Journal of Psychosocial Nursing and Mental Health Services

Original Article 

Social Determinants of Resilience Among Syrian Refugees in Jordan

Hamza Alduraidi, PhD, MPH, RN; Latefa Ali Dardas, PhD, PMHN, CP; Malena M. Price, MScGH

Abstract

The current study explores the level and social determinants of resilience among Syrian refugees residing in Jordan. Having high levels of resilience can help refugees positively adapt to challenges and cope with the burden of stressors associated with warfare, turmoil, and displacement. A sample of 151 Syrian refugees ages 18 to 69 residing in Jordan completed the Arabic version of the Connor-Davidson Resilience Scale. Resilience scores among Syrian refugees in Jordan were generally low. Refugees' place of residence, educational level, employment status, and monthly income were significantly associated with lower resilience scores and together explain approximately 37% of variance in resilience scores. Tailored resilience-building and educational programs are needed to help Syrian refugees develop the ability to withstand, adapt to, and recover from stress and adversity, and maintain or return to healthy mental states. Future research involving longitudinal assessment of resilience is needed to fully understand the role and determinants of resilience in this population. [Journal of Psychosocial Nursing and Mental Health Services, 58(8), 31–38.]

Abstract

The current study explores the level and social determinants of resilience among Syrian refugees residing in Jordan. Having high levels of resilience can help refugees positively adapt to challenges and cope with the burden of stressors associated with warfare, turmoil, and displacement. A sample of 151 Syrian refugees ages 18 to 69 residing in Jordan completed the Arabic version of the Connor-Davidson Resilience Scale. Resilience scores among Syrian refugees in Jordan were generally low. Refugees' place of residence, educational level, employment status, and monthly income were significantly associated with lower resilience scores and together explain approximately 37% of variance in resilience scores. Tailored resilience-building and educational programs are needed to help Syrian refugees develop the ability to withstand, adapt to, and recover from stress and adversity, and maintain or return to healthy mental states. Future research involving longitudinal assessment of resilience is needed to fully understand the role and determinants of resilience in this population. [Journal of Psychosocial Nursing and Mental Health Services, 58(8), 31–38.]

Refugees represent 32.8% (21.3 million) of the world's displaced population (Alduraidi & Waters, 2018). Currently, the highest concentrations of refugees reside in Lebanon, Jordan, Nauru, Turkey, Chad, and the United States (Bump, 2017). Since the fighting in Syria began in 2011, more than 470,000 people have been killed, 1 million injured, and several million forced to flee their homes for fear of persecution and seek asylum elsewhere (Rizkalla & Segal, 2018). Refugees have headed to other regions in Syria, or other countries in search of safety and protection (Rizkalla & Segal, 2018). The United Nations (UN) has declared the Syrian crisis to be the worst and largest refugee crisis since World War II (Murphy et al., 2016).

Most Syrian refugee communities in Jordan (approximately 80%) are located in non-camp settings, specifically in cities close to the northern border between Jordan and Syria, including Mafraq and Irbid, and in greater Amman (Figure 1). Many Syrians are illegally smuggled into Jordan for various reasons, such as lack of identification, lack of mobility, and fear of arrest, and thus, these individuals are not registered by the UN High Commissioner for Refugees (UNHCR) (Rizkalla & Segal, 2018). Eighty-five percent of Syrian refugees in Jordan live below the poverty line (96 USD per individual monthly). Forty-eight percent of Syrian refugees are children (<15 years old), and 4% are older adults (Government of Jordan [GOJ] & Fafo Institute for Applied International Studies, 2019). Given Jordan's small size and limited economic resources, burdened health infrastructure, and dwindling water supply, the country lacks adequate capacity to meet the needs of Syrians, as well as other refugee populations that it has welcomed through its borders. The clear concentration of poverty and unemployment among Syrian refugee communities requires resilience to adapt to these socioeconomic hardships. Thus, the purpose of the current study is to explore the levels and social determinants of resilience among Syrian refugees who reside inside and outside refugee camps in Jordan.

