Self-efficacy and locus of control as transdiagnostic factors in Middle Eastern refugees

ABSTRACT

Background: Many refugees report high levels of psychopathology. As a countermeasure, some psychological interventions aim at targeting mental health difficulties in refugees transdiagnostically. However, there is a lack of knowledge about relevant transdiagnostic factors in refugee populations.

Objective: To inform intervention efforts empirically, we investigated whether self-efficacy and locus of control are transdiagnostically associated with symptoms of depression, anxiety, somatisation, psychological distress, and a higher-order psychopathology factor (‘p’) in Middle Eastern refugees residing in Germany.

Method: In total, 200 Middle Eastern refugees took part in this cross-sectional study, comprising 160 male and 40 female refugees. Participants were, on average, 25.56 years old (SD = 9.19), and 182 (91%) originally came from Syria, while remaining refugees were from Iraq or Afghanistan. They completed measures of depression, anxiety, somatisation, self-efficacy, and locus of control.

Results: In multiple regression models adjusting for demographic factors (gender and age), self-efficacy and external locus of control were transdiagnostically related to depression, anxiety, somatic symptoms, psychological distress, and a higher-order psychopathology factor. Internal locus of control had no detectable effect in these models.

Conclusions: Self-efficacy and external locus of control appear critical in the mental health of refugees and may be important mechanisms in overcoming posttraumatic stress and resettlement stressors. Our findings support the need to target self-efficacy and external locus of control as transdiagnostic factors of general psychopathology in Middle Eastern refugees.

HIGHLIGHTS

• Middle Eastern refugees report high levels of psychopathology.

• Transdiagnostic interventions are often applied, yet knowledge about relevant transdiagnostic factors is scarce.

• Self-efficacy and external locus of control emerged as relevant transdiagnostic factors.

Antecedentes: Muchos refugiados reportan altos niveles de psicopatología. Como contramedida, algunas intervenciones psicológicas tienen como objetivo abordar las dificultades de salud mental en los refugiados de forma transdiagnóstica. Sin embargo, existe una falta de conocimiento sobre los factores transdiagnósticos relevantes en las poblaciones de refugiados.

Objetivo: Para informar empíricamente los esfuerzos de intervención, investigamos si la autoeficacia y el locus de control se asocian transdiagnósticamente con síntomas de depresión, ansiedad, somatización, malestar psicológico y un factor psicopatológico de orden superior (‘p’) en refugiados del Medio Oriente que residen en Alemania.

Método: En total, 200 refugiados de Medio Oriente participaron en este estudio transversal, incluyendo 160 hombres y 40 mujeres refugiados. Los participantes tenían, en promedio, 25,56 años (SD = 9.19), y 182 (91%) procedían originalmente de Siria, mientras que el resto de los refugiados eran de Irak o Afganistán. Ellos completaron medidas de depresión, ansiedad, somatización, autoeficacia y locus de control.

Resultados: En modelos de regresión múltiple ajustados por factores demográficos (género y edad), la autoeficacia y el locus de control externo se relacionaron transdiagnósticamente con depresión, ansiedad, síntomas somáticos, malestar psicológico y un factor psicopatológico de orden superior. El locus de control interno no tuvo ningún efecto detectable en estos modelos.

Conclusiones: La autoeficacia y el locus de control externo parecen ser críticos en la salud mental de los refugiados y pueden ser mecanismos importantes para superar el estrés postraumático y los factores estresantes del reasentamiento. Nuestros hallazgos respaldan la necesidad de enfocarse en la autoeficacia y el locus de control externo como factores transdiagnósticos de la psicopatología general en refugiados de Medio Oriente.

