A Systematic Review of Factors Affecting Mental Health and Well-Being of Asylum Seekers and Refugees in Germany

Treating sleep disturbances in refugees and asylum seekers: results from a randomized controlled pilot trial evaluating the STARS group intervention

Background: Sleep disturbances are highly prevalent in traumatized refugees and often persist despite treatment, and adapted scalable interventions are needed. The group intervention 'Sleep Training adapted for Refugees' (STARS) is a culturally- and context-sensitive approach based on evidence-based treatments for sleep disturbances (e.g. CBT-I, IRT). This study evaluated the feasibility, acceptability, and effectiveness of STARS.Method: A randomized-controlled trial (STARS vs. waitlist) with 47 young male Afghan refugees was conducted in a routine clinical setting (DRKS-ID: DRKS00024419) with pre-, post- and 3-month follow-up assessments. The primary outcome was insomnia severity (Insomnia Severity Index); secondary outcomes included PTSD, anxiety and depression symptoms, nightmares, coping with nightmares, fear of sleep, selected sleep diary measures, and quality of life. The data were analysed using mixed models.Results: Adherence to STARS was high (dropout = 17.4%, average attended sessions = 77%) as was client satisfaction (MCSQ-4 = 12.74, SDCSQ-4 = 2.08). A medium to large significant effect of time was observed for insomnia severity (d = 0.96) and most secondary measures (except nightmares and fear of sleep). However, there was no significant interaction with condition at post-treatment for the primary outcome (d = 0.29) and most secondary outcomes; the only exceptions were increased coping with nightmares, decreased daytime sleep, and time in bed.Conclusions: STARS appears feasible for treating sleep disturbances in traumatized refugees in a routine clinical setting, showing moderate to large within-group effects. However, it was not superior to the waitlist, likely due to unexpected improvements in the waitlist group. Adjustments to STARS may enhance its efficacy. Further research is needed to determine how STARS can be a scalable add-on treatment for sleep disturbances in traumatized refugees and asylum seekers.Trial registration: German Clinical Trials Register identifier: DRKS00024419..

Psychotherapists' readiness to treat PTSD: the influence of refugees' country of origin

Background: Previous research suggests that psychotherapists' readiness to treat traumatized patients varies according to patient and therapist characteristics, including the patient's refugee background.Objective: This study aims to examine the relationship between psychotherapists' readiness to treat patients with symptoms of post-traumatic stress disorder and various patient and therapist characteristics, including refugee background and country of origin.Method: In our vignette study with a nationwide online survey in Germany (N = 871), we assessed the readiness of licensed psychotherapists (LPTs) and therapists in training (PiTs) to treat patients with PTSD. Vignettes described patients with PTSD who differed in gender, refugee background, and country of origin (Syria vs. Ukraine). Participants rated treatment readiness and expected treatment success based on the vignette they received.Results: Treatment readiness and expected success were significantly lower for refugee patients. There was no difference in treatment readiness between refugees from Syria and Ukraine, but therapists expected less therapeutic success for Syrian patients compared to Ukrainian patients. Gender did not influence the results.Conclusions: The study shows that refugee background and country of origin influence psychotherapists' readiness to treat PTSD and their expectations of treatment success. These findings highlight potential reasons for the undertreatment of refugees and suggest opportunities for intervention and training, such as informing therapists about effective treatments for refugee patients.

Mental Health of Host and Refugee Youth in the Turkish Education System: The Role of Daily Material Stress, Well-Being, Social Support and Resilience

Refugee youth across the world cope with the complexity of fulfilling developmental tasks and cultural adaptation requirements while struggling with different stressors and problems. This situation has been pointed out in scientific studies that refugee youth are vulnerable in terms of mental health. However, refugees may differ in the severity of their mental health problems due to certain personal or interpersonal factors. To examine these factors, we linked mental health to psychological stress in a sample of Turkish and refugee youth. We discussed the potential roles of daily material stress, well-being, perceived social support and resilience among Turkish and refugee youth. 552 Turkish host youth and 500 refugee youth participated in the study. Questionnaires were prepared for Turkish and bilingual refugees, and Turkish youth participated in the study face-to-face. The findings revealed that the perception of well-being may have different meanings for refugees and Turkish youth: while refugees associate well-being with basic needs like nutrition and inclusion in education, Turkish youth often see systemic challenges in education as obstacles to well-being, which increases their stress levels. The study points to factors that need to be considered in explaining and protecting the mental health of refugees and Turkish youth involved in the Turkish education system.

Psychoactive substance use among Russian migrants relocated in Georgia following the 2022 invasion of Ukraine: Qualitative study

INTRODUCTION

Study aimed at exploring the experience of migrants from Russia who use psychoactive substances, who arrived in Georgia in the wake of the invasion of Ukraine.

METHODS

Qualitative individual interviews and focus group discussions. The data collection took place from May to August 2023.

RESULTS

The final sample consisted of 23 respondents, who were mostly young and employed. Participants left Russia because of the war in Ukraine and the threat of conscription in Russia, but also due to political dissent. Participants experienced depressive symptoms and a worsening of mental health conditions. The increased consumption of sedatives and alcohol was closely associated with the efforts to manage stress and depression, acting as a means to cope with adverse effects on mental health. The absence of leisure alternatives emerged as a significant factor, with drug use becoming a feature of socialising in circumstances where such behaviour was not typical in their Russian lives. Participants exhibited low awareness of available relevant health services (including drug-related) and typically addressed recurrent health needs by consulting Russian specialists online or Russian-speaking professionals within Georgia's migrant community.

DISCUSSION AND CONCLUSIONS

Migration was associated with a deterioration in mental health status and substance use often manifested as a maladaptive strategy to cope with mental health problems. The difficulties encountered in the process of assimilation contributed to behaviours related to drug consumption. Immigration policies need to be inclusive of the health needs of migrants and provide opportunity to integrate effectively into society.

'Sweden has changed me': a qualitative study exploring the sexual health needs and associated mental health aspects of young male former unaccompanied minors, asylum seekers and refugees in Region Stockholm, Sweden

OBJECTIVES

Sexual health needs of young refugees and asylum-seeking men are seldom explored or addressed, adversely affecting their mental and physical well-being. By interviewing young male former unaccompanied minors, refugees and asylum seekers in Stockholm, Sweden, this study aimed to get a deeper understanding of what they needed to achieve a positive and respectful approach to sexuality, romantic and consensual relationships. Additionally, we explored how their sexual health needs were related to their mental health, as well as the factors influencing both.

DESIGN

An exploratory qualitative study using semi-structured interviews was employed. Theoretical sampling was used for participant selection. Analysis of the data was performed using constructivist grounded theory.

SETTING

The study took place in Stockholm, Sweden.

PARTICIPANTS

A total of 32 young male (aged 16-28) former unaccompanied minors, asylum seekers and refugees from Afghanistan, Eritrea and Syria were interviewed.

RESULTS

Our analysis showed that our participants' sexual and mental health needs followed a process of individual change. One core category described the different stages of the process: 'On my way, but not there yet'. It contains four subcategories: 'being on the move: the migration journey'; 'newly arrived: contrasting old and new values and learning new concepts'; 'navigating relationships, love and sex'; and 'the respectful man'. We identified six key factors that influenced their sexual and mental health needs: attending school/receiving accurate sexual information, support to adapt, experiencing enjoyable relationships, restrictive parental values, exposure to stigma/discrimination and the negative image of young male refugees.

