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Introduction
The emergence of the novel Coronavirus disease (COVID-19) in late 2019 has developed a global health crisis. In addition to presenting public health challenges and creating massive economic disruption, the COVID-19 pandemic has had profound psychological and social impacts on our communities. Its universally high rates of infection and mortality have caused worldwide fear and anxiety. 1 Fear of COVID-19 has been associated with decreased life satisfaction and giving rise in sleep disturbances. 2 According to Di Crosta et al,3 it is reasonable to expect an increase in acute stress disorders, Post-Traumatic Stress Disorder, and emotional and sleep depressive disorders due to factors such as fear of being infected with COVID- 19 or having a loved one infected. Srivastava et al,4 even show that fear of contracting COVID-19 resulted in several cases of suicide in India.

Literature suggests that fear of COVID-19 significantly varies in different countries, regions, and across different demographic groups. Fitzpatrick et al 5 collected information from a representative sample of 10,368 American adults in 2020, and asked participants to rate their fear of COVID-19 from 0 not at all fearful to 10 very fearful. Results indicated that participants were fearful with an average score of 7 being reported. Results from this study also highlighted that factors such as being female, Asian, Hispanic, foreign-born, married, laid off work, and having children resulted in significantly higher levels of fear of COVID-19 compared to counterparts. 5 Another study conducted in Australia that gathered information on 587 individuals who were aged 18 years and older reported that 16.9% of the participants strongly agreed with the statement I am most afraid of COVID-19. 6 This study suggested that those who were 30-59 years old, female, unemployed, living with family members, and whose financial situation was impacted by the pandemic were more likely to experience higher levels of fear from COVID-19 compared to others. 6

Theoretical/conceptual framework

We hypothesize that as a highly vulnerable group, refugees may experience higher levels of fear than others. Many refugees are afraid of losing their jobs due to the pandemic or getting arrested, being deported, or losing their legal status in their host countries. 7 An additional concern is the fear of social stigma and the impact that COVID-19 has had on increasing restrictions and crackdowns on refugees in host communities. 8 Elisabeth et al 9 further suggest that language barriers in the host country, poverty, low health literacy, and lack of adequate knowledge about the nature of COVID-19 and the safety measures in place may create feelings of confusion and fear among refugee populations.

Since the war that began in Syria in 2011, Canada has welcomed over 56,000 Syrian refugees. 10 Little is currently known about the prevalence and characteristics of fear of coronavirus among Syrian refugees. It is essential to explore the psychological impact of the COVID-19 pandemic on vulnerable populations in Canada to ensure our communities overall health and well- being. The main purpose of this paper is to investigate the prevalence of fear of COVID-19 among Syrian refugee parents in Ontario and assess other self-reported factors associated with this fear.
Methods
Participants and Data Collection
A cross-sectional sample of 540 Syrian refugee parents were interviewed between March 2021, and March 2022. The inclusion criteria were as follows: being a Syrian refugee above 16 years of age, being a parent with at least one child under 18 years of age, residing in Ontario, Canada, and having been resettled in Canada after 2015. Participants were recruited through convenience sampling, with the assistance of key community members and partner settlement organizations, Access Alliance Multicultural Health and the Arab Community Centre of Toronto (ACCT).

All study materials were translated to Arabic to reduce barriers of access for those who are not comfortable participating in English. To comply with social distancing recommendations due to the COVID-19 pandemic, the questionnaire surveys were administered remotely over the phone. Trained research assistants read out the consent form to participants and audio-recorded the participants oral consent. The research assistants conducted the questionnaires orally by reading out the questions in Arabic, in the Syrian dialect, and recording participants oral responses on a Qualtrics (Qualtrics, Provo, UT) 11 survey on password-protected electronic tablets. Participants then received a $20 honorarium as compensation for their time.
MEASURES

The major outcome of this study was assessed using psychometric tool, the Fear of COVID-19 Scale (FCV-19S), which was translated into Arabic. FCV-19S has strong psychometric properties and is valid and reliable in evaluating the fear of COVID-19 among populations 12. The scale consists of 7 items which measured how uncomfortable and afraid the participants felt about COVID-19. The items ranged from broad (e.g. I am most afraid of COVID-19.) to specific (e.g. My hands become clammy when I think about COVID-19.”). Responses were measured using a 5- point Likert scale ranging from 1- strongly disagree to 5- strongly agree. Each response was scored and the total score, ranging from 7 to 35, was calculated for all the items on the FVC-19S. Scores ranging between 7 to 21 and 22 to 35 indicated low and high levels of fear of COVID-19, respectively. 6 Sociodemographic and other self-reported factors were assessed. Sociodemographic factors included gender (mother, father), age, number of children, the highest level of formal education completed (none or elementary school, middle school, high school, university education, and postgraduate education), working status (yes, no), and self-perceived socioeconomic status measured by the question In your current condition, here in Canada, would you say most people would categorize a household like yours as? (Values ranging from 1=lower income to 5=upper income).

