Three core researchers developed the initial English version of the COVID-19 questionnaire from two centers that study stress, trauma, and cumulative traumas in the United States. The questionnaire included measures of COVID-19 as traumatic stress, PTSD, anxiety, cumulative stressors, and traumas, among other measures. The Arabic version of the questionnaire was translated and back-translated and culturally adapted by a researcher at Fayoum University, Egypt. The team used Google Drive and developed a survey link. The collaborating professionals in different Arab countries followed the chain recruiting method in collecting data from their respective countries by emailing the survey link to their contacts and asking the contacts, after completing the questionnaire, to email the survey link to their contacts to participate and subsequently send on to contacts with the same request. Once the participant completed the survey, it was sent anonymously to Gmail and then downloaded to an Excel file. All questionnaires were answered individually by participants from 4/28/2020 to 5/25/2020. Participation was voluntary; each person took approximately 25 min to complete the full questionnaire. The Fayoum University IRB approved the research as a cross-cultural study of the COVID-19 mental health impact.

One thousand and three hundred seventy-four (N = 1374) adult participants were recruited from seven Arab countries (Egypt, Kuwait, Saudi Arabia, Jordan, Algeria, Iraq, and Palestine). Because the number of participants from Palestine (N = 72) and Iraq (N = 67) was relatively small, and the initial analysis indicated that they are similar regarding their trauma load; also, they live under similar circumstances of internal and external conflicts, we combined the participants from the two countries in one subsample (N = 139). Table 1 summarizes the characteristics of the subsamples.

The COVID-19 traumatic stress scale is a 12-item scale including three subscales “threat/fear of the present and future infection and death” (5 items), “traumatic economic stress” (4 items), and “isolation and disturbed routines” (3 items). Items are scored on 5 point Likert-scale, with (1) indicating not at all and (5) very much. Examples of items include, “How concerned are you that you will be infected with the coronavirus?” “The Coronavirus (COVID-19) has impacted me negatively from a financial point of view.” “Over the past two weeks, I have felt socially isolated due to the coronavirus.” In the initial study (Kira, Shuwiekh, et al., 2020b), the scale showed good construct convergent-divergent and predictive validity. The COVID-19 scale had an alpha of .88 in the current study and. Its three Subscales had Cronbach alphas of .84, .75, and .70, respectively.

The CTS-S-36 scale was designed to measure seven types of stressors/traumas (collective identity trauma, personal identity trauma, identity/achievement trauma, survival trauma, attachment trauma, secondary trauma, and gender discrimination). Additionally, the scale includes three items that measure chronic and significant life stressors. Example items for the collective identity traumas (e.g., discrimination and oppression) include: “I have been discriminated against because of my sexual preference.” A personal identity trauma (e.g., early childhood traumas such as child neglect and abuse) example is: “I was led to have sexual contact with a person who was older than me (when I was young.)”. An example of a status identity/achievement trauma (e.g., failed business, fired, and drop out of school; non-criterion A traumas) is: “I have been fired, terminated, laid off suddenly, or have had a failed business.” A survival trauma (e.g., combat experience, car accidents, and natural disasters) example item is: “I have experienced a life-threatening medical condition (e.g., cancer, stroke, serious chronic illness, major injury, etc.).” As indicated above, the scale also includes items related to attachment trauma (e.g., abandonment by parents), secondary trauma (i.e., indirect trauma impact on others), and gender discrimination by parents and society. The CST-S evaluates cumulative stressors and traumas by measuring their occurrence, frequency, type, negative and positive appraisal, and chronological age at the first event. However, in the present study, we used only trauma occurrence (whether a trauma had occurred for a participant) and frequency, measured on a 5-point Likert-type scale (0 = never; 5 = many times). The CST-S has shown adequate internal consistency (α = .85), and test-retest stability (.95 in 4 weeks), and predictive, convergent, and divergent validity in several different studies (e.g., Bedoya et al., 2020; Eltan, 2019; Head, Singh, & Bugg, 2012; Kira et al., 2018a; Kira et al., 2019b; Kira, Barger, Shuwiekh, Kucharska, & Al-Huwailah, 2019a; Kira, Barger, Shuwiekh, Kucharska, & Al-Huwailah, 2020a; Kira, Fawzi, & Fawzi, 2013b; Robles, Badosa, Roig, Pina, & Feixas Viaplana, 2009). The measure has been translated and validated in several languages, 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, as measured by traumas occurrence, was .89.