CONCLUSIONS

This study highlighted that the sexual health needs and related mental health aspects of young former unaccompanied minors, asylum seekers and refugees change over time and are influenced by contextual factors. Educational interventions aiming to improve the well-being of this population must address both sexual and mental health aspects, including issues related to gender norms, relationships, sex and consent.

Use and application of geographical restrictions in systematic reviews with the aim of including studies about Germany: An update of a methodological review

BACKGROUND

In systematic reviews (SRs), geographical limitations in literature searches can aid in focussing research efforts. A methodological review published in 2016 examined the approaches SR authors use to identify studies about Germany, analysing 36 SRs.

OBJECTIVE

The aim of this study was to update the original review.

METHODS

We conducted a literature search on PubMed for SRs synthesising evidence from studies about Germany published between 22 January 2016 and 7 June 2022. Two reviewers independently performed study selection and data extraction. We evaluated the application of search syntax for restricting studies to those about Germany using the peer review of electronic search strategies criteria. The updated findings were reported and summarised alongside those of the original review.

RESULTS

Thirty-two additional SRs were newly included (total = 68). Geographic restrictions were applied in 57 SRs, representing 72% in the original review and increasing to 97% in the newly included SRs. Moreover, there was an increased use of truncations and field tags.

CONCLUSION

Although geographical restriction methods are increasingly utilised, additional tools are necessary to enhance the robustness of search strategies. The development of a dedicated geographical search filter would facilitate the identification of studies about Germany.

Impact of the asylum determination process on mental health in the UK and EU+: a systematic review and thematic synthesis

Introduction

People seeking asylum are at increased risk of mental health difficulties due to premigration and postmigration experiences. The objective of this review was to understand how asylum determination process in the EU+ and UK influences the mental health of asylum seekers.

Methods

Web of Science, MEDLINE, PsycINFO, PsychArticles and Scopus were searched, with no start date specified, up to 24 August 2023. Peer-reviewed studies were eligible if they provided a qualitative analysis of primary data from adult asylum seekers and refugees regarding lived experience of asylum determination procedures in the UK and EU+, and contextual factors associated with the mental health and well-being. The protocol was not preregistered. From a total of 4902 articles, duplicates were removed, 3235 abstracts were assessed and of the remaining 113 identified for full-screen articles, 39 relevant qualitative studies were retrieved. Six further studies were identified through citation searches.

Results

45 studies were included in the qualitative thematic synthesis, representing the perspectives of 1158 asylum seekers and refugees. Themes demonstrate high levels of psychological distress during and after the asylum process. This was associated with the hostile environments created by policies and procedures. Participants' mental health was affected by being caught in a stalemate while awaiting the outcome of their claim. The procedures exacerbated previous mental health difficulties. External and internal protective factors were identified, such as non-governmental organisations, religion and cognitive strategies.

Conclusions

The accumulation of each step of the asylum process contributes to psychological distress and exacerbates mental health difficulties, leading to longer-term consequences for asylum seekers and refugees. Preventive strategies and policy changes are recommended. To minimise the impact of asylum procedures, clinicians should consider peer-led groups, interventions that cultivate a sense of autonomy and meaning and reduce a sense of alienation and isolation.

[Metacognitive Training for Depression (D-MCT) for Arabic Speaking Patients with Refugee Experience: Cultural Adaptation and Piloting]

OBJECTIVES

Despite high demand, culturally adapted therapies for Arabic speaking refugee patients with depression are rare. Aim of the study was to culturally adapt and evaluate the group treatment Metacognitive Training for Depression (D-MCT) for them.

METHODS

The cultural adaptation of the D-MCT included translation and surface adaptation as well as an expert discussion. The comprehensibility, acceptance and feasibility of the outpatient culturally adapted D-MCT (CA-D-MCT) were then tested in an uncontrolled pilot study with n=11 refugee patients.

RESULTS

The experts rated 83% of the translations and 78% of the illustrations as unproblematic in terms of equivalence. The acceptability and feasibility of the eight modules were predominantly positive.

CONCLUSIONS

From the patients' perspective, the adapted training shows a high acceptance and comprehensibility for culturally sensitive, interpreter-supported implementation.

Suicide among post-Arabellion refugees in Germany

BACKGROUND

Although immigrants are considered to be vulnerable to mental illness, there is limited knowledge regarding their suicide mortality.

AIMS

To investigate standardised mortality ratios (SMR) for suicide among the largest immigrant populations in Germany before and after the refugee movement of 2015.

METHOD

Data on immigrants and the general population in Germany between 2000 and 2020 were provided by the scientific section of the Federal Statistical Office. SMR with 95% confidence intervals were calculated by indirect standardisation for gender, age and calendar year for the pre-2015 and post-2015 time interval, first for all the immigrant populations studied and second for the Syrian, Afghan and Iraqi populations separately.

RESULTS

Immigrants from the countries studied showed a lower suicide risk compared with the German reference population (SMR = 0.38, 95% CI = 0.35-0.41). No differences in SMR were found between pre- and post-2015 time intervals, in either the aggregate data for all populations or the data for Syrian, Afghan and Iraqi populations. Post-2015, Afghan immigrants (SMR = 0.68, 95% CI = 0.54-0.83) showed a higher SMR than Syrians (SMR = 0.30, 95% CI = 0.25-0.36) or Iraqis (SMR = 0.37, 95% CI = 0.26-0.48).

CONCLUSIONS

Despite the many and varied stresses associated with flight, comparison of the pre- and post-2015 time intervals showed that the suicide risk of the populations studied did not change and was considerably lower than that of the German reference population. We attribute this to lower suicide rates in the countries of origin but also to flight-related selection processes that favour more resilient individuals.

Unrecognized grief - Prevalence and comorbidity of prolonged grief among refugees in Sweden

Refugees often experience multiple losses. Despite this, and even though the loss is often due to unnatural causes and violent killings, the presence of Prolonged Grief (PG) among refugees may be obscured by other diagnoses such as depression and post-traumatic stress disorder (PTSD). In this cross-sectional study, we assessed the prevalence of PG and its comorbidity with depression and PTSD among 679 adult refugees in Sweden. Results showed that 401 (59.06 %) individuals had lost someone close to them, whom they were grieving intensely. Of these, 76 individuals (18.95 % of 401) fulfilled the criteria for PG. In the full sample, 304 individuals fulfilled the criteria for depression and 56 (18.42 % of 304) of these individuals also fulfilled the criteria for PG. Similarly, 315 fulfilled the criteria for PTSD. Among these individuals, 201 reported loss and 64 (20.32 % of 315) also fulfilled the criteria for PG. The results indicate that behind symptoms of depression and PTSD, there may be a layer of grief. This needs to be considered if we are to provide accurate and effective assessments and interventions for refugees.

The Socio-Ecological Factors Associated with Mental Health Problems and Resilience in Refugees: A Systematic Scoping Review

Despite the immense challenges to mental health faced by refugees, research consistently finds that many nevertheless demonstrate remarkable resilience. However, a systematic account of the scientific literature on resilience among refugees is currently lacking. This paper aims to fill that gap by comprehensively reviewing research on protective and risk factors affecting refugees' resilience and mental health problems across four socio-ecological levels: individual, family, community, and society. We conducted a systematic search in the databases PsycINFO, Web of Science, and SocINDEX, as well as contacted topic experts to seek out unpublished manuscripts. This yielded 223 studies (171 quantitative, 52 qualitative), which were subjected to systematic content coding. We found consistent evidence for substantive risk factors, including traumatic experiences and gender at the individual level and postmigration stress and unemployment at the societal level. We found social support to be a clear protective factor at the family and community levels. We discuss these findings in the context of policy and intervention programs and make recommendations at different socio-ecological levels for supporting refugees' resilience.