Migration-related factors consisted of participants self-ratings of their official Canadian language ability, often referring to English, (values ranging from 1= excellent to 6=not at all), the need for and availability of a language interpreter (categorized into four levels: participants needed an interpreter and were always provided with an interpreter, they needed an interpreter and were sometimes provided with an interpreter, they needed an interpreter and were never provided with an interpreter, and they never needed an interpreter), feeling satisfied with the support received from friends, based on the question How satisfied are you with the support you get from your friends? (values ranging from 1=very satisfied to 5=very unsatisfied), experience of living in a refugee camp (yes, no), and the number of years that the participants had been in Canada. Lastly, health- related factors included whether participants had a family doctor (yes, no), their self-rated mental health (collected on a five-point Likert scale, ranging from 1=excellent to 5=poor), and their trust in healthcare professionals in Canada, captured by the question To what extent do you trust healthcare professionals in Canada? (measured on a five-point Likert scale ranging from 1=not at all to 5=an extreme amount).

Analysis
Descriptive statistics were reported for the FCV-19S and the different sociodemographic and other self-reported factors. Simple linear regression analysis was performed to assess the bivariate relationship between each of the factors and FCV- 19S. Furthermore, multiple linear regression analysis was conducted with FCV-19S scores as the dependent variable and the sociodemographic, personal and health-related factors as the independent variables. Unadjusted and adjusted beta coefficients (β) and 95% Confidence Intervals (95% CI) were reported. All regression models were adjusted for the clustering effect of belonging to the same family. All analyses were conducted using the Statistical Package for Social Science (SPSS, version 28.0). The project was approved by the Research Ethics Board at York University (certificate # e2019-128).

Results
Results, in Table 1, showed that the average (SD) age of the 540 participants was 39.7 (7.3) years, and the average (SD) number of years in Canada was 4.3 (1.7) years. Mothers constituted 60.9% of the sample, and 62.1% of participants had a high school level education or higher. Most of the participants were not employed (65.6%) and reported their household as being lower or lower- middle income (60.2%). Moreover, almost half of the participants did not need a language interpreter for their appointments (47.1%), and most participants had a family doctor in Canada (93.1%) and were satisfied or very satisfied with their friendships in Canada (57.4%). Participants had a mean (SD) fear of COVID-19 scores of 15.6 (6.02) and 15.4% of the participants were categorized as having high levels of FCV-19 (scores between 22 to 35) [6]. Results, in Table 2, showed that 20.9% of participants strongly agreed that their heart races or palpitates when they think about getting COVID-19 and 30.9% agreed or strongly agreed that they are most afraid of COVID-19 (Table 2).

Table 1: Characteristics of study participant

Results of the multiple linear regression model, in Table 3, showed that the relationship between self-perceived socioeconomic status and FCV-19 was significant wherein the higher the reported socioeconomic status, the less afraid participants were of COVID-19 (Adjβ = -0.76, SE=0.29, p= 0.009). In addition, lower self-rated Canadian language ability was significantly associated with increased FCV-19S scores (Adjβ=0.65, SE=0.33, p= 0.047), and participants who always had an available interpreter when needed had decreased FCV-19S scores with this relationship approaching significance (Adjβ= - 1.56, SE=0.83, p= 0.061), when compared to participants who do not need an interpreter. Furthermore, refugees who had lived in a refugee camp experienced increased scores on the FCV- 19S compared to those who did not (Adjβ =2.27, SE=0.87, p=0.010). Lastly, having been in Canada longer (Adjβ=0.58, SE=0.21, p= 0.005) and a decrease in self-rated mental health ratings fear (Adjβ=0.84, SE=0.25, p<0.001) was significantly associated with increased fear (Adjβ=0.84, SE=0.25, p<0.001).
 
