Exploring the psychological effects of war on indirectly affected groups: a cross-sectional study on residents of Jordan

Abstract

The Gaza War has significantly escalated conflict and humanitarian crises in the Gaza Strip, causing profound human suffering and psychological impact. This study investigates the mental health of residents of Jordan, examining anxiety and depression levels, sociodemographic factors, and resilience mechanisms to understand the psychological resilience of communities facing conflict-related stressors. This cross-sectional study used a convenience sampling method to collect data from Jordanian residents over 18 years of age. An online questionnaire shared on social media platforms was used, the Patient Health Questionnaire-4 (PHQ-4) was used to measure anxiety and depression, the Perceived Stress Scale (PSS) 4-item questionnaire was used to measure perceived stress, and the Brief Resilience Scale was used to measure population resilience. A total of 1,664 participants were included in the study. The mean stress score was reported as 8.72 (SD +/-2.342). Stress, anxiety, and depression were significantly associated with age and sex, with younger populations and female participants reporting higher stress scores. Among the sample, 65.0% of individuals displayed both anxiety and depression indicators, with 25.9% exhibiting severe, 66.4% exhibiting moderate and 33.6% exhibiting mild level. A comprehensive, multi-institutional approach is needed to increase awareness and screening of mental health conditions.

Introduction

The Gaza strip, the smaller part of two Palestinian territories, is situated on the eastern coast of the Mediterranean Sea and bordered by Egypt and Israel [1]. Since 7 October 2023, a state of war has been declared in the Gaza Strip, a region that has suffered over 55 years of Israeli military occupation and more than 15 years of blockade [2, 3]. Since its start, over 1.7 million (80% of the total population) have been displaced in the Gaza strip, with more than 13,000 civilians’ deaths, including over 100 United Nations personnel [3, 4]. The impact of war extends beyond material catastrophes to impact mental health, with estimates of depression, anxiety, and posttraumatic stress disorders in 22% of the population affected by war [5]. This is more pronounced in certain subpopulations, such as women, children, elderly individuals and disabled individuals, indicating that the degree of trauma is highly dependent on a multitude of factors, including the availability of physical and emotional support [6].

The mental health ramifications of war extend beyond immediate participants, refugees, or directly involved parties [7, 8]. Psychological distress caused by war events, as portrayed in media coverage or witnessed by individuals worldwide, generates anxiety, uncertainty, and lasting effects on mental health [9, 10]. Anxiety disorders, acute stress reactions, depressive episodes, personality changes, and posttraumatic stress disorders (PTSDs) are evident among broader groups influenced by pervasive media coverage of war events [11]. Continual exposure to distressing news through various media platforms poses a risk to mental health. This understanding underscores the substantial adverse psychological effects propagated by sustained exposure to war-related information [12–14].

Neuroscientific studies suggest that ongoing conflicts can have profound implications for global mental health, extending beyond directly affected populations [14–16]. Consequently, advocating for reducing international tension and minimizing the likelihood of global conflicts has become crucial for preserving humanity’s mental health and potentially alleviating the burden of such diseases globally [8]. Evidence suggests that dysfunctional anxiety and persistent negative thinking can be significant indicators of mental health during crises, which extends far beyond directly impacted individuals and encompasses broader societal segments [7]. Thus, comprehensive strategies are urgently needed to mitigate and address the adverse mental health effects of war and conflicts.

Jordan is bordered in the west by the West Bank of the Palestinian territory and Israel. According to data from the United Nations, Jordan has an estimated total of 3,346,703 international migrants, accounting for 33.1% of the country’s overall population [17]. The number of Gazans in Jordan has ranged between 118,000 and 150,000 of the 2.3 million Palestinian refugees assimilated into the Jordanian community since the late 1940s. In the Eastern Mediterranean Region, scholars have reported that 85% of the population is either in conflict situations or has previously experienced such situations [18]. In Jordan, the National Centre for Mental Health reported that 20% of Jordanians suffer from depression and anxiety [19]. The current study aims to better appreciate the impact of the Gaza War on the mental health and well-being of residents of Jordan and their ability to recover from stress. This study focused on the susceptibility and levels of anxiety and depression among the general population in Jordan, linking them to different sociodemographic factors. The study focused on exploring the impact of conflict on indirectly impacted population in a neighboring country.