Links between ethnic discrimination, mental health, protective factors, and hair cortisol concentrations in asylum seekers living in Germany

Objective: Asylum seekers often experience ethnic discrimination on the flight or in the host country, which may be associated with chronic stress and impaired mental health. Dysregulation of the hypothalamic-pituitary-adrenal axis, a known physiological correlate of chronic stress, can be assessed using hair cortisol concentrations (HCC). The present study aimed to investigate how different forms of perceived ethnic discrimination are associated with mental health outcomes, HCC, and protective factors in asylum seekers living in Germany.Methods: Somatic symptoms (PHQ-15), symptoms of posttraumatic stress (PDS), depressive symptoms (PHQ-9), different forms of ethnic discrimination (active harm, passive harm, institutional discrimination), and protective factors (in-group identification, social support) were assessed cross-sectionally in 144 asylum seekers (average age 32 years, average duration of stay in Germany nine months; 67% men). HCC were obtained from 68 participants. Multiple regression analyses were conducted and social support and in-group identification were tested as potential moderators.Results: Active ethnic discrimination was positively associated with all assessed mental health outcomes, and all forms of ethnic discrimination positively correlated with depressive symptoms. Ethnic discrimination was not associated with HCC. When controlling for other possible influences (e.g. age, gender, traumatic events), passive harm was negatively associated with depressive symptoms (β = -0.17, p = .033) and active harm was positively associated (β = 0.28, p = .022) with somatic symptoms. After the inclusion of the protective factors, the associations were no longer significant. Lower social support was associated with higher depressive symptoms (β = -0.35, p < .001), posttraumatic stress (β = -0.77, p < .001), and somatic symptoms (β = -0.32, p < .001), but did not moderate the associations between ethnic discrimination and the mental health outcomes.Conclusions: Perceived ethnic discrimination may negatively influence asylum seekers' mental health but does not seem to be associated with HCC. Social support was associated with psychological symptom severity, but did not buffer the effects of ethnic discrimination on mental health.

Interplay of sociocultural factors, health literacy and well-being among African asylum seekers and refugees in Asia: A systematic review

Background

There are many African asylum seekers and refugees (AAR) in Asia. However, little research has been conducted on their well-being within the sociocultural milieu. This systematic review explores the characteristics of AAR's psychological and mental well-being and how their acculturation practices, social networks and support (i.e. social capital), health-related knowledge and skills (i.e., health literacy) influence their psychological and mental well-being.

Methods

The study included relevant peer-reviewed articles from any Asian country/region, published in English. No date restriction was applied. Five databases (i.e. Scopus, PubMed, Web of Science, PsycINFO, and CINAHL) were searched for studies conducted about AAR from any of the 54 African countries and residing in any of the 51 Asian countries. Following a predefined inclusion criteria and quality assessment, nine articles were included in this study. Narrative synthesis approach was used to analyse the articles.

Results

It was found that AARs face significant challenges that culminate in poor psychological and mental well-being, including conditions such as depression and discontent with their lives. Notwithstanding, being in a safe place made some of them optimistic about their future. However, many AARs had difficulties adjusting to the host culture. They had limited awareness of the prevailing health system and services and faced restrictions on their rights to social services, partly because of difficulty obtaining appropriate information. The few social bonds and bridges they possessed enabled them to develop a sense of belonging and protected them from psychological distress. However, problematic social relationships increased the chances of poor health-related outcomes.

Conclusion

The psychological and mental well-being of AAR in Asia is concerning. Hence, more research on how critical health determinants (i.e. social capital, health literacy and acculturation processes from this study) directly and interactively influence their well-being across age cohorts. Given their roles in promoting AAR's well-being, appropriate interventions to improve those critical health determinants are also sorely needed.

Post-migration stress, quality of life, and mental health among accompanied and unaccompanied young refugees in Germany: How do adolescents feel after fleeing?

This study examines the impact of post-migration living difficulties (PMLDs) and quality of life (QoL) on the mental health of 55 young refugees who arrived in Germany either accompanied or unaccompanied. The results reveal that nearly 62% of the participants exhibited clinically significant symptoms of depression or post-traumatic stress disorder. Regression analyses indicate that psychopathology was associated with being unaccompanied and experiencing lower QoL, while QoL was associated with higher economic status and lower PMLDs. Mediation analysis further demonstrates that higher economic status and reduced PMLDs were associated with higher QoL, which, in turn, correlated with lower levels of psychopathology. These findings emphasise the importance of considering PMLDs and QoL, as well as economic status and being accompanied/unaccompanied, in the assessment and treatment of young refugees in the host country.

Cluster analysis of prolonged grief, posttraumatic stress, and depression symptoms in bereaved asylum seekers and refugees

Background: Refugees and asylum seekers (ASRs) are frequently exposed to loss in addition to a variety of other stressors and often display high levels of various psychological symptoms.Objective: The study aimed to primarily determine clusters of prolonged grief disorder (PGD), posttraumatic stress disorder (PTSD), and depression symptoms in bereaved ASRs and secondly identify predictors of cluster membership. Sociodemographic  - and flight-related variables were investigated in exploratory analyses.Method: ASRs in Germany (N = 92) with interpersonal loss exposure, i.e. at least one missing or deceased relative or friend, were assessed with interview-based questionnaires for PGD, PTSD, and depressive symptoms. We used k-means cluster analysis to distinguish symptom profiles and logistic regression analyses to identify predictors of cluster membership.Results: We found a three-cluster-solution. The PGD-cluster (30%) was characterised predominantly by PGD symptoms, while the PGD/PTSD-cluster (32%) had high PGD and PTSD and moderate depressive symptoms. The resilient cluster (38%) showed low symptoms overall. insecure residence status predicted membership in the PGD and PGD/PTSD clusters relative to the resilient cluster, whilst higher attachment anxiety predicted membership in the PGD/PTSD cluster relative to the other clusters. Explorative analysis revealed duration of stay as a significant predictor.Conclusion: Findings can extend the current knowledge about different symptom profiles among bereaved ASRs in Europe. Insights to attachment  - and migration-related variables distinguishing between these profiles offer starting points for interventions.

Age of migration and common mental disorders among migrants in early adulthood: a Norwegian registry study

BACKGROUND

Younger age of migration is associated with higher risk of psychotic disorders but the relationship between age of migration and common mental disorders is less clear. This study investigates the association between age of migration and diagnosed common mental disorders among migrants living in Norway.

METHODS

Using national Norwegian register data from 2008 to 2019, we compared the odds of a common mental disorder diagnosis in healthcare services during early adulthood among non-migrants, descendants and migrants with different ages of migration and lengths of stay. We also investigated differences in the relationship for different migrant groups and for men and women.

RESULTS

Descendants and childhood migrants with ≥ 19 years in Norway had higher odds of common mental disorders than non-migrants, while those migrating during adolescence with ≥ 19 years in Norway had similar odds. Those migrating during emerging and early adulthood had lower odds. Overall among migrants, the relationship between age of migration and common mental disorders was more pronounced for migrants < 19 years in Norway than ≥ 19 years and for non-refugees compared with refugees, especially men.