Table 2: Distribution of individual items of the Fear of COVID-19 Scale (FCV-19S)

Table 3: Results of the bivariate and multivariate analyses of association between socio-demographic, migration, and health-related factors, and fear of COVID-19

Discussion
This study aimed to evaluate the prevalence of fear of COVID-19 and factors associated with this fear among Syrian refugee parents residing in Ontario, Canada. Results from this study highlighted that 15.4% of the participants were categorized as having high levels of fear from COVID-19. In addition, findings indicated that low Canadian language ability, low self-perceived socioeconomic status, more years spent in Canada, living in a refugee camp, and poor self-rated mental health contributed significantly to elevated levels of FCV-19. Overall, these findings are valuable as they can assist in guiding the government to implement interventions or prevention strategies to alleviate the fear of COVID-19 among Syrian refugee parents in Canada, which will result in their improved mental health and overall well-being. Contrary to what we hypothesized, the fear of COVID-19 among Syrian refugee parents in Canada was not higher than what had been reported in other studies for general populations.

The mean score of FCV-19S (15.56) reported in our study was less than the percentages reported in India (45.2%) 13 and in Lebanon (44.8%) 14. However, the mean score of FCV-19S reported in our study was consistent with those reported for samples from Bosnian 15 Italian 16 English 17 and Eastern European 18 countries where the mean scores ranged between 15 and 18. Although the reason behind these unexpected results remains unclear, we speculate that having access to free and reliable healthcare in Canada may reassure Syrian refugee parents and alleviate their fear of COVID-19. In addition, it is possible that the myriad of traumatic experiences that refugees have passed through would make them resilient and less afraid of COVID-19.

One of the main findings of this study was that lower self-ratings of participants official Canadian language ability, often referring to English, was significantly associated with increased FCV-19S scores. Additionally, the availability of having interpreters when needed approached significance to having decreased FCV-19S, when compared to not needing an interpreter. Previous studies show that language barriers in the host country can be associated with feelings of confusion and fear among refugee populations 9 and that a lack of available translated information about COVID-19 can lead refugees to seek information from non-reliable sources, such as social media. 19 Lower host country language abilities lead to lower health literacy, which can decrease one’s ability to find, comprehend, and implement information required for appropriate health-related decision- making, as well as the ability to find assistance. 20,21 Studies suggest that people with lower health literacy showed more depression and lower quality of life during the COVID-19 pandemic. 22 The best way to lower corona-phobia is to raise more awareness and knowledge, 23 which requires no language barrier. Moreover, another study conducted during the pandemic reported that immigrants and refugees in Toronto, Canada, had anxiety and fear, and were at a higher risk of contracting COVID-19 due to not having access to COVID-19 guideline information in their preferred language at work. 24,25 Researchers stressed the importance of finding solutions to ensure equitable healthcare access for marginalized populations. 26

The present study showed that low self-perceived socioeconomic status (SES), more years spent in Canada, and living in a refugee camp contributed significantly to elevated levels of FCV-19. Participants who reported lower self-perceived socioeconomic status were more afraid of COVID-19. This is consistent with Rubin & Stuart 21 prior work which indicated that people with lower socioeconomic status are usually faced with more mental stress during COVID-19 in general. Another Chinese study 28 reported a negative association between SES and  psychological  panic. Moreover, number of years spent in Canada was significantly associated with fear of COVID-19, wherein those who had spent fewer years in Canada had reduced scores on the FCV-19S compared to their counterparts. It is speculated that newcomers may be less afraid of COVID-19 because they are coming from potentially volatile and dangerous environments such as war or conflict zones. Having recently been exposed to the possibility of death in a warzone, newcomers may perceive COVID-19 as less dangerous compared to those who had arrived in Canada prior to 2015 where they have become accustomed to the relative stability and security of Canada.

Furthermore, the present study showed that refugees who lived in a refugee camp prior to arriving in Canada had higher FCV-19S scores compared to those who did not (p=0.01). According to Alemi et al, 29 this might be due to their fear of being forced to quarantine, being isolated from their families, or even killed to slow the spread of the pandemic. Their study showed that refugee residents in Rohingya camps with COVID-19 symptoms refrained from seeking medical attention and had a lower number of COVID-19 tests reported. 29 Finally, this study found that participants with lower-rated mental health had higher FCV-19S scores. Previous studies highlighted that the COVID-19 pandemic exacerbated anxiety and depression symptoms in general 30 due to fears related to lockdowns, 31 fear of worthlessness, and fear of infection. 32 Another study 33 found that fear of COVID-19 is related to increased negative mental health symptoms such as anxiety and depression symptoms. As with most studies, the design of the current study is subject to limitations. The main limitation is information bias since the collected data is subjective and has been obtained through self- reported questionnaire items. Selection bias is another potential concern due to convenience sampling. In addition, the authors did not adjust for potentially confounding variables such as participants’ personalities and coping abilities. Despite the mentioned limitations, this study is one of the first to look into the experience of refugee parents during the COVID-19 pandemic.

