Gender differences in Syrian refugees in Jordan: Psychological,self-esteem,family function,marital satisfaction,and life satisfaction

Abstract

Aim:

The current study examined gender differences in mental health, self-esteem, family function, marital satisfaction, and life satisfaction between men and women living in a refugee camp for Syrian refugees in Jordan.

Method:

A snowball method used by local female and male students trained to collect data according to culturally competent methods. The following research instruments were deployed: Symptoms Checklist-SCL90, Self-esteem Scale, the McMaster Family Assessment Device, Marital Satisfaction Scale, and life Satisfaction Scale.

Results:

A sample of 290 adults (196 women and 94 men) living in a refugee camp in Jordan participated in the study. Findings revealed that marital satisfaction, self-esteem, and life satisfaction were significantly different between males and females, indicating less subjective well-being for women. Many of the mental health symptoms in this study were more common for women than men; particularly noteworthy were somatization, obsessive compulsive behavior, interpersonal sensitivity, depression, hostility, psychoticism, and higher scores on the Global Severity Index (GSI).

Conclusion:

While some stressors are not gender-specific, there are unique factors that women face which place them at increased risk of mental health problems. Implications for practice include a greater understanding of the challenges and resilience mechanisms that are related to gender and culture.

Keywords

Jordan mental health refugee resettlement Syrian women

Since the outbreak of the Syrian crisis, more than 250,000 Syrians have lost their lives and 11 million more Syrians have been displaced. The crisis has made nearly 4 million Syrians refugees, most of whom have fled to Lebanon, Jordan, and Turkey (Hiil, 2018). Jordan hosts approximately 665,000 registered Syrian refugees, although the number reaches about 1.3 million when non-registered Syrians are considered (UNHCR, 2021). Thus, refugees from Syria constitute roughly 10% of the Jordanian population. Seventeen percent of these persons live in refugee camps in Jordan, while the majority of Syrian refugees reside in Jordanian communities, with the largest numbers in the northern governorates. Three governorates, namely, Amman, Irbid, and Mafraq, host about 76% of the total Syrian refugee population in Jordan (Stave & Hillesund, 2015, cited in Christopherson, 2015; UNHCR, 2019, 2021).

Syrian refugees have been exposed to a wide range of potentially traumatic events and war-related stressors, including the destruction of their homes, the loss of their livelihoods, and forced displacement. In many cases, they have witnessed the death of loved ones, and some have experienced torture. Their forced migration in the context of state failure has been marked by hardship, risk, and danger – and they face a highly precarious future (Silove et al., 2017). In addition to experiences of major loss and potentially traumatic experiences in their country of origin, Syrian refugees are also affected by stressful circumstances in host countries, where the capacity for self-help and mutual support has been negatively impacted by forced migration, separation from families and communities, collective violence, and mistrust. Over 36% of all registered Syrian refugees in Jordan are separated from a member of their family. Such separation increases the likelihood of harsh child labor, loss of child education, while also increasing challenges to family roles and structure through the destruction of kinship and social ties (McNatt et al., 2018). As reported by one woman (head of household):

He [my husband] did not stay in Jordan because he could not find a job. I mean, we suffered a lot. We are a family of [five]. It is [six] with my husband. He was an employee in ______. And they fired him later. So, we stayed a whole year with no work, and what would it do for us. The man was weary. He said ‘I will look for a country to live like everyone else. And hopefully I can bring you to me.’ He went there [to a European country] and we are still waiting (McNatt et al., 2018, p. 9).

Another mother explained:

My children are responsible, they know the situation. We want to live and pay for the house. They never complain. The other boy [works at a] socks factory. His school refused to let him work. They said it’s either school or work. They told us the same thing last year. He left school this year because we needed money. He wants to return to school. He was so upset about leaving his school. . . I told him that I will go to work next year and let him go to school (McNatt et al., 2018, p. 13).

Poverty among Syrians living in Jordan, Lebanon, and Turkey is widespread (Budosan et al., 2016), and the civil and employment rights of these refugees are often limited. Syrian refugees in Jordan, whether housed in refugee camps or in host communities, live in unfamiliar, under-provisioned and overcrowded quarters, and largely rely for day-to-day sustenance on aid from non-governmental organizations (Gammouh et al., 2015). One refugee woman reported:

My mother has been in Germany for three years, my sister in Holland and my brother in France. I long to be reunited with them. My dream is to see them, to see my mother. I don’t want to be in Jordan. Every day, I am being reborn here. I’m psychologically exhausted. My husband earns 60 [dinars] a week. We need 120 for rent and 20 for water and electricity; that’s 150 for bills monthly. We were dying before the salary. Literally dying (McNatt et al., 2018, p. 11). Such desperation leaves family members refugees vulnerable to exploitation, social isolation, gender-based violence, and girls’ early marriage (Al-Zaghoul, 2016).

Studies have shown that refugees suffer from a wide array of mental health issues (Brune et al., 2002; Kirmayer et al., 2014; Porter & Haslam, 2005; Steel et al., 2009). Specifically, exposure to premigration trauma, journey to the host country, and resettlement stressors have been linked to mental health difficulties with cumulative effects (Lindencrona et al., 2008). A refugee remarked,

We were separated because of the war. My mother was here [in Jordan] with us. . . I told you, my nephew died in the shelling. My brother was extremely affected by that. Whenever a plane flies over, he starts to panic, scream and cry of fear for his daughters. He had a boy and three girls; the boy died in the shelling. Then he sold all that he owned in Syria and was smuggled. . .to Turkey. He then talked to my mother after not seeing her for three years because she was in Jordan. . .He called her and said: come here and travel with me. He was a psychological wreck. And my mother’s heart bled for him. Then she said: I have to leave you; your brother needs me now more than you do. . . So, she left for Turkey. And they left in winter and their inflatable boat ruptured and water got inside, but God delivered them (McNatt et al., 2018, p. 9).