CONCLUSIONS

Descendants and childhood migrants with long stays may have higher odds of common mental disorders due to the associated stress of growing up in a bicultural context compared with non-migrants. Age of migration has a negative association with diagnosed common mental disorders but much of this effect may attenuate over time. The effect appears weaker for refugees, and particularly refugee men, which may reflect higher levels of pre-migration trauma and stress associated with the asylum-seeking period for those arriving as adults. At the same time, migrants, especially those arriving as adults, experience barriers to care. This could also explain the particularly low odds of diagnosed common mental disorders among adult migrants, especially those with shorter stays.

Health system responsiveness to the mental health needs of Syrian refugees: mixed-methods rapid appraisals in eight host countries in Europe and the Middle East

Background

Syrian refugees have a high burden of mental health symptoms and face challenges in accessing mental health and psychosocial support (MHPSS). This study assesses health system responsiveness (HSR) to the MHPSS needs of Syrian refugees, comparing countries in Europe and the Middle East to inform recommendations for strengthening MHPSS systems.

Methods

A mixed-methods rapid appraisal methodology guided by an adapted WHO Health System Framework was used to assess HSR in eight countries (Egypt, Germany, Jordan, Lebanon, Netherlands, Sweden, Switzerland, and Türkiye). Quantitative and qualitative analysis of primary and secondary data was used. Data collection and analysis were performed iteratively by multiple researchers. Country reports were used for comparative analysis and synthesis.

Results

We found numerous constraints in HSR: i) Too few appropriate mental health providers and services; ii) Travel-related barriers impeding access to services, widening rural-urban inequalities in the distribution of mental health workers; iii) Cultural, language, and knowledge-related barriers to timely care likely caused by insufficient numbers of culturally sensitive providers, costs of professional interpreters, somatic presentations of distress by Syrian refugees, limited mental health awareness, and stigma associated to mental illness; iv) High out-of-pocket costs for psychological treatment and transportation to services reducing affordability, particularly in middle-income countries; v) Long waiting times for specialist mental health services; vi) Information gaps on the mental health needs of refugees and responsiveness of MHPSS systems in all countries. Six recommendations are provided to address these issues.

Conclusions

All eight host countries struggle to provide responsive MHPSS to Syrian refugees. Strengthening the mental health workforce (in terms of quantity, quality, diversity, and distribution) is urgently needed to enable Syrian refugees to receive culturally appropriate and timely care and improve mental health outcomes. Increased financial investment in mental health and improved health information systems are crucial.

Health system responsiveness to the mental health needs of Syrian refugees: mixed-methods rapid appraisals in eight host countries in Europe and the Middle East

BACKGROUND

Syrian refugees have a high burden of mental health symptoms and face challenges in accessing mental health and psychosocial support (MHPSS). This study assesses health system responsiveness (HSR) to the MHPSS needs of Syrian refugees, comparing countries in Europe and the Middle East to inform recommendations for strengthening MHPSS systems.

METHODS

A mixed-methods rapid appraisal methodology guided by an adapted WHO Health System Framework was used to assess HSR in eight countries (Egypt, Germany, Jordan, Lebanon, Netherlands, Sweden, Switzerland, and Türkiye). Quantitative and qualitative analysis of primary and secondary data was used. Data collection and analysis were performed iteratively by multiple researchers. Country reports were used for comparative analysis and synthesis.

RESULTS

We found numerous constraints in HSR: i) Too few appropriate mental health providers and services; ii) Travel-related barriers impeding access to services, widening rural-urban inequalities in the distribution of mental health workers; iii) Cultural, language, and knowledge-related barriers to timely care likely caused by insufficient numbers of culturally sensitive providers, costs of professional interpreters, somatic presentations of distress by Syrian refugees, limited mental health awareness, and stigma associated to mental illness; iv) High out-of-pocket costs for psychological treatment and transportation to services reducing affordability, particularly in middle-income countries; v) Long waiting times for specialist mental health services; vi) Information gaps on the mental health needs of refugees and responsiveness of MHPSS systems in all countries. Six recommendations are provided to address these issues.

CONCLUSIONS

All eight host countries struggle to provide responsive MHPSS to Syrian refugees. Strengthening the mental health workforce (in terms of quantity, quality, diversity, and distribution) is urgently needed to enable Syrian refugees to receive culturally appropriate and timely care and improve mental health outcomes. Increased financial investment in mental health and improved health information systems are crucial.

A conceptual framework on pre- and post-displacement stressors: the case of Syrian refugees

Researchers have documented multiple stressors and mental health problems along the journey of refugees as they are displaced to seek refuge in nearby and remote host countries. This article examines published research on Syrian refugees to propose a framework to conceptualize Syrian refugees' pre- and post-stressors and their collective impact on their mental health. The proposed framework provides a comprehensive understanding of the interconnected pathways between pre-displacement stressors, post-displacement stressors, and mental health outcomes for Syrian refugees. Pre-displacement stressors are best captured by the concept of trauma centrality and emotional suppression. Post-displacement stressors, categorized under financial, political, and social themes, have a direct impact on the mental health of the refugees, but could also play a partial mediating role on the impact of pre-displacement stressors on mental health. The framework suggests a direct pathway between the experience of war-related traumatic events and mental health and introduces the country of residence as a potential moderator of the severity of mental health. The latter is primarily influenced by local policies and the host communities' acceptance of refugees. We believe that the proposed framework can guide the work of researchers, policymakers, and practitioners concerned with the mental health and well-being of Syrian refugees. Additionally, although based on the experience of Syrian refugees, it presents a holistic perspective that could be adapted in other refugee settings.

'They tried to evil me': An explanatory model for Black Africans' mental health challenges

This paper explores the explanatory models of mental challenges among Black Africans in England. It argues that understanding these models is critical for providing culturally appropriate care to this population. The study employed qualitative methodology, and interpretative phenomenological analysis (IPA). Twelve mental health service users who are living in England and self-identified as first or second-generation Black Africans were purposively selected. The data were gathered using face-to-face semistructured interviews. Data were manually analysed in accordance with IPA concepts of searching for common, unique and idiosyncratic themes across transcripts. The findings revealed three themes Black Africans associated to their explanatory model of mental health challenges: complexities of migration, African-centred worldview and negative life experiences. To help alleviate the Eurocentric nature of mental health practice in England, it is hoped that this explanatory model will become an integral part of mental health practice in England and around the world.

Research on psychotherapy for refugees in Germany: A systematic review on its transdisciplinary and transregional opening

Recently, an increasing amount of research has focused on adapting psychotherapy concepts for refugees moving to Germany. For a long time, research from disciplines like anthropology and cultural studies has problematized the eurocentrism of psychology's theoretical premises and methodologies. Currently, scholarship around Global Mental Health and decolonization emphasizes how knowledge production from various disciplines and regions relates to this topic and could contribute to improving respective approaches. Consequently, this review aims at evaluating the actual transdisciplinary and transregional opening of studies on psychotherapeutic interventions for refugees in Germany. It provides a theoretically as well as empirically informed basis for looking at disciplinary premises, practices, and boundaries as well as the regional locatedness of respective research. Fourteen relevant studies, published between January 1, 2007 and March 4, 2022, were identified by systematically searching the databases PubPsych and Web of Science. The studies were reviewed regarding study design, choice and characterization of target groups, regional origin and target group specific adaptations of the therapeutic concepts, integration of elements from and connections to other disciplines, and use of references to scholarship from the Global South. The findings show a pronounced focus on the development of trauma therapy approaches and moreover a broad variety of concept adaptations in response to the assumed characteristics, situations, and needs of the target groups. While the findings reveal a complex transregional pattern of development and adaptation of the therapeutic concepts, transdisciplinary opening and reference to the Global South appear scarce.