Methods

The cross-sectional study collected data throughout a 4-week period in November 2023. A convenience sampling method was adopted utilizing an online questionnaire that was shared through various social media platforms. The inclusion criterion was any resident of Jordan over the age of 18 years with the ability to provide informed consent. Any participant with a history or current diagnosis of a psychiatric disorder or with relatives in Gaza impacted by the war was excluded. The study used Google Forms to gather data sharing the survey link on various social media and messaging platforms, including Facebook, Instagram, WhatsApp, and Telegram. It is acknowledged that complete elimination of duplicate entries cannot be guaranteed due to the nature of online surveys, however measures to minimize duplications were followed as possible.

All the questions were in the Arabic language and were face validated by a subgroup of the population. The content validity test was conducted by a group of subject matter experts. The questionnaire collected data on sociodemographic factors, including sex, age, marital status, employment status and region. The Patient Health Questionnaire-4 (PHQ-4) was used to measure anxiety and depression [20]. The Cronbach’s α of the PHQ-4 was 0.81, with the availability of an Arabic version that was previously translated and validated [21, 22]. In addition, the Perceived Stress Scale (PSS) 4-item questionnaire was used to measure perceived stress in the last month [23]. The 4-item scale previously demonstrated acceptable internal consistency, with a Cronbach’s alpha coefficient of 0.79, whereas the Arabic version was previously reported to have acceptable reliability (Cronbach’s alpha between 0.5 and 0.878) and good stability, with a Pearson correlation coefficient of 0.55 [24, 25]. Moreover, the Brief Resilience Scale (BRS) was adopted to measure population resilience and the ability to recover from stress [26]. Similarly, the BRS was previously translated into Arabic and has excellent internal consistency (0.98) and good reliability (0.88) [27].

Statistical analysis was conducted via IBM Statistical Package for the Social Sciences (SPSS) version 25. Descriptive statistics, such as the means, standard deviations (SD), frequencies, and one-way analysis of variance (ANOVA), were used. A significance level of 0.05 was adopted in the analysis.

Results

A total of 1,664 individuals participated in the study. A total of 216 (13%) participants had relatives who were impacted by the war, either financially or economically, and 68 (4.1%) participants were being treated for mental health conditions. Out of the 68 respondents, 10 had impacted relatives in the Gaza Strip. After individuals on treatment and those with impacted relatives in Gaza were excluded, 1,390 (83.5%) participants were included in the study. Females constituted the majority of the respondents, with 1,075 participating individuals comprising 77.3% of the sample compared with 315 (22.7%) male respondents. Compared with 35.5% of the participants who were employed, 14.8% were unemployed, and 3.3% were retired. As shown in Table 1, over half of the sample was young adults between 18 and 25 years of age, followed by the 26–40 years of age group, which accounted for 31.6% of the sample. The sample included 181 individuals between 41 and 59 years of age and 29 elderly individuals over the age of 60 years. With respect to marital status, most respondents were single (65.8%), whereas 31.9% were married. Half of the samples were from the central region, whereas 44.5% were from the northern region, and 4.6% were from the southern region.

Table 1.

Sociodemographic characteristics of the sample

		No.	%
Sex	Male	315	22.7
	Female	1075	77.3
Marital status	Married	443	31.9
	Single	914	65.8
	Widowed	10	0.7
	Divorced	23	1.7
Age group	18–25	741	53.3
	26–40	439	31.6
	41–59	181	13
	60+	29	2.1
Occupational status	Employees	493	35.5
	Student	645	46.4
	Unemployed	206	14.8
	Retiree	46	3.3
Residency	North	618	44.5
	Center	708	50.9
	South	64	4.6

Almost the whole cohort followed ongoing events and posted about them via various social media and messaging platforms (97.1%). Among those, 98.6% of the participants followed the events daily, with more than one-third of the sample spending more than three hours daily. Overall, Instagram was the most popular social media platform utilized (81.3%), followed by Facebook, Telegram, and X (58.1%, 36.3%, and 33.0%, respectively).