背景：许多难民报告了高水平的精神疾病。 作为一种对策，一些心理干预旨在跨诊断地针对难民心理健康困难。 然而，对难民人群中相关跨诊断因素了解不足。

目的：为了从实证角度为干预工作提供信息，我们在居住在德国的中东难民中考查了自我效能感和控制点是否与抑郁、焦虑、躯体化、心理困扰症状和高阶心理病理学因素（“p’）具有跨诊断相关性。

方法：共有 200 名中东难民参加了这项横断面研究，包括 160 名男性难民和 40 名女性难民。 参与者平均年龄为 25.56 岁 (SD = 9.19)，其中 182 人 (91%) 最初来自叙利亚，其余难民来自伊拉克或阿富汗。 他们完成了抑郁、焦虑、躯体化、自我效能感和控制点的测量。

结果：在控制了人口因素（性别和年龄）的多元回归模型中，自我效能感和外部控制点与抑郁、焦虑、躯体症状、心理困扰和高阶心理病理学因素跨诊断相关。 内部控制点在这些模型中没有可检测的效果。

结论：自我效能感和外部控制点对难民的心理健康至关重要，可能是克服创伤后应激和重新定居应激源的重要机制。 我们的研究结果支持将自我效能感和外部控制点作为中东难民一般精神疾病跨诊断因素的必要性。

KEYWORDS:

• Refugee mental health
• transdiagnostic approach
• self-efficacy
• locus of control
• p-factor

PALABRAS CLAVE:

• Salud mental de refugiados
• enfoque transdiagnóstico
• autoeficacia
• locus de control

关键词:

• 难民心理健康l
• 跨诊断方法
• 自我效能
• 控制点

1. Introduction

Conflicts and political instability in the Middle East have forced millions of individuals to flee their homes (UNHCR, 2020). Many refugees report high levels of psychopathology. Most research has focused on posttraumatic stress disorder (PTSD) and current evidence-based psychological interventions for PTSD seem to be also effective in refugees with this disorder (Kip et al., 2020). However, refugees usually present with a multitude of post-migration stressors and a wide range of mental health complaints that go beyond or are comorbid to PTSD, such as anxiety, depression, or somatisation (Bogic et al., 2012; Henkelmann et al., 2020; Nesterko et al., 2020). These challenges may be better addressed by focusing on potential transdiagnostic mechanisms that maintain different forms of psychopathology among refugees (Van Heemstra et al., 2019). For instance, the Seven Recovery-Oriented Survivor Empowerment Strategies (7ROSES) intervention aims at increasing self-efficacy among refugees as a means of improving mental health (Van Heemstra et al., 2019). In this program, refugees learn practical tools to approach daily problems, and exercises to increase awareness of personal or cultural resources. Likewise, the Problem Management Plus (PM+) developed by the World Health Organization (WHO) represents a brief transdiagnostic intervention targeting symptoms of depression, anxiety, and distress (e.g. De Graaff et al., 2020). This intervention aims to address the urgent need for affordable psychological interventions in low-income settings that can be adjusted and delivered by trained non-specialist peer providers. It includes evidence-based strategies of stress management, problem solving, behavioural activation, and accessing social support (Acarturk et al., 2022). Yet, despite the importance of such interventions, there is lack of knowledge about relevant transdiagnostic factors among refugee populations (cf. Koch et al., 2020). To inform intervention efforts empirically, the identification of transdiagnostic factors is crucial. To this end, we investigated whether self-efficacy and locus of control transdiagnostically relate to depression, anxiety, somatic symptoms, psychological distress, and a higher-order psychopathology factor in Middle Eastern refugees residing in Germany.