Conclusion
Our research has important policy implications, and the findings could aid in the development of more effective interventions tailored at alleviating mental health issues among Syrian refugee parents in Canada. Government initiatives should consider tackling fear around pandemics among this population to help enhance their mental well-being. Our findings suggest that language barriers are significantly related to fear of COVID-19, thus governments should give attention to the availability of interpreters and health information in different languages, especially during times of crisis and mass confusion. To our knowledge, this study is the first to assess the prevalence of fear of COVID-19 among Syrian refugee parents in Canada and the factors associated with it. The present study provided the initial information needed for further investigation. Future research may focus on potential interventions that aim at directing policies and regulations that support vulnerable populations in Canada.

Conflict of interest: The authors have no conflicts of interest to declare.

Funding: This work was supported by the Social Sciences and Humanities Research Council of Canada [Application number 435-2018-1109].

References
1. Evren C, Evren B, Dalbudak E, Topcu M, Kutlu N. Measuring anxiety related to COVID-19: A Turkish validation study of the Coronavirus Anxiety Scale. Death Stud. 2022;46(5):1052- 1058. doi:10.1080/07481187.2020.1774969
2. Duong CD. The impact of fear and anxiety of Covid-19 on life satisfaction: Psychological distress and sleep disturbance as mediators. Pers Individ Dif. 2021;178(November):293.
3. Di Crosta A, Palumbo R, Marchetti D, et al. Individual Differences, Economic Stability, and Fear of Contagion as Risk Factors for PTSD Symptoms in the COVID-19 Emergency. Front Psychol. 2020;11(September):1-9. doi:10.3389/fpsyg.2020.567367
4. Srivastava A, Bala R, Srivastava AK, Mishra A, Shamim R, Sinha P. Anxiety, obsession and fear from coronavirus in Indian population: a web- based study using COVID-19 specific scales. Int J Community Med Public Heal. 2020;7(11):4570.    doi:10.18203/2394- 6040.ijcmph20204763
5. Fitzpatrick KM, Harris C, Drawve G. Fear of COVID-19 and the mental health consequences in America. Psychol Trauma Theory, Res Pract Policy. 2020;12:S17-S21. doi:10.1037/tra0000924
6. Rahman MA, Hoque N, Alif SM, et al. Factors associated with psychological distress, fear and coping strategies during the COVID-19 pandemic in Australia. Global Health. 2020;16(1):1-15. doi:10.1186/s12992-020- 00624-w
7. Fouad FM, McCall SJ, Ayoub H, Abu-Raddad LJ, Mumtaz GR. Vulnerability of Syrian refugees in Lebanon to COVID-19: quantitative insights. Confl Health. 2021;15(1):1-6. doi:10.1186/s13031-021-00349-6
8. Kassem II. Refugees besieged: The lurking threat of COVID-19 in Syrian war refugee camps. Travel Med Infect Dis. 2020;38(August).

