Quality-of-life among Syrian refugees residing outside camps in Jordan relative to Jordanians and other countries

Sample and sampling procedure

The following three groups were recruited: Syrian refugees, average socioeconomic status (ASES) Jordanians, and low socioeconomic status (LSES) Jordanians. A total sample of 1,583 participants was collected as detailed below. It included everyone willing to participate aged 18 years old or above. Data collection took place between February and August 2017.

Syrian refugees

Syrian refugees was recruited from the refugees and their companions (if any), who sought the Caritas Al-Husn Center for Humanitarian and Medical Services between February and June 2017. The Caritas Al-Husn Center serves Syrian refugees residing outside camps as well as vulnerable Jordanians. Caritas Al-Husn Center refers some of the beneficiaries to a local pharmacy, so we used the pharmacy as a data collection point when data collection became hard to accomplish at the center when no proper space was available for data collection anymore due to the increase in beneficiary numbers. Data collection was also performed at two humanitarian assistance campaigns for the Syrian refugees; they were designed to provide food, and took place at Al-Hasan Sports City-Irbid during the data collection period.

Average socioeconomic status Jordanians

Average socioeconomic status Jordanians were defined as people with average living circumstances, and not eligible for social development department (SDD) financial assistance. This category was recruited from Al-Husn Health Care Center from February to August 2017. Everyone who attended the clinic in the specified period and who were willing to participate was included in the study.

Low socioeconomic status Jordanians

Low socioeconomic status Jordanians were defined as people who were eligible for services and assistance from the SDD. The SDD has a strict vetting system to identify their eligibility. The SDD conducts a social vulnerability study for the applicants who are seeking financial assistance, and requests a number of documents: bank statements showing their monthly salary, loans, and monthly deductions, prison services certificates, detailed medical reports explaining the reason why the family should get financial assistance from SDD, detailed medical reports for any disabled family members, divorce and custody certificates, alongside their identity documents including their family book and identification cards (Development MoS, 2018). We recruited LSES Jordanians from SDD in Irbid. Anyone who attended the SDD from February to May 2017 and who were willing to participate was included in the study.

Measures

WHOQOL-BREF is a QOL assessment tool, developed by the World Health Organization (WHO) (2012). WHOQOL-BREF is the short version of a much more detailed questionnaire, WHOQOL-100, and can be used as an efficient alternative in studies aiming to assess QOL. WHOQOL-BREF is much more practical to use in surveys than WHOQOL-100 as using 26 questions to assess QOL is easier than using 100 questions in the original version. It’s rapid, easy and gives a good estimate of the overall QOL. WHOQOL-BREF assesses the quality of physical health (seven items; e.g., “To what extent do you feel that physical pain prevents you from doing what you need to do?”), psychological health (six items; e.g., “How satisfied are you with yourself?,” social QOL (three items; e.g., “How satisfied are you with the support you get from your friends?”), and environmental QOL (eight items; e.g., “How healthy is your physical environment?”) (World Health Organization (WHO), 2012).

Answers were scored from one to five with various anchor statements (e.g., from (Very dissatisfied) to (Very satisfied) or (Very poor) to (Very good)), except for question 26 that asked about the frequency the subject experiences negative feelings. Question 26’s anchor statements had different meanings; (1: Never), (2: Seldom), (3: Quite often), (4: Very often), and (5: Always). The psychometric properties of the WHOQOL-BREF’s have been validated as a QOL assessment tool for various cultures and socioeconomic status (Skevington et al., 2004).

Data management and statistical analysis

A pilot study was performed to insure internal consistency. The test was performed on 56 participants, above 18 years of age and willing to participate from Al-Farouq Health Center in the Irbid area. Cronbach’s alpha was above 0.7 for all domains except for the social relationships domain, and according to the WHO manual, the internal consistency test for this domain cannot be trusted because it consists of three items only, so we proceeded with the actual study. Data entry and analysis was performed using SPSS-PC software v20 and SAS v9.2 software. Data cleaning was performed to check for data entry errors; we performed range and logic checks to find out possible errors in data entry. Detected errors were corrected by returning back to the study forms, remaining errors were treated as missing if they were not possible to correct.

The assessment is discarded when more than 20% of the data is missing. In the case of a missing item, the mean of other items in the domain is substituted. When two items are missing, the domain score was not calculated according to WHOQOL-BREF instructions, except for domain 3, where the domain 3 should only be calculated if ≤ 1 items is missing. The Arabic version of the WHOQOL-BREF reliability and validity has been tested through a study done among large Arabic-speaking samples (Ohaeri & Awadalla, 2009). The following item of the social relationships QOL (“How satisfied are you with your sex life?”) was only answered by 4.4% Syrians, 7.7% LSES Jordanians and 22.2% ASES Jordanians, due to the sensitivity of the question in this cultural context, although some participants did answer it. According to the WHOQOL-BREF manual, missing items are allowed in the transformational methods for scoring of the scale. ANOVA and post hoc Tukey-Honest tests were used to find the differences between the means of QOL questions in the three groups (Syrians, ASES, LSES). Stepwise multivariate linear regression was performed for each domain to determine the most associated factors. Population was included in all regression models as “population” is the variable of interest in this study. In addition to population (ASES Jordanians LSES Jordanians and Syrian refugees), adjustment for the following possible confounders was made: age, having a chronic disease, family size, monthly income, having a job, personal description of financial situation, education, marital status, and gender.