Stress (PSS)

The stress scores obtained via the PSS ranged from 0 to 16 and had an overall mean of 8.72 (SD +/-2.342). After adjusting for confounders via multiple regression, only age and sex were significantly associated with PSS scores, with an increase of 0.709 among females and a 0.444 decrease in the PSS score with increasing age (p-value < 0.001). Moreover, the population following and posting about the events reported a significantly higher stress score after adjusting for confounders; p-value < 0.01.

Resilience

The mean level of resilience of the sample was 2.97 (SD ± 0.527), with only 1.0% of the sample reporting high resilience and 52.5% with normal resilience and 46.4% with low resilience. After adjusting for confounders, age and sex were the only significantly associated factors. Significantly greater resilience was observed with increasing age, with a reported resilience of 2.94 among those aged 18–25 years and 3.21 among those over the age of 60 years (p-value < 0.005). Males had a 0.0261 higher average resilience score (p-value < 0.001). As shown in Fig. 1, the stress score, as indicated by the PSS score, and the resilience score, indicated by the BRS score, were significantly negatively correlated (r=-0.413, p-value < 0.001).

Fig. 1.

Correlation between the brief resilience scale (BRS) score and the perceived stress scale score

Anxiety and depression

Based on the PHQ-4 results, 183 participants (13.2% of the total) showed no indication of depression or anxiety. Moreover, 903 (65.0%) patients reported both anxiety and depression, with an additional 262 (18.8%) showing depression indicators only and 42 (3.0%) showing anxiety indicators with no depression. Among those with depression and anxiety, 669 (74.1%) were deemed severe, whereas 234 (25.9%) were moderate. Out of the participants showing exclusively depression indicators, 174 (66.4%) were deemed moderate, and 88 (33.6%) were mild, with no severe scores. The 42 individuals who showed only anxiety indicators were either classified as mild or moderate: 22 (52.4%) and 20 (47.6%), respectively. All severe scores were associated with both anxiety and depression indicators.

The process of following and posting about events along with sex were significantly associated with depression, anxiety, and severity scores (p-value < 0.001). Females scored comparatively higher than males in all three areas, as did those who followed and posted about the events. Anxiety was observed both more frequently and more severely among females, with 70.0% of females having indications of anxiety compared with 61.0% among males. Severe anxiety was reported among 72.0% of the females with anxiety, whereas severe anxiety was reported among 66.1% of the males with anxiety. Similarly, females had higher rates of depression, with 85.8% of the sample having an indicator of depression compared with 77.1% of males. Moreover, the interpretation of the PHQ-4 results revealed that females more frequently reported severe indications of depression than males (58.8% and 52.3%, respectively). Meanwhile, occupation was only significantly associated with anxiety scores, with unemployed individuals having the highest scores, with a mean of 4.26 (SD +/- 1.667), whereas the scores were 3.43 (SD +/- 1.858) among retirees, 3.72 (SD +/- 1.783) among employed individuals and 3.56 (SD +/- 1.701) among students.

A comparison of the depression score and anxiety score revealed a strong linear correlation of 0.663 (p-value < 0.001). Similarly, the overall PHQ-4 severity score was significantly associated with the stress and resilience scores (p-value < 0.001). The correlation was negative with resilience, indicating that higher scores on the PHQ-4 are associated with lower resilience scores. Moreover, the correlation was positive in the case of the PSS, indicating that higher stress scores are associated with greater severity of anxiety and depression, as measured by the PHQ-4 (Table 2).

Table 2.

Correlations between the PSS, PHQ-4, and BRS

		PSS total score	Total BRS Score	Total PHQ-4 Severity
PSS total score	Pearson Correlation	1	− 0.413**	0.393**
	Sig. (2-tailed)		0.000	0.000
	N	1390	1390	1390
Total BRS Score	Pearson Correlation	− 0.413**	1	− 0.339**
	Sig. (2-tailed)	0.000		0.000
	N	1390	1390	1390
Total PHQ-4 Severity	Pearson Correlation	0.393**	− 0.339**	1
	Sig. (2-tailed)	0.000	0.000
	N	1390	1390	1390

