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Current literature points towards several challenges in the access to sufficient and effective psychosocial care for Syrian refugees in host settings. This study is a comparative investigation into the relationship between ‘perceived social stress’ and ‘perceived social support’ on three of the most prevalent symptom dimensions in Syrian refugees across two host capitals, Berlin and Amman. 89 Syrians refugees were recruited between January 2017 and March 2018. Participants were contacted through local institutions and organisations collaborating with the Charité – Universitätsmedizin Berlin. Assessments include the PHQ-9, GAD-7, HTQ, MSPSS and PSS. Primary analyses consist of non- or parametric tests and multiple linear regression analyses. Subsample analyses showed relevant depressive, anxiety and trauma-related symptoms. Significant differences in PTSD symptoms (p < 0.04) were found. Participants reported high perceived stress and moderate to high social support. Linear regressions revealed that perceived stress had a significant negative effect (p < 0.01) on clinical outcomes in both subsamples. Perceived social support had a positive influence on depressive (p = 0.02) and PTSD symptoms (p = 0.04) for participants in Berlin. Analyses revealed significant positive effects of ‘significant others’ (p = 0.05) on depressive- in Berlin and ‘family’ (p = 0.03) support for PTSD symptoms in Amman. Study results show that levels of ‘perceived stress’ appear to be the same across different host countries, whereas types of social support and their effect on mental health differ significantly depending on the host setting. Outcomes may guide future comparative study designs and investigations to promote well-being, integration and the development of effective social support structures for the diverse needs of Arabic-speaking refugees.
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ORIGINAL RESEARCH
published: 30 June 2020
doi: 10.3389/fpubh.2020.00239
Frontiers in Public Health | www.frontiersin.org 1June 2020 | Volume 8 | Article 239
Edited by:
Patrik Roser,
Psychiatric Services
Aargau, Switzerland
Reviewed by:
Andres Barkil-Oteo,
American University of
Beirut, Lebanon
Francisco Pedrosa Gil,
Fachkrankenhaus Bethanien
Hochweitzschen, Germany
*Correspondence:
Malek Bajbouj
malek.bajbouj@charite.de
Specialty section:
This article was submitted to
Public Mental Health,
a section of the journal
Frontiers in Public Health
Received: 11 October 2019
Accepted: 18 May 2020
Published: 30 June 2020
Citation:
Böge K, Karnouk C, Hahn E, Demir Z
and Bajbouj M (2020) On Perceived
Stress and Social Support:
Depressive, Anxiety and
Trauma-Related Symptoms in
Arabic-Speaking Refugees in Jordan
and Germany.
Front. Public Health 8:239.
doi: 10.3389/fpubh.2020.00239
On Perceived Stress and Social
Support: Depressive, Anxiety and
Trauma-Related Symptoms in
Arabic-Speaking Refugees in Jordan
and Germany
Kerem Böge, Carine Karnouk, Eric Hahn, Zaynab Demir and Malek Bajbouj*
Department of Psychiatry and Psychotherapy, Campus Benjamin Franklin, Charité – Universitätsmedizin Berlin, Corporate
Member of Freie Universität Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany
Current literature points toward several challenges in the access to sufficient and effective
psychosocial care for Syrian refugees in host settings. This study is a comparative
investigation into the relationship between “perceived social stress” and “perceived
social support” on three of the most prevalent symptom dimensions in Syrian refugees
across two host capitals, Berlin and Amman. Eighty nine Syrians refugees were recruited
between January 2017 and March 2018. Participants were contacted through local
institutions and organizations collaborating with the Charité—Universitätsmedizin Berlin.
Assessments include the PHQ-9, GAD-7, HTQ, MSPSS, and PSS. Primary analyses
consist of non- or parametric tests and multiple linear regression analyses. Subsample
analyses showed relevant depressive, anxiety and trauma-related symptoms. Significant
differences in PTSD symptoms (p<0.04) were found. Participants reported high
perceived stress and moderate to high social support. Linear regressions revealed that
perceived stress had a significant negative effect (p<0.01) on clinical outcomes in both
subsamples. Perceived social support had a positive influence on depressive (p=0.02)
and PTSD symptoms (p=0.04) for participants in Berlin. Analyses revealed significant
positive effects of “significant others” (p=0.05) on depressive- in Berlin and “family” (p=
0.03) support for PTSD symptoms in Amman. Study results show that levels of “perceived
stress” appear to be the same across different host countries, whereas types of social
support and their effect on mental health differ significantly depending on the host setting.
Outcomes may guide future comparative study designs and investigations to promote
well-being, integration, and the development of effective social support structures for the
diverse needs of Arabic-speaking refugees.
Keywords: mental health, perceived stress, social support, depression, anxiety, trauma, refugees
Böge et al. Stress, Support and Psychopathology in Refugees
INTRODUCTION
The Syrian conflict, which is now approaching its eighth
consecutive year, has forced more than 5.6 million of the
country’s citizens to take refuge in many corners of the world
(1,2). Countries in the Middle East and Europe were among
the first to respond to the urgent plea for humanitarian aid
and assistance. Of these nations, Germany and the Kingdom of
Jordan have hosted a high number of Syrian refugees and asylum
seekers (3). At first, Syrian citizens sought refuge in neighboring
countries, but in response to the crisis, by the summer of 2015,
Germany’s open-door policy allowed Syrian citizens to request
asylum and make Europe their new home (4).
