PONE-D-20-11520

Post-traumatic stress, social, and physical health: A mediation and moderation analysis of Jordanians and Syrian refugees in border communities

PLOS ONE

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Reviewer #1: Yes

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Reviewer #1: Yes

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Reviewer #1: No

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Reviewer #1: Yes

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Reviewer #1: Thank you for submitting your manuscript to PLOS ONE. The study holds valuable information and advancement in the understanding of Syrian refugees and host community populations’ physical and mental health in the Jordan.

The following are my comments:

In general, the manuscript would benefit from English professional editing. There are many places with spelling issues, grammatical issues and other issues that can be addressed.

Abstract:

The abstract need to include the results of the difference between Syrian refugees and local Jordanians at high risk of physical and mental health ailments. Such comparison needs to be also included in the results section, since it is well established that Syrian refugees have many physical and mental health issues due to experiencing multiple traumatic events of the war. However, Jordanians have not experienced such events and therefore such comparison is required.

Background:

The title needs to be changed. It is the Syrian Crisis and its impacts in Jordan, or Syrian refugees in Jordan.

In the second paragraph, it is important to state that the number of Syrian refugees registered are by UNHCR in Jordan. Jordan has hosted more than 1.4 million Syrian refugees, who are not registered by UNHCR.

Page 4: Please write the full term of PTS, since it can be confused with PTSD.

Page 5: Forced migration, please change the tem to forced displacement, since migration is associated with a choice.

Page 6: the authors say “… which may be due to a lack of medications and appropriate health care, coupled with high risk for mental health issues that is caused by trauma these individuals may have experienced in their country of origin (33)”. Syrian refugees suffer from extreme poverty and insufficient resources that prevent them from seeking care. In Jordan, health care is private and very expensive. These consideration needs to be taken into account when considering the reasons to why Syrian refugees have high prevalence rates of NCDs.

Please consider including the following in the background literature review and references:

Al-Rousan T, Schwabkey Z, Jirmanus L, Nelson BD. Health needs and priorities of Syrian refugees in camps and urban settings in Jordan: perspectives of refugees and health care providers. East Mediterr Heal J. 2018; 24(3):243–53. Available from: https://doi.org/10.26719/2018.24.3.243

Ibraheem B Al, Kira IA, Aljakoub J, Ibraheem A Al. The health effect of the Syrian conflict on IDPs and refugees. Peace Confl. 2017; 23(2):140–52. Available from: http://doi.apa.org/getdoi.cfm?doi=10.1037/pac0000247

Rizkalla N, Segal SP. Well-being and posttraumatic growth among Syrian refugees in Jordan. J Trauma Stress. 2018; 31(2):213–22. Available from: http://doi.wiley.com/10.1002/jts.22281

Rizkalla et al. Women in refuge: Syrian women voicing health sequelae due to war traumatic experiences and displacement challenges. Journal of Psychosomatic Research. 2020; https://doi.org/10.1016/j.jpsychores.2019.109909

Social, physical, and mental health

Please start this paragraph with the definition of social health.

Please include the hostility among Jordanian towards Syrian refugees and the lack of work permit by the Jordanian government, which limits the income of refugees and their social interactions and may therefore have a negative impact on their self-control, self-concept, and self-worth. You may consider this reference as well:

Achilli L. Syrian refugees in Jordan: a reality check. Migr Policy Cent Eur Univ Inst. 2015; 2(February):1–12. Available from: http://www.reach-initiative.org/wp-content/

The background is a bit confusing, since it is focuses on the Syrian refugees and their physical and mental health. However, the authors states in page 7 that their study aims at examining the physical and mental health “within a Jordanian community near the Syrian border”. Where is the literature review related to the Jordanian community? The statistic of physical and mental health issue in Jordan is completely different than the one related to the Syrian refugees!!!

Methods

Page 7: Please state that the fliers with information on the study were in Arabic.

Page 8: Who were the research team trained by the PI? Were they Arabic speakers? Jordanians? Syrians? Both? Please specify their educational background as well since they may have affected the responses of participants.

Page 8: “self- report questionnaires” means that the participants have filled out the survey independently. However, according to the explanation provided, the research team helped participants with the survey. Did they interview them or only answered questions when needed?

Please add ethical issues related to anonymous participation, confidentiality, incentives if provided, oral consent form or written consent form, etc.

Page 9: Reliability of social health scale is low. Asking refugees who hardly find the means to eat or for transportation to reach their illegal work places about “attended social, religious, or recreation activities” is problematic. Please include this as part of the study limitations.

Page 10: Usually the measures section starts with the description of demographics. Please relocate.

Page 11: How was the mediation effects tested? Were they also done via SPSS PROCESS? Please clarify.

Page 11: “We adjusted for the effect of sociodemographic correlates (age, gender, nationality, trauma exposure, and education level) in the moderation and mediation models.” Income needs to also be included with the controlled variables. If the authors found that all participants were low on income, they need to indicate that this was the reason to not include this variable as one of the controlled variables.

Page 12: Please indicate results related to the comparison between Jordanians and Syrians, other than the obvious “Syrians reported significantly higher PTS scores than Jordanians”. If there were no other differences, please indicate that. I also think that all the analyses need to be divided into Jordanians and Syrians to see the difference between the two groups, especially because of the large sample size. Also, who are the “others” in the sample? Are they Palestinians?

Discussion

Though the findings are important in the field of trauma studies, they lack addressing the specific population. Syrian refugees who were uprooted and displaced, naturally lack the social connections and interactions that Jordanians have. Therefore, the whole analyses need to address these differences both in the results section and the discussion. The authors only mention this comparison in page 14. Please re-write the discussion to put these results upfront.

Also, please add into the results and discussion what were the main traumatic events experienced by Jordanians, since for the Syrians, the war events are obvious.

Page 15: Gender differences in PTSD among Syrian refugees can also be found in: Rizkalla N, Segal SP. War can harm intimacy: consequences for refugees who escaped Syria. J Glob Health. 2019; 9(2):1–10. Available from: https://doi.org/10.7189/jogh.09.020407

Page 17: “For example, activities for greater social contact could include religious events, participating in sporting events, or having community-based health and mental health education”. Please consider adding a budget for transportation or allocating buses/taxes, especially with activities related to Syrian refugees, so they can actually attend.

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Reviewer #1: No

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Post-traumatic stress, social, and physical health: A mediation and moderation analysis of Syrian refugees and Jordanians in a border community

PONE-D-20-11520R1

Dear Dr. Powell,

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Kind regards,

Neil J. Vincent, Ph.D.

Academic Editor

PLOS ONE

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