Location of Syrian refugees in Jordan in 2017. Source: UNHCR (2017; in the public domain; permission is not required).

Figure 1.

Location of Syrian refugees in Jordan in 2017. Source: UNHCR (2017; in the public domain; permission is not required).

Facing high unemployment, nonexistent political freedoms, and limited opportunities for upward mobility, Syrian individuals witnessed their country implode and reach unparalleled heights of unrest. With nothing but a passport (if they possessed one), the clothes on their back, and revered and cherished photographs, the Syrian population has been forced to cross borders of turbulence and show resilience in the face of monumental plight. They have made it to neighboring nations, such as Lebanon, Jordan, and Turkey, to stay safe and salvage their lives and their family's lives, and muster up hope that there will be a better future.

From an estimated pre-war population of 22 million, the UN has identified 13.5 million Syrian refugees around the world requiring humanitarian assistance (Doocy et al., 2015). Moreover, it is estimated that since 2011, 5 million Syrian individuals have been forced to flee their home country (Doocy et al., 2015). As of May 2020, more than 5.6 million Syrian refugees were registered with the UN Refugee Agency (UNHCR, 2020). There is also an unregistered population that is unknown in size, and an internally displaced population in Syria that totals 6.6 million individuals (UNHCR, 2016). Jordan hosts 693,704 registered Syrian refugees alone, but this only represents a fraction of the total number of Syrian refugees in the country, which is estimated to be 1.4 million, or 20% of Jordan's population (Rizkalla & Segal, 2018). Despite assistance made available to them, Syrian refugees residing in Jordan are not able to make ends meet, and thus, are at higher risk for poor health outcomes. Furthermore, as confirmed in a comparative cross-sectional study, poorer refugees are less likely to have good social relations and environmental health-related quality of life (Alduraidi & Waters, 2018).

Resilience

Over the past several decades, the concept of resilience has received a great deal of attention as a psychological resistance against adversity (Connor & Davidson, 2003). Resilience has been explored through psychosocial, genetic, biological, and neurobiological fields (Davydov et al., 2010; Rutten et al., 2013). Resilience has been studied on individual, social, and ecological levels, and has been used to assess protective and risk factors related to positive and negative psychological and mental health outcomes (Doty, 2010). However, it is important to note that, especially in the field of mental health, conceptualizations of resilience have been heavily contested and debated due to non-uniformity of the contexts in which resilience is defined.

Resilience is defined as an ability in children and adults to adapt to, adjust to, or overcome chronic or acute adversity, providing protection against the development of psychopathology (Connor & Davidson, 2003). However, taking an alternative approach, Bonanno (2004) criticizes resilience as a personality characteristic that is linked to an absence of pathology and/or assumed to be an indicator of good health. Instead, he is in favor of an approach that involves clear temporal delineation of an adverse event and recognition of resilience as a stable adjustment to that event (Bonanno, 2004). Bonanno (2004) also measures resilience at multiple time points post-adversity.

Increased political instability in the Middle East over the years has forced hundreds of thousands of individuals to leave their homes in search of safety and asylum. Conflict-driven forced displacement is inextricably linked to increased burden of mental illness in impacted populations (Bonanno, 2012). Externally (i.e., crossing borders) and internally (i.e., within country) displaced migrants are at higher risk for depression, posttraumatic stress disorder (PTSD), anxiety, somatization, and other psychological illnesses (Bonanno, 2012). However, the literature indicates individual and communal resilience can act as potential protective and mediating factors in the development of mental illness (Siriwardhana & Stewart, 2013; Stewart, 2010; Tol et al., 2013). Prior research also found that lower levels of resilience associated with prolonged displacement, continued adversity, and older age of forced migrants predicted poor mental health outcomes, and higher levels of resilience associated with better socioeconomic circumstances, younger migration age, and social support were associated with better outcomes (Mels et al., 2010; Siriwardhana & Stewart, 2013; Tol et al., 2013; Ziaian et al., 2012).

The current article presents findings from a study conducted among a population of urban and camp Syrian refugees who have been affected by 7 years of prolonged displacement. The study aimed to explore levels and social determinants of resilience among Syrian refugees in Jordan.