Various barriers, which include cultural, linguistic, financial,
as well as risks of discrimination, exploitation, and social
isolation, have led to an inability to satisfy the basic needs of the
Syrian refugee population (5). In turn, this has had a direct effect
on mental health, prospects of integration and overall well-being
(6). Recent studies have confirmed that the three most common
psychiatric disorders observed in Syrian refugees are PTSD,
depression and anxiety (1). Prevalence rates range between 20.5
and 35.7% for PTSD, 20 to 43.9% for depression (7,8), and
from 19.3 to 31.8% for anxiety disorders (9). Furthermore, loss
and grief have been reported to be central themes (10). Other
factors, such as the length of stay, living environment, uncertain
residence status, acculturation processes, also seem to play a
crucial role in the development of psychological distress (1).
In host environments, familiar sociocultural habits and
routines are often disrupted (10). It has been reported that
Syrian families often become estranged, report a loss of identity
and a longing for home (5). According to Cohen and Syme
(11), social support from family, friends and significant others
(12) have been identified as protective factors “that aid in the
maintenance of health as well as in disease recovery.” In Syrian
host communities, basic community support groups, recreational
spaces and development programs are scarce. Similarly, little
attention is given to psychological and cognitive injuries, their
consequences, and services to assist long-term recovery, despite
available evidence psychosocial support as a coping resource and
catalyst for positive change and well-being (1315).
Combined, the Kingdom of Jordan and Germany have hosted
more than 1 million Syrian refugees (3,16). According to reports
from 2019, there are a total of 664,330 registered Syrian refugees
in Jordan (16) and there are about 646,665 asylum applicants
in Germany since 2015 (17). Although both host countries are
accommodating a large number of Syrian refugees, it seems like
many sociodemographic variables influence refugee choices of
a final destination (18). This choice is often informed by age,
gender, education, marital status, national politics, and other
factors. Although choices are often limited, some Syrian refugees
choose to migrate to a neighboring country for reasons of
“cultural proximity,” such a familiar language, similar religious
values, national views and most importantly transferable skills
(18). Some refugee communities also choose host countries,
where they already have existing social ties and familial support
networks. For young women, cultural norms and gender roles
can play a role an important role in this choice (19), whereas
this may be a different case for young men (20)—leading to
diverse migration trends within one community. Furthermore,
response to Syrian crisis, many organization and development
programs have established mental health and psychosocial
support activities, particularly in their capitals—Amman and
Berlin (21).
Jordan is a relatively small, middle-income country with a
climate that is influenced by ongoing political conflict, high
poverty rates, and treatment gaps (2224). Therefore, priority
is given to the physical and basic needs of refugees (2,25). In
Jordan, the official national language is Arabic. Cultural customs
and social fabrics are familiar to those of most Syrian refugees.
According to a recent report (2), Jordan is currently considered
the country with the highest number of NGOs operating in the
MENA (Middle East and North Africa) region.
In contrast, Germany is a high-income country with
developed structures (legal, medical, and educational), open
recreational spaces and financial wealth. Nonetheless, Germany
still seems to be facing ongoing challenges that are different from
those of Jordan. These challenges are mostly related to linguistic,
cultural and social barriers surrounding the integration and
psychosocial support of refugee populations (5). In 2013, Charité
Universitätsmedizin, Berlin was spearheading many initiatives in
Jordan with its ChariteHelp4Syria project (CH4S) (5), yet despite
increased knowledge and integrating best practice models, a
treatment gap still remains.
Therefore, the present study aims to understand the
relationship between “perceived stress” and “perceived social
support” on the three most prevalent symptom dimensions
(depressive-, PTSD-, and anxiety-related symptoms) observed in
refugee populations residing in the capitals of two of the world’s
largest host countries for Syrian refugees—Amman and Berlin.
METHODS
Participants and Procedure
Eighty nine Syrian refugees who resettled in either Berlin,
Germany (n=49) or Amman, Jordan (n=40) were recruited
between January 2017 and March 2018. In total, 89 participants
were invited to take part in the study, all gave informed consent
and none dropped out throughout the study process. In Berlin,
participants were recruited at the central clearing clinic, an
outpatient institution by Charité—Universitätsmedizin Berlin,
specialized in offering psychiatric services for refugees and
collaborates with multiple refugee camps and civic initiatives. In
Amman, participants were recruited via the CharitéHelp4Syria
project, a joint project of Charité and the German humanitarian
non-governmental Organization “Help—Hilfe zur Selbsthilfe.”