2. The transdiagnostic approach to psychopathology

Transdiagnostic variables are defined as such when they are assumed to be involved in the development and maintenance of several mental disorders (Harvey et al., 2004). Such variables comprise dysfunctional versions of processes that vary along continua in the general population and can be observed across different mental disorders (Mansell et al., 2009). A crucial advantage of the transdiagnostic approach is that identifying and applying psychological interventions aimed at remediating a transdiagnostic factor may have effects on all the disorders it is related to (Nolen-Hoeksema & Watkins, 2011). The transdiagnostic approach seems especially relevant in the context of refugee mental health care that often suffers from language barriers or a lack of cultural sensitivity of diagnostic instruments and intervention techniques applied (Hassan et al., 2015). By adopting a transdiagnostic perspective, there is less need for extensive assessments of a nosological diagnosis. In addition, Middle Eastern refugees have specific idioms to describe their distress, different mental health conceptualizations (Hassan et al., 2015), and report lower psychotherapy motivation compared to Western residents (Schlechter, Wagner et al., 2023). Focusing on broader issues outside the boundaries of a diagnosis may engage refugees to participate in transdiagnostic programs as suggested by high acceptability of PM + among Syrian refugees (Acarturk et al., 2022). Lack of cultural knowledge among practitioners may also lead to a lower readiness to work with refugees (Schlechter, Hellmann et al., 2021). Identifying relevant transdiagnostic processes enables the application of culturally sensitive interventions that can be disseminated with a broad outreach, thus being helpful for both patients (Van Heemstra et al., 2019) and practitioners (Schlechter, Hellmann et al., 2021). Despite the clinical relevance, we are aware of only one publication on this topic, which identified emotion regulation as a transdiagnostic contributor to different mental health symptoms in refugees (Koch et al., 2020). Specifically, emotion regulation was associated with PTSD, depression, anxiety, insomnia, and social impairment beyond demographics and trauma exposure in Afghan refugees exposed to trauma (Koch et al., 2020).

The psychological antecedents of refugee integration (PARI) model proposes that self-efficacy and loss of control are key factors for successful refugee integration (Echterhoff et al., 2020). Perceived self-efficacy, that is, the expectation of being able to perform an intended behaviour that is required to attain a certain outcome (Bandura, 1977), is a strong predictor of behavioural change, self-regulation, and goal setting. Such processes appear critical for refugees to overcome posttraumatic stress while simultaneously facing a myriad of resettlement stressors (Echterhoff et al., 2020). Across different samples in Western populations, self-efficacy was associated with depressive symptoms (Sawatzky et al., 2012), panic disorder (Sandin et al., 2015), anxiety disorders (Goldin et al., 2009), and PTSD (Samuelson et al., 2017). In Kurdish and Afghan refugees in Australia and New Zealand, lower self-efficacy was associated with lower subjective well-being (Sulaiman-Hill & Thompson, 2013). Similarly, an association of higher self-efficacy with more psychological security (Alharbi, 2017) and positive affect (Tip et al., 2020) was found among Syrian refugees. Moreover, in Syrian refugees in Turkey, self-efficacy was associated with social support and resilience (Pak et al., 2022). Accordingly, high levels of self-efficacy may equip refugees with cross-situational competence beliefs that enable them to navigate difficult post-migration stressors in the receiving countries (Echterhoff et al., 2020). Another relevant construct in the context of refugee migration and the experience of traumatic events is locus of control, which describes the extent to which people believe that they have control over their own life (Rotter, 1966). Outcomes in life can either be believed to be the result of their own abilities and behaviour (internal locus of control) or attributable to external forces out of their control (external locus of control). Although locus of control has consistently been found to be related to mental health in Western populations (for a meta-analysis, see Groth et al., 2019), surprisingly few studies have investigated locus of control in the context of refugee mental health (see Echterhoff et al., 2020). However, premigration perils (e.g. war), migration forcedness (i.e. the extent to which individuals are forced to leave their home country), and ensuing perils (e.g. dangerous migration routes) may led to an experienced loss of control among refugees (Echterhoff et al., 2020). Accordingly, locus of control may play a significant role in mental health of refugees and may shape their beliefs about the world in a post-migration setting. While locus of control has conceptual overlap with self-efficacy, they may affect refugees’ behaviour differently. Refugees may have a lower internal locus of control compared to populations that have not been exposed to comparable stressors. However, within this narrower range of perceived control, high levels of self-efficacy may still contribute to more successful coping with upcoming stressors. Therefore, it is important to examine both constructs in refugees in conjunction and how they relate to refugees’ mental health.