A number of risk and protective factors have been identified in the refugee mental health literature (Porter & Haslam, 2005). While some of these factors are gender-specific, others apply to both men and women. With respect to personal factors, younger age at migration has been found to be a reliable protective factor against mental health symptoms in a large-scale meta-analysis (Porter & Haslam, 2005). Personal resources and characteristics have also been found to buffer the effects of stress on adjustment. Individuals with a higher sense of coherence, a construct related to self-mastery and internal locus of control, were found to cope more effectively with migration stress and its psychological sequelae (Lindencrona et al., 2008). Interestingly, while education level may intuitively be viewed as a protective factor, Porter and Haslam (2005) found that higher levels of education prior to migration were associated with increased mental health challenges among refugees during resettlement. Highly educated refugees often experience a greater loss of the social recognition of competence, and consequently may experience heightened levels of stress (Porter & Haslam, 2005).

A significant body of research has demonstrated that refugee women suffer from higher levels of mental health problems than refugee men (Porter & Haslam, 2005). In addition to PTSD and depression, refugee women are more likely than their male counterparts to report psychosomatic complaints, for example, fatigue, dizziness, and headaches (Al-Krenawi, 2020). In large-scale studies, depressive disorders have been found in 41.9% of refugee women compared to 29.3% in refugee men (World Health Organization [WHO], 2021). Hamdan (2009) pointed out that women are more likely to suffer various disorders including depression, anxiety disorders, somatization. Women of the Arab world are diverse in terms of ethnicity, religion, and culture. Nevertheless, there are some regional trends that uniquely affect the approach to health care in the region. Islam and other spiritual elements play a significant role in women’s view and response to their health needs across educational and socioeconomic lines. As one Palestinian woman said, ‘Of course screening for cancer is important . . . but it won’t change the fact that health and illness are in the hands of Allah’. While religiosity offers comfort in the face of ill health, it may cause some to avoid seeking health care until absolutely necessary (Asi, 2020, p. 1).

Furthermore, the ways in which refugees display emotional distress tend to be gender specific. For example, while it is often considered socially acceptable for refugee women to seek support when needed many refugee men follow their traditional gender roles and attempt to minimize their distress (Al-Krenawi, in Press). In some cases, they adopt coping behaviors that are injurious to themselves and others, such as engaging in domestic violence or abusing substances (Al-Krenawi, in Press; Deacon & Sullivan, 2009).

Policies and issues related to refugee trauma, resettlement, adjustment, and health outcomes have received a great deal of attention in the scholarship (Kirmayer et al., 2014; Porter & Haslam, 2005; Steel et al., 2009). Much of the earlier research on refugees, however, was gender blind (Goodkind & Deacon, 2004). Such research failed to disentangle the ways in which gender may shape the experience of migration and resettlement. Research on gender-based differences in war settings gained increased attention in the 1980s and 1990s, stimulated by media reports of ethnic cleansing and rape camps during the Yugoslavian civil war (Pittaway & Bartolomei, 2001). Recent decades have seen a greater emphasis on studying the experiences of refugee women (Goodkind & Deacon, 2004; Pittaway & Bartolomei, 2001). In this research, women refugees have often been portrayed as vulnerable victims of war and violence, and thus in need of protection from male family members or from foreign humanitarian aid workers. While women may indeed be at greater risk than men of gender-based violence in war settings, the aforementioned attitudes can potentially lead to the further oppression and marginalization of refugee women, as well as invalidate their lived experience (Al-Krenawi, in press). An alternative approach is that of gender-sensitive research, which builds on the premise that gender roles and power differentials often affect the lived experiences of individuals, including immigrants and refugees (Trbovc & Hofman, 2015).

By adopting a more gender and cultural-sensitive approach, we can begin to better understand the multifaceted ways in which gender and culture shape refugees’ migration and resettlement experiences (Trbovc & Hofman, 2015). During the process of resettlement refugees encounter a host of challenges and barriers, including a new language, being un- or underemployed, discrimination, culture shock, acculturative stress, and cultural bereavement (Young & Chan, 2015). These stressors have been found to negatively affect refugee wellbeing (Abu Tarboush, 2014; Deacon et al., 2009). Furthermore, gender may play a significant role in shaping the economic adaptation and employment of refugees (Aljundi, 2016). Studies have shown that the process of acculturation is stressful under a wide range of conditions, and refugees must add to an already taxing list of forced migration stressors the negotiation of conflicts that arise when identity, values, and behaviors of the heritage culture do not match those of the dominant culture (Al-Krenawi et al., 2021). Marital conflict, for example, may emerge when members of a couple follow different acculturation strategies (Al-Krenawi & Al-Krenawi, 2022). Refugee women who work outside the home often have greater exposure to the new culture and thus adopt new cultural norms, behaviors and language more readily compared to their husbands (Al-Krenawi, in press). Yet, many refugee women who are employed out of the home continue to shoulder the main responsibilities for the household and childrearing. As a result, refugee women are stuck with the infamous ‘triple burden’ of caretaking, work for income, and work that supports the community (Zibani, 2016). With respect to gender differences, scholars have suggested that immigrant women tend to experience significantly higher levels of acculturative stress and depression compared to their male counterparts due to a ‘double burden’ or ‘role overload’ (Dion & Dion, 2001). To the best of our knowledge, the current study is among the first to compare the psychological, self-esteem, family function, marital satisfaction, and life satisfaction of male and female Syrian refugees in Jordan.

Hypothesis

Based on previous studies in the Arab world, we hypothesized that Syrian refugee women will report more psychological problems, lower self-esteem, more problems in family function, less marital satisfaction and less life satisfaction compared to Syrian refugee men.