For the study inclusion criteria were defined as (a) 18–65
years of age, (b) literate in Arabic language, and (c) having been
exposed to the Syrian Civil War from 2011 onwards. Exclusion
criteria included (a) lifetime diagnosis of psychotic disorder,
bipolar disorder, personality disorder, (b) intellectual disability,
(c) any mental disorder due to a general medical condition, and
(d) current substance abuse.
An information sheet about study procedures was handed out
by physicians. Participants were informed about the anonymity
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Böge et al. Stress, Support and Psychopathology in Refugees
of data and their right to withdraw from the study at any time
without giving a reason or the withdrawal having an impact on
the services received by any governmental or non-governmental
organizations. Ethics approval (EA4/067/10) was granted by
the ethics review board of Charité—Universitätsmedizin Berlin
according to the Declaration of Helsinki. All participants were
provided with written informed consent and were financially
reimbursed for their participation.
Questionnaires
The self-rated Patient Health Questionnaire-9 (PHQ-9) (26) a
validated Arabic instrument (2729) which is used to assess the
presence and severity of depressive symptoms. It includes a score
range from 0 to 27. Responses for each of the nine items range
from “0” (“not at all”) to “3” (“nearly every day”) with higher
scores corresponding to higher symptom severity. In the present
study, the PHQ-9 total score displayed good internal consistency
(Cronbachs α=0.85).
The Generalized Anxiety Disorder-7 (GAD-7) (30) is a self-
reported screening instrument aiming to detect generalized
anxiety symptoms and measure anxiety symptoms. It consists
of seven items, which are scored on a four-point Likert-scale,
ranging from “0” (“not at all”) to “3” (“nearly every day”). The
validated Arabic version of the GAD-7 has been shown to have
good psychometric validity (27,29). In the current study, αwas
0.86, indicating good internal consistency.
The Harvard Trauma Questionnaire (HTQ) (31) is a self-rated
questionnaire assessing multiple facets of trauma experiences.
The first part compromises of 42 items illustrating traumatic
events, such as lack of food and clean water, torture, rape,
and murder of family member or friend which are rated on a
dichotomous scale: yes (1) and no (0). The second part consists
of an open-ended question, in which participants can describe
the most hurtful and terrifying. The third part encompasses
16 items, which aim to assess posttraumatic stress disorder
symptoms (PTSD) severity. Responses are rated on a five-point
Likert scale. Cut-off scores for current PTSD is set at >2.5 For
the current study, the Arabic version of the HTQ was used, which
has already been validated with refugees from Iraq and shown
sufficient validity and a good test-retest reliability in previous
studies (32,33). Furthermore, part one and three showed good
internal consistency with 0.89 and 0.87, respectively.
The self-report Multidimensional Scale of Perceived Social
Support (12) is a brief questionnaire designed to measure
perceptions of support from three main sources: (1) family,
(2) friends, and (3) a significant other. The MSPSS comprises
in total 12 items, subdivided into four items per subscale.
Responses are given on a seven-point Likert scale. High scores
resemble stronger perceived stronger support. The MSPSS was
administered in Arabic language and its validation has shown
good internal and test-retest reliability, good validity, and a fairly
stable factorial structure (34). For the current study, αwas 0.88,
indicating good internal consistency.
The Perceived Stress Scale (PSS) (35) is a self-rated
questionnaire developed to assess the degree to which situations
in one’s life are appraised as stressful. The PSS consists of ten
items, is two-dimensional and includes positively and negatively
phrased items. Participants give their responses on a five-point
Likert scale. The Arabic version (36) of the administered PSS has
good psychometric properties and displayed acceptable internal
consistency (α) with 0.77 in the current study.
Statistical Analysis
All data was collected, stored, and analyzed by using the
Statistical Package for the Social Sciences (IBM, SPSS, Version
23), MacOS-X. Sociodemographic variables were descriptively
represented using frequencies, percentages, means and standard
deviations. Subsample analyses were performed to assess possible
differences in clinical outcomes between both communities
using non- or parametric tests, either one-tailed independent
t-test or Mann-Whitney-U-Test. In a next step, regression
analyses including non-standardized regression coefficient (B)
and standardized regression coefficient (ß) were calculated using
perceived social support and perceived stress as the independent
variable and the clinical outcomes such as depressive-, anxiety-,
and post-traumatic stress symptoms as the dependent variable.
The level of significance was set at p<0.05.
RESULTS
Demographic characteristics of the sample and both cohorts,
Amman and Berlin, are summarized in Table 1. For the whole
sample, participants were mainly female (53.9%), on average 33.9
years old, Syrian (96.6%), married (58.4%), not graduated from
high school (39.3%), flew with their family (67.4%), escaped
Syria for 42.71 months, and spent 39.15 months in German
or Jordan, respectively. Furthermore, there are substantial
differences between both cohorts as a majority in Berlin were
male (59.2%) while in Amman female (70%). In Berlin, the age
ranged between 18 and 40 years (93.8%) with an average of
30.00 (7.99) years while in Amman participants’ age were rather
balanced across years with an average of 38.9 (10.6). Furthermore,
most participants who arrived in Berlin were single (53.1%) and
flew alone (45.0 %) and were educated (81.6%) which stands in
contrast to primarily married (82.5%) participants in Amman
who escaped with their family (95%) and had not graduated
from high school (65 %). Lastly, the departure from Syria was
on average 29.2 (16.1) months ago for participants from Berlin
and 59.3 (12.3) for Amman while time spent in the new country
was 23.0 (11.6) and 58.9 (12.8) months indicating considerable
difference between both cohorts, respectively.