**. Correlation is significant at the 0.01 level (2-tailed)

Discussion

Overall, the study population displayed high levels of anxiety and depression, with 68.0% expressing anxiety and 83.8% expressing depression. With a global estimate that 5.0% of adults experience depression and that 4.0% suffer anxiety disorders, the reported figures are rather alarming [28]. Jordan is already facing a high prevalence of psychological conditions, with an estimated 20.0% suffering from depression [19]. This relatively high prevalence of psychiatric conditions indicates the presence of environmental stressors that are already impacting the Jordanian population. Thus, ongoing conflicts might have aggravated the situation, as mental health is linked to both wider determinants and individual vulnerabilities. The ongoing events also impacted the situation on the political, economic and social level. Jordan’s huge Palestinian refugee population and strong ties to the Palestinian territories, would impact the political and social aspects. Furthermore, the religious significance resembled in the Church of Nativity, the Pilgrimage Route, and Aqsa Mosque may have also aggravated the impact. Finally, the ongoing events put additional pressures on the already suffering economy.

Elevated stress levels can further impact individual’s resilience, with a significant negative association between stress and resilience [29, 30]. Elevated stress levels exert pressure on an individual’s mental and physical capacities, hindering their ability to effectively manage and adapt. This pressure results in a reduction in resilience because increased stress depletes resources, impairs problem-solving skills, disrupts coping mechanisms, and affects general mental well-being, hence reducing the ability to recover from obstacles [31]. Moreover, the impacts of COVID-19 on mental health have been well documented and may have impacted resilience [32, 33].

The devastating impact of war on mental health has been previously documented in many studies [9]. This study indicated that the impact of war on mental health is not restricted to war zones and can spread to neighboring populations indirectly impacted by war. Though it is higher among directly exposed groups, a Thai study reported the presence of mental health problems among indirectly- and directly- exposed populations [34]. The current study investigated the population of Jordan and does not capture the population directly impacted, whether physically or economically. More research is needed to capture the impacts in the affected territories. However, the indirect impact of war could be facilitatedvia the media coverage of the conflict [12, 35, 36]. This is well observed in the current study through the increased reported stress among individuals following war events on social media. The mental health impact of the Gaza war was reported to fall disproportionately on females and younger age groups. This might be due to the significantly greater use of social media platforms, the adopted channel to follow ongoing events [37]. The use of social media platforms to disseminate online questionnaires may have caused a shift in participation trends toward younger age groups. Even though social media exposure was found to be a factor that increases anxiety and stress, other key psychosocial determinants of psychological distress, including economic status, family relationships, and culture, were not explored in more detail in this work. Future studies should employ more of these social factors in order to understand the factors influencing mental health in conflict ridden areas intimately. The duration of the psychological impacts is not well established as some scholars reported that the increase in psychological consequences among indirectly impacted individuals is short-lived with declines in rates after the cease of the conflict [38]. The prevalence of lifelong anxiety or depression is more common among directly impacted individuals and refugees [39].

This study revealed greater female participation, which is commonly reported in online surveys and might be related to the greater degree of communication among females than among males [40]. Irrespective of social media usage, the gender effect on psychological consequences matches previous reports indicating increased vulnerability of females and, accordingly, higher stress levels [9, 41, 42]. Cultural and societal factors in Jordan, such as traditional gender roles, societal expectations, and disparities in access to mental health resources, likely contribute to this disparity. Women in patriarchal societies may face additional pressures, including caregiving responsibilities and limited autonomy, which exacerbate their psychological burden. Addressing these underlying factors in future studies could provide a more comprehensive explanation for the observed gender differences. In Jordan, a similar effect was observed with COVID-19, as females were more likely to have higher anxiety and depression indicators [32]. This might be linked to the comparatively lower resilience of those subpopulations, as reported in the current sample. One possible explanation for the relatively higher resilience among males is the influence of sociocultural factors, such as gender roles and statuses, as well as the societal preference and privilege bestowed over men in patriarchal communities [43, 44]. Nonetheless, a previous study from Gaza reported higher rates of PTSD among adolescent males, highlighting the need to address this among both genders [45].

The current study reported increased anxiety and depression among younger age groups. This finding agrees with previous findings reporting an increased psychological impact among young adults [46]. While previous reports associated anxiety with elderly individuals as well, this was not the case in the current study [47]. This could stem from the nature of COVID-19 and the greater perceived risk among elderly people and the greater number of years of ongoing conflict in the region. The lower reported anxiety and depression could also be linked to increased resilience with age, which is attributed to the accumulation of life experiences, the development of more effective coping mechanisms, emotional regulation maturation, and strong social support networks [48–51]. Other scholars have further elaborated on the role of personal control in the levels of anxiety and depression, which increase with age [52].