3. The present study

In the present research, we investigated whether self-efficacy and locus of control are transdiagnostically related to mental health in Middle Eastern refugees (primarily from Syria) residing in Germany. We investigated the association of self-efficacy and locus of control with symptoms of depression, anxiety, somatisation, and psychological distress. In addition, we tested their relationships with a transdiagnostic psychopathology factor, coined ‘p’ (Caspi & Moffitt, 2018). The p-factor of psychopathology addresses diagnostic overlap in mental disorders by modelling shared variation among symptoms with a bifactor approach. In this approach, an overarching p-factor transdiagnostically accounts for an overall level of psychopathology (Caspi & Moffitt, 2018). We expected self-efficacy and internal locus of control to be negatively associated with depression, anxiety, somatic symptoms, psychological distress, and the p-factor of psychopathology; external locus of control was expected to be positively related to these variables. To detect potential level-dependent effects of self-efficacy and locus of control, we exploratorily tested moderation models of these constructs with the outcomes.

4. Methods

4.1. Data availability and open science statement

Data and the corresponding R code to run the analyses of the present manuscript are openly available on the open science framework: https://osf.io/kes9y/?view_only=04fc48cdd0a14a6cba3fb4866f06c130. Parts of the data have already been analysed and published including some of the mental health outcome measures that we report in the present study (Schlechter et al., 2022). However, the variables self-efficacy and locus of control had not yet been analysed. The present study was not preregistered.

4.2. Participants and procedure

Refugees were recruited via social media (e.g. Facebook groups such as ‘Syrians in Germany’) and email lists from local organisations helping refugees. To take part, respondents had to be 18 years old and provided informed consent. There were no further data exclusions. The ethics committee of the University of Münster approved the study protocol. Participants received 5 Euro as monetary compensation for their participation. In total, N = 200 refugees participated. While most refugees came from Syria, we decided to include all participants to have higher statistical power, which was particularly important for our bifactor approach. We aimed to have around 200 refugees in our analyses to approximate sufficiently stable correlations and parameter estimates for our structural equation models (see Schönbrodt & Perugini, 2013; Wolf et al., 2013).

4.3. Materials

All materials were translated into Modern Standard Arabic by a professional translation office and then checked by an independent Arabic native speaker. In a first step, we asked participants for demographic characteristics, namely gender, age, country of origin, flight reason, legal status, and religion. Before scale composite scores were then analysed, the psychometric properties of the scales were evaluated with Confirmatory Factor Analyses. This is because scales that have been developed in non-Western contexts are not directly applicable to different populations without independent psychometric evaluation (Milfont & Fischer, 2010). Given that data were ordinal, we used the weighted least squares mean and variance adjusted (WLSMV) estimator for all models (Asparouhov & Muthén, 2010). Following criteria were used to evaluate model fit: The comparative fit index (CFI) and the Tucker–Lewis Index (TLI) should both be larger than 0.95 or 0.90, for a good or acceptable model fit, respectively. For the root mean square error of approximation (RMSEA) and Standardised Root Mean Square Residuals (SRMR), values lower than .05 indicate good fit values and values up to 0.08 suggest acceptable model fit (Hu & Bentler, 1999).

We used the brief version of the Patient Health Questionnaire (Brief PHQ-D; Gräfe et al., 2004) to assess depressive (9 items), anxiety (10 items), and somatic (13 items) symptoms.

4.3.1. Depressive symptoms

Depressive symptoms were assessed for the last 2 weeks with response options ranging from (0) Not at all, (1) Several days, (2) More than half of the days, to (3) Nearly every day with nine items. Psychometric properties for the one-factorial solution were good (Table 1; M = 11.40; SD = 6.58. α = .89).

Table 1. Psychometric properties of the different models.