Clinical Outcomes and Differences
Between Both Communities
Concerning each subsample, results for participants from Berlin
indicate relevant depressive—(8.31) and anxiety symptoms
(7.89), which are at the threshold of mild to moderate
symptom severity. With a cut-off score for current PTSD set
at >2.5, participants illustrate post-traumatic stress symptoms
bordering the diagnostic threshold (2.11). Furthermore, on
average 15.98 of 43 items of the HTQ “after war” subscale was
marked exhibiting relevant traumatic experiences. Participants
from Berlin displayed high perceived stress (28.20) and were
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Böge et al. Stress, Support and Psychopathology in Refugees
TABLE 1 | Sociodemographic characteristics of the survey sample and each
subsample.
Socio-demographic
variables
Survey sample
(n=89)
Refugees living
in Berlin (n=49)
Refugees living
in Amman (n=
40)
Gender [%]
Male 46.1 59.2 30.0
Female 53.9 40.8 70.0
Age (range) [%]
18–30 41.6 57.1 22.5
31–40 36.0 36.7 35.0
41–50 12.4 0 27.5
51–60 10.1 6.1 15.0
Nationality [%]
Syria 96.6 93.9 100.0
Iraq 1.1 2.0 0
Saudi Arabia 1.1 2.0 0
Palestine 1.1 2.0 0
Marital status [%]
Single 36.9 53.1 15.0
Married 58.4 38.8 82.5
Divorced 5.6 8.2 2.5
Educational status [%]
Not graduated high school 39.3 18.4 65.0
High school degree 28.1 34.7 20.0
Bachelor’s degree 13.5 24.5 0
Master’s degree 19.1 22.4 15.0
Course of flight [%]
Alone 27.0 45.0 5.0
Family 67.4 44.8 95.0
Friends 5.6 10.2 0
Months since departure from Syria [%]
0–24 30.3 53.1 2.5
25–48 24.8 34.7 12.5
49–72 39.3 12.2 72.5
73–96 5.6 0 12.5
Months spent in Germany/Amman [%]
0–24 37.1 63.3 5.0
25–48 23.6 34.7 10.0
49–72 33.7 2.0 72.5
73–96 5.6 0 12.5
considered to have moderate, at the border to high, social
support (4.69).
For participants from Amman, results demonstrated similar
results with relevant depressive—(9.55) and anxiety symptoms
(9.60), which are also at the cut-off threshold from mild to
moderate symptom severity. Like the Berlin cohort, participants
revealed post-traumatic stress symptoms at the diagnostic
boarder (2.31) with 18.23 on average for the HTQ “after war”
subscale. Perceived stress was high (26.91) and perceived social
support at the border from moderate to high (5.09).
Statistical comparisons regarding clinical outcomes
between subsamples demonstrated significant differences
TABLE 2 | Mean, standard deviation and p-values of clinical outcomes according
to each subsample.
Outcome Variable Mean (SD) p
PHQ-91
Berlin (n=49) 8.31 (4.64) 0.13b
Amman (n=40) 9.55 (5.64)
PHQ-72
Berlin (n=49) 7.98 (4.74) 0.10a
Amman (n=40) 9.60 (5.38)
HTQ after war3
Berlin (n=49) 15.98 (6.99) 0.08b
Amman (n=40) 18.23 (7.63)
HTQ PTSD4
Berlin (n=49) 2.11 (0.59) 0.04b
Amman (n=40) 2.31 (0.44)
PSS5
Berlin (n=49) 28.20 (7.32) 0.21b
Amman (n=40) 26.91 (7.23)
MSPSS6
Berlin (n=49) 4.69 (1.34) 0.21b
Amman (n=40) 5.09 (1.25)
1=Cronbach’s α=0.85; 2=Cronbach’s α=0.86; 3=Cronbach’s α=0.89;
4=Cronbach’s α=0.87; 5=Cronbach’s α=0.77; 6=Cronbach’s α=0.88; a=
Mann-Whitney-U Test; b=independent samples t-test; α=0.05 (one-tailed).
Significant p-values <0.05 are marked in bold.
in post-traumatic stress symptoms (p<0.04).
Table 2 summarized all clinical outcomes including
mean, standard deviation and p-values according to
each subsample.
Regression Analysis
To analyse the impact of perceived social support and perceived
stress on symptoms of depression, anxiety and post-traumatic
stress, multiple linear regression analyses were performed.
