Procedures
We used five datasets collected on a broader research project that included EAA, will-to-exist, live, and survive (WTELS) measures, and other measures. The data sets included Egypt, Turkey, Kuwait, Syria (and Palestinians who lived in Syria), and the UK. The combined data set (N=1566) represented different cultures, different levels of exposure to cumulative adversities, different age groups (adolescents and adults), different religious affiliations, and Western and non-Western cultures. All data were previously collected upon IRB approval of the sponsoring universities in Egypt and Turkey as a cross-cultural research project (The same data sets and some of the measures were used in previous studies, see, for example, Kira et al., 2020a; Kira et al., 2020b).
Participants
Participants (N = 1566) included five subsamples from different five countries: Egypt (N = 490), Turkey (N = 420), Kuwait (N = 300), the UK (N = 177), and Syrians/ Palestinians (N = 179). The five samples represent different levels of traumatization and existential identity threats, which made them ideal for testing the model's assumptions. Syrians and Palestinians in Syria went and were still ongoing through the complicated Syrian civil war and the Palestinian's Israeli conflict (e.g., Giacaman et al., 2011; Kira et al., 2017; Pappéé, 2006). Turkish people were recovering from an attempted military coup that threatened their democracy and followed extreme measures to prevent additional attempts. Egyptian participants went through the Arab Spring turmoil rising against dictators. The UK participants have been exposed recently to terrorism and interpersonal traumas and the turmoil of Brexit. Kuwaiti citizens represent the other side of those relatively less exposed to existential identity threats. The different samples' recruitment strategies were similar, using a mix of networking and electronic platforms and university students associations and their families and faculties. While the subsamples in Egypt, Kuwait, and Turkey included adolescents (about 20%), the Syrian and the UK subsamples included only adults. There were different religious backgrounds in the subsamples. The subsamples represent rich variations of social, religious, and economic, cultural affiliations, and different levels of exposure to stressors and existential challenges.
Participants included 51.4% of males. Age ranged from 14–75 (M = 25.63, SD = 9.02), with 14.6% adolescents (under 18 years of age). It included 59.5% students, 17.6% employees, 8.5% workers, 2.9% professionals, 1.2% merchants, 2%retired, and 9.6% other occupations. For marital status, 24.4% were married, 71.8% were single, 1% were widows, 1.3% were divorced, and 1.5% had other marital statuses. For the level of education, the sample included 5.8% with minimum reading and writing skills, 8.6% had an elementary level, 4.8% were middle school, 16.7% high school, 57.8% college, and 6.3% graduate level. For income, 3.6% reported to be very poor, 8.6% poor, 71.5% reported to have enough income, while 13.1% reported having a high income, and 3.25% reported to be of very high income. For religion, 70.5% were Muslims, 18.9% were Christians, and 10.6% were either atheists, agonists, or do not believe in any religion. Table 1 summarizes the main demographics of the five sub-samples (Kira et al., 2020).
Table 1
The detailed demographics of each of the five sub-samples
variable
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Egypt (N = 490)
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Turkey (N = 420)
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Kuwait (N = 300)
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Syrians(N = 179)
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UK (N = 177)
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Age
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Age ranged from 14 to75, Mean = 26.03, SD = 10.90, 20.4% adolescents.
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Age ranged between 15 and 64 (M = 23.20,SD = 8.68) from which 18.9% were adolescents
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age ranged from 15–50 (M = 26.37,SD = 8.50), from which 18.7% were adolescents
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Age ranges between 19 and 54 (M = 28.7, SD = 6.16).
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Age ranged between 18 and 40, M = 25.89, and SD = 5.66.
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Gender
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41.4 males
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72.4% males.
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39% males
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62.6% males
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60.7% females
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Religion
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49.6% of Muslims and 50.4%
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94.3% were Muslims and the balance was from other religious affiliations.
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99.7% Muslims, .3% Christians
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90.5% were Muslims, .6% Ismaili Muslim, 2.2% Christians, 2.2% atheists, .6% agonists, 2.2% identified with no religion, and .6% identified themselves as humanists
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24.2% Christians, .6% Jewish, 4.5% other religions, while 70.8% with no religious affiliation.
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Education
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7.9% elementary level, 1.8% middle school level, 27.3% high school level, 51.8% college level, and 11% graduate studies level
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5.9% elementary, 2.9%middle school, 17.5% high school, 71.7% college, and 1.9% graduate levels
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4.7% elementary school, 20.6% high school, 72.7% college and 2% graduate students
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.6% was elementary school, .6% middle school, 8.4% high school, 74.9% undergraduate degree, and 15.6% have graduate degree.
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21.3% had a high school, 57.3% had an undergraduate degree, and 21.3% had a postgraduate degree
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Marital Status
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28.6% married, 68.8% single, 1.6% widowed, .4% divorced, .06% other
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15.5% were married, 82.6% were single and 1.9% other marital statuses
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35% married, 60.3% singles, 3% divorced, and 1.7% other.
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25.7% were married, 70.9% single, 2.8% divorced and .6% widowed?