Method

Design

The current study used a cross-sectional, descriptive design, where participants were approached in the community in two settings: inside Al-Azraq Syrian refugee camp in northeast Jordan, and in Jordan's largest cities, Amman and Zarqaa'. Levels of resilience were tested and compared to identify social determinants.

Data Collection

Prior to data collection, Institutional Review Board approval was obtained from the University of Jordan to ensure ethical integrity of the study. In summer 2018, Syrian refugee communities inside and outside camps were approached. Potential participants signed informed consent indicating their agreement to participate in the study. After applying inclusion criteria, a sample of 151 adult Syrian refugees in Jordan was recruited; 60 from Al-Azraq refugee camp, and 91 from the cities of Amman and Zarqaa'. Inclusion criteria were: official registration as a Syrian refugee in the UNHCR registrar, age ≥18 years, and ability to read simple Arabic (7th grade level). No specific exclusion criteria were applied.

Measures

Participants filled out a survey consisting of sociodemographic information, which addressed participants' gender, age, marital status, living place (i.e., inside camp or outside camp), educational level, employment status, and household's monthly income; as well as the Arabic version of the Connor-Davidson Resilience Scale (CD-RISC) (Toma et al., 2017). The CD-RISC is a self-report, 25-item assessment of adult individuals' psychological resilience level. Each item is rated on a 5-point Likert scale, where responses range from 0 (not true at all) to 5 (often true). The 25 items test a variety of concepts in the daily life of individuals, covering personal competence, trust in one's instinct, tolerance of negative events, acceptance of change, secure family and social relationships, control, and spiritual affect (Connor & Davidson, 2003). Based on their answers, each participant had a general resilience score ranging between 0 and 100, where higher scores indicated greater levels of resilience. The CD-RISC has been used in multiple studies in various cultures and languages. The Arabic version of the CD-RISC shows excellent psychometric properties, with a reported internal consistency reliability (Cronbach's alpha) of 0.91 (Alqudah, 2013).

Statistical Analysis

Data collected from participants were entered, cleaned, and analyzed using IBM SPSS 23.0. To answer research questions, the following statistical tests were run: (a) descriptive statistics to summarize sample sociodemographic characteristics; (b) independent sample t tests to test the association between resilience score and dichotomous independent factors, such as gender, living place, and employment status; (c) oneway analysis of variance (ANOVA) to test the association between resilience score and ordinal independent factors, such as age group, marital status, educational level, and income level; and (d) multiple linear regression to determine social determinants that contribute to refugees' overall resilience level.

Results

Sample Characteristics

The study sample comprised 151 adult Syrian refugees whose ages ranged from 18 to 69 years, with a mean of 31.3 (SD = 10 years). Age was recoded into three age groups for statistical purposes, as shown in Table 1. Most (73.5%) participants were males and married (54.3%), 31.8% were single, and a few reported being widowed (7.3%) or divorced (6.6%). Ninety-one (60.3%) participants resided in Amman or Zarqaa', and 60 (39.7%) participants resided in Al-Azraq refugee camp. Thirty-eight (25.2%) participants reported receiving education lower than middle school, 20 (13.2%) participants had middle school education, 70 (46.4%) participants had high school education, and 23 (15.2%) participants had some college or a university degree.

Participant Characteristics (N = 151)

Table 1:

Participant Characteristics (N = 151)

According to the GOJ (2019), the absolute poverty line is 200 Jordanian Dinars (JD) per household, and the poverty line is 400 JD per household. Approximately one half (49.7%) of participants reported being unemployed, and monthly family income ranged between 50 and 800 JD, with a mean of 318 (SD = 139). Family monthly income was recoded into three groups: seven (7.3%) participants who reported a monthly family income below the absolute poverty line (approximately 200 JD per month per household), 36 (37.5%) participants who reported a family monthly income between the absolute poverty line and poverty line (approximately 400 JD per month per household), and 53 (55.2%) participants who reported a family monthly income above the poverty line (Department of Statistics, 2019). Fifty-five participants did not answer the income question.