Overall, regression analyses revealed that perceived stress had
a significant negative effect (p<0.01) on all three clinical
outcomes in Berlin as well as Amman. However, regression
analyses concerning the influence of perceived social support on
depressive, anxiety, and post-traumatic stress symptoms showed
significant positive effects for two clinical outcomes in Berlin
but not in Amman. Here, results indicate that perceived social
support had a positive influence on depressive- (β= −0.065; p=
0.02) and post-traumatic stress symptoms (β= −0.009; p=0.04)
for participants in Berlin. On a subscale level, analyses displayed
a significant positive effect of “significant other” (β= −0.118; p
=0.05) on depressive- in Berlin and “family” (β= −0.029; p=
0.03) on post-traumatic stress symptoms in Amman. A summary
of the primary regression analyses, including on-standardized
regression coefficient (B) and standardized regression coefficient
(ß) and p-values (p) for each subsample, are depicted in
Table 3.
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Böge et al. Stress, Support and Psychopathology in Refugees
TABLE 3 | Regression analysis for perceived stress and social support on
depression, anxiety, and post-traumatic stress symptoms in Berlin and Amman
with beta scores, standardized beta values, and their significance values.
Berlin Amman
Questionnaire b ß pb ß p
PHQ-9
MSPSS 0.065 0.240 0.02 0.018 0.048 0.36
PSS 0.325 0.595 <0.01 0.571 0.696 <0.01
PHQ-7
MSPSS 0.042 0.143 0.10 0.063 0.178 0.12
PSS 0.414 0.642 <0.01 0.428 0.547 <0.01
PTSD
MSPSS 0.009 0.230 0.04 0.001 0.030 0.43
PSS 0.033 0.412 <0.01 0.034 0.535 <0.01
Significant p-values <0.05 are marked in bold.
DISCUSSION
The present study aimed to explore “perceived stress” and
“perceived social support” on three of the most prevalent
symptom dimensions including depressive-, PTSD- and anxiety
symptoms in Syrian refugees (1) in both host capitals, Berlin
and Amman. Similar to other studies (1), the main findings
of this study revealed that perceived stress has a significant
negative effect on all three clinical outcomes in both cohorts.
Moreover, perceived social support showed positive effects for
only depressive—and PTSD symptoms in the Berlin sample, but
not for Amman. There were no associations observed between
perceived social support and anxiety symptoms in both samples.
When analyzing the subscales of “perceived social support”,
only two types of social support had a positive influence on
the participants’ mental health. In the Berlin cohort, “perceived
social support” from a “significant other” had a positive effect on
depressive symptoms, whereas, in the Amman sample, support
from a “family member” had a positive effect on trauma-
related symptoms.
According to global trends in forced displacements, most
refugee communities remain close to their homeland, while
only a small number of individuals move to more distant and
remote host countries. While most arrivals in Jordan were
documented between 2012 and 2015 (37), Germany’s open door
policy gave access to asylum seekers mostly in the summer of
2015 (4). This timeline thus reflects a realistic representation of
why participants reported having stayed for longer periods in
Amman. Official data from census also confirm that over two-
thirds (about 69.2%) of asylum seeking applicants in Germany
are also males (20) reflecting the significantly higher prevalence
of educated, single males in the Berlin sample.
Germany offers newly arriving refugees integration-
and language courses, as well as professional development
opportunities (38). In contrast, the Kingdom of Jordan offers
proximity to home, a similar language, cultural norms and more
easily transferable skills. Young adult males may be fulfilling
their familial duties of “scouting the route” for other “more
vulnerable” family members that are yet to follow (possibly
through reunification programs). However, for young Syrian
refugee women, a close tie to gender and cultural norms,
especially with regards to marital prospects and proximity to
family may take precedence over professional or economic
goals (5,19) The motivations to favor some host countries over
others may have led to the heterogeneity of sociodemographic
variables within our samples, making a sound methodological
comparison practically impossible. In contrast, one of the
major strengths of this study is its ecological validity, in which
real-life circumstances and similarities are clearly noticeable in
our cohorts. It is, thus, important to interpret the study’s data
cautiously without making claims of inferences or causality.
Nonetheless, results from such studies may help policy makers
in the development and implementation of more formal and
visible social support structures. Findings may also influence
new treatment models that are more suitable for this population’s
needs and offer compelling evidence in support of new scalable
peer-to-peer intervention efforts, such as the STRENGTHS
project (39), and other hybrid stepped-care models, such as
MEHIRA (Mental Health of Refugees and Asylum Seekers (40).
A significant strength of this study is that the results give first
insights into the types of social support that have shown to have
a significant positive effect on Syrian refugee mental health. So
far, the relationship between mental health and social support has
been under-investigated in this vulnerable population, although
there has been evidence proving the general benefits of social
support on mental and physical well-being (11,41,42). In the
Berlin cohort, it seems like support offered by a “significant
other” had a positive influence on depressive symptoms, whereas
“family” support seemed to alleviate trauma-related symptoms
in the Amman sample. The Syrian culture is known for its
rich cultural customs and traditions, as well as strong familial
relationships and social fabrics (5). Therefore, family separation
undoubtedly leads to increased feelings of emotional distress
(5,43). Because most of the Berlin sample is made up of single
males, it may be possible that, as a coping mechanism, this cohort
relies on social support from “significant other” as a substitute
for the absent family. In contrast, within the Amman sample,
which is made up of mostly Syrian women, relying on the family
unit may reflect traditional gender roles. Investigating further
aspects were not within the scope of the present paper, but
it is imperative that future studies also focus “within-group”
differences in experiences and perceptions of stress and social
support needs of refugee communities.