	${\chi }^2\left(\mathrm{d}\mathrm{f}\right)$	p	CFI	RMSEA	SRMR	TLI
Self-efficacy	66 (35)	.001	.996	.067	.055	0.995
Locus of control*	0.44 (1)	.057	1.00	.000	.015	1.033
Depression	28 (27)	.389	1.00	.015	.047	0.999
Anxiety	61 (35)	.004	.986	.061	.080	0.982
Distress	0.23 (2)	.892	1.00	.000	.011	1.012
P-factor-Model	584 (559)	.217	.999	.015	.076	0.998

Note. df = degrees of freedom; CFI = Comparative Fit Index; RMSEA = Root Mean Square Error of Approximation; SRMR = Standardised Root Mean Square Residuals; TLI = Tucker–Lewis index; *two-factor solution.

4.3.2. Anxiety symptoms

Participants rated the impact of anxiety (which is labelled other anxiety symptoms in the PHQ) from (1) Not bothered, (2) Bothered a little, to (3) Bothered a lot with 10 items. Psychometric properties of the one-factorial solution were good (Table 1; M = 15.18; SD = 3.61. α = .75).

4.3.3. Somatic symptoms

The following somatisation symptoms were assessed: stomach pain, back pain, pain in arms and legs, pain during intercourse, headaches, chest pain, dizziness, heart race, short breath, constipation, nausea, gas, trouble sleeping, and feeling tired. Symptoms were assessed for the last four weeks on a three-point Likert scale ranging from 0 (not bothered at all), over 1 (bothered a little), to 2 (bothered a lot). The derived total scores thus range from 0 to 30. Higher scores indicate greater severity of somatic symptoms. (Table 1; M = 6.30; SD = 4.97. α = .83). Psychometric properties of the PHQ-15 have been established in a previous study using these data (Schlechter et al., 2022).

4.3.4. Psychological distress

The four-item psychological distress subscale from the Questionnaire on Psychotherapy Motivation (Fragebogen zur Psychotherapiemotivation – FPTM-23; Schulz et al., 2003) was used to assess psychological distress. The FPTM-23 consists of 23 items with scales ranging from 1 (strongly disagree) to 4 (strongly agree). An example item reads: ‘I can no longer cope with my problems.’ Psychometric properties for the proposed factor solution were good (Table 1; M = 9.32, SD = 3.09, α = .78).

4.3.5. Self-efficacy

The General Self-Efficacy Scale (GSES; Schwarzer & Jerusalem, 1995) measures optimistic self-beliefs about one’s ability to cope with a variety of life demands. Respondents were asked to rate 10 statements on a 4-point scale, ranging from 1 (not at all) to 4 (exactly true). An example item is ‘I can solve most problems if I invest the necessary effort’. The one-factor solution displayed good model fit (Table 1; M = 27.55, SD = 6.26, α = .88).

4.3.6. Locus of control

We used the four-item IE-4 questionnaire to assess locus of control (Kovaleva et al., 2012). Two items tap into internal control beliefs (i.e. internal locus of control) and two items into external control beliefs (i.e. external locus of control). Response options are 1 (does not apply at all), 2 (applies a bit), 3 (applies somewhat), 4 (applies mostly), 5 (applies completely). High scores indicate high internal or external locus of control. Note, however, that we expected internal and external locus of control to be differently associated with psychopathology. High internal locus of control should be negatively correlated with psychopathology while high external locus of control should be positively correlated with psychopathology. An example item for internal locus of control reads ‘If I work hard, I will succeed’, and an example item for external locus of control reads ‘Whether at work or in my private life: What I do is mainly determined by others’. The two factors had good model fit (Table 1; internal locus of control: M = 7.40, SD = 1.78; external locus of control: M = 5.36, SD = 1.97).

5. Results

Of the 200 participants, 160 were male and 40 were female. Participants were, on average, 25.56 years old (SD = 9.19), 182 (91%) were originally from Syria, the remaining refugees were from Iraq or Afghanistan. War and political persecution were named by 170 and 104 participants as flight reasons, respectively, with the opportunity to provide multiple reasons. Most refugees had a limited (n = 110) or an unlimited residential permit (n = 67) in Germany. The majority of refugees (n = 180) reported to be Muslim.