CD-RISC Scores

CD-RISC scores varied widely, ranging from 0 to 90 on a scale from 0 to 100. The mean score of all participants was 39.3 (SD = 18.4). Figure 2 shows the distribution of scores.

Resilience score distribution.

Figure 2.

Resilience score distribution.

Social Determinants of Resilience

Sociodemographic factors were separately tested for their association with resilience score. These factors are either dichotomous (e.g., gender, living place, employment status), or ordinal, multi-categorical (e.g., age group, marital status, educational level, income level). Association between resilience score and dichotomous factors was tested using independent sample t tests; and association between resilience score and ordinal, multi-categorical factors was tested using one-way ANOVA (Table 2). Gender, age group, and marital status were not found to have a statistically significant association with resilience score (t144 = 0.551, p = 0.583; F145 = 0.306, p = 0.737; and F145 = 1.553, p = 0.204, respectively).

Association Between Resilience Score and Sociodemographic Factors

Table 2:

Association Between Resilience Score and Sociodemographic Factors

Living place was significantly associated with resilience score, and participants residing inside the refugee camp scored significantly higher than those residing outside the camp (t144 = 1.885, p = 0.027). Educational level was also significantly associated with resilience score, and participants with high school education or higher scored significantly higher than those with middle school or lower education (F145 = 3.550, p = 0.009). Participants who were employed scored significantly higher on the resilience scale than those who were unemployed (t144 = −1.835, p = 0.012). Family monthly income was also significantly associated with resilience score, and participants with family monthly income >300 JD scored significantly higher than those with lower family monthly income (F90 = 3.137, p = 0.018).

To establish social determinants of resilience among Syrian refugees in Jordan, a multiple linear regression model was conducted after checking all assumptions, with CD-RISC score as a dependent variable, and employment, educational level, living place, and family monthly income as independent predictors. The regression model was overall significant (F4 = 3.323, p = 0.014). The combination of the four independent predictors (employment, educational level, living place, and family monthly income) can explain approximately 37% of variance in the Syrian refugees' resilience scores (R = 0.606, R2 = 0.369). Table 3 shows the standardized coefficient (Beta), t statistic, and p value for each independent predictor of the multiple linear regression model.

Multiple Linear Regression Model of Resilience Score Using Predictors

Table 3:

Multiple Linear Regression Model of Resilience Score Using Predictors

Thus, resilience levels among Syrian refugees in Jordan can be predicted by these four social determinants: employment status, educational level, living place, and family monthly income.

Discussion

Although resilience is observed in a multitude of settings, understanding how resilience outcomes are defined and shaped across sociocultural contexts is vital to promote resilience. Using the CD-RISC, findings revealed that resilience scores among Syrian refugees were generally low compared to other refugee communities (Ssenyonga et al., 2013), refugees residing in Jordan (Alqudah, 2013), trauma survivors (Karairmak, 2010; Wang et al., 2010), and Jordanian citizens (Panter-Brick et al., 2018). These alarming results call for immediate interventions aimed at equipping Syrian refugees with the needed skills to bounce back and adapt in the face of the tragedy, substantial loss, suppression, and insecurity they experienced.

According to the American Psychological Association (APA; 2019), resilience is not a trait. Rather, resilience involves behaviors, thoughts, and actions that can be learned and developed. Thus, interventions are needed to help Syrian refugees build resilience. However, such interventions need to be individualized approaches (APA, 2019). Resilience-building programs also need to: (a) start with a detailed contextual (qualitative) assessment to select appropriate resilience outcomes; (b) recognize the personal qualities and strengths of refugees; (c) augment the possible family and contextual predictors that may contribute to the development of resilience; and (d) enhance refugees' capacities and resources to cope with and recover from the crisis (Oswald et al., 2003; Tol et al., 2013; UNHCR, 2015). Promoting resilience among refugees was indeed found to be significantly correlated with lower risks for developing PTSD and other psychological disorders (Rutten et al., 2013; Wrenn et al., 2011).

