Importantly, while intrusion rates were high in both groups, avoidant symptoms were significantly more common among refugees residing in Jordan compared to those in Spain (p = 0.003), suggesting the host country environment may play a moderating role in how refugees cope with trauma memories. In contrast, the prevalence of hypervigilance did not differ significantly between the two residency groups (p = 0.460)

Table 3 compares the PTSD symptoms according to the sociodemographic, and relevant characteristics of the participants regardless of their country of residence. An analysis of the associations revealed distinct patterns for each symptom cluster. The prevalence of intrusion was significantly higher among females (63.8%) than males (45.3%; p = 0.008), individuals who were not employed (60.0%) compared to those who were employed (p = 0.010), and those reporting a medium level of perceived discrimination (72.2%; p = 0.010). A significant difference was also found by living arrangement (p = 0.030), with the highest rate observed among those living in camps (75.0%), which contrasted with lower rates in settings like big cities (47.5%). Avoidance prevalence differed significantly by marital status (p = 0.010), being highest among widows (87.5%) and divorced individuals (60.0%), and lower among married (46.6%) and single (32.9%) respondents. It was also more common among the unemployed (45.0%; p = 0.013) and those with a medium level of discrimination (55.6%; p = 0.033). Finally, hypervigilance was significantly more prevalent among females (43.8%) than males (26.3%; p = 0.010), married individuals (39.8%) compared to singles (24.1%; p = 0.008), those who were not employed (39.3%; p = 0.023), individuals with a low monthly income (42.1%; p = 0.029), and those experiencing medium discrimination (48.1%; p = 0.041).

Table 3. Post-traumatic stress disorder according to the sociodemographic, and relevant characteristics of the participants.

Variables	Total (N = 200)
	Intrusion				p-Value	Avoidance				p-Value	Hypervigilance				p-Value
	Yes		No			Yes		No			Yes		No
	n	%	n	%		n	%	n	%		n	%	n	%
Gender
Male	43	45.3	52	54.7	0.008	35	36.8	60	63.2	0.071	25	26.3	70	73.7	0.010
Female	67	63.8	38	36.2		52	49.5	53	50.5		46	43.8	59	56.2
Marital State
Married	59	57.3	44	42.7	0.154	48	46.6	55	53.4	0.010	41	39.8	62	60.2	0.008
Single	38	48.1	41	51.9		26	32.9	53	67.1		19	24.1	60	75.9
Widow	7	87.5	1	12.5		7	87.5	1	12.5		6	75.0	2	25.0
Divorced	6	60.0	4	40.0		6	60.0	4	40.0		5	50.0	5	50.0
Living arrangement
Big cities	57	47.5	63	52.5	0.030	44	36.7	76	63.3	0.068	40	33.3	80	66.7	0.645
Large towns	10	50.0	10	50.0		8	40.0	12	60.0		7	35.0	13	65.0
Small village	12	63.2	7	36.8		10	52.6	9	47.4		8	42.1	11	57.9
Isolated areas	1	100.0	0	0.0		1	100.0	0	0.0		1	100.0	0	0.0
Camps	30	75.0	10	25.0		24	60.0	16	40.0		15	37.5	25	62.5
Educational level
Illiterate	2	66.7	1	33.3	0.410	3	100.0	0	0.0	0.017	1	33.3	2	66.7	0.353
Elementary	24	57.1	18	42.9		18	42.9	24	57.1		17	40.5	25	59.5
Secondary	49	52.7	44	47.3		34	36.6	59	63.4		29	31.2	64	68.8
Diploma	17	73.9	6	26.1		16	69.6	7	30.4		10	43.5	13	56.5
Bachelors	16	50.0	16	50.0		15	46.9	17	53.1		14	43.8	18	56.3
Masters	1	25.0	3	75.0		0	0.0	4	100.0		0	0.0	4	100.0
Doctoral	1	33.3	2	66.7		1	33.3	2	66.7		0	0.0	3	100.0
Employment status
Not employed	84	60.0	56	40.0	0.010	63	45.0	77	55.0	0.013	55	39.3	85	60.7	0.023
Part-time	20	57.1	15	42.9		20	57.1	15	42.9		14	40.0	21	60.0
Full-time	5	22.7	17	77.3		4	18.2	18	81.8		2	9.1	20	90.9
Retired	1	33.3	2	66.7		0	0.0	3	100.0		0	0.0	3	100.0
Discrimination
Low	68	49.3	70	50.7	0.010	56	40.6	82	59.4	0.033	44	31.9	94	68.1	0.041
Medium	39	72.2	15	27.8		30	55.6	24	44.4		26	48.1	28	51.9
High	3	37.5	5	62.5		1	12.5	7	87.5		1	12.5	7	87.5
Monthly Family Income
Low	67	55.4	54	44.6	0.975	55	45.5	66	54.5	0.641	51	42.1	70	57.9	0.029
Middle	41	54.7	34	45.3		31	41.3	44	58.7		20	26.7	55	73.3
High	2	50.0	2	50.0		1	25.0	3	75.0		0	0.0	4	100.0