9. Elisabeth M, Maneesh PS, Michael S. Refugees in Sweden During the Covid-19 Pandemic—The Need for a New Perspective on Health and Integration. Front Public Heal. 2020;8(October):6-10. doi:10.3389/fpubh.2020.574334
10. Government of Canada. Syrian Refugee Resettlement Initiative – Looking to the future. Published online 2019. https://www.canada.ca/en/immigration- refugees- citizenship/services/refugees/welcome-syrian- refugees/looking-future.html
11. Qualtrics, Provo. “The data analysis for this paper was generated using Qualtrics software Version 2020 of Qualtrics”, Copyright © 2020 Qualtrics. Qualtrics and all other Qualtrics product or service names are registered trademarks or trademarks of Qualtrics Provo UT U.
12. Ahorsu DK, Lin CY, Imani V, Saffari M, Griffiths MD, Pakpour AH. The Fear of COVID-19 Scale: Development and Initial Validation. Int J Ment Health Addict. 2022;20(3):1537-1545. doi:10.1007/s11469-020-00270-8
13. Doshi D, Karunakar P, Sukhabogi JR, Prasanna JS, Mahajan SV. Assessing Coronavirus Fear in Indian Population Using the Fear of COVID-19 Scale. Int J Ment Health Addict. 2021;19(6):2383-2391. doi:10.1007/s11469-020-00332-x
14. Haddad C, Zakhour M, Bou Kheir M, et al. Association between eating behavior and quarantine/confinement stressors during the coronavirus disease 2019 outbreak. J Eat Disord. 2020;8(1):1-12. doi:10.1186/s40337- 020-00317-0
15. Šljivo A, Kaamakovi M, Quraishi I, Kulenovi AD. Fear and depression among residents of Bosnia and Herzegovina during covid-19 outbreak- Internet survey. Psychiatr Danub. 2020;32(2):266-272. doi:10.24869/PSYD.2020.266
16. Soraci P, Ferrari A, Abbiati FA, et al. Validation and Psychometric Evaluation of the Italian Version of the Fear of COVID-19 Scale. Int J Ment Health Addict. 2022;20(4):1913-1922. doi:10.1007/s11469-020-00277-1
17. Winter T, Riordan BC, Pakpour AH, et al. Evaluation of the English Version of the Fear of COVID-19 Scale and Its Relationship with Behavior Change and Political Beliefs. Int J Ment Health Addict. Published online 2020:372- 382. doi:10.1007/s11469-020-00342-9
18. Reznik A, Gritsenko V, Konstantinov V, Khamenka N, Isralowitz R. COVID-19 Fear in Eastern Europe: Validation of the Fear of COVID-19 Scale. Int J Ment Health Addict. 2021;19(5):1903-1908. doi:10.1007/s11469-020-00283-3
19. Ross J, Diaz CM, Starrels JL. The disproportionate burden of COVID-19 for immigrants in the Bronx, New York. JAMA Intern Med. 2020;180(8):1043-1044. doi:10.1001/jamainternmed.2020.2131
20. Brickhill-Atkinson M, Hauck FR. Impact of COVID-19 on Resettled Refugees. Prim Care - Clin Off Pract. 2021;48(1):57-66. doi:10.1016/j.pop.2020.10.001
21. Singleton K, Krause E. Understanding Cultural and Linguistic Barriers to Health Literacy. OJIN Online J Issues Nurs. 2009;14(3). doi:10.3912/ojin.vol14no03man04
22. Nguyen HC, Nguyen MH, Do BN, et al. People with suspected covid-19 symptoms were more likely depressed and had lower health-related quality of life: The potential benefit of health literacy. J Clin Med. 2020;9(4). doi:10.3390/jcm9040965
23. Heiat M, Heiat F, Halaji M, et al. Phobia and Fear of COVID-19: origins, complications and management, a narrative review. Ann di Ig Med Prev e di Comunita. 2021;33(4):360-370. doi:10.7416/ai.2021.2446
24. Leung D, Lee C, Wang AH, Guruge S. Immigrants’ and refugees’ experiences of access to health and social services during the COVID-19 pandemic in Toronto, Canada. J Heal Serv Res Policy. 2023;28(1):34-41. doi:10.1177/13558196221109148
25. Greenaway C, Hargreaves S, Barkati S, et al. COVID-19: Exposing and addressing health disparities among ethnic minorities and migrants. J Travel Med. 2021;27(7):1-3. doi:10.1093/JTM/TAAA113
26. Knights F, Carter J, Deal A, et al. Impact of COVID-19 on migrants’ access to primary care and implications for vaccine roll-out: A national qualitative study. Br J Gen Pract. 2021;71(709):E583-E595. doi:10.3399/BJGP.2021.0028
27. Rubin M, Stuart R. Kill or cure? Different types of social class identification amplify and buffer the relation between social class and mental health. J Soc Psychol. 2018;158(2):236-251. doi:10.1080/00224545.2017.1327405
28. Xie X, Wu T, Zhang Y, Guo Y. Socioeconomic status and covid-19-related psychological panic in china: The role of trust in government and authoritarian personality. Int J Environ Res Public Health. 2021;18(20). doi:10.3390/ijerph182010888
29. Alemi Q, Stempel C, Siddiq H, Kim E. Refugees and covid-19: Achieving a comprehensive public health response. Bull World Health Organ. 2020;98(8):510-510A. doi:10.2471/BLT.20.271080
30. Sharif-Esfahani P, Hoteit R, El Morr C, Tamim H. Fear of COVID-19 and depression, anxiety, stress, and PTSD among Syrian refugee parents in Canada. J Migr Heal. 2022;5(January):100081. doi:10.1016/j.jmh.2022.100081
31. Meda N, Pardini S, Slongo I, et al. COVID-19 and depressive symptoms in students before and during lockdown. MedRxiv. Published online 2020. https://www.researchgate.net/deref/https%3 A%2F%2Fdoi.org%2F10.1101%2F2020.04.2 7.20081695
32. Dubey S, Biswas P, Ghosh R, et al. Psychosocial impact of COVID-19. Diabetes Metab Syndr Clin Res Rev. 2020;14(5):779-788.
33. Belen H. Self-blame Regret, Fear of COVID-19 and Mental Health During Post-Peak Pandemic. Int J Psychol Educ Stud. 2021;8(4):186-194. doi:10.52380/ijpes.2021.8.4.447