The current study predicts that adult Syrian refugees who are unemployed, poorly educated, live outside a refugee camp, and have a family monthly income below the poverty line have lower resilience scores than adult Syrian refugees who are employed, have high school or higher education, live inside an official refugee camp, and have a family monthly income above the poverty line. On the other hand, refugees' gender, age, and marital status did not seem to have a significant differential impact on resilience scores. These results are in line with Alqudah's (2013) study on resilience levels among Iraqi refugees in Jordan. It seems that education contributes significantly to the resiliency of refugees in Jordan in a way that exceeds the contribution of gender, age, or marital status. Nevertheless, we believe that gender matters in resilience programming. According to Masson (2016), gender-based inequalities and social exclusion are key factors undermining individuals' capacities to cope. Socially constructed status, roles, and norms are gendered and intersect with other social identities, such as age or ethnicity, creating unequal levels of marginalization and access to assets between women and men (Dankelman, 2010). Thus, gender-blind programs may fail to enhance people's livelihoods, and therefore, their resilience (Le Masson et al., 2015).

The role of education in developing resilience cannot be overemphasized. Although the current sample included only adult refugees, the results highlight the importance of protecting Syrian children refugees' right to education to help promote their resilience. The arrival of approximately 1.3 million Syrian refugees to a country of 6.6 million citizens has spurred Jordan's Education Ministry to take several steps to accommodate refugees' educational needs. These steps include hiring new teachers, allowing free public school enrollment for Syrian children, and having second shifts at 100 primary schools to create more classroom spaces. According to a Human Rights Watch report (2019), although donor aids are consistently falling short of that requested by Jordan to host refugees, they have played an important role in providing educational opportunities and are set to increase their aid. In its 2016 education report, the UNHCR reported that an important part of its strategic plan is to increase quality of and access to education and improve retention by supporting innovative approaches to education, infrastructure, teacher training, and development, as well as better provision of teaching and learning materials. The report described these factors as milestones to promote refugees' psychosocial health and adaptation.

The results of our study showed a significantly higher resilience score among Syrian refugees residing inside camps compared to those living outside camps. These results are similar to another study's findings among Palestinian refugees in Jordan (Alduraidi & Waters, 2017), in which refugees inside camps fared better in terms of the social relations aspect of health-related quality of life, as compared to refugees outside camps. This finding may be explained by the relatively strong social connections inside camps, which strengthen refugees' feelings of perceived support from their social networks inside camps, compared to those outside camps. It is, however, necessary to study social capital among Syrian refugees inside and outside camps to better understand such findings and better promote and use the relatively strong social connections of refugees who reside inside camps in Jordan and elsewhere.

Limitations

The current study is not without limitations. As with all cross-sectional studies, causal pathways cannot be delineated, and as such findings should be considered exploratory. Delineating causal pathways awaits longitudinal data collection. Furthermore, resilience is not a static trait, but rather an ongoing process in which new vulnerabilities and strengths arise during developmental, societal, and cultural transitions throughout one's life and during periods of acute stress and trauma. Longitudinal studies can help understand resilience trajectories. This study has, however, made important contributions to understanding resilience and its social determinants among Syrian refugees. In addition, the researchers were unfortunately unable to provide refugees who scored low or very low resilience with any type of follow up or referral due to lack of resources. Future studies should allocate resources for proper follow up and referral for those in need.

Implications

Implications of the current study's findings for clinical practice include establishing specialized programs targeting Syrian refugees to promote their resilience, specifically psychosocial support programs focusing on assisting Syrian refugees in coping with hardships and overcoming challenges. In addition, health care providers in primary and secondary health care facilities can modify their practices with Syrian refugee patients to consider the promotion of resilience through providing psychosocial support services, as well as considering diversifying options to promote more positive coping with Syrian refugees' daily concerns and burdens.

In terms of policy implications, Jordanian governmental agencies and international organizations in contact with Syrian refugees are invited to correct any substandard practices that may have led to decreasing resilience. For example, legislation that limits Syrian refugees' opportunities in employment needs to be revised, and programs that empower Syrian refugees' positive transition into normal life (e.g., vocational training, direct financial aid, access to psychological health services programs) need to be extended and better funded. In the end, a more resilient and productive Syrian refugee community means a more stable Jordan, and a more promising future for the entire Middle Eastern region.