Regarding the limitations of the study, all variables were
assessed with subjective, self-report questionnaires, however
reports of past experiences may be prone to reporting bias
(44). Moreover, no psychiatric standardized interview was
conducted to assess diagnostic criteria. Therefore, clinical
outcomes only display symptom dimensions. Furthermore, the
research is cross-sectional limiting any conclusions regarding
causality and generalizability. Due to limited resources, the role
of some factors such as resilience, education, socioeconomic
background, were beyond the scope of this paper. Such analyses
may be useful to follow up on in future research to make
meaningful associations.
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Böge et al. Stress, Support and Psychopathology in Refugees
In conclusion, the present study gives the first comparative
insights into the relationship between “perceived social stress”
and “perceived social support” on three most prevalent
symptom dimensions in Syrian refugees in both Germany and
Jordan’s capitals—Berlin and Amman. Overall, results show
that “perceived stress” levels are the same across different host
countries; however, types of social support and their effect on
symptoms differ significantly depending on the host setting.
DATA AVAILABILITY STATEMENT
The datasets generated for this study are available on request to
the corresponding author.
ETHICS STATEMENT
The studies involving human participants were reviewed and
approved by Charité - Universitätsmedizin Berlin, Ethics
Committee. The patients/participants provided their written
informed consent to participate in this study.
AUTHOR CONTRIBUTIONS
KB, CK, EH, ZD, and MB contributed to the study conception
and research design. ZD and MB led all aspects concerning data
recruitment and assessment. KB, CK, EH, and MB contributed to
the drafting of the manuscript. KB conducted the data analysis
while ZD prepared the data sheets. All authors commented and
contributed to the final manuscript and have seen and given final
approval of the version to be published.
FUNDING
This study was funded by the Else-Kröner-Fresenius Foundation
(2014_EKFSmhF.HA26) and the German Ministry of Economic
Development and Cooperation (1255).
ACKNOWLEDGMENTS
The authors would like to thank Joachim Seybold, who played an
important role in the establishment phase of the study.
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Conflict of Interest: The authors declare that the research was conducted in the
absence of any commercial or financial relationships that could be construed as a
potential conflict of interest.
Copyright © 2020 Böge, Karnouk, Hahn, Demir and Bajbouj. This is an open-access
article distributed under the terms of the Creative Commons Attribution License (CC
BY). The use, distribution or reproduction in other forums is permitted, provided
the original author(s) and the copyright owner(s) are credited and that the original
publication in this journal is cited, in accordance with accepted academic practice.
No use, distribution or reproduction is permitted which does not comply with these
terms.
Frontiers in Public Health | www.frontiersin.org 7June 2020 | Volume 8 | Article 239
... Numerous empirical studies have proposed that for migrant workers social capital can significantly improve their mental health (18), which has been applied to mental health promotion programs (19). Using the stress process model, some scholars pointed out that social capital can alleviate perceived stress and buffer the negative impact of life events, and thereby promote mental health (20). Some scholars have noted how communitybased social capital acts on the mental health, arguing that community-based cognitive social capital can promote mutual trust between migrants and local residents, eliminate the state of exclusion among floating populations, and create a good atmosphere for the community (21). ...
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The rise of migrant workers has been a unique social phenomenon as China goes through industrialization, urbanization, and modernization. They are a special social group formed during the economic and social transition of the country. Migration of rural labor has pushed China on its new path toward industrialization and urbanization. Because of the urban-rural dual system of the country, however, it is difficult for migrant workers to be fully integrated into host cities, making them susceptible to negative emotions and mental health issues. Therefore, their mental health is an issue of great volume in the domains of social undertakings, people's livelihood, and public health. However, existing studies have paid limited attention to the psychological profile of migrant workers and even less to the interplays among their social capital, social integration, and mental health. Targeting China's internal migrant workers, this article tapped the interactions among their social integration, social capital, and mental health with a sample of the cross-sectional data from the China Labor Dynamics Survey (CLDS) in 2018. Multi-group structural equation modeling (SEM) was employed to test the moderating action of age by analyzing whether the mediation model differed significantly in the paths among young, middle-aged, and older migrant workers. The SEM based on bootstrapping suggested that, after controlling for the influence of gender, education, marital status, personal annual income, employer type, and self-rated health, migrant workers' social capital positively affect their mental health in a significant way, with social integration playing a mediating role. In terms of age difference, middle-aged migrant workers were more subject to the aforementioned mechanism than young ones, and young migrant workers were more affected by the mechanism than older ones. This study revealed different psycho-social interplays among social capital, social integration, and mental health across young, middle-aged, and elderly migrant workers. The findings could serve as an important theoretical reference and as practical guidance for improving policies concerning migrant workers' mental health and social benefits in the context of economic transition.