Good practice in reaching and treating refugees in addiction care in Germany - a Delphi study

BACKGROUND

Health and adequate access to health care are human rights. Refugees are at risk for substance abuse. Despite the known structural and personal risk factors for abuse, refugees in Germany continue to face barriers to adequate addiction prevention and care, which is a violation of the fundamental human right to health care. The question arises as to how barriers for refugees in reaching addiction services and care can be overcome. In the presented study, strategies for good practices to deconstruct these barriers were identified.

METHOD

A total of 21 experts participated in a three-round, consensus-oriented Delphi-Process. The experts represented five different fields: addiction care services, including specialized programs for women, refugee aid services, academia, policy-making and immigrants' self-help services.

RESULTS

The Delphi-Process generated 39 strategies of good practice summarized in 9 major categories: Care System, Framework Conditions, Multilingualism, Information and Education, Access, Service-Level, Employee-Level, Employee-Attitudes and Networking.

CONCLUSION

In order to guarantee human rights regarding health and adequate access to health care for refugees, institutional barriers limiting access to prevention and treatment programs for addictive disorders must be abolished. The identified good practice strategies for Germany, if widely implemented, could contribute to this aim. By opening up prevention and treatment facilities for refugees, other marginalized groups could also benefit. While some of the strategies need to be implemented at the institutional level, political steps are also required at the system level including, e.g. financing of adequate translation services.

Structure and features of psychopathological symptoms in forced migrants and internally displaced persons

OBJECTIVE

Aim: To study the structure and characteristics of psychopathological symptoms in FM who left Ukraine as a result of the full-scale armed aggression of the Russian Federation against Ukraine, and internally displaced persons, in a comparative aspect.

PATIENTS AND METHODS

Materials and Methods: Examination was performed in compliance with the principles of biomedical ethics, based on informed consent. Research was provided on the basis of the Ternopil Regional Clinical Psychoneurological Hospital. Inclusion criteria were women who were forced to leave the territory of Ukraine as a result of hostilities after February 24, 2022, and who left for temporary residence in the territory of the Republic of Poland (Poland) (FM), and women who were temporarily relocated within Ukraine in connection with connection with hostilities (IDP). Exclusion criteria from the study were presence of language disorders, pronounced cognitive disorders, severe somatic condition. The examination was organized by the method of a semi-structured clinical interview according to the developed by us protocol and was conducted remotely. During the examination, depressive, anxiety-phobic, asthenic and dyssomnic disorders, addictive behavior and symptoms of PTSDwere identified and verified. Statistical and mathematical processing a was carried out using Fisher's exact test.

RESULTS

Results: The data we obtained indicate a significant spread of psychopathological symptoms in FM and IDP.

CONCLUSION

Conclusions: FM and IDP are characterized by a high incidence of psychopathological symptoms. The most frequent were: depressed mood (FM - 67.2%, IDP - 58.5%), feelings of anxiety and fear (FM -52.5%, IDP - 43.6%), obsessive thoughts (FM - 58.9 %, IDP - 49.5%).

Exploring contextual effects of post-migration housing environment on mental health of asylum seekers and refugees: A cross-sectional, population-based, multi-level analysis in a German federal state

Asylum seekers and refugees (ASR) in Germany are dispersed quasi-randomly to state-provided, collective accommodation centres. We aimed to analyse contextual effects of post-migration housing environment on their mental health. We drew a balanced random sample of 54 from 1 938 accommodation centres with 70 634 ASR in Germany's 3rd largest federal state. Individual-level data on depression and anxiety as well as sociodemographic- and asylum-related covariates, were collected and linked to contextual geo-referenced data on housing environment ('Small-area Housing Environment Deterioration' index, number of residents, remoteness, urbanity, and German Index of Multiple Deprivation). We fitted two-level random-intercept models to exploratively estimate adjusted contextual effects. Of 411 surveyed participants, 45.53% and 44.83%, respectively, reported symptoms of depression or anxiety. 52.8% lived in centres with highest deterioration, 46.2% in centres with > = 50 residents, 76.9% in urban, and 56% in deprived districts. 7.4% of centres were remote. We found statistically significant clustering in reporting anxiety on the level of accommodation centres. The model resulted in an intraclass correlation of 0.16 which translated into a median odds ratio of 2.10 for the accommodation-level effects. No significant clustering was found for symptoms of depression. The highest degree of deterioration, large accommodation size, remoteness, and district urbanity showed higher, but statistically not significant, odds for reporting anxiety or depression. District deprivation demonstrated higher odds for anxiety and lower odds for depression yet remained statistically insignificant for both. Evidence for contextual effects of housing environment on mental health of ASR could not be established but residual confounding by length of stay in the accommodation centre cannot be ruled out. Confirmatory analyses with prior power calculations are needed to complement these exploratory estimates.

Perceived post-migration discrimination: the perspective of adolescents with migration background

Discrimination has a negative impact on mental health and wellbeing of persons affected. The aim of the present study was to investigate perceived discrimination of migrant adolescents. Focus groups with migrant adolescents were conducted, audio-recorded and transcribed verbatim. The transcripts were analyzed using the manifest qualitative content analysis by Mayring. The foci of interest (persons discriminated against and by whom, where and how the discrimination took place, which behavioral and emotional reactions the affected persons showed to the experiences and which reasons they assumed for the discrimination) were determined based on the pre-defined guideline, and inductive subcategories were extracted from the transcripts and grouped into main categories. Five focus groups with students with migration background (n = 35, 13 females, mean age: 18.78, SD = 2.26, range 16-24) were conducted. The adolescents in our focus groups and their acquaintances (families and friends) experienced discrimination in Germany in several forms (verbal and non-verbal), places and on an individual as well as institutional level, with an impact on their emotional well-being. To combat discrimination, culturally sensitive information must be provided on the part of those affected as well as their perpetrators.

Challenges in substance use treatment as perceived by professionals and Arabic-speaking refugees in Germany

BACKGROUND

Substance use (SU) and substance use disorders (SUDs) have been recently documented among forcibly displaced populations as a coping mechanism to migration and postmigration stressors. Although the literature exploring substance use among refugees has grown recently, little is known about SU among Arabic-speaking refugees and, more specifically, on the challenges and experiences in regards to SU treatment. This study investigates this topic from the perspectives of Arabic-speaking refugees and professionals in Germany.

METHODS

Design and participants To expand our knowledge on this topic, a qualitative approach was employed by conducting in-depth and semi-structured interviews among 26 participants (13 refugees and 13 professionals) in Germany during 2020-2021. Purposive sampling was used to recruit Arabic-speaking refugees in two rehabilitation centers in Berlin. Data and analysis Interviews were conducted with 26 participants of which 13 were refugees and 13 professionals. Refugees were interviewed individually in the rehabilitation centers, they ranged from 21 to 52 years of age, and their average time in Germany was 6.3 years. An open-ended survey was conducted among the professionals via the SoSci-survey platform, and they ranged from 22 to 66 years of age, with an average of 5 to 9 years of work experience. Data were analyzed using thematic analysis.