The high reported levels of anxiety and depression indicate the need to enact a social support mechanism. The role of physical and psychological support in attenuating the impacts of conflict-related mental health consequences was previously well established. A previous study from Ukraine attributed low anxiety and depression levels postwar to social support given that it promotes resilience [53]. The role of intra- and interpersonal coping mechanism is integral in stress recovery and is interlinked with the perceived self-efficacy, self-discovery, as well as social relations dynamics and biological dispositions [54]. Thus, an integrated holistic approach warrants better results and outcomes. This can include subpopulation tailored approaches such as innovative digital mental health support tools which were deemed effective and usable [55]. Community-based mental health programs are another intervention that was deemed effective in combating psychological events in developing countries [56].

The study excluded individuals previously diagnosed with psychiatric diseases and those with families in Gaza. This might have brought variability in the mental health outcomes since Jordan has numerous Palestinians, with direct family members from Gaza. There is a possibility that people originating from Gaza or those with direct family members from Gaza might have more psychological impact given their refugee status, family and materialistic ties could exacerbate the impact and the rationale of this study was to measure the impact of war on indirectly affected groups than those who do not have any relations with Gaza. Similarly, groups with previous psychiatric diagnosis are more vulnerable and could experience more drastic consequences. Therefore, both groups were excluded in a trial to reduce confounding as the rationale of this study was to measure the impact of war on indirectly affected groups. This exclusion might limit the generalizability of the results reporting lower rates. Thus, the provided results could be an underestimate of the existing situation conferring the need for a holistic response.

The cross-sectional design implies the situation at the time of data collection, which was shortly after the beginning of the conflict and cannot be generalized. The tools used for screening are not intended for clinical diagnosis, but their performance can potentially indicate mental well-being. Despite these limitations, the current study is highly important because it highlights the need to tailor interventions to address ongoing mental health conditions. Obviously, the information on the participants’ country of origin and immigration status was not obtained in the current study and this may be viewed as a limitation. This might have brought variability in the mental health outcomes since Jordan has numerous Palestinians, with direct family members from Gaza. There is a possibility that people originating from Gaza or those with direct family members from Gaza might have more psychological impact than those who do not have any relations with Gaza. Subsequent research should include more specific questions pertained to participants’ country of origin and family members in conflict areas.

Finally, the study utilized descriptive statistics and hence could not fully capture the sociodemographic differences in mental health outcomes and resilience. It only collected minimal sociodemographic factors, such as age and sex. Future holistic studies reviewing various factors to examine predictors and associations with psychological impacts and resilience is strongly recommended.

Conclusion

The mental health impact of the ongoing war clearly impacts the mental health of residents in Jordan. This is more pronounced among the younger population and females. This study indicates an urgent need for effective and comprehensive strategies to address the psychological situation in Jordan, with an emphasis on the impact of war on mental health. Social support and mental health interventions to mitigate the impact of conflict on the well-being of Jordanian residents could be beneficial in addressing these issues. There is an urgent need for a tailored, multi-institutional approach to address the ongoing situation with programs to increase awareness and screening of mental health conditions.

Abbreviations

ANOVA

Analysis of variance

BRS

Brief Resilience Scale

COVID-19

Coronavirus Disease 2019

PHQ-4

Patient Health Questionnaire-4

PSS

Perceived Stress Scale

PTSD

Posttraumatic Stress Disorder

SD

Standard Deviation

SPSS

Statistical Package for the Social Sciences

Author contributions

S.A and H.A conceptualized and designed the work. S.A, H.A, and M.A participated in the data acquistionA.A analyzed and interpreted the data, and drafted the workAll authors reviewed the manuscript.

Funding

This research received no funding.

Data availability

The data that support the findings of this study are not openly available due to reasons of sensitivity but are available from the corresponding author upon request.

Declarations

Ethical approval and consent to participate

The studied was approved by the Institutional Review Committee at Jordan University of Science and Technology, number 224/2023. This study was conducted in accordance with the Declaration of Helsinki. The data collection was performed in a compliant manner. All participants were asked to consent to participate prior to completion of the form.

Competing interests

The authors declare no competing interests.