Method

A sample of 369 refugees participated in this study. Of the sample, 290 participants completed the questionnaire and met the selection criteria of being married and living in the refugee camp. Of these 290, 196 were women and 94 were men. Data was collected in 2018 from Azrak camp, home to 36,874 Syrian refugees, of which nearly 21% are under 5 years old. Children account for 61.50% of the refugees, including 100 unaccompanied and separated children. Among the refugees in the camp, 1,179 (3.20%) have disabilities. One in four households are headed by women. There are 8,660 shelters currently in use in the camp. The camp is co-coordinated by Syrian Refugee Affairs Directorate (SRAD) and UNHCR. Azrak has the potential to be expanded to accommodate 120,000 to 130,000 refugees at maximum capacity (UNHCR, 2021). It is located in a desert region 90 km from the Jordan-Syria border and is 15 km in length. The camp’s decentralized facilities, including health clinics and child play areas, were intended to provide the functionality of multiple villages within the camp. The objective of this design was for the camp to mimic more traditional Syrian social structures and improve upon safety concerns that have plagued other refugee camps (Knell et al., 2014; Oddone et al., 2014, cited in Meade, 2021).

A snowball method of sampling was used which was conducted by local female and male students trained to collect data according to culturally competent methods. To facilitate the research, the data collectors were selected from NGOs that operate in the camp. In cases of limited reading or writing skills, the interviewers read the questionnaire to the respondent and completed it according to the given responses. The data collectors met with the participants prior to the interview and explained the goal of the study, the issue of confidentiality, and that no identifying information would be used in the study. After receiving the consent of the participants to participate in the study, the interview was conducted in a location convenient to the respondent. All respondents were informed that their participation was voluntary and that they could withdraw their consent at any time during the interview. All research instruments were translated into Arabic and back translated for accuracy of translations.

Ethical approval

All interviews were carried out with the voluntary consent of participants and anonymity was assured to all study participants. Ethical approval for the study was given by the Ethical Review Board of the Al-Ahliyya Amman University, Amman, Jordan.

Research instruments

Socio-demographic characteristics

Social and demographic variables included participant’s age, age of marriage, education level, number of children, satisfaction with economic state, number of rooms in their camp house, and physical and psychological aggression in the family.

The Symptoms Checklist (SCL)-90

The SCL-90 is a self-report questionnaire originally designed to assess the symptomatic behavior of psychiatric outpatients (Derogatiset al., 1973). It has since been applied as a psychiatric case-finding instrument, as a measure of symptom severity, and as a descriptive measure of psychopathology in different populations (Derogatis, 2000). The SCL-90 is intended to measure symptom intensity on nine different subscales: somatization, interpersonal sensitivity, obsessive-compulsive behavior, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. The 90 items of the questionnaire are scored on a 5-point Likert scale, indicating the rate of occurrence of the symptom during the time reference. The instrument’s global index of distress is the Global Severity Index (GSI), which is the mean value of all the 90 items (Derogatis, 2000). To assess the reliability of individual symptomatic measures and the Global Severity Index (GSI) in SCL-90 Cronbach’s alpha coefficients were calculated. Values of the coefficient that were higher than .7 were considered acceptable. Reliabilities of the nine subscales in this study were satisfactory (Cronbach’s α = .74–.82) and the reliability of the GSI was high (Cronbach’s α = .96).

Rosenberg Self-Esteem (SE) Scale

The Rosenberg (1979) SE scale consists of 10 items, which range from a score of 1 to 4 with higher scores indicating higher SE. It has high internal consistency (Gutman measurement of reconstruction 0.92) and high test-retest validity (r = .85). The Rosenberg Self-Esteem Scale is a widely used instrument that has been tested for reliability and validity in many settings including with Arab people (Al-Krenawi, 2014). The SE scale yielded a satisfactory level of internal consistency in the current study (Cronbach’s α = .73).

McMaster Family Assessment Device (FAD)

Family function was assessed by using the McMaster FAD (Epstein et al., 1983). It has 60 items on the following seven dimensions of family functioning: (1) problem solving; (2) communication; (3) roles in the family; (4) emotional involvement; (5) behavior control; (6) emotional responses; and (7) general functioning. All subscales range from 1 to 4, with higher scores indicating more problems in a family’s functioning. Previous findings indicated that the scale has satisfactory reliability (Cronbach’s α = .72–.92), good test-retest reliability (r = .66) and high validity, as indicated by comparing the scale’s scores with other measures of the same matters (Epstein et al., 1983). Ridenour et al. (1999) found that the 12 items of the subscale ‘general functioning’ give a satisfactory picture of the family’s general functioning, and there is little to gain in using all 60 questions. In the current study, we used only the 12 items that assess the family’s general functioning (Al-Krenawi & Slonim-Nevo, 2008). The results of the study found that the reliability value of the FAD instrument for measuring family functionality was .972 exceeding the alpha value of .6. Furthermore, the reliability of less than .60 is considered low and unacceptable. The reliability of the subscale was satisfactory (Cronbach’s α = .71).

Marital Satisfaction Scale (ENRICH)

We used the Enrich questionnaire, following a comprehensive overview of the literature on marital problems and interpersonal conflicts (Fournier and Olsen as cited in Lavee et al., 1987). The questionnaire, which measures satisfaction with marriage and quality of adjustment to marriage, is divided into eight parts, each containing 10 items. Several studies (Lavee et al., 1987) found that it has a rather high reliability (Cronbach’s α = .88–.89). Other studies indicated a high degree of discriminating validity and concurrent validity. Research that used this instrument in Arab society (Al-Krenawi, 2014) found a satisfactory level of internal reliability (Cronbach’s α = .96). In this study, we used the shortened version of the ENRICH questionnaire composed by Lavee that includes 10 items, each rated on a Likert scale ranging from 1 (less) to 5 (great satisfaction). The internal reliability of the shortened version among the sample in the current study is high (Cronbach’s α = .82).

Satisfaction With Life Scale (SWLS)

We used the SWLS scale, which consists of five items examining life satisfaction. It uses a Likert scale ranging from 1 (low) to 7 (high satisfaction); the scale has high internal reliability (Cronbach’s α = .87) and good stability examined by test-retest reliability (r = .82; Diener et al., 1985). Diener et al. (1985) tested the validity of the scale by comparing it with existing scales finding good validity. The internal consistency coefficient (Cronbach’s alpha) for the Syrian SWLS was .74, suggesting adequate internal consistency for the sample of Syrian refugee participants. The internal reliability in the current research was satisfactory (Cronbach’s α = .74).