Ethical considerations

The study protocol was approved from the institutional review board (IRB) of Jordan University of Science and Technology IRB 33/107/2017. All data were kept strictly confidential and used only for scientific reasons without identifying information for the participants. Verbal informed consent was obtained from each participant. The study carries no foreseeable harm to participants as it was based on interviewing the participants without any invasive procedures. Each person was given the choice of participating or not without any pressure.

Domain results

Physical health domain

Table 2 and Fig. 1A shows the means of physical health domain questions for the three populations. Syrian refugees scored average or less in all the questions and were the lowest among all groups. LSES Jordanians had the highest pain tolerance among all groups (F3) among all groups, followed by Syrian refugees then ASES Jordanians. Similarly, LSES Jordanians needed less medical treatment (F4) than the other two groups, followed by Syrian refugees and ASES Jordanians. Stepwise multivariate linear regression resulted in the following: overall physical health was better for ASES Jordanians, followed by LSES Jordanians then by the Syrian refugees. Aging, having a disease, being married and increasing family size had negative effect on overall physical health. On the other hand, higher monthly income and having a job had a positive effect on overall physical health, Table 3. Supplemental Table shows analysis stratified for each population for each domain.

Table 2:

Means of domain’s questions for the three populations, Jordan 2017.

Domain’s questions	Population/Means*
	Syrian population (N = 655)	LSES Jordanians (N = 208)	ASES Jordanians (N = 712)	P-value
Physical domain
f3: Physical pain	2.7	2.87	2.38	<0.0001
f4: Need for medical treatment	2.69	2.69	1.99	<0.0001
f10: Energy	2.81	2.8	3.25	<0.0001
f15: Mobility	2.98	3.08	3.74	<0.0001
f16: Sleep	3.02	2.93	3.48	<0.0001
f17: Satisfaction of the daily activities performance	2.9	3.13	3.55	<0.0001
f18: Satisfaction of the capacity of work	2.87	3.14	3.62	<0.0001
Psychological domain
f5: Enjoying life	2.68	2.43	3.07	<0.0001
f6: Meaningful life	2.93	2.79	3.45	<0.0001
f7: Concentration ability	2.89	3.07	3.24	<0.0001
f11: Acceptance of bodily appearance	3.07	3.54	3.72	<0.0001
f19: Satisfaction of oneself	3.29	3.49	3.82	<0.0001
f26: Negative feelings	2.85	3.45	2.78	<0.0001
Social domain
f20: Relationships satisfaction	3.22	3.64	3.9	<0.0001
f21: Sexual life satisfaction (29,16,158)a	3.34	3.44	3.81	0.05
f22: Satisfaction with friends support	2.76	2.65	3.34	<0.0001
Environmental domain
f8: Feeling secure	3.26	3.14	3.71	<0.0001
f9: Physical environment	3.08	2.73	3.28	<0.0001
f12: Money availability	2.34	1.93	2.94	<0.0001
f13: Information availability	2.87	3.02	3.27	<0.0001
f14: Opportunity for leisure activities	2.41	1.99	2.38	<0.0001
f23: Living place environment	3.14	2.9	3.45	<0.0001
f24: Healthcare access satisfaction	3.01	2.89	3.68	<0.0001
f25: Transportation	3.04	3.06	3.67	<0.0001

DOI: 10.7717/peerj.6454/table-2

Notes:

* On the Likert scale were 5 means very satisfied or very good, and 1 means very dissatisfied or very poor.

a N(%) was 29 (4.4%) for Syrian refugees, 16 (7.7%) for LSES Jordanians and 158 (22.2%) for ASES Jordanians.

Table 3:

Stepwise multivariate linear regression for each domains.

Variables	Change in domain scores	P-value
Physical health domain
Intercept	62.75	<0.0001
Population	−3.63	<0.0001
Age	−0.15	<0.0001
Diseases	−2.5	<0.0001
Family size	−0.54	<0.05
Monthly income	0.01	<0.0001
Job	3.93	<0.0001
Personal description of financial situation	3.49	<0.001
Marital status	1.22	<0.05
Psychological health domain
Intercept	52.78	<0.0001
Population	−1.93	<0.001
Age	−0.11	<0.001
Diseases	−0.89	<0.05
Monthly income	0.01	<0.001
Job	2.21	<0.05
Personal description of financial situation	6.98	<0.0001
Marital status	1.1	<0.05
Social relationships domain
Intercept	55.38	<0.0001
Population	−5.12	<0.0001
Diseases	−1.04	<0.05
Monthly income	0.0	<0.05
Personal description of financial situation	6.80	<0.0001
Marital status	1.29	<0.05
Environmental domain
Intercept	51.33	<0.0001
Population	−1.05	<0.05
Monthly income	0.01	<0.0001
Education	−0.14	>0.05
Gender	−2.78	<0.001
Personal description of financial situation	8.54	<0.0001