First, we tested the model fit of the p-factor model. For the p-factor model, a bifactor model was specified with an overarching latent trait coined ‘p’ and four orthogonal disorder specific factors (Figure 1). Model fit evaluation was based on the same criteria concerning the CFI, TLI, RMSEA, and SRMR as described for the evaluation of model fit for the scales we used. As shown in Table 1, the p-factor model had a good fit to the data. Accordingly, we derived factor scores from the p-factor model with the empirical Bayes method (Muthén, 2004), to have an overall score of psychopathology.

Figure 1. The p-factor of psychopathology. P represents an overarching factor capturing psychopathology, whereas the other orthogonal factors capture disorder specific aspects. D1 to D9 refer to the depression items, A1 to A10 to the anxiety items, S1 to S13 to the somatic items and DS1 to DS4 to the distress items.

Second, we ran several multiple regression models with self-efficacy, internal locus of control, and external locus of control as predictor variables and depressive, anxiety, somatic symptoms, psychological distress, and the p-factor (factor scores) as criterion variable (Table 2). We ran these regression models to discern whether the predictor variables were associated with the outcomes in a similar way, which would underscore their transdiagnostic nature. Multicollinearity was no concern; all variance inflation factors were below 1.5. To have comparable estimates across regression models, we z-standardised all variables. We set alpha to .05 and calculated 95% confidence intervals to gauge whether the estimates of the predictor variables overlap in their prediction across different disorders. Depression, anxiety, somatic symptoms, psychological distress, and the p-factor were all negatively associated with self-efficacy and positively with external locus of control. Internal locus of control was not significantly associated with the outcomes. Explained variance ranged from 9% (somatic symptoms) to 24% (psychological distress). Confidence intervals between the regression models were all overlapping for the estimates of self-efficacy and external locus of control, respectively. No significant interactions between the variables self-efficacy and locus of control emerged when predicting our outcome variables, all p > .21. Neither age nor gender were significant after adjusting for them in the regression models, all p > .12.

Table 2. Multiple regression models with self-efficacy and locus of control as independent variables.

	Depression	Anxiety	Somatic	Distress	P-factor
R²	.14	.14	.09	.24	.16
Self-efficacy
β	−0.28	−0.17	−0.21	−0.30	−0.27
LL	−0.44	−0.33	−0.36	−0.44	−0.42
UL	−0.12	−0.01	−0.04	−0.15	−0.11
p	<.001	.035	.015	<.001	<.001
External Loc
β	0.24	0.30	0.21	0.32	0.27
LL	0.10	0.17	0.07	0.20	0.15
UL	0.37	0.44	0.34	0.45	0.41
p	<.001	<.001	.003	<.001	<.001
Internal Loc
Β	0.03	−0.01	0.02	−0.04	0.02
LL	−0.13	−0.16	−0.15	−0.19	−0.13
UL	0.19	0.15	0.18	0.10	0.18
p	.714	.941	.834	.560	.774

Note. LL = lower limit of the 95% confidence interval, UL = upper limit of the 95% confidence interval; Loc = Locus of control.

Third, we explored self-efficacy and locus of control in multiple regression models predicting the four symptom types (depression, anxiety, somatic symptoms, and psychological distress), while adjusting for the three other respective symptom types (Table 3). In these regression models, self-efficacy was significantly associated with depressive symptoms and psychological distress. External locus of control was significantly associated with psychological distress while adjusting for the other symptoms. Internal locus of control displayed no significant associations.

Table 3. Multiple regression models with self-efficacy and locus of control as predictors controlling for the other three variables.