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14.6% were married, 74.2% were single, 1.7% were divorced, and 9.6% had other marital statuses.
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Employment
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64.5% Students, 12.9% Employees, 3.4% professionals, 3.1% workers, 2.4% merchants, 1.4% retired, and 12.2% others
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75.1% students, 9.2% workers, 2% employees, .4% professionals, 2.9% retire, and 9.9% other
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55.3% students, 35.7% employees, 1.3% professionals, 4% retired, and 3.7% others.
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27.4% students, 18.4% are unemployed, 43% are employees, 3.4% merchants, 2.2% professionals, 1.7% workers, .6% retired, and 3.4% others
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48.9% were college students, 39.3% were employees, 6.2% were professionals, and 5.6% were others.
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Socio-Economic-Status
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1% very low, 2% low, 75.1% in the middle, 18.2% high, 3.7% very high
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.5% very low, 6.5% low, 84.8% in the middle, 6.5% high, 1.7% very high
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0.0% very low, .7% low, 77% in the middle, 18.3% high, 4% very high
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25.7% very low, 33% low, 22.9% in the middle, 11.2% high, 7.3% very high
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1.7% very low, 20.3% low, 70.6% in the middle, 7.3% high, 0.0% very high
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Measures (Note the same samples and measures were used in previous studies with different focuses, e.g., Kira et al, 2020; Kanaan et al., 2019).
Independent variables:
Cumulative Stress and Trauma Scale (CST-S) short version (Kira et al., 2008. It includes 32 items. CST-S is grounded on the development-based trauma platform (DBTF) (e.g., Kira, 2001; Kira, 2019; Kira et al., 2008; Kira et al., 2018; Kira et al., 2019; Kira, 2021a, Kira, 2021b). The CST-S evaluates cumulative stressors and traumas concerning its mere occurrence, frequency, type, and negative and positive appraisals. The scale is designed to classify a sample of 29 stressors into six stressors/trauma types, in addition to gender discrimination. Additionally, it includes 3 items that measure chronic and major life stressors. The six types of stressors/ traumas include collective identity traumas (e.g., discrimination and oppression). They include personal identity trauma (e.g., early childhood traumas such as child neglect and abuse). They include status identity/achievement trauma (e.g., failed business, fired, and drop out of school) (non-criterion A traumas). They also include survival trauma (e.g., getting involved in combat, car accidents, and natural disasters). They include attachment trauma, secondary trauma (i.e., indirect trauma impact on others), and gender discrimination. Participants were asked to specify their experience with an event on a 5-point Likert-type scale (0 = never; 4 = many times). Those who reported that they experienced the event were asked how much the event had affected them. They asked to use a 7-point Likert-type scale (1 = extremely positive; 7 = extremely negative) to rate its effect. In the analysis, the appraisal scale was split into two subscales: the positive (1 - 4) and negative (5 - 7) appraisal subscales. The CST-S includes two overall measures for cumulative stressors and traumas’ dose: occurrence and frequency, and two appraisals: negative and positive appraisal and general appraisal.
Investigators can compute these subscales for each of the stressor/trauma types. The CST-S has shown adequate internal consistency (α =.85) (Kira et al., 2008, Kira, Fawzi, & Fawzi, 2013), test-retest stability (.95 in 4 weeks), and predictive, convergent, and divergent validity. The measure has been translated into languages appropriate for each sample, including Arabic, Polish, Spanish, Turkish, Korean, Burmese, and Yoruba. In the present analysis, we used the cumulative stressors and traumas occurrence sub-scale. The current alpha of cumulative stressors and traumatic occurrence is .88.
Mediating Variables
The Centrality of Event Scale – 7 items short form (Berntsen and Rubin, 2006) assesses the degree to which a stressful occurrence is a point of reference for the individual's identity and the designation of its significance to the person's life and identity. The scale instructs the participant to consider the most stressful or traumatic event in his/her life and respond to the questions sincerely and honestly." The scale's short form consists of 7 items about the event, followed by a five-point Likert type scale, with "1" – strongly disagree" and "5" – totally agree." An example of the items is. " I feel that this event has become part of my identity." The authors reported that the scale had an excellent internal consistency (Cronbach's alpha = .94) and good convergent validity. In current data, the scale has an Alpha of.93.