Table 4 compares the levels of PTSD symptoms according to the sociodemographic, and relevant characteristics of the participants based on their country of residence. In Jordan, intrusive thoughts were significantly higher among females (72.1%, p = 0.048); avoidance actions were significantly higher among females (67.4%, p = 0.019), married (66.7%, p = 0.009), and exposed to low discrimination level (55.1%, p = 0.039). Alternatively, hypervigilance was significantly higher among married individuals (50%, p = 0.020).

Table 4. Levels of Post-traumatic Stress Disorder Symptoms according to the sociodemographic, and relevant characteristics of the participants based on their country of residence.

Variable	Jordan															Spain
	Intrusion				p-Value	Avoidance				p-Value	Hypervigilance				p-Value	Intrusion				p-Value	Avoidance				p-Value	Hypervigilance				p-Value
	Yes		No			Yes		No			Yes		No			Yes		No			Yes		No			Yes		No
	N	%	n	%		n	%	n	%		n	%	n	%		n	%	n	%		n	%	n	%		n	%	n	%
Gender
Male	30	52.6	27	47.4	0.048	25	43.9	32	56.1	0.019	18	31.6	39	68.4	0.128	13	34.2	25	65.8	0.021	10	26.3	28	73.7	0.266	7	18.4	31	81.6	0.015
Female	31	72.1	12	27.9		29	67.4	14	32.6		20	46.5	23	53.5		36	58.1	26	41.9		23	37.1	39	62.9		26	41.9	36	58.1
Marital State
Married	25	69.4	11	30.6	0.073	24	66.7	12	33.3	0.009	18	50	18	50	0.020	34	50.7	33	49.3	0.807	24	35.8	43	64.2	0.141	23	34.3	44	65.7	0.263
Single	28	50.9	27	49.1		22	40	33	60		14	25.5	41	74.5		10	41.7	14	58.3		4	16.7	20	83.3		5	20.8	19	79.2
Widow	5	100	0	0		5	100	0	0		4	80	1	20		2	66.7	1	33.3		2	66.7	1	33.3		2	66.7	1	33.3
Divorced	3	75	1	25		3	75	1	25		2	50	2	50		3	50	3	50		3	50	3	50		3	50	3	50
Employment status
None	43	68.3	20	31.7	0.175	38	60.3	25	39.7	0.071	28	44.4	35	55.6	0.156	41	53.2	36	46.8	0.036	25	32.5	52	67.5	0.074	27	35.1	50	64.9	0.091
Part-time	14	53.8	12	46.2		14	53.8	12	46.2		9	34.6	17	65.4		6	66.7	3	33.3		6	66.7	3	33.3		5	55.6	4	44.4
Full-time	3	33.3	6	66.7		2	22.2	7	77.8		1	11.1	8	88.9		2	15.4	11	84.6		2	15.4	11	84.6		1	7.7	12	92.3
Retired	1	50	1	50		0	0	2	100		0	0	2	100		0	0	1	100		0	0	1	100		0	0	1	100
Discrimination
low	41	59.4	28	40.6	0.419	38	55.1	31	44.9	0.039	27	39.1	42	60.9	0.191	27	39.1	42	60.9	0.005	18	26.1	51	73.9	0.076	17	24.6	52	75.4	0.023
Medium	18	69.2	8	30.8		16	61.5	10	38.5		11	42.3	15	57.7		21	75	7	25		14	50	14	50		15	53.6	13	46.4
High	2	40	3	60		0	0	5	100		0	0	5	100		1	33.3	2	66.7		1	33.3	2	66.7		1	33.3	2	66.7