Results

This section will present the study results that test the study’s hypothesis, showing the differences between the groups (men vs. women) by using various statistics such as: t-test, χ², and linear regression. Table 1 represents the demographic characteristics of participants. Overall, women were younger than men, and women were married younger than the men in this sample. Men were found to have more years of formal education than women. Male participants reported more children compared to female participants. Most of the participants reported being unsatisfied with their economic status, as indicated in Table 1. Both men and women reported a high level of physical and psychological aggression within their families, with women reporting a higher level than men.

Table 1.

Socio-demographic characteristics of the sample (M ± SD).

	Men (n = 94)	Women (n = 196)	Statistical t test value
Age (year)	42.73 ± 8.31	30.82 ± 9.03	9.03**
Age of marriage	21.11 ± 5.0	18.12 ± 3.23	4.75**
Education	11.52 ± 4.90	8.53 ± 4.74	5.28*
Number of children	6.72 ± 3.77	4.56 ± 3.03	5.67**
Satisfaction with economic state	–	–	χ² = 9.09^*
Unsatisfied	30%	40%	–
Moderately satisfied	17%	10%	–
Numbers of rooms in the house	2.5	2.1	χ² = 10.60*
Physical and psychological aggression in the family	39.9%	60%	χ² = 5.570*

p < .05. **p < .01 between men and women.

Analyses of the differences between men and women in family function and well-being and mental health symptoms were assessed using independent sample t-tests. As demonstrated in Table 2, women experienced more problems in family functioning compared to men; women reported lower marital satisfaction, less SE, and less satisfaction with life. In addition, women experienced more mental health symptoms as indicated by higher levels of somatization, obsessive-compulsive behavior, interpersonal sensitivity, depression, hostility, phobic anxiety, paranoid ideation, and psychoticism and their general severity index was higher as well (GSI).

Table 2.

Differences in family function, wellbeing, and mental health symptoms (mean ± SD).

	Men (n = 94)	Women (n = 196)	t Value
Family functioning (FAD)	2.30 ± 0.37	3.54 ± 0.40	5.12**
Marital relationship (Enrich)	2.91 ± 0.5.30	3.40 ± 0.56	3.95**
Self esteem	2.61 ± 0.44	2.99 ± 0.39	5.47**
Life satisfaction (SWLS)	3.77 ± 1.17	4.70 ± 0.99	5.05**
Mental health (SCL-90)
Somatization	2.021 ± 0.37	4.65 ± 0.69	4.50**
Obsessive-compulsive	1.77 ± 0.37	2.85 ± 0.82	2.79**
Interpersonal sensitivity	2.23 ± 3.79	1.94 ± 0.75	2.58*
Depression	2.10 ± 0.41	3.79 ± 0.77	3.70**
Anxiety	1.89 ± 0.25	2.77 ± 0.73	3.07
Hostility	1.23 ± 0.50	2.85 ± 0.75	3.59**
Phobic anxiety	1.09 ± 0.39	2.72 ± 0.80	3.59**
Paranoid ideation	1.18 ± 0.37	2.84 ± 0.69	3.77**
Psychoticism	1.09 ± 0.36	2.77 ± 0.78	3.75**
GSI	1.10 ± 0.46	2.84 ± 0.63	3.89**

Note. FAD = Family Assessment Device; SWLS = Satisfaction With Life Scale; SCL-90 = symptom checklist-90; GSI = global severity index.

p < .05. **p < .01 between male and female.

Next, multivariate linear regression analysis was used to assess the effect of gender on the various measures of family function and marital satisfaction, wellbeing, and mental health symptoms, while controlling for socio demographic variables. Gender was entered as the independent measure while controlling for the effects of age, education, and economic status. Regressions were conducted for each of the study’s dependent measures. Standardized effects of the independent variables and R² are presented in Table 3. The results supported the research hypothesis. Gender was found to be a major predictor of marital relationship, SE, subjective well-being, and mental health symptoms. Specifically, it was demonstrated that women experienced less marital satisfaction, lower SE, and less life satisfaction compared to men. Furthermore, women were found to have more mental health problems. In particular, women experienced more somatization, obsessive-compulsive behavior, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. In addition, the GSI of women was higher than the GSI of men, indicating that women experienced more mental health symptoms.

Table 3.

Male-female and socio-demographic variables as predictors of the study’s dependent measures: Standardized regression effect and R².

	Gender	Age	Education	Economic state	R ²
Family functioning (FAD)	0.04	−0.05	0.03	−0.26^**	0.059
Marital relationship (Enrich)	0.30^*	0.25^**	0.02	−0.07	0.170^**
Self esteem	0.39^**	0.06	0.03	−0.05	0.194^**
Life satisfaction (SWLS)	0.37^**	0.08	0.07	0.08	0.163^**
Mental health (SCL-90)
Somatization	−0.49^**	0.12	−0.17	−0.33^**	0.266^**
Obsessive-compulsive	−0.34^**	0.11	−0.07	−0.18	0.097^*
Interpersonal sensitivity	−0.33^**	0.09	−0.12	−0.19^*	0.104^**
Depression	−0.43^**	0.09	−0.04	−0.27^**	0.159^**
Anxiety	−0.26^**	0.24^*	−0.19	−0.20^*	0.151^**
Hostility	−0.37^**	−0.03	−0.09	−0.28^**	0.154^**
Phobic anxiety	−0.41^**	0.13	−0.22^*	−0.24^**	0.194^**
Paranoid ideation	−0.40^**	0.09	−0.26^**	−0.23^**	0.213^**
Psychoticism	−0.38^**	0.09	−0.18^*	−0.17^*	0.177^**
GSI	−0.45^**	0.13	−0.16	−0.27^**	0.202^**

Note. FAD = Family Assessment Device; SWLS = Satisfaction With Life Scale; SCL-90 = Symptom Checklist-90; GSI = Global Severity Index.

p < .05. **p < .01 between 0 – male and 1 – female.