	Depression	Anxiety	Somatic	Distress
R²	.68	.64	.64	.45
Self-efficacy
β	−0.10	0.07	0.01	−0.18
LL	−0.20	−0.04	−0.10	−0.31
UL	−0.01	0.17	0.11	−0.06
p	.041	.211	.874	.005
External Loc
Β	0.01	0.08	−0.04	0.17
LL	−0.07	−0.01	−0.13	0.06
UL	0.10	0.18	0.05	0.29
p	.753	.071	.404	.002
Internal Loc
Β	0.02	−0.01	0.01	−0.05
LL	−0.07	−0.11	−0.09	−0.17
UL	0.12	0.08	0.11	0.08
p	.619	.763	.802	.444
Depression
Β	-	0.06	0.31	0.02
LL	-	0.04	0.18	−0.01
UL	-	0.08	.45	0.05
p	-	<.001	<.001	.104
Anxiety
Β	0.33	-	0.08	0.31
LL	0.21	-	0.06	0.14
UL	0.46	-	0.10	0.48
p	<.001	-	<.001	<.001
Somatic
Β	0.47	0.32	-	0.05
LL	0.35	0.18	-	−0.08
UL	0.58	0.45	-	0.27
p	<.001	<.001	-	.302
Distress
Β	0.09	0.20	0.06	-
LL	−0.02	0.09	−0.05	-
UL	0.20	0.31	0.17	-
p	.104	<.001	.302	-

Note. LL = lower limit of the 95% confidence interval, UL = upper limit of the 95% confidence interval; Loc = Locus of control.

6. Discussion

We examined the extent to which self-efficacy and locus of control are transdiagnostically related to mental health in Middle Eastern refugees residing in Germany. To this end, we investigated how self-efficacy and locus of control relate to the p-factor of psychopathology and different mental health outcome variables. In multiple regression models, adjusting for age and gender, we identified self-efficacy and external locus of control to be transdiagnostically related to symptoms of depression, anxiety, somatisation, psychological distress, and the p-factor of psychopathology. Also, when controlling for all other symptoms, which were expected to account for a large proportion of the variance, self-efficacy was still significantly associated with depressive symptoms and psychological distress. External locus of control was also significantly associated with psychological distress when adjusting for the other symptoms.

Our findings are in line with social cognitive theory that defines self-efficacy as one’s core belief affecting basic processes of personal change (Bandura, 2001, 2018). They are furthermore in line with theoretical considerations of refugee integration that highlight factors of human agency (Echterhoff et al., 2020) as well as with research findings in Western (Sheeran et al., 2016) and refugee populations (Alharbi, 2017; Pak et al., 2022) that found similar associations. Accordingly, cross-study evidence indicates that high self-efficacy is associated with a range of positive mental health outcomes among refugees, arguably by bolstering competence beliefs that enable them to manage difficult post-migration stressors in the receiving countries (Echterhoff et al., 2020). External control beliefs, on the other hand, are associated with worse mental health, likely because these individuals perceive the world as a dangerous place with a limited capacity to exert any control (Groth et al., 2019). In the present study, all confidence intervals between disorders were overlapping for the standardised estimates of self-efficacy and external locus of control. There is thus no indication that these factors are differentially related to the specific disorders, underscoring their transdiagnostic nature. This points to the need to identify factors that increase self-efficacy and control beliefs in refugees. Current literature provides important hints on factors that could increase self-efficacy in these populations: For example, Morina et al. (2017) study with torture survivors concluded that an induction of self-efficacy based on mastery-related autobiographical memories led to less distress in response to traumatic stimuli. In another qualitative study, Syrian refugees asked about ways to increase their self-efficacy reported improving access to employment and language courses, learning about the social and cultural system of the receiving country, practical information to master daily life, and improving social networks as core topics (Tip et al., 2020).

Contrary to our predictions, internal locus of control was not significant in any of the present multiple regression models. We believe that this is likely attributable to the strong effect of self-efficacy capturing a similar construct, a result also reported in prior research (Wu et al., 2004).