RESULTS

Three themes resulted from the thematic analysis: (1) The treatment is facilitated by institutional and emotional support; (2) The affected refugees struggle with complex contextual barriers to access SUD treatment; and (3) Individual and community preventive strategies are needed.

CONCLUSIONS

This study provides insight into the support and challenges of accessing effective SU treatment and prevention among Arabic-speaking refugees in Germany. Collaborative efforts by the community, professionals, and policymakers are needed to facilitate access to effective treatment and implement culturally and linguistically sensitive approaches for the treatment and prevention of SU among refugees.

Cognitive factors underlying the impact of postmigration stressors on subjective well-being: Well-being comparisons and self-efficacy

BACKGROUND

Migration and the resulting challenges in the host country can have a profound impact on the mental health of refugees and intensify preoccupation with one's own well-being. Yet, cognitive factors underlying the adverse impact of postmigration stressors are poorly understood.

OBJECTIVE

We aimed at exploring the frequency and nature of well-being comparisons in the context of flight and migration using the Comparison Standards Scale for Well-being (CSS-W), which assesses well-being related social, temporal, counterfactual, criteria-based and dimensional aversive and appetitive comparisons. We further aimed at examining the mediating role of well-being comparisons and general self-efficacy in the relationship between postmigration stressors and psychological well-being.

METHODS

We conducted a survey with 1070 Arabic speaking forcibly displaced people in Germany assessing well-being comparisons, general self-efficacy, postmigration stressors, subjective well-being and social media engagement.

RESULTS

Factor analysis of the CSS-W yielded a theoretically grounded two-factor structure proposing an aversive (mostly upward) and an appetitive (mostly downward) comparison factor. Aversive and appetitive comparisons were reported by more than 99% of participants, with temporal comparisons being reported by 98.7% of participants. Postmigration stressors were significantly related to subjective well-being and aversive well-being comparisons and general self-efficacy partially mediated this relationship. Appetitive well-being comparisons, however, were not significantly related to neither postmigration stressors nor general self-efficacy.

CONCLUSION

Aversive well-being comparisons and general self-efficacy seem to play a significant role in the adverse effects of postmigration stressors on subjective well-being. Longitudinal research is needed to examine the directional dynamics between general self-efficacy, well-being comparisons and postmigration stressors.

Determinants of life satisfaction among migrants in South Africa: an analysis of the GCRO's quality of life survey (2009-2021)

BACKGROUND

Migrant populations in any country are a vulnerable group, and psycho-demographic research measuring life satisfaction has been used to assess migrants' well-being in developed and developing countries. However, South Africa, with its high influx of migrant populations, has investigated these topical concerns from the perspective of xenophobia, with mixed findings. However, no, or very few studies have examined life satisfaction among migrants in South Africa. This study, therefore, extends previous literature by examining the determinants of life satisfaction among South Africa's internal and international migrant populations.

METHODS

We conducted a cross-sectional study from the 2009 to 2021 Gauteng City-Region Observatory (GCRO) Quality of Life (QoL) surveys among migrant populations in two ways: a full sample and a gender-stratified sample. A sample of male and female migrants ranging from 15 to 49 years of age were recruited into this study. Cantril's Self-Anchoring Ladder Life Satisfaction scale captured their life satisfaction alongside relevant social demographic factors. Descriptive statistics were applied for the data analysis of the demographic factors. Bivariate and multivariate logistics regression analyses were conducted to assess the associations and the predictive factors of life satisfaction among migrants, both internal and international.

RESULTS

The key findings were the gender distribution of life satisfaction, showing that more international (male - 66.0% and female - 67.1%) migrants reported having a thriving life satisfaction than internal migrants (male - 61.7% and female - 61.5%). Findings from the Pearson correlation coefficient revealed a significant association between the individual, household, and community factors by migrant status (ρ < 0.05). However, the probit coefficients revealed that individual factors (age 48+: AOR = 2.18, 95% CI: 1.13, 3.23, and secondary/higher education: AOR = 1.1., 95% CI: 0.01, 1.19) and household factors (two persons living in households (H/H): AOR = 1.05, 95% CI: 0.50, 1.10), and community factors (international migrant status: AOR = 2.12, 95% CI: 0.08, 2.16) significantly increase the prediction of higher odds of life satisfaction by gender among migrants. The ordered logit coefficients also showed that individual factors (middle and high income and having health insurance) and household factors (receiving SASSA social grant) predicted the highest life satisfaction among migrants (internal and international).

CONCLUSION

We found substantial evidence that individual-, household-, and community-level factors were associated with life satisfaction among migrants. In particular, the pattern of life satisfaction varied slightly between male and female migrants, as well as with migrant status in South Africa. These findings collectively may provide helpful information for policymakers and practitioners to optimise interventions for migrant populations to improve their life satisfaction. Evidence from this study also calls on the government of South Africa to begin tracking the life satisfaction of its nationals, whether migrants or not.

A conceptual study on the relationship between daily stressors, stressful life events, and mental health in refugees using network analysis

Introduction

There is growing recognition that daily stressors, such as social and material deficiencies, can be highly detrimental to the mental health of refugees. These stressors are in addition to stressful life events, which have been widely studied in the context of migration and forced displacement. Despite increasing evidence for an ecological model, there is still no consensus regarding the conceptualization of these highly influential factors. In particular, the demarcation of daily stressors from stressful life events and the categorization of daily stressors require further examination in order to develop usable and accurate tools for researchers, design effective interventions for practitioners and assist politicians in designing meaningful policies.

Methods

To address these challenges, we used data from a sample of 392 unaccompanied young refugees from diverse backgrounds and employed network analysis to examine the relationships between daily stressors, stressful life events, and symptoms of depression, anxiety, and post-traumatic stress.

Results

Our findings highlight the significant relationship between daily stressors and mental health, particularly depression. Meaningful clusters of daily stressors include material stressors, social stressors, and social exclusion stressors.

Conclusion

Our results demonstrate the importance of considering daily stressors in the mental health of refugees and suggest that using a network approach offers a viable way to study these complex interrelationships. These findings have implications for researchers, practitioners, and policymakers in understanding and addressing the mental health needs of refugees.

Risk factors for mental disorder development in asylum seekers and refugees resettled in Western Europe and Turkey: Participant-level analysis of two large prevention studies

BACKGROUND

In asylum seekers and refugees, the frequency of mental disorders, such as depression, anxiety and post-traumatic stress disorder, is higher than the general population, but there is a lack of data on risk factors for the development of mental disorders in this population.

AIM

This study investigated the risk factors for mental disorder development in a large group of asylum seekers and refugees resettled in high- and middle-income settings.

METHODS

Participant-level data from two randomized prevention studies involving asylum seekers and refugees resettled in Western European countries and in Turkey were pooled. The two studies randomized participants with psychological distress, but without a diagnosis of mental disorder, to the Self-Help Plus psychological intervention or enhanced care as usual. At baseline, exposure to potentially traumatic events was measured using the Harvard Trauma Questionnaire-part I, while psychological distress and depressive symptoms were assessed with the General Health Questionnaire and the Patient Health Questionnaire. After 3 and 6 months of follow-up, the proportion of participants who developed a mental disorder was calculated using the Mini International Neuropsychiatric Interview.