DOI: 10.7717/peerj.6454/table-3

General look at the QOL domains for each population

Syrian refugees scored significantly higher than LSES Jordanians in the environmental domain but were still below average; on the other hand they scored lower than LSES Jordanians in the psychological health and social relationship domain. No significant difference was found between Syrian refugees and LSES Jordanians in the physical health domain. ASES Jordanians scored the highest among all groups in all domains, with all its scores above the average, Table 4 and Fig. 2.

Table 4:

Overall means scores for each domain in the three populations (0–100 scale).

Domain	Syrian population (N = 655)	LSES Jordanians (N = 208)	ASES Jordanians (N = 712)	P-value
Physical health	50.68	48.68	65.28	<0.0001
Psychological health	49.35	53.23	60.24	<0.0001
Social relationships	49.82	53.59	65.89	<0.0001
Environmental domain	47.37	42.67	57.39	<0.0001

DOI: 10.7717/peerj.6454/table-4

Physical health

Syrian refugees had significantly lower physical pain and need for treatment than the ASES Jordanians, but significantly higher than LSES Jordanians. Syrian refugees also scored more or less the same as the LSES Jordanians scores in most of the physical health domain questions. The overall physical health score for the Syrian refugees were very close to LSES Jordanians and the scores were around average, in opposite to ASES Jordanians who scored above average. Syrian refugees are still facing challenges in obtaining healthcare services despite the assistance Jordan is trying to provide, either because of the cost, especially after the new healthcare fees imposed in 2014, lengthy bureaucratic procedures, or the lack of the documents needed for healthcare access eligibility. At least 58.3% of Syrian adults with chronic conditions are not able access health services including medicines, according to the UNHCR (Amnesty International, 2016).

Psychological health

The psychological scores were below average for most of the questions, and the lowest among all three groups in the overall questions, those findings are maybe due to the challenges that any refugee goes through trying to build new life in different country. In the first 2 years of this crisis, The Ministry of Health spent about US $53 million on care to refugees, with only US $5 million provided by UN agencies. That being said, proper mental health care seems challenging. Finance is just one of many challenges; a lack of trained mental health practitioners, and the lack of the basic factors essential to mental health (that is, education for children, employment for adults, comfortable and a sanitary living environment) are not yet accessible to many Syrian refugees in Jordan (Al Hadid, 2016).

Social relationships

Syrian refugees scored significantly less than the other two groups in the overall social relationships domain, and they were not satisfied with the support they got from their friends, maybe due to the hard economical circumstances they are facing. Syrian refugees outside camps in Jordan scored higher than camp refugee residents of Oru community in West Africa (Oru-Ijebu, Southwest Nigeria (Akinyemi et al., 2012)) in all domains, except for the social relationships domain, which can be explained by the nature of the camp as it may provide a more social environment.

Environment

Syrian refugees scored significantly higher than LSES Jordanians when asked about money availability; nonetheless they all scored below average. One-fifth of the registered Syrian refugees with UNHCR in Jordan receive cash assistance using iris-scanning biometric technology, to help them meet their basic needs (United Nations High Commissioner for Refugees (UNHCR), 2017d). In 2016, the Jordanian government has legalized work for Syrian refugees by giving work permits and encouraged the Syrian refugees to get legal work permits by easing the process. However, Syrian refugees were cautious due to application procedures and fear that their access to emergency aid would be at risk. The proportion of Syrian urban refugees who depend on humanitarian assistance as an income source, instead of work, dramatically increased in 2016. Only 36% of household earnings among Syrian urban refugees comes from work, and this percent continues to decline, as only 22% of them are working, compared to 35% of vulnerable Jordanians, in 2016 (CARE, 2017).

The unemployment rate was high in all groups, as being unemployed was around seven times more likely than being employed among the Syrian refugees, four times more among LSES Jordanians and two times more among ASES Jordanians. The employment rate in Jordan was on average 32.95 between the years 2007 and 2018 which can explain the unemployment rate among Jordanian groups (CARE, 2017).

Syrian urban refugees in Jordan and other refugees

Syrian refugees residing outside camps in Jordan scored lower than refugees in the camps of Gaza (Eljedi et al., 2006) and Kurdistan (Aziz, Hutchinson & Maltby, 2014) in the physical, psychological and social domains, and that may be due to the availability of free services inside the camp areas provided by the UNRWA and the UNHCR which offers a secure life for refugees on many aspects; food, health, shelter, and educational security, and this is not the case outside the camps. Shelter is the main concern for Syrian refugees outside camps in Jordan followed by utilities and education United Nations High Commissioner for Refugees (UNHCR) (2017a).