Several of the socio-demographic variables were found to be associated with the research dependent variables. Women’s age was positively associated with marital satisfaction and anxiety. More educated women experienced less phobic anxiety, paranoid ideation, and psychoticism. Higher economic status predicted fewer family problems and fewer mental health issues.

Discussion

The present study reveals significant differences between women and men in the following parameters: Marital satisfaction, SE, and life satisfaction, indicating less subjective wellbeing for women. Likewise, as indicated in Tables 2 and 3, many of the mental health symptoms in this study were more common in women; particularly noteworthy were somatization, obsessive compulsive behavior, interpersonal sensitivity, depression, hostility, psychoticism, and higher scores on the GSI. Broadly, the findings of the current study on Syrian women refugees align with previous studies on women in Arab societies. A robust literature has indicated that cultural factors, arising mainly from the subordinate position of women in Arab communities, influence the prevalence, pattern, and management of psychiatric disorders among Arab women in traditional societies (Al-Krenawi, 2020; El Islam, 2001). A number of culture-related risk factors, including education, work, marriage, polygamy, sexuality, infertility, domestic violence, sexual harassment, lack of birth control, among others, are associated with mental disorders among women in the Arab world (Al-Krenawi, 2014, 2020; Hamdan, 2009; Saif Al Dawla, 2001). Koranic verses such as the following have been cited to support such an argument: ‘Men are superior (kawamouna) to women because Allah has made some of them to excel others . . ..’ [Koran, 4, 34]. Regarding women’s symptomology and traditional Arab societies, Chaleby (1988) found that, among female outpatients who were either married or divorced, conjugal discord and wife abuse were more frequent when the couple had not met before the marriage ceremony or were consanguineous. Traditional marriage was also more likely to be associated with anxiety and dysthymic disorders, and to affect women more than men (El-Zanaty et al., 1996).

Unsurprisingly, economic status emerged as a primary hardship in the current study. This is consistent with previous studies on refugees, such as that conducted by Al-Zaghoul (2016), who found that securing sufficient funds to meet daily needs was a major stressor among residents of the Al-Zaatari camp. Syrian refugees live in challenging conditions in Jordan, whether in camps or in the governorates. Their high rates of unemployment increase the likelihood of forced child labor, as families try to supplement their income. Overcrowding tends to increase stress and heighten conflict between family members. This may provide a partial explanation for the psychological and physical aggression reported by the participants. Life after displacement and forced migration affects all levels of society: the individual, the couple, the family, and the community (Al-Zaghoul, 2016; Deacon et al., 2009). Studies have demonstrated that family separation is a central stressor for refugees – but so is family reunification, which involves major, multiple, and often conflictual reorganizations of roles and relationships (Barudy, 1989, cited in Kirmayer et al., 2014). In their study of refugees from the Ivory Coast, Hossain et al. (2014) found that 57.1 % of refugee women reported being victims of physical and/or sexual violence. A high percentage of men (40.2 %) also reported that they had experienced physical and/or sexual violence. Notably, the study concluded that intimate partner violence and trauma may be even more widespread than conflict-related sexual violence. Tensions between Syrian refugees and Jordanians in host communities due to competition over limited resources and job opportunities, as well as variations in habits and customs, may contribute to the heightened levels of aggression found in refugee families and communities.

The gender construction of women as stoic wives and mothers has been theorized to contribute to the prevalence of the types of symptomatology found in the current study. Powerlessness (both real and perceived), paucity of choices, and limitations on social, economic, and familial resources may generate distress (Al-Krenawi, 2020). Moreover, the notion of self-sacrifice has a cultural and political dynamic in Arab societies, and the need to maintain a relationship for the sake of the children is a significant motivator for many Arab women. Despite inroads being made in this direction, greater awareness is called for on the part of practitioners and policymakers about the specific psychological, familial, and economic effects of living in refugee camps on women. As the findings of the current study demonstrate, refugee women experience heightened levels of marital distress. Such distress may negatively impact on the wellbeing of their children – high percentages of whom do not receive any formal education and who are at high risk for emotional and behavioral disorders (Christophersen, 2015; Fazel & Stein, 2002). It is worth mentioning that research on the intergenerational impact of refugee trauma is only in its very early stages (Sangalang & Vang, 2017).

Implications for practice

The majority of the Syrian refugees living in Jordan have experienced potentially traumatic events, and many have difficulty meeting their most basic needs. Such experiences are associated with increased risk of psychopathology (Steel et al., 2009), yet the mental health impact of traumatic dislocation on Syrian refugees, particularly the women in this population, remains poorly understood. According to Michelson and Scare (2009, cited in Murray et al., 2010), there is often a mismatch between refugees’ mental health and the services that are made available to them. In the current context, the design of effective interventions for Syrian refugee populations requires knowledge about how Syrians perceive and express distress. Thus, it is important to gain an understanding of Syrian culture-specific expressions of distress, healing practices, and coping strategies. For example, there is a need for community initiatives to promote resilience and increase the use of positive coping mechanisms such as cultural, religious, and traditional healing rituals, skills, and strategies (Al-Krenawi, 2016). Arab clients may express their distress through metaphors and proverbs. Culturally specific idioms of distress and explanatory models of illness and health are crucial to understanding this process of meaning-making (Kleinman, 1988), as well as the considerations of social context and power structures (Kirmayer, 2006). Individuals and practitioners need to co-construct a shared understanding of the focus of treatment. Among Arab persons, common idioms of distress may include one’s whole life or self being tired, an unbearable sense of pressure, or the world closing in front of one’s face (Al-Krenawi, 2000). Culturally competent programs give due recognition to indigenous wisdom and promote what Papadopoulos (2007) has referred to as ‘Adversity-Activated Development’ (p. 6, cited in Murray et al., 2010).