Conclusion

Syrian refugees are considered a particularly vulnerable population. As a result of political turmoil, destruction, and armed conflict, they find themselves facing the reality of having to leave their previous lives, their homes, and sometimes, members of their families. Tailored resilience-building programs are needed to help Syrian refugees develop the ability to withstand, adapt to, and recover from stress and adversity, and maintain or return to a state of mental health well-being. Educational opportunities and training programs aimed at enhancing Syrian refugees' capabilities, knowledge, and skills are needed. Future studies that involve longitudinal and multidimensional assessments of resilience are needed to fully understand the role and determinants of resilience in refugee populations.

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Participant Characteristics (N = 151)

Characteristicn (%)
Gender
  Male111 (73.5)
  Female40 (26.5)
Age (years)
  18 to 2973 (48.3)
  30 to 3954 (35.8)
  ≥4024 (15.9)
Marital status
  Married82 (54.3)
  Single48 (31.8)
  Widowed11 (7.3)
  Divorced10 (6.6)
Place of residence
  Outside refugee camp91 (60.3)
  Inside refugee camp60 (39.7)
Educational level
  Below middle school38 (25.2)
  Middle school20 (13.2)
  High school70 (46.4)
  College or higher23 (15.2)
Employment status
  Employed76 (50.3)
  Unemployed75 (49.7)
Family monthly income (JD) (n = 96)a
  <1997 (7.3)
  200 to 29936 (37.5)
  ≥30053 (55.2)

Association Between Resilience Score and Sociodemographic Factors

FactorMean (SD) (Range)t (df)F (df)p Value
Gender0.551 (144)0.583
  Male39.8 (18) (0 to 90)
  Female37.9 (19.4) (6 to 81)
Age (years)0.306 (145)0.737
  18 to 2940.1 (21.3) (0 to 90)
  30 to 3939.3 (15.6) (13 to 81)
  ≥4036.6 (14.3) (11 to 62)
Marital status1.553 (145)0.204
  Single40 (19) (7 to 81)
  Married40.9 (17.5) (13 to 90)
  Widowed30.2 (18.1) (7 to 62)
  Divorced32.9 (21) (0 to 62)
Place of residence1.885 (144)0.027*
  Inside refugee camp42.6 (21.1) (12 to 90)
  Outside refugee camp37 (16) (0 to 81)
Educational level3.550 (145)0.009*
  Below middle school31 (13.6) (0 to 76)
  Middle school37.9 (19.5) (7 to 81)
  High school44.6 (18.8) (12 to 90)
  College or higher43.3 (15) (13 to 62)
Employment status−1.835 (144)0.012*
  Unemployed36.5 (18.3) (0 to 81)
  Employed42.7 (18.2) (7 to 90)
Family monthly income (JD)3.137 (90)0.018*
  <19931.9 (12.8) (0 to 51)
  200 to 29934.1 (16.6) (7 to 81)
  ≥30043.3 (18.8) (14 to 90)

Multiple Linear Regression Model of Resilience Score Using Predictors

PredictorBetatp Value
Employment status0.3543.4480.001
Educational level0.2681.3860.016
Place of residence−0.251−1.4820.031
Family monthly income−0.258−1.4970.026
Authors

Dr. Alduraidi is Assistant Dean for Quality Affairs, and Dr. Dardas is Assistant Professor, School of Nursing, The University of Jordan, Amman, Jordan; and Ms. Price is Fulbright Scholar, Duke University's Global Health Institute, Durham, North Carolina.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Hamza Alduraidi, PhD, MPH, RN, Assistant Dean for Quality Affairs, The University of Jordan, School of Nursing, Queen Rania Street, Amman, 11942, Jordan; email: h.alduraidi@ju.edu.jo.

Received: February 12, 2020
Accepted: April 20, 2020
Posted Online: July 1, 2020

10.3928/00989134-20200624-04

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