The Mediating and Moderating Role of Self-Esteem on Post-Traumatic Stress Symptoms and Physical Health Among Syrian Refugees in Host Communities

Background and Purpose: The Syrian civil war, which began in 2011, has been labeled the worst humanitarian crisis since World War II. Over 6 million people have fled to neighbor countries and Europe with Turkey, Lebanon, and Jordan taking the largest influx of Syrian refugees. Those who are living in exile from their home country are at a disproportionate risk for physical and mental health symptoms. Studies have suggested that clinical levels of post-traumatic stress (PTSD) are as high as 71% among Syrian Refugees and at least 50% of Syrian households have at least one family member with a non-communicable disease. Given the high influx of Syrian Refugees in Jordan, border communities have been unable to provide adequate healthcare to individuals with chronic non-communicable diseases (NCDs) and mental health conditions. To address the need for physical and mental health services among Syrian Refugees in Jordan, an international humanitarian organization, Americares, in collaboration with a local partner, implemented a health education project addressing non-communicable disease, behavior change, and mental health in the city of Irbid, 70 km north of Amman, Jordan.  

Method: A cross-sectional study was conducted with 598 Syrians and Jordanians in April 2017 in the city of Irbid, 70 km north of Amman and 21 km southeast of the Syrian border. This research project, funded by Americares Foundation, is part of a longitudinal intervention study measuring the impact of a health awareness project with the Royal Health Awareness Society in Jordan. Measures used in this study included the primary care PTSD checklist and Duke Health Profile examining physical, mental, social, general, perceived health, and self-esteem, and four dysfunction measures anxiety, depression, pain, and disability. The mediation analysis for this study was conducted using the PROCESS macro for SPSS and moderation analyses were conducted using hierarchical multiple regression.

 Results: One way ANOVAs indicated self-reported physical health significantly differed between age (f=7.47, p<.01) and gender (f=2.53, p<.01).  Level of education was significantly different for self-esteem (f=7.61, p<0.001), PTSD (f=3.35, p<0.01), and physical health (f=7.04, p<0.001). Correlation results indicated that higher self-esteem was significantly associated with lower PTSD scores (r= -.330) and higher self-reported physical health scores (r=.201). Controlling for education level, gender, and age, the mediation analysis illustrated an indirect effect of PTSD on physical health through self-esteem, B =-.89. Mediation analyses illustrated an indirect effect of PTSD on physical health through self-esteem, B =-.89. Hierarchical multiple regression illustrated that self-esteem had a significant moderating effect on PTSD on physical health, F(10,483)=9.808, p<.001.

Conclusion and Implications: This study was among one of the first to examine the mediating and moderating effect of role identity constructs such as self-esteem on health and mental health measures. Our results illustrate causal pathways which may influence the impact that PTSD has on physical health symptoms in individuals affected by a complex emergency. Future studies should continue to examine role identity such as self-esteem and social ties influence on mental and physical health symptoms.