Gender may significantly shape the relocation and adjustment experience of refugees. According to Deacon et al. (2009), the gendered experiences of women refugees during conflict and flight, alongside the adversities of dislocation, make their needs substantially different from those of male refugees. In their review article on the psychological wellbeing of refugees resettling in Australia, Murray et al. (2008) noted that being a woman consistently resulted in worse resettlement outcomes across studies in the literature. In this vein, Mohwinkel et al. (2018) found in their review of nine studies on gender differences in the mental health of unaccompanied refugee minors (URM) that female URM were more often affected by post-traumatic or depressive symptoms than their male counterparts. Scholars have stressed that there is a strong need to evaluate treatment interventions among groups that are currently being resettled (Lustig et al., 2003, cited in Murray et al., 2010). Moving from the individual to the policy level, there is a need for both researchers and international development agencies to advocate for improved gender mainstreaming with respect to refugee protection issues (Goodkind & Deacon, 2004; UNHCR, 2008). Gender mainstreaming refers to the practice of recognizing the inherent power imbalance between men and women and considering these gendered implications in the development, implementation, and evaluation of policies and interventions (Pittaway & Bartolomei, 2001). We recommend that such mainstreaming be incorporated in the broader systematic social integration of refugee men and women into the host country.

From a clinical perspective, gender-sensitive and culturally competent programs are urgently needed to improve the adaptation and wellbeing of refugee men and women (Celik et al., 2011; Eisenbruch et al., 2004). Gender sensitivity involves recognizing gender differences and inequalities with respect to health and adjustment and designing intervention-delivery to accommodate those differences (Al-Krenawi & Graham, 2000). Relatedly, culturally competent service providers aim to recognize their own cultural assumptions and take an active interest in acquiring new attitudes and knowledge (Al-Krenawi, 2020; Eisenbruch et al., 2004). It is worth emphasizing that different cultural traditions deal with trauma in different ways. Rather than the direct working through the trauma, favored in the West, some cultures prefer more indirect strategies. For example, as Arab clients often opt for treatment that is more medically focused, instrumental, and directive. It may be more in line with treatment expectations to use psychoeducational and cognitive behavioral therapies than a psychodynamic approach (Nasir & Al-Qutob, 2005). Additionally, a family perspective is useful, as the organized-violence-based traumas experienced by refugees tends to impact entire families, and this modality may be one that is more readily accepted by Arab clients (Al-Krenawi, 2000; Kirmayer et al., 2014). Murray et al. (2008) notes that the use of family-oriented interventions has had some reported success in the case of refugee treatment. Discussing the mental health needs of those who have suffered human rights abuses, Roizblatt et al. (2014) suggest that family therapy focusing on grief and trauma can help to deal with ‘the familial and psychological consequences of human rights violations’ which ‘is relevant not only for dealing with the past and in a specific locale. . . but also for the here and now’ (p. 36). This approach has the advantage of providing space for all family members to give voice to their experience, including those, such as women, who may be less inclined to do so due to cultural expectations. It is worth mentioning, however, that practice-based evidence for refugee-related interventions remains in its very beginning stage (Murray et al., 2010).

Conclusion

Despite a longstanding focus in the refugee literature on the psychological sequelae of trauma, an enormous gap remains in our knowledge of the mental health needs of women refugees. This study has contributed to addressing that gap, but a great deal remains to be done from an evidence-based perspective. Along with Murray et al. (2008), we advocate for an examination of the ‘breadth of human experience’ (p. 15) in the refugee population, with a special emphasis on women’s experience. Promising directions include the development of gender-sensitive assessment measures and longitudinal designs that map the processes associated with intergenerational trauma in families. The present study calls for further research on refugees, gender, and culture, toward developing culturally competent and effective practice. At this time of massive – and rapidly multiplying – refugee numbers on a global scale, such research is a desideratum.

Limitations of the study

This study has several limitations. First, we used the snowball method to recruit participants instead of using a random sample. Second, the study sample was relatively small. Third, the sample included participants from only one refugee camp, and we did not include Syrian males and females who live in the wider Jordanian community. Thus, it is recommended that policymakers and practitioners interpret the study findings with due caution.

Footnotes

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Melissa M. Bell

References

Abu Tarboush

. (2014). Social and psychological effects of the Syrian crisis on the Syrian refugee children in Jordan [Unpublished MA thesis]. The University of Jordan (in Arabic).

Aljundi

(2016). Gender-based violence among Syrian refugees: Reality and how to address it [Unpublished MA thesis]. The University of Jordan (in Arabic).

Al-Krenawi

(2000). Bedouin-Arab clients’ use of proverbs in the therapeutic setting. International Journal for the Advancement of Counselling, 22(2), 91–102.

Al-Krenawi

(2014). Psychosocial impact of polygamy: The Middle East case. Springer.

Al-Krenawi

(2016). The role of the mosque and its relevance to social work. International Journal of Social Work, 59(3), 359–367.

Al-Krenawi

(2020). Women and mental health: The Middle East Case. Whiting & Birch Ltd.

Al-Krenawi

(in press). Syrian refugees in Jordan and mental health: Challenges and culturally sensitive practice. Springer.

Al-Krenawi

(2022). Acculturative stress and reverse culture shock among international students: Implication for practice. The Arab Journal of Psychiatry, 33(1), 9–18.

Al-Krenawi

Alotabi

Elbedour

(2021). Acculturative stress among female Saudi college students in the United States. Community Mental Health Journal, 57(2), 372–379.

10.

Al-Krenawi

Graham

J. R.

(2000). Culturally sensitive social work practice with Arab clients in mental health settings. Health & Social Work, 25(1), 9–22.

11.

Al-Krenawi

Slonim-Nevo

(2008). Psychosocial and familial functioning of children from polygynous and monogamous families. Journal of Social Psychology, 148(6), 745–764.