RESULTS

A total of 1,101 participants were included in the analysis. At 3- and 6-month follow-up the observed frequency of mental disorders was 13.51% (115/851) and 24.30% (207/852), respectively, while the frequency estimates after missing data imputation were 13.95% and 23.78%, respectively. After controlling for confounders, logistic regression analysis showed that participants with a lower education level (p = .034), a shorter duration of journey (p = .057) and arriving from countries with war-related contexts (p = .017), were more at risk of developing mental disorders. Psychological distress (p = .004), depression (p = .001) and exposure to potentially traumatic events (p = .020) were predictors of mental disorder development.

CONCLUSIONS

This study identified several risk factors for the development of mental disorders in asylum seekers and refugees, some of which may be the target of risk reduction policies. The identification of asylum seekers and refugees at increased risk of mental disorders should guide the implementation of focused preventative psychological interventions.

A Mobile-Based Preventive Program for Young, Arabic-Speaking Asylum Seekers during the COVID-19 Pandemic in Germany: Design, Feasibility, and Implementation

BACKGROUND

A majority of individuals seeking asylum in Germany are living in collective housings and thus exposed to a higher risk of contagion during the COVID-19 pandemic.

OBJECTIVE

To test feasibility and efficacy of a culture-sensitive approach combining mobile app-based interventions and a face-to-face group intervention to improve knowledge about COVID-19 and promote vaccination readiness among collectively accommodated Arabic-speaking adolescents and young adults.

METHODS

We developed a mobile app that was composed of short video clips to explain the biological basis of COVID-19, demonstrate behavior to prevent transmission, and combat misconceptions and myths about vaccination. Explanations were given in a YouTube-like interview setting by a native Arabic-speaking physician. Elements of gamification (quizzes, rewards for solving test items) were also used. Consecutive videos and quizzes were presented over an intervention period of six weeks, the group intervention was scheduled as an add-on for half of participants in week 6. The manual of the group intervention was designed to provide actual behavior planning on the basis of the health action process approach. Sociodemographic information, mental health status, and knowledge about Covid-19 and available vaccines were assessed with questionnaire-based interviews at baseline and after six weeks. Interpreters assisted with the interviews in all cases.

RESULTS

Enrollment in the study proved to be very challenging as among other things, the housing facilities allowed contact with potentially eligible participants only during certain periods because of the pandemic situation. Also due to tightened contact restrictions, the face-to-face group interventions could not be held as planned. A total of 88 participants from 8 collective housing institutions were included in the study. 61 participants completed the full intake interview. Most participants had already been vaccinated at study enrollment (76.5%). They also yet claimed to comply with preventive measures to a very high extent (e.g., "always wearing masks" was indicated by 66% of participants), but practicing behavior that was not considered as effective against Covid-19 transmission was also frequently reported as a preventive measure (e.g., mouth rinsing). On the other hand, factual disease knowledge for COVID-19 was limited. Preoccupation with the information materials presented in the app steeply declined after study enrollment (e.g., 19% of participants watched the videos scheduled for week 3). Only 18 participants could be reached for the follow-up interview. Their COVID-19 disease knowledge did not shown to have increased after the intervention period (p=0.558).

CONCLUSIONS

The results indicate that vaccine uptake was high and seemed to be depending on organizational determinants for the target group. The current mobile app-based intervention demonstrated low feasibility, which might have been related to various obstacles faced during the delivery: Learning from mobile phone content based on short videos requires a basic understanding of biological and IT-aspects as well as sufficient literacy and a living situation enabling the practical application of the learned behavioral prevention strategies. Therefore, in case of future pandemics, transmission prevention in the specific target group should rely more on structural aspects instead on sophisticated psychological interventions.

CLINICALTRIAL

https://www.drks.de, identifier: DRKS00028825.

The impact of the war in Ukraine on the perinatal period: Perinatal mental health for refugee women (pmh-rw) protocol

Background

The aim of the Perinatal Mental Health for Refugee Women (PMH-RW) Project is to investigate the impact of the war on perinatal mental health: anxiety, post-traumatic stress, depression, and birth trauma symptoms. It will also evaluate the factors that serve as protective elements for the development of these potential diagnoses (such as personality traits, social support, sociodemographic characteristics, and access to medical/mental health services).

Method

An international observational cohort study with baseline data is being assessed in Ukraine (for internal refugees) and several European Countries (for external refugees). The study includes as participants both pregnant women and those who have recently given birth (with babies up to 1 year old). The assessment includes measures on depression (EPDS), anxiety (GAD-7), experiences during birth (City Birth Questionnaire), post-traumatic stress symptoms [Impact of events scale—revised (PTSD-R)], Personality (10-Item Personality Inventory-TIPI), and a questionnaire for socio-demographic data which also such social support.

Conclusion

This study will provide needed information for determining the impact of the Ukrainian Crisis on perinatal mental health by studying potential risk and protective factors. The data collected will be used to inform policymakers with useful information that can be used in the development of plans to protect and promote the mental health of the perinatal refugees impacted by this event. Also, it is our hope that data collected from this study will serve to plant the seeds for further research regarding the impact of the crisis in Ukraine on the offspring and to analyze how these events are affecting further generations.

Clinical Trial Registration

ClinicalTrials.gov, Identifier: NCT05654987.

Exploring the Impact of Family Separation on Refugee Mental Health: A Systematic Review and Meta-narrative Analysis

The refugee crisis is spreading rapidly, with the number of global refugees this decade doubling in comparison to the last, leading to further concern regarding asylum policies and their psychological impacts. The aim of this systematic review is to further emphasize the correlation between familial separation and the risk of mental health disorders in refugees. This particular review uses quantitative and qualitative data sourced from a variety of countries to comparatively view the mental health status of approximately 8,737 refugees ages 15 and older. This was done to determine if familial separation could potentially impact their overall quality of life. As a result, separation from one's family was found to be correlated with symptoms of posttraumatic stress disorder, depression, anxiety, adult separation anxiety disorder, intermittent explosive disorder, and more. Studies reported a high variance in the prevalence of mental health disorders when models were adjusted for family separation. Methods to improve asylum procedure and mental health services for refugees is taken into consideration.

Geographical Disparities and Settlement Factors and Mental Health of Refugees Living in Germany

(1) Background: Approximately half of all refugees living in Germany experience discrimination, which may negatively affect their mental health. Moreover, German refugees have experienced hostility, especially in eastern regions. (2) Aims: We examined the effect of perceived discrimination on refugees' mental health in Germany, with a particular focus on possible regional differences of refugee mental health and perceived discrimination. (3) Method: The data of 2075 refugees who arrived in Germany between 2013 and 2016, from a large-scale survey, was analysed using binary logistic regression. The refugee health screener, 13-item version, was used to assess psychological distress. All effects were investigated for the entire sample and both sexes independently. (4) Results: A third of refugees experienced discrimination which increased the risk of psychological distress (OR = 2.25 [1.80, 2.8]). Those living in eastern Germany were more than twice as likely to report experiences of discrimination, compared to their counterparts living in western Germany (OR = 2.52 [1.98, 3.21]). Differences were noted between males and females, and religious attendance. (5) Conclusions: Perceived discrimination is a risk factor for refugee mental health, particularly female refugees in eastern Germany. An east-west regional difference may be explained by socio-structural factors, rural placement, differential historical exposure to migrant populations, and a greater presence of right-wing and populist parties in eastern Germany.