... The best health infrastructure and the largest mental health care resources are of no value if affected populations are stigmatized or if no knowledge exists regarding diseases or treatment options on the caretakers' side. Equally important, health literacy needs to be present on the caregivers' side with respect to cultural differences in idioms of distress or concerning culture-sensitive treatment modifications (10,11). ...
... A study among refugees in Germany using survey data showed that on average, refugees knew two people (mostly family members and persons from the same country of origin) with whom they could share personal thoughts and feelings [48]. A study assessing perceived social support among Arabic-speaking refugees in Jordan and Germany showed moderate to high social support among respondents [49]. This study also showed that there is a positive effect for mental health issues such as depressive and PTSD symptoms. ...
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... Our results support the stress-buffering model asserting that social support immunizes individuals against the adverse impacts of stressful events (Cohen & Wills, 1985). Furthermore, as shown in the previous studies, social support is an indispensable resilience asset for mental health among refugees (Siriwardhana et al., 2014 for a review) including Syrians in Turkey and other countries (Böge, Karnouk, Hahn, Demir, & Bajbouj, 2020;Yildirim, Isik, Yildirim-Firat, & Aylaz, 2020). Having acknowledged the limited capacity and resources of organizations to provide necessary assistance for refugees, this finding is of paramount importance. ...
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... This is also reported by a systematic review on clinical populations with mental disorders (51) and studies from outside the EU on refugees (18). Böge et al. (2020) (52) found a difference between types of social support and their effect on mental health in different host countries. Remarkably, Shelton et al. (2017) (53) highlighted the moderating role of cultural orientation on the association between perceived social support and mental health in a group of college students. ...
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Thesis
In recent years, Mindfulness-Based Interventions (MBI) have gained popularity as a modern psychotherapeutic approach, primarily in English-speaking countries. A growing body of evidence demonstrates the clinical benefits of MBI for a wide range of symptoms experienced in Schizophrenia Spectrum Disorders (SSD). However, research in German speaking countries remains scarce. Against this background, the present dissertation aims to contribute to the available body of literature by developing and validating a Mindfulness-Based Group Therapy (MBGT) for the treatment of inpatients with schizophrenia spectrum disorders. This comprehensive research study will include both qualitative and quantitative data analysis concerning the three subprojects revealed below. A qualitative research design based on inductive thematic analysis in the form of a semistructured interview guide was developed and 27 interviews were conducted with inpatients having SSD after attending a mindfulness-based intervention in study one. Analyses revealed two domains (content and function) of MBI. The domain content had further subcategories, including core elements, as well as effects on emotions, cognition, and symptoms changes. The second domain was related to the relevance of perception of context and transfer to everyday life. Overall, individuals reported improvements on several clinical parameters and gave an indepth understanding of underlying processes and mechanisms at action. Based on these outcomes, a novel Mindfulness-Based Group Therapy (MBGT) was developed for the first time in the German language through a fundamental participatory and iterative research process and finally published in a manual's printed book form. Moreover, historical concerns regarding the therapeutic utility of mindfulness for SSD are discussed, while recommendations and careful adaptations are given to implement MBI in inpatient and outpatient settings as a part of an editorial article. In study two, the newly translated German version of the Southampton Mindfulness Questionnaire (SMQ) was validated regarding convergent and divergent validity, reliability, factor structure, and treatment sensitivity while providing evidence for clinical practice and research for healthy individuals, mediators, and clinical groups. In the third study, a rater-blinded randomized controlled trial was conducted to assess the feasibility, acceptability, and preliminary outcomes of MBGT with inpatients having SSD. Results showed high protocol adherence and retention rates indicating feasibility and acceptability. Furthermore, various improvements were revealed on clinical- and process dimensions compared with treatment-as-usual. Overall, the present dissertation gives compelling evidence regarding the effects of mindfulness for SSD and adds a modern psychological treatment option for this marginalized patient group.
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Background: Syrian refugees face multiple hardships and adversities which put them at risk for the development of mental health problems. However, access to adequate mental health care in host countries is limited. The WHO has developed Problem Management Plus (PM+), a brief, scalable psychological intervention, delivered by non-specialist helpers, that addresses common mental disorders in people affected by adversity. This study is part of the STRENGTHS project, that aims to evaluate peer-refugee delivered psychological interventions for Syrian refugees in Europe and the Middle East. Objective: To evaluate the effectiveness and cost-effectiveness of the peer-refugee delivered PM+ intervention among Syrian refugees with elevated levels of psychological distress in the Netherlands. Methods: PM+ will be tested in a randomized controlled trial (RCT) among Arabic-speaking Syrian refugees in the Netherlands aged 18 years and above with self-reported psychological distress (Kessler Psychological Distress Scale; K10 >15) and impaired daily functioning (WHO Disability Assessment Schedule; WHODAS 2.0 >16). Participants (N = 380) will be randomized into care as usual with PM+ (CAU/PM+, n = 190) or CAU only (CAU, n = 190). Baseline, 1-week post-intervention, and 3-month and 12-month follow-up assessments will be conducted. Primary outcomes are symptoms of depression and anxiety. Secondary outcomes are functional impairment, posttraumatic stress disorder symptoms, self-identified problems, anger, health and productivity costs, and hair cortisol concentrations. A process evaluation will be carried out to evaluate treatment dose, protocol fidelity and stakeholder views on barriers and facilitators to implementing PM+. Results and Conclusions: PM+ has proved effectiveness in other populations and settings. After positive evaluation, the adapted manual and training materials for individual PM+ will be made available through the WHO to encourage further replication and scaling up. Trial registration: Trial registration Dutch Trial Registry, NL7552, registered prospectively on March 1, 2019. Medical Ethics Review Committee VU Medical Center Protocol ID 2017.320, 7 September 2017.
