Syndemic Clustering of Noncommunicable Disease Risk Among Syrian Refugees and Jordanian Nationals: A Subnational Analysis of the WHO STEPS 2019 Survey

Understanding the intersection of noncommunicable disease (NCD) risk and displacement in fragile settings is critical for equitable global health policy. This study employs a syndemic framework to investigate the clustering of behavioral risk factors--tobacco use, insufficient fruit intake, and physical inactivity--among Syrian refugees and Jordanian nationals, using data from the WHO STEPS 2019 survey. A composite risk score was constructed, and subnational analyses were conducted by sex and region. Among 2707 adults with complete data, 61.5% exhibited all three risk behaviors. Syrian refugees had a significantly higher prevalence of full-risk clustering (67.8%) than Jordanians (52.2%, p < 0.001), with the North and Center governorates displaying the greatest burden. Syrian women exhibited the highest syndemic risk. No statistically significant associations were found between the risk score and self-reported hypertension or diabetes. These findings underscore the need for gender-sensitive, subnationally targeted NCD strategies that address the structural drivers of health inequity in displacement-affected settings.