The PCL-V is a 20-item self-report measure. Each item is scored on a five-point scale with “0,” indicating “not at all” and 4 indicating “extremely.” Initial research suggests that a PCL-5 cut-off score between 31 and 33 is indicative of PTSD. A provisional PTSD diagnosis can be made by treating each item rated as 2 = “Moderately” or higher as a symptom endorsed, then following the DSM-5 diagnostic rule, which requires at least: 1 B item (questions 1–5), 1 C item (questions 6–7), 2 D items (questions 8–14), 2 E items (questions 15–20). The Arabic version of the PCL-V has been previously validated in Arabic samples (Ibrahim, Ertl, Catani, Ismail, & Neuner, 2018). Cronbach’s alpha reliability of the scale in the current study was .94.

The GAD-7 is a 7-item self-report questionnaire that assesses general anxiety. Items are scored on a 4-point scale with (0) indicating “does not exist,” and (3) indicating “nearly every day.” The scores range between 0 and 21, with a cut-off point of 15, indicating severe GAD. The GAD-7 has a sensitivity of 89% and a specificity of 82%. Increasing scores on the scale have been strongly associated with multiple domains of functional impairment (Spitzer et al., 2006). The Arabic version of the GAD-7 was previously validated in Arabic samples (Sawaya, Atoui, Hamadeh, Zeinoun, & Nahas, 2016). Cronbach’s alpha reliability for the scale in the current study was .92.

is a 9-item self-report questionnaire that measures the degree of depression symptom severity. Items are scored on a 4-point scale with (0) indicating “does not exist,” and (3) indicating “nearly every day.” The scores range between 0 and 27, with a cut-off range of 15–19 indicating moderately severe depression and 20 and above indicating severe depression. The Arabic version of the PhQ-9 was previously validated in Arabic samples (Sawaya et al., 2016). Cronbach’s alpha reliability for the instrument in the current study was .88.

We used Cohen's (1992) criteria and recommendations to confirm the sample size necessary to detect a medium population effect size at power = .80 for α = .05 for the study’s number of variables. The data were analyzed utilizing IBM-SPSS 22. There were no missing data reported. In addition to descriptives, we conducted a linear polynomial one-way ANOVA. We used the Tukey HSD Post hoc for multiple comparisons to test for differences between the Arab countries in cumulative traumas, trauma types, COVID-19 traumatic stress, PTSD, depression, and anxiety.

We conducted stepwise multiple regression analyses, for each Arab subsample, with PTSD, depression, and anxiety as dependent variables. The data were evaluated to ensure that the multivariate tests’ assumptions were fulfilled (linearity, multicollinearity, homogeneity of variances, and homogeneity of covariance-variance matrices). The results of Bartlett’s Test of Sphericity (p < 0.001) and the residual SSCP matrix shows that the variables under analysis met the assumptions of linearity and multicollinearity. Also, the results of Levene’s test of equality of variances and Box’s M test of equality of variance-covariance matrices indicated that homogeneity of variances and homogeneity of variance-covariance matrices were satisfied (p > 0.01). We tested for collinearity between variables, and variance inflation factor (VIF) was less than 5.00 for the model, indicating no multicollinearity (e.g., Hair, Hult, Ringle, & Sarstedt, 2017; Williams, Grajales, & Kurkiewicz, 2013). In the first step in each analysis, we recoded the categorical variables into dummy variables and entered gender, age, religion, education, and income as independent variables. In the second step, we entered “cumulative stressors and traumas” as an independent variable to control their potential impact. In the third step, we entered COVID-19 traumatic stress as an independent variable.