Existential Annihilation Anxieties measure (EAA) (Kira et al., 2012; Kira et al., 2018; Kira et al., 2019; Kira et al., 2020) is a 15-item scale that assesses anxieties associated with four types of existential threats. Existential threats include threats to personal identity(3 items), threats to one's collective identity (4 items), threats to one's social status identity(5 items), and threats to his/her physical identity(3 items). An example of the items in the scale that represents collective identity threats is: "Sometimes I feel the threat of extermination/annihilation/ subjugation (that is, the threat of destruction or "getting rid "of my group ) because of discrimination or stereotyping or acts committed against me, my race, religion, culture, or ethnic or cultural group." Another example representing the threats to personal identity is "Because of what has happened to me personally or is happening to me now, being fragmented unable to cope, and losing control, and I fear the disintegration of myself or identity". Each item is scored on a scale from 0=disagree to 3= strongly agree. The scale was examined in samples in five countries: Egypt (N=490), Kuwait (N=300), Turkey (N=420), the UK (N=177), Syrian refugees in Turkey (N=179). Factor analysis on a combined sample (N=1566) identified 4 factors (subscales): Psychic EAA related to personal identity trauma (psychic), EAA related to collective identity trauma, EAA related to Social status traumas, and EAA related to fear of physical death (Kira et al., 2020). EAA scale was highly correlated with PTSD (.50), cumulative stressors and traumas, depression, thought disorder, internalizing, externalizing, and suicidality. It was associated with poor reported physical health, gender, other discriminations, and sexual abuse. It was negatively correlated with "will to exist-live and survive," spirituality, religiosity, self-esteem, and emotion regulation. EAA was strictly invariant across genders and age groups and strongly invariant across the five national groups. A critical cut-off point of 21 or more is proposed to discriminate between those critically high in EAA (Kira, Shuwiekh, Kucharska & Al-Huwailah, 2019; Kira et al., 2020). In current data, the measure had an alpha of .90. The alpha's of its four subscales ranged between .80 and .85.
Outcome Variables
Psychopathology Measure (Kira et al., 2017) is a 20-item screener that identifies adults and adolescents who are likely to have mental health disorders. The measure has three subscales: Internalizing, Externalizing, and thought disorder (psychoticism). Exploratory and Confirmatory Factor Analysis of different data in Egypt and Poland yielded three factors: Internalizing, Externalizing, and Psychoticism validating the current structure of psychopathology (e.g., Caspi et al., 2014; Laceulle, Volleberge, & Ormel, 2015). In the items of the measure, the participant is asked to indicate if the behavior (or feeling) happened in the past month (scored 4), or happened in the last 2-3 months (scored 3), or in the last 3-12 months (scored 2), or the last year or more (scored 1), or never happened (scored 0). High scores indicate potentially higher symptoms in these areas. Test-retest using an independent sample of 35 males with four weeks interval yielded excellent stability coefficients (0.970 for internalizing, 0.908 for externalizing, 915 for the combined externalizing and addiction subscale. In the current study, alpha reliability for internalizing was 0.84, 0.88 for externalizing and addiction, and 0.93 for psychoticism. The full scale of the psychopathology has an alpha of 0.90 in current data.
Poor Physical Health Scale (15 items, modified; Kira, Clifford, Wiencek, & Al-Haidar, 2001) was previously developed on refugees. The high score was positively correlated with higher PTSD, CTD (complex PTSD) scores, and older age (Kira et al., 2006). The reliability of the scale in several studies ranged between 70 and 85. The scale consists of questions about self-rated health on a 5-point Likert-type scale, and other questions on how does health conditions affected his/ her work, her/ his social relationships, and his/her memory (cognitive functioning). The scale also consists of physical health problems, based on ICD-9-CM codes for selected general medical conditions that include neurological, blood pressure and digestive system, musculoskeletal, and endocrine disorders. The higher the score, the worse is the reported health. The scale’s alpha in current data is .75.
Demographic variables: Demographic information was collected and included gender, age, marital status, religion, education, and socio-economic status (SES). SES was self-rated was (1) indicated very low SES, (2) indicated: low SES, (3) in the middle SES, (4) indicated high SES, and (5) indicated very high SES.
Statistical Analysis
We analyzed the data using IBM-SPSS 22, Amos 22. We computed frequencies, descriptions, and correlations between the variables. We computed path analysis to examine a model that identifies the effects of cumulative stressors and traumas (CTS) on psychopathology as mediated via centrality of the event (COE) and the four types of existential annihilation anxiety (EAA).
We examined the associations between CST and psychopathology mediated by COE and the four existential anxieties types (psychic, collective, physical, and status) using path analysis. Following Byrne's (2012), the path model was assessed to confirm an adequate fit to the data. The criteria for adequate model fit were a non-significant chi-square (χ²), chi-square/degrees of freedom (χ²/d.f. >5), comparative fit index (CFI) values > 0.90, and root-mean-square error of approximation (RMSEA) values < 0.06 (Weston & Gore, 2006). We used a bootstrapping method with 10,000 bootstrap samples to test the significance of direct, indirect, and total effects and 95% bias-corrected confidence intervals (95% CI) for each variable. To streamline the results, we modified the model by deleting the non-significant paths.
Additionally, we utilized PROCESS macro (Hayes, 2017) (model 4) to examine the CST direct and indirect effects via the mediators and the effect size and confidence intervals. Covariates introduced were age, gender, marital status, and religion. Further, we used bootstrapping sampling (n=10000) distributions to compute the direct and indirect effects and confidence intervals (95%) of the estimated effects. When the confidence interval does not contain zero, this point estimate is considered significant.
Further, to check the potential nonlinear associations between the variables and if the nonlinear models provide a better fit for the data, we utilized curve-estimation regression to examine the nonlinear (quadratic and cubic) and linear associations among the predictor variable: CST and the outcome variables: Psychopathology and its three components: thought disorder, externalizing, and internalizing as well as poor physical health.