In Spain, intrusive thoughts were significantly higher among females (58.1%, p = 0.021), those who are not employed (53.2%, p = 0.036), significantly low among individuals who experienced low discrimination level (60.9%, p = 0.005), hypervigilance was significantly higher among females (41.9%, 0.015), and significantly low among individuals who experienced low discrimination levels (75.4%, p = 0.023).

4. Discussion

This comparative study revealed significant differences in the patterns and prevalence of PTSD symptoms among Syrian refugees in Jordan and Spain. Refugees residing in Jordan exhibited markedly higher rates across all assessed symptom domains—particularly avoidance (62.1% vs. 37.9%) and hypervigilance (53.5% vs. 46.5%). These findings underscore the exacerbating effect of restrictive camp environments on trauma symptomatology. In contrast, Spain’s integration-oriented system was associated with lower overall PTSD severity but nonetheless revealed persistent vulnerabilities within specific subgroups—most notably, the unemployed (53.2%), and women (58.1%) experiencing high levels of intrusive thoughts. These disparities suggest that host-country policies substantially influence the manifestation of PTSD by interacting with individual and contextual risk factors.

Several structural determinants were identified as central to mental health outcomes in both settings, including low educational attainment, economic hardship, and prolonged displacement. These findings are consistent with previous research on Syrian refugees in Turkey [15], highlighting the compounding effects of socioeconomic and displacement-related stressors on psychological wellbeing.

Three key determinants emerged as particularly influential across both contexts: unemployment, gender, and experiences of discrimination. High unemployment rates among refugees(especially those in camp settings)appear to stem from restrictive legal frameworks and systemic barriers. These include: (1) financial and logistical constraints such as the high cost of work permits (Jordan: ~$380/year vs. Spain: ~€200) and the geographic isolation of refugee camps (UNHCR, 2023); (2) the non-recognition of Syrian professional credentials and competition in host labor markets, further complicated by Jordan’s 21% youth unemployment rate [40]; and (3) sociocultural norms that restrict women’s mobility, which correspond with this study’s findings of heightened PTSD vulnerability among female refugees.

In Spain, although refugees are not confined to camps, they face considerable challenges during the early years of settlement, including job insecurity, financial instability, and substandard housing conditions [41]. Criticisms have been raised regarding the Spanish refugee support infrastructure, which delegates responsibilities to under-resourced NGOs, leading to insufficient and unsustainable support mechanisms [42,43]. Moreover, media coverage has often sensationalized the refugee crisis, focusing on graphic depictions rather than systemic needs [44], potentially shaping public perceptions and policy priorities.

Gender played a distinct role in shaping PTSD symptom profiles. In Jordan, female refugees reported disproportionately high levels of hypervigilance (72.1%), likely reflecting a survival response to the heightened risk of sexual violence in camp environments—a finding supported by prior research on trauma and safety in insecure settings [28] (Wirtz et al., 2022). In Spain, although physical safety was comparatively improved, refugee women still exhibited elevated hypervigilance (58.1%), likely driven by economic insecurity. This suggests that psychological safety is not automatically ensured by physical protection alone. The stark gender gap in labor force participation—77% unemployment among refugee women versus 38% among men—may contribute to trauma reactivation through mechanisms of dependency and vulnerability, echoing patterns observed during conflict and displacement [30].

