Assessment of quality of life of Syrian refugees in Jordan: a questionnaire survey

INTRODUCTION

Over 79.5 million people are currently forcibly displaced around the world, of which 26 million are refugees, a number that has more than doubled in the last decade.ˡ Civil wars, severe economic and political instability, ethnic persecution, and many other current conflicts, have been relevant in increasing the global migration wave in recent years.²

Traumas are experienced by the vast majority of refugees. They endure pre-migration traumas in their country of origin, including as war, torture, imprisonment, and the murder of relatives. They frequently experience physical and sexual abuse while transiting to their destination, in addition to maltreatment by traffickers and authorities. Even after refugees arrive at their destination, they are grappled with post-migration stresses, which include feelings of uprootedness and loneliness, a social exclusion that sometimes culminate into hostilities, and difficulties in securing a subsistence. Undoubtedly, all of these aspects are closely related to mental health problems, such as post-traumatic stress disorder (PTSD), depression, and anxiety.³ Evidence for this effect is the fact that the prevalence of PTSD, depression, and anxiety among refugees is twice as high as the prevalence among labour migrants, which is 20%.⁴

Since the beginning of the civil war in Syria in 2011, 5.1 million left their country and became refugees. Syria's neighboring countries have been affected by the crisis, such as Turkey, Lebanon, and Jordan. In particular, Jordan has registered more than 673,000 Syrian refugees in the United Nations High Commissioner for Refugees (UNHCR), 2018 databases. The Syrian refugees settled first in the five camps designated for them in the north and northeast of Jordan as well as in the capital, Amman. With the continuation of the Syrian conflict, the number of Syrian refugees in Jordan increased and they started to move and reside outside camps and in the neighboring cities.⁵

Quality of life (QOL) is an essential tool for assessing health situations. According to the World Health Organization (WHO) (QOL) can be defined as "individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns".^6,7 WHOQOL-BREF questionnaire developed by the WHO assesses the individual's perceptions in the context of their culture, value systems, personal goals, standards, and concerns.⁸

The assessment of this group's quality of life may help to better understand and develop an insight into measures that can be improved in their lives. Considering that this specific group of migrants deserves peculiar attention, as having distinct needs and vulnerabilities. To the best of the researcher's knowledge, no study has been done concerning the (QOL) of Syrian refugees residing inside or outside camps in Jordan. Thus, the current study was conducted to assess the quality of life among Syrian refugees residing outside camps in Jordan and find out association between quality of life and various socio-demographic variables of refugees, if any.

METHODS

Sample size and sampling procedures

A survey questionnaire was distributed to target Syrian refugees during a campaign "warmth and peace" to distribute winter needs to Syrian and Palestinian refugees organized by Qatar charity in cooperation with the Jordanian Hashemite Charitable Organization during the month of 12/2021. 239 questionnaires eligible for analysis were collected during the campaign days. In carrying out the study, the standard ethical considerations were observed, which include obtaining Syrian refugees' consent; where refugees huddled in the campaign center gave oral consent to participate in the study after they heard a brief explanation of the study's aim, in addition to ensuring confidentiality.

Study instrument

QOL was assessed by using WHO QOL-BREF scale which was tested and validated. This instrument contains 26 questions which reference to each four domains namely physical health, psychological, social relationships and environment to be studied. Each of these domains was rated on a 5-point Likert scale. As per the WHO guidelines, 25 raw scores for each domain were calculated by adding values of single items and it was then transformed to a score ranging from 0 to 100, where 100 is the highest and 0 is the lowest value. The mean score of each domain, total score and average score were calculated. This questionnaire was translated to Arabic and then, back to English to assess the liability of the study instrument.

After obtaining verbal informed consent from each participant, they were interviewed and the data was collected on socio-demographic factors using a structured questionnaire along with the application of the instrument WHOQOL-BREF.

Data analysis

Data acquired from the questionnaire was analyzed using Microsoft office excel and statistical package for the social sciences (SPSS). Descriptive statistics were calculated for background variables including socio-demographic characteristics. The findings for each domain were expressed in terms of mean and standard deviation (SD). The difference between mean scores was tested by using an independent sample t-test. P value less than 0.05 was considered statistically significant.

RESULTS

Socio-demographic socio-demographic variables of the study participants

From Table 1 it was observed that most of the study population were females (57.3%). it was also observed that most of the study population were in the age group of 31−45 years (56.5%) followed by 46−60 years (31%), >60 years (7.9%), and 18-30 years (4.6%). (90.4%) of the study population were married, (5.4%) were widow/widowed, (2.9%) were single and (1.3%) were separated. More than half of them have studied up to the primary level (63.6%), (15.9%) have studied up to the secondary level, (11.7%) have studied up to the tertiary level and only (8.8%) had no formal education. Concerning family size, (44.8%) of households consisted of 4−6 person, (38.5%) of households consisted of over six persons, and (16.7 %) of households consisted of 1-3 person. With regard to monthly household income, most of them (87%) earned <300 JD.

Assess the quality of life (QOL)

The final scores in each domain are shown in Table 2. The mean score was 47.32±11.48, 48.96±12.22, 24.68±10.01, 40.44±9.35 for physical, psychological, social and environmental domains. The skewness/SE values for all four domains were <1.96. Hence, the data distributions are fairly normal.

