Compounding inequalities: Adolescent psychosocial wellbeing and resilience among refugee and host communities in Jordan during the COVID-19 pandemic

Purpose The COVID-19 pandemic and associated risk-mitigation strategies have altered the social contexts in which adolescents in low- and middle-income countries live. Little is known, however, about the impacts of the pandemic on displaced populations, and how those impacts differ by gender and life stage. We investigate the extent to which the pandemic has compounded pre-existing social inequalities among adolescents in Jordan, and the role support structures play in promoting resilience. Methods Our analysis leverages longitudinal quantitative survey data and in-depth qualitative interviews, collected before and after the onset of COVID-19, with over 3,000 Syrian refugees, stateless Palestinians and vulnerable Jordanians, living in camps, host communities and informal tented settlements. We utilize mixed-methods analysis combining multivariate regression with deductive qualitative tools to evaluate pandemic impacts and associated policy responses on adolescent wellbeing and mental health, at three and nine months after the pandemic onset. We also explore the role of support systems at individual, household, community, and policy levels. Findings We find the pandemic has resulted in severe economic and service disruptions with far-reaching and heterogenous effects on adolescent wellbeing. Nine months into the pandemic, 19.3% of adolescents in the sample presented with symptoms of moderate-to severe depression, with small signs of improvement (3.2 percentage points [pp], p<0.001). Two thirds of adolescents reported household stress had increased during the pandemic, especially for Syrian adolescents in host communities (10.7pp higher than any other group, p<0.001). Social connectedness was particularly low for girls, who were 13.4 percentage points (p<0.001) more likely than boys to have had no interaction with friends in the past 7 days. Adolescent programming shows signs of being protective, particularly for girls, who were 8.8 percentage points (p<0.01) more likely to have a trusted friend than their peers who were not participating in programming. Conclusions Pre-existing social inequalities among refugee adolescents affected by forced displacement have been compounded during the COVID-19 pandemic, with related disruptions to services and social networks. To achieve Sustainable Development Goal targets to support healthy and empowered development in adolescence and early adulthood requires interventions that target the urgent needs of the most vulnerable adolescents while addressing population-level root causes and determinants of psychosocial wellbeing and resilience for all adolescent girls and boys.


Comment:
Introduction from pages 1-3 provides a general context of the impact of covid related lockdowns on adolescents health and wellbeing. The authors seek to imply the effect of educational disruptions and social isolation bought on by the lockdown as the primary pathway affecting wellbeing. While the first three introductory pages set the context, the research population for this paper is introduced much later on page 3 . Even outside of the pandemic, the health and wellbeing of vulnerable adolescents living in settlements camps and under settlements is already expected to be impacted due to disruption of the social determinants of health. The impact of the pandemic hence adds additional burden over and above an existing health risk. The paper currently does not adequately introduce the research population with relevant context. The authors on page 10 make reference to 'pre-existing social inequalities'; however, the preceding introduction does not substantiate what these are. Comment:Page 10(line numbers-not provided in paper) As the pandemic now stretches >2 years; the authors may like to state the data collection dates earlier in relation to the following statement-three and nine months after its onset, on adolescent psychosocial wellbeing and mental health, exploring the role of support systems at the individual, household, community, and policy levels among communities affected by displacement

Methods.
Comment:The reference to dates (in pages 10,11)to explain the COVID-19 pandemic trajectory in Jordan was appreciated. However, as infection and case fatality rates are likely to be higher for vulnerable people living in camps where population density is higher, the authors may like to add a few references (if available about death/infection rates) in such communities which are different from the general population Comment:Could you please define 'host communities' as its relevant to the study and not part of common knowledge?

Comment:References are missing on page 5, last para.-Drawing on the work of Amartya Sen [X] and Marta Nussbaum [X]
Comment:On page 16, table 3, panels a and b provide the paper's main quantitative findings across different timelines. While the effect sizes are provided, the authors may like to add a note on the underlying measure of association used to obtain the effect size(RR or OR, e.g.). Additionally, some of the measures reported currently don't have background information provided in the introduction(pages 1-3). This is a repeated comment as I have previously suggested adding few references(if available) in the introduction to provide readers with some context about the social vulnerabilities encountered by the study's population Results Section: Comment:The transition from quantitative results on page 27 to qualitative results on page 28 is linked well and allows a gradual transition to the qualitative findings under the section on 'COVID19-and adolescent psychosocial wellbeing'.
Comment:Some of the key characteristics in how ITS, camps and host families differ would provide valuable context to the paper. Adding details in the method or as a section in the introduction would be important. Page 28, last para reflects on the nature of social networks in ITS as a reason for better PHQ-8 scores. Readers would be better placed to link the insight with a previous description of characteristics as suggested.
Comment:While the paper has collected data from younger and older cohorts in baseline(pre-pandemic), the presentation of results in tables 3 and 4 and in subsequent sections is grouped around residential affiliation(camp versus ITS vs Host family). The qualitative insights presented on page 29 provides reflections using age as a reference which is valuable. I found that the quantitative section in table 5(page 31) presents age-based reflections. As the results move between qualitative and quantitative sections fairly, I would advise the authors to have a summary section before or soon after the 'results' section starts to provide a pathway for readers to follow and improve the section's linking.

Comment:
The authors have previously mentioned on page 13 that the paper explores whether access to adolescent-specific programs in the form of 'Makani centres act as a protective factor. This would be a valuable finding to report, especially in R1 and R2 of data collection if the centres were functional. I was unable to adequately tease out the effect of access to Makani centres on the outcomes produced in tables 3-5. I understand that not all residential camps may have the program, but if the authors have looked at it as one of the main interventions available in the camps, it would be valuable to have a section on it in results. This is especially important when reporting qualitative outcomes such as pages 28/39 where adolescents report higher mental health issues. This is relevant to readers understanding the association between availability of access to Makani centres on adolescent mental health(boys/girls and young vs old) during the data collection rounds.

Comment:
The results on page 40 were insightfully presented, especially with regards to the associations of wealth and age on feeling pressured to marry early.

Comment:
The limited evidence of illicit drug use, as reported on page 43, may also have been due to respondents withholding sensitive information. As qualitative interviews were done virtually, the opportunity to develop rapport between interviewee and interviewer is limited. However, the role of the social support offered by families may have a mitigating effect on illicit drug use. The influence of family support is evident on page 49 /table 7where family and community coping skills are presented.
Comment :The reduced aid offered to families during the pandemic, as explained on page 61 is an important determinant of household wellbeing and vulnerability and may explain some of the transmitted mental health stresses that are common within a household encountering common stressor(s) The discussion and conclusion are well-presented sections