12.

Al-Zaghoul

(2016). Problems facing Syrian refugees in Al-Zaatri refugee camp [Unpublished MA thesis]. The University of Jordan (in Arabic).

13.

Asi

M. Y.

(2020). Do Arab women need saving? The health of women in the Arab world. Arab Center Washington, DC.

14.

Barudy

(1989). A programme of mental health for political refugees: Dealing with the invisible pain of political exile. Social Science & Medicine, 28(7), 715–727.

15.

Boswall

Akash

R. A.

(2015). Personal perspectives of protracted displacement: An ethnographic insight into the isolation and coping mechanisms of Syrian women and girls living as urban refugees in northern Jordan. Intervention, 13(3), 203–215.

16.

Brune

Haasen

Krausz

Yagdiran

Bustos

Eisenman

(2002). Belief systems as coping factors for traumatized refugees: A pilot study. European Psychiatry, 17, 451–458.

17.

Budosan

Aziz

Benner

M. T.

Abras

(2016). Perceived needs and daily stressors in an urban refugee setting: Humanitarian emergency settings perceived needs scale survey of Syrian refugees in Kilis, Turkey. Intervention, 14(3), 293–304.

18.

Celik

Lagro-Janssen

T. A. L. M.

Widdershoven

G. G. A. M.

Abma

T. A.

(2011). Bridging gender sensitivity into healthcare practices: A systematic review. Patient Education and Counseling, 84, 143–149.

19.

Chaleby

(1988). Traditional Arabian marriages and mental health in a group of outpatients Saudis. Acta Psychiatrica Scandinavica, 77(2), 139–142.

20.

Christophersen

(2015). Securing education for Syrian refugees in Jordan. International Peace Institute. https://www.ipinst.org/wp-content/uploads/2015/05/IPI-E-pub-Securing-Education-for-Syrian-Refugees.pdf

21.

Cleveland

Rousseau

Guzder

(2014). Cultural consultation for refugees. In Kirmayer

L. J.

Guzder

Rousseau

(Eds.) Cultural consultation: Encountering the other in mental health care (pp. 245–266). Springer.

22.

Deacon

Sullivan

(2009). Responding to the complex and gendered needs of refugee women. Affilia, 24(3), 272–284. https://doi.org/10.1177/0886109909337401

23.

Derogatis

L. R.

(2000). The brief symptom inventory-18 (BSI-18): Administration, scoring and procedures manual. National Computer Systems.

24.

Derogatis

L. R.

Lipman

R. S.

Covi

(1973). SCL-90: An outpatient psychiatric rating scale–preliminary report. Psychopharmacology Bulletin, 9, 13–28.

25.

Diener

Emmons

R. A.

Larsen

R. J.

Griffin

(1985). The Satisfaction With Life Scale. Journal of Personality Assessment, 49, 71–75.

26.

Dion

K. K.

Dion

L. K.

(2001). Gender and cultural adaptation in immigrant families. Journal of Social Issues, 57, 511–521.

27.

Eisenbruch

de Jong

J. T. Y. M.

van de Put

(2004). Bringing order out of chaos: A culturally competent approach to managing the problems of refugees and victims of organized violence. Journal of Traumatic Stress, 17, 123–131.

28.

El Islam

. (2001). Social psychiatry and the impact of religion. In Okasha

Maj

(Eds.), Images in psychiatry: An Arab perspective (pp. 21–35). WPA Publications.

29.

El-Zanaty

Hussein

E. M.

Shawky

G. A.

Way

A. A.

Kishor

(1996). Egypt demographic and health survey-1995. National Population Council.

30.

Epstein

N. B.

Baldwin

L. M.

Bishop

D. S.

(1983). The McMaster family assessment device. Journal of Marital Family Therapy, 9, 171–180.

31.

Fazel

Stein

(2002). The mental health of refugee children. Archives of Disease in Childhood, 87, 366–370.

32.

Francis

(2015). Jordan’s refugee crisis. Carnegie Endowment for International Peace, 12.! http://carnegieendowment.org/2015/09/21/jordan-s-refugee-crisis-pub-61338

33.

Gammouh

O. S.

Al-Smadi

A. M.

Tawalbeh

L. I.

Khoury

L. S.

(2015). Chronic diseases, lack of medications, and depression among Syrian refugees in Jordan, 2013–2014. Preventing Chronic Disease, 12, E10. https://doi.org/10.5888/pcd12.140424

34.

Goodkind

J. R.

Deacon

(2004). Methodological issues in conducting research with refugee women: Principles for recognizing and re-centering the multiply marginalized. Journal of Community Psychology, 32, 721–739.

35.

Hamdan

(2009). Mental health needs of Arab women. Health care for Women International, 30(7), 593–611.

36.

Hiil. (2018). https://www.hiil.org/wp-content/uploads/2018/09/Justice-Needs-of-Syrian-refugees.pdf

37.

Hossain

Zimmerman

Kiss

Kone

Bakayoko-Topolska

Manan

Watts

(2014). Men’s and women’s experiences of violence and traumatic events in rural Côte d’Ivoire before, during, and after a period of armed conflict. BMJ Open, 4, e003644.

38.

Kirmayer

L. J.

(2006). Beyond the “new cross-cultural psychiatry”: Cultural biology, discursive psychology and the ironies of globalization. Transcultural Psychiatry, 43, 126–144. http://doi.org/10.1177/1363461506061761

39.

Kirmayer

L. J.

Guzder

Rousseau

(Eds.). (2014). Cultural consultation: Encountering the other in mental health care. Springer.

40.

Kleinman

(1988). Rethinking psychiatry: From cultural category to personal experience. Simon and Schuster.

41.

Lavee

McCubbin

H. I.

Olson

D. H.

(1987). The effect of stressful life event and transitions of family functioning and well-being. Journal of Marriage and Family, 49, 857–873.

42.