Association between the QOL and socio-demographic variables

From Table 3 it was observed that the mean physical domain transformed score was high among the male population, 31−45 years, widow, and primary education level, households of 4-6 person, and households with a monthly income <300.

All these differences were statistically non-significant.

Table 4 shows mean psychological domain transformed score was high among males, single. The mean psychological domain transformed score was high among 18−30 years group, primary education level, households of 1-3 person, and households with a monthly income >600. These differences were statistically non-significant.

Table 5 shows the mean social relationship transformed score domain was high among 31−45 years, males, single, primary education level, and households with a monthly income >600.

These differences were statistically non-significant. The mean social relationship domain transformed score was high among households of 4-6 person. This difference was statistically significant.

Table 6 shows mean environmental domain transformed score was high among males, single, <60 years group, primary education level, households of 1-3 person, and households with a monthly income >600. These differences were statistically non-significant.

DISCUSSION

The study shows that the overall (QOL) score of Syrian refugees residing outside camps is below average. On further look at the score of each domain, the social relationship domain has the lowest score. A similar finding was observed in studies done by Kumar et al, Praveen et al, and Qadri et al, which show a higher overall score and also better social and interpersonal relationship scores than our study.^9-11 The differences observed in (QOL) scores among this study and other studies might be due to the difference in the pattern of associated factors as (QOL) would be affected by events of life related to person community.

The study has revealed a higher psychological domain score which shows that Syrian refugees are more satisfied with their psychological situations. The existence of basic factors essential to mental health (that is, education for children, employment for adults, comfortable and a sanitary living environment) are accessible to many Syrian refugees in Jordan could be the reason for this higher score among all the domains which was not shown by other studies.

It was observed in this study that though gender, marital status, education level, household size, or monthly household income seems to have a say on the quality of life, the association was not statistically significant except for the household size variable which was statistically significant with the mean social relationship domain transformed score. This finding was similar to other studies such as Guthi et al study.¹²

CONCLUSION

The purpose of this study was to assess the quality of life of Syrian refugees residing outside camps using WHO QOL-BREF questionnaire. Despite the support Jordan provides to the Syrian refugees, they still generally suffer from poor physical, psychological health, social relationships, and environmental domains, with scores below 50 on (0–100) scale. Among the domains, the psychological and social domain had higher and lower means scores. Additionally, variables having an effect on their quality of life were also revealed which included gender, marital status, education level, household size, or monthly household income.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the institutional ethics committee

REFERENCES

1. 1. United Nations High Commissioner for Refugees. The UN Refugee Agency, Figures at a glance. Available at: https://www.unhcr.org/figures-at-a-glance.html. Accessed on 20 July 2022.
2. 2. Gagliardi J, Brettschneider C, König HH. Health-related quality of life of refugees: a systematic review of studies using the WHOQOL-Bref instrument in general and clinical refugee populations in the community setting. Confl Health. 2021;15:44.
3. 3. Hauff E, Vaglum P. Vietnamese boat refugees: the influence of war and flight traumatization on mental health on arrival in the country of resettlement. Acta Psychiatr Scand. 1993;88(3):162-8.
4. 4. Lindert J, Ehrenstein OS, von Priebe S, Mielck A, Brähler E. Depression and anxiety in labor migrants and refugees – a systematic review and metaanalysis. Soc Sci Med. 2009;69(2):246-57.
5. 5. Khawaldah H, Alzboun N. Socio-economic and environmental impacts of Syrian Refugees in Jordan: A Jordanians’ perspective. Heliyon. 2022;8(8):e10005.
6. 6. World Health Organization. WHOQoL User Manual. Scoring and Coding for the WHOQOLSRPB Field-Test Instrument. Programme on Mental Health. Available at: www.who.int/mental_health/media/en/620.pdf. Accessed on 20 July 2022.
7. 7. Guthi VR, Prathyusha TVD, Kondagunta N, Kavyasree N, Kavitha C, Kavitha M. Quality of life among elderly population in an urban slum of Tirupati city. Int J Community Med Public Health. 2019;6:2430-4.
8. 8. World Health Organization (WHO). The World Health Organization Quality of Life (WHOQOL). Available at: https://www.who.int/toolkits/whoqol. Accessed on 20 July 2022.
9. 9. Kumar SG, Majumdar AGP. Quality of life (QOL) and its associated factors using WHOQOL-BREF among elderly in urban Puducherry, India. J Clin Diagnost Res. 2014;8(1):54-7.
10. 10. Qadri SS, Ahluwalia S, Ganai AM, Bali spS, Wani FA, Bashir. H. An epidemiological study on quality of life among rural elderly population of northern India. Int J Med Sci Public Health. 2013;2(3):514-22.
11. 11. Praveen V, Rani AM. Quality of life among elderly in a rural area. Int J Community Med Public Health. 2016;3:754-7.
12. 12. Guthi VR, Prathyusha TVD, Kondagunta N, Kavyasree N, Kavitha C, Kavitha M. Quality of life among elderly population in an urban slum of Tirupati city. Int J Community Med Public Health. 2019;6:2430-4.