Altogether, our research points to the importance of transdiagnostic intervention approaches in refugees such as 7ROSES (Van Heemstra et al., 2019) or scalable WHO interventions like PM+ (De Graaff et al., 2020). Although current psychological interventions for PTSD are effective in refugees (Kip et al., 2020) and may also increase self-efficacy, these treatments require intensive training and lengthy duration of treatment, mostly with interpreters, to enable the intervention to be adequately delivered and effective. The result is that most refugees in need do not get treatment (Priebe et al., 2016). Accordingly, a major challenge is to develop more low intensity interventions that can still achieve reasonable effect sizes but require less lengthy treatment duration. By targeting stress management, behavioural activation, and social support beyond diagnostic boundaries transdiagnostic interventions may require less training and be delivered in a shorter period of time (Acarturk et al., 2022; Van Heemstra et al., 2019). Transdiagnostic interventions are critical in light of the myriad of challenges that refugees face including resettlement stress, language barriers, family separations, and asylum uncertainties (Echterhoff et al., 2020). In addition, mental health in refugees is also influenced by time-varying factors depending on the migration period (Wu et al., 2020). Such complexity may be better treated with transdiagnostic approaches as they seem to be better equipped to increase refugees’ required abilities to face a multitude of ongoing stressors. In the broader literature, different transdiagnostic principles seem effective in increasing self-efficacy. Examples are coping skill trainings, fostering performance experiences, reduction of avoidance behaviour, or participative goal setting (e.g. Lozano & Stephens, 2010; Warner et al., 2018). Testing these approaches in a culturally sensitive context may help refugees to (re)gain self-efficacy by simultaneously improving their functionality, sense of agency, and life quality sustainably. Synthesising this knowledge holistically and translating it into culturally sensitive interventions appears critical. For such interventions, it needs to be considered that Middle Eastern refugees have specific idioms to express their distress (Hassan et al., 2015). Systematically evaluating and implementing interventions tailored to refugees’ sociocultural backgrounds may lead to high acceptability of interventions with a broad outreach to refugees with low psychotherapy motivation (Schlechter, Wagner et al., 2023).

6.1. Limitations

First, the cross-sectional design of our study does not enable any references about causality of the present data. Hence, future research needs to examine whether these between-individual effects translate into within-individual differences in experimental or longitudinal settings. Second, the theoretical meaning of the p-factor of psychopathology remains unclear. While some authors argue that it captures a transdiagnostic psychopathological factor (Caspi & Moffitt, 2018), other authors posit that it is merely the sum of the parts of its constitutive elements (Fried et al., 2021). Either way, the derived p-factor factor scores displayed similar relationships with self-efficacy and locus of control as the disorder specific sum scores, bolstering support for the transdiagnostic nature of these factors regardless of the true nature of ‘p’. Third, our sample composition has limitations. The present sample was predominantly male, relatively young, and most refugees came from Syria. We did not exclude non-Syrian refugees to achieve more statistical power, but our results cannot be generalised to non-Syrian refugees. Although the potential degree of bias introduced by our sampling remains unknown, our sample composition mirrors the distribution of Middle Eastern refugees that have been arriving in Germany since 2015 (Juran & Broer, 2017). Last, although our own psychometric analyses on this sample indicated good model fit for the scales we used, these scales were not developed for Middle Eastern refugees in (Modern Standard) Arabic. Accordingly, other symptoms or linguistic subtleties that resonate better with specific idioms refugees might use to describe their distress may be missing in the present analyses. While qualitative studies and item development involving people with lived experience are warranted to improve these scales, the used scales were psychometrically sound in line with psychometric investigations of the PHQ-15 in Syrian refugees (Schlechter et al., 2022).

7. Conclusion

Self-efficacy and locus of control seem to be significant transdiagnostic factors in Middle Eastern refugees. Further research on this relationship has the potential to inform intervention approaches, which then need to test enduring effects of targeting these factors. Increasing a sense of agency in a culturally sensitive setting may help refugees to cope more effectively with mental health problems, language barriers, and post-migration stressors.

Open Scholarship

This article has earned the Center for Open Science badge for Open Data. The data are openly accessible at https://osf.io/kes9y/?view_only=04fc48cdd0a14a6cba3fb4866f06c130. This article has earned the Center for Open Science badge for Open Materials. The materials are openly accessible at https://osf.io/kes9y/?view_only=04fc48cdd0a14a6cba3fb4866f06c130.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

The study was funded by SAFIR Münster.