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Importance Childhood maltreatment is associated with mental illness. Researchers, clinicians, and public health professionals use prospective or retrospective measures interchangeably to assess childhood maltreatment, assuming that the 2 measures identify the same individuals. However, this assumption has not been comprehensively tested. Objective To meta-analyze the agreement between prospective and retrospective measures of childhood maltreatment. Data Sources MEDLINE, PsycINFO, Embase, and Sociological Abstracts were searched for peer-reviewed, English-language articles from inception through January 1, 2018. Search terms included child* maltreatment, child* abuse, child* neglect, child bull*, child* trauma, child* advers*, and early life stress combined with prospective* and cohort. Study Selection Studies with prospective measures of childhood maltreatment were first selected. Among the selected studies, those with corresponding retrospective measures of maltreatment were identified. Of 450 studies with prospective measures of childhood maltreatment, 16 had paired retrospective data to compute the Cohen κ coefficient. Data Extraction and Synthesis Multiple investigators independently extracted data according to PRISMA and MOOSE guidelines. Random-effects meta-analyses were used to pool the results and test predictors of heterogeneity. Main Outcomes and Measures The primary outcome was the agreement between prospective and retrospective measures of childhood maltreatment, expressed as a κ coefficient. Moderators of agreement were selected a priori and included the measure used for prospective or retrospective assessment of childhood maltreatment, age at retrospective report, sample size, sex distribution, and study quality. Results Sixteen unique studies including 25 471 unique participants (52.4% female [SD, 10.6%]; mean [SD] age, 30.6 [11.6] years) contained data on the agreement between prospective and retrospective measures of childhood maltreatment. The agreement between prospective and retrospective measures of childhood maltreatment was poor, with κ = 0.19 (95% CI, 0.14-0.24; P < .001). Agreement was higher when retrospective measures of childhood maltreatment were based on interviews rather than questionnaires (Q = 4.1521; df = 1; P = .04) and in studies with smaller samples (Q = 4.2251; df = 1; P = .04). Agreement was not affected by the type of prospective measure used, age at retrospective report, sex distribution of the sample, or study quality. Conclusions and Relevance Prospective and retrospective measures of childhood maltreatment identify different groups of individuals. Therefore, children identified prospectively as having experienced maltreatment may have different risk pathways to mental illness than adults retrospectively reporting childhood maltreatment. Researchers, clinicians, and public health care professionals should recognize these critical measurement differences when conducting research into childhood maltreatment and developing interventions.
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The sudden arrival of culturally diverse asylum seekers and refugees into Germany has created a strong demand for recognizing and appropriately treating those suffering from mental health issues. Due to many systemic, organizational, cultural and socio-linguistic barriers, psychiatric treatment of refugees is posing a major challenge to Germany’s mental health care system. Thus, there is a need for alternative models that allow for increased access to adequate, effective and efficient culturally sensitive mental health care services. Here, we describe the Mental Health in Refugees and Asylum Seekers (MEHIRA) project, a multicentre randomized controlled trial investigating a stepped collaborative care model (SCCM) for providing mental health treatment in this vulnerable population. The proposed SCCM aims to decrease the aforementioned barriers. Adult and adolescent participants will be screened for depressive symptoms and matched to appropriate psychological interventions, including group-level interventions (START intervention, Empowerment/Gender-sensitive/Peer to peer), and other innovative, digital treatment approaches (Smartphone application). The therapeutic effect of the SCCM will be compared to TAU (treatment-as-usual). All interventions have been designed to be culturally sensitive, and offered in two different languages: Arabic and Farsi. The outcome of this study may contribute significantly to future clinical and legal guidelines in developing parallel and efficient new structures of treatment. Collected data will inform primary and secondary mental health care providers with recommendations concerning the design and implementation of effective treatment models and programmes. Guidelines and recommendations may also potentially be adopted by other host countries, developing countries and also in humanitarian aid programmes.
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OECD Report which assesses the labour market integration of refugees in Germany, in light of recent high inflows and policy developments and international good practice. Includes findings from a joint OECD survey with the German Association of the Chambers of Industry and Commerce (DIHK) and the Ministry of Labour and Social Affairs.
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