Substance (mis)use among refugees as a matter of social ecology: insights into a multi-site rapid assessment in Germany

BACKGROUND

Previous research concluded that substance (mis)use is increasing among forcibly displaced populations. Nevertheless, little research has been conducted within a social ecological framework aimed at identifying and understanding the factors affecting substance (mis)use embedded in the post-migration context in high-income countries. The present study aims to develop an understanding of the links and underlying mechanisms between refugees' social ecological determinants and substance (mis)using behavior.

METHODS

Rapid assessments (RAs), including 108 semi-structured interviews and 10 focus group discussions with key persons from various professional, and personal backgrounds, were carried out in German urban and rural areas. The RA approach of interviewing key persons and not solely refugees that (mis)use substances allowed us to gather multi-perspective knowledge on this sensitive topic. Qualitative content analysis was applied, aiming at identifying determinants of substance (mis)use embedded in the post-migration context of refugees and understanding the underlying mechanisms.

RESULTS

One main result of the data suggests that the link between refugees' countries of origin and their post-migration substance (mis)use is not as direct as often assumed. It is observed that refugees' prospects and opportunities in receiving countries (e.g., work permits) undermine this commonly reproduced link. Further determinants are related to living conditions in German refugee shelters and social relations with peers and families. The influence of refugees' living conditions can be summarized as potentially increasing substance availability and distress, whereas family separation produces a loss of control and responsibility, increasing the risk for substance (mis)use. Peers' influence on substance (mis)use was reported to reflect a search for a sense of belonging.

CONCLUSIONS

Given that refugees who (mis)use substances have limited to no control over the factors identified in our study to be associated with substance (mis)use, common treatment and prevention approaches are challenged. Furthermore, we recommend aiming for a holistic comprehension of refugees' substance (mis)use by expanding the focus beyond individuals to the social ecological context in any attempt, including prevention, treatment, research, and policy.

Psychological health outcome of Sub-Saharan African migrants in Germany

African migrants living in Europe have an increased risk of adverse psychological health outcomes compared to people without a migration background. The increased vulnerability may be due to their migration experience and possible challenges in adapting and integrating into the host community. This study explores the association between community solidarity and psychological health outcome among Sub-Saharan African (SSA) migrants in Germany.<br /> The study used data from 518 SSA migrants in Germany collected in a cross-sectional survey across the 16 German federal states. A correlation matrix was computed to evaluate the bivariate relationship between psychological health, community solidarity, and socioeconomic, and demographic features. Furthermore, regression models were calculated to predict the effect of community solidarity on psychological health outcomes and the added predictive effects of socioeconomic and demographic characteristics.<br /> Community solidarity shows a moderately significant positive association with psychological health (r=.41; p≤.01). A linear regression model suggests that community solidarity, education and age explained 19% of the variance in psychological health scores for SSA migrants in Germany.<br /> These results confirm community solidarity as a significant but multi-layered determinant of various factors that affect migrants’ psychological wellbeing. It supports implementing policies that promote community solidarity to facilitate SSA migrants’ wellbeing.

An Integrative Review of Community-Based Mental Health Interventions Among Resettled Refugees from Muslim-Majority Countries

Resettled refugees from Muslim-majority countries are underrepresented in research and meeting their mental health needs remains a challenge for countries of resettlement. In this integrative review, we synthesize community-based mental health interventions using an ecological framework. Eleven relevant studies were identified using PubMed and PsychInfo database. Most interventions focus on micro-system level factors like promoting integration and social connections suggest improvement of outcomes including depression, anxiety, and psychological distress. Studies suggest how mental health programs addressing psychosocial wellbeing improves outcomes across ecological levels through: (1) early screening upon resettlement; (2) education and raising awareness of mental health; and (3) engagement of refugees in local community social support systems. Largely qualitative studies suggest benefits of engagement and education program for refugees, but there is a need for high quality, rigorous mental health intervention studies with resettled refugees with explicit attention to equitable and collaborative partnerships across multiple sectors in the community.

Need for training or already OnTracc? Development and psychometric properties of an online transcultural competence questionnaire among psychotherapists

The prevalence of mental disorders among people with migration experiences is high. Studies have shown that despite the increasing number of patients from different cultures requiring therapy, treating them is still a major challenge. Furthermore, professional training aimed at improving transcultural competence is rare, and psychometric instruments assessing transcultural competence require improvement. Accordingly, this study aimed to develop and evaluate an online transcultural competence questionnaire (OnTracc) to assess transcultural competence among psychotherapists. Based on extensive literature research and expert interviews, 38-self-report statements referring to aspects of transcultural therapy (e.g., skills, knowledge, and awareness) were compiled. In two studies, 306 psychotherapists completed the OnTracc questionnaire. The multicultural counseling inventory (MCI), personality factors (BFI-K), experience in transcultural therapy, and demographic data were assessed as control variables. The exploratory factor analysis (EFA) revealed a 3-factor structure. The reliability of the scale ranged from ω = 0.73 to 0.81. These scales demonstrated substantial convergent and discriminant validity with the BFI-K and MCI subscales. Factorial validity was confirmed through confirmatory factor analysis. This validated inventory is the first to assess transcultural competence in therapeutic settings in the German language. Further analysis of the factorial validity of the different samples is recommended. Given the increasing diversity in the therapeutic landscape, additional development could help close the gap between the evolving treatment demands of culturally diverse patients and the lack of consideration in mental health and education.

Does Time Heal Trauma? 18 Month Follow-Up Study of Syrian Refugees' Mental Health in Iraq's Kurdistan Region

The findings of longitudinal studies on traumatized refugees have shown that factors related to premigration, migration, and post-migration experiences determine changes in mental health over time. The primary aim of this follow-up study was to examine the potential change in the prevalence rates of probable PTSD and depression among Syrian refugees in Iraq. An unselected group of N = 92 Syrian adult refugees was recruited from Arbat camps in Sulaymaniyah Governorate in Iraq's Kurdistan Region, and then interviewed at two different time points between July 2017 and January 2019. Locally validated instruments were used to assess traumatic events and mental health symptoms. The primary results showed no significant change in the mean scores of PTSD and depression symptoms from the first measurement to the second measurement over the course of 18 months. On the individual level, no reliable change was found for either PTSD or depression symptoms in more than three-quarters of the participants (78.3% and 77.2%, respectively). New adversities and traumatic events that occurred over the 18 months between the interviews were a significant predictor of increasing trauma-related symptoms. After the flight from conflict settings, trauma-related disorders seem to be chronic for the majority of Syrian refugees. Further longitudinal studies are needed in order to identify specific risk factors that lead to maintaining or worsening mental health symptoms over time, and to explore effective therapeutic intervention methods for this traumatized population.

Homesickness in asylum seekers: The role of mental health and migration-related factors

Background

While homesickness in refugees is a recurring theme in clinical practice, respective research in this population is scarce. The Utrecht Homesickness Scale (UHS) allows distinguishing between certain aspects of homesickness, namely genuine separation distress like missing family and friends or yearning for home on the one side and problems regarding adjustment to the new situation on the other; so far, the instrument was applied mainly in samples of university students, and never in refugees.

Objective

We aimed to explore homesickness in a refugee population and its association with mental health symptoms and migration-related factors. In addition, we wanted to evaluate the UHS's factor structure in a sample other than students.