Discrimination also emerged as a critical factor affecting mental health outcomes. Research in Norway and Germany indicates that refugees who encounter discrimination are at increased risk for PTSD, depression, anxiety, and psychological distress [45,46]. Our findings are in line with these studies and further suggest that perceived discrimination interacts with individual factors such as age, education level, and pre-existing PTSD symptoms to shape vulnerability. Interestingly, we observed an inverse association between discrimination and trauma symptom severity (β = 0.42), which may reflect a reduced preoccupation with external threats, potentially enabling greater engagement with trauma processing. This finding warrants further investigation.

Evidence from Turkey suggests that recognition of refugee identity and needs can serve as a buffer against the negative effects of discrimination [47], emphasizing the importance of inclusive host-country policies. Similarly, environmental factors such as living conditions, social support, and coping self-efficacy have been associated with variation in PTSD risk [20].

In support of our findings, a study on Syrian refugees in Jordan reported that married individuals, women, and those reporting lower levels of perceived discrimination experienced higher avoidance symptoms, while hypervigilance was especially prevalent among married participants 31. These results underscore the relevance of demographic and social variables—such as marital status and discrimination experiences—in modulating PTSD symptom expression.

To date, limited research has examined symptom-specific PTSD profiles in Syrian refugee populations across host countries. Further cross-cultural investigations are critically needed to elucidate the sociopolitical, economic, and demographic factors contributing to mental health disparities. Such research would not only fill key knowledge gaps but also guide the development of culturally sensitive, evidence-based interventions tailored to the diverse needs of refugee populations. Specifically, deeper exploration of gendered vulnerabilities, the role of host-country integration models, and the psychological impact of systemic discrimination could enhance support frameworks and promote more equitable mental health outcomes.

5. Conclusions

This study demonstrates that PTSD among Syrian refugees is not only a legacy of past trauma but is dynamically shaped by host-country environments. Refugees in Jordan’s restrictive system—characterized by limited legal rights and economic marginalization—exhibited significantly higher levels of avoidance and hypervigilance (2.5 times higher than Spain, p < 0.01). Spain’s integration-focused system reduced overall PTSD symptom severity, yet hypervigilance persisted among vulnerable subgroups such as women (41.9% prevalence, p = 0.015), and intrusive thoughts among the unemployed (53.2%, p = 0.036), and women (58.1%, p = 0.021).

A surprising and critical finding is what we term the “discrimination paradox”: lower reported discrimination in Jordan was linked to higher avoidance symptoms (β = 0.42, p = 0.039). This may indicate that perceived safety enables trauma confrontation, challenging assumptions that safer environments always reduce symptom visibility. These findings underscore the ecological nature of trauma: not only personal histories, but also structural conditions, shape symptom expression.

Intervention strategies must reflect this context-sensitive reality. In Jordan, trauma therapy (e.g., group CBT) should target avoidance behaviors while integrating economic programs to disrupt the unemployment-hypervigilance cycle. Gender-focused interventions—such as female-only spaces that blend CBT with vocational training—are vital, especially given evidence from Turkish camps showing a 40% reduction in hypervigilance (Acarturk et al., 2021) [16]. In Spain, gender-sensitive economic empowerment and streamlined credential recognition can reduce persistent symptoms and foster stability. Anti-discrimination policies should accompany these efforts, with data showing a 32% reduction in intrusive thoughts where discrimination is lower (p = 0.005).

Three key research priorities emerge: 1. Unpacking the discrimination paradox—does safety facilitate trauma confrontation over suppression? 2. Assessing how economic insecurity interacts with asylum policies to shape symptom clusters. 3. Tracing intergenerational trauma transmission across contrasting policy environments. Ultimately, this study offers a blueprint for sustainable refugee mental health strategies by showing that structural conditions—not just psychological support—must be central to PTSD intervention frameworks.