Lindencrona

Ekblad

Hauff

(2008). Mental health of recently resettled refugees from the Middle East in Sweden: The impact of pre-resettlement trauma, resettlement stress and capacity to handle stress. Social Psychiatry Psychiatric Epidemiology, 43, 121–131.

43.

Lustig

S. L.

Kia-Keating

Grant-Knight

Geltman

Ellis

Birman

Kinzie

Keane

Saxe

(2003). Review of child and adolescent refugee mental health. White Paper, National Child Traumatic Stress Network, Refugee Trauma Task Force. http://www.nctsnet.org/nctsn_assets/pdfs/reports/refugeereview.pdf

44.

McNatt

Boothby

Al-Shannaq

Chandler

Freels

Mahmoud

Majdalani

Zebib

(2018). Impact of the separation on refugee families, Syrian refugees in Jordan. Amman. Columbia Global Centers, UNHCR MENA Director’s Office in Amman.

45.

Meade

(2021). https://storymaps.arcgis.com/stories/c3315f5c71e644e09f2b1f0507c31b82

46.

Michelson

Scare

(2009). Psychological needs, service utilization and provision of care in a specialist mental health clinic for young refugees: A comparative study. Clinical Child Psychology and Psychiatry, 14, 273–296.

47.

Mohwinkel

L.-M.

Nowak

A. C.

Kasper

Razum

(2018). Gender differences in the mental health of unaccompanied refugee minors in Europe. A systematic review. BMJ Open, 8(7), e022389. https://pub.uni-bielefeld.de/record/2930453

48.

Murray

K. E.

Davidson

G. R.

Schweitzer

R. D.

(2008). Psychological wellbeing of refugees resettling in Australia. The Australian Psychological Society. https://psychology.org.au/getmedia/73cf6347-82f2-4b2d-bb27-6ccc123f8bb8/refugee-literature-review.pdf

49.

Murray

K. E.

Davidson

G. R.

Schweitzer

R. D.

(2010). Review of refugee mental health interventions following resettlement: Best practices and recommendations. The American journal of orthopsychiatry, 80(4), 576–585. https://doi.org/10.1111/j.1939-0025.2010.01062.x

50.

Nasir

L. S.

Al-Qutob

(2005). Barriers to the diagnosis and treatment of depression in Jordan. A nationwide qualitative study. The Journal of the American Board of Family Practice, 18(2), 125–131.

51.

Papadopoulos

R. K.

(2007). Refugees, trauma, and adversity-activated development. European Journal of Psychotherapy and Counselling, 9, 301–312.

52.

Pittaway

Bartolomei

(2001). Refugees, race, and gender: The multiple discrimination against women. Refugee, 19, 21–32.

53.

Porter

Haslam

(2005). Pre-displacement and post displacement factors associated with mental health of refugees and internally displaced persons: A meta-analysis. Journal of the American Medical Association, 294(5), 602–612.

54.

Ridenour

T. A.

Daley

J. G.

Reich

(1999). Factor analyses of the family assessment device. Family Process, 38, 497–510.

55.

Rosenberg

(1979). Conceiving the self. Basic Books.

56.

Roizblatt

Biederman

Brown

(2014). Extreme traumatization in Chile: The experience and treatment of families. Journal of Family Therapy, 36(S1), 24–38.

57.

Saif Al Dawla

(2001). Social factors affecting women’s mental health in the Arab region. In Okasha

Maj

(Eds.) Images in psychiatry: An Arab perspective (pp. 207–223). WPA Publications.

58.

Sangalang

C. C.

Vang

(2017). Intergenerational trauma in refugee families: A systematic review. Immigrant Minority Health, 19, 745–754. https://doi.org/10.1007/s10903-016-0499-7

59.

Silove

Ventevogel

Rees

(2017). The contemporary refugee crisis: An overview of mental health challenges. World Psychiatry.

60.

Stave

S. E.

Hillesund

(2015). Impact of Syrian refugees on the Jordanian labour market: Findings from the governorates of Amman, Irbid and Mafraq. International Labour Organization (ILO) and Fafo Research Foundation.

61.

Steel

Chey

Marnane

Bryant

R. A.

van Ommeren

(2009). Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: A systematic review and meta-analysis. Journal of the American Medical Association, 302(5), 537–549.

62.

Trbovc

J. M.

Hofman

(2015). Toolkit for integrating gender-sensitive approach into research and teaching. https://eige.europa.eu/sites/default/files/garcia_working_paper_6_toolkit_integrating_gender_research_teaching.pdf

63.

UNHCR. (2008). UNHCR handbook for the protection of women and girls. Retrieved May 20, 2014, from http://www.unhcr.org/47cfae612.html

64.

UNHCR. (2019). https://www.unhcr.org/statistics/unhcrstats/5ee200e37/unhcr-global-trends-2019.html

65.

UNHCR. (2013). UNHCR mid-year trends 2013. Retrieved May 20, 2014, from http://www.unhcr.org/52af08d26.html

66.

UNHCR. (2021). UNHCR Jordan: Azraq Refugee Camp – Factsheet, June 2021. https://reliefweb.int/report/jordan/unhcr-jordan-azraq-refugee-camp-factsheet-june-2021

67.

UNHCR. (2017). Resettlement and Other Forms of Admission for Syrian Refugees. http://www.unhcr.org/52b2febafc5.html

68.

World Health Organization. (2021). Gender and Women’s Mental Health UNHCR (2021). https://reporting.unhcr.org/sites/default/files/Jordan%20country%20factsheet%20-%20February%202021.pdf

69.

Young

M. Y.

Chan

K. J.

(2015). The psychological experience of refugees: A gender and cultural analysis. In Safdar

Kosakowska-Berezecka

(Eds.), Psychology of gender through the lens of culture: Theories and applications (pp. 17–36). Springer.

70.

Zibani

(2016). The triple burden and the triple role of women. https://www.empowerwomen.org/en/community/discussions/2016/11/the-triple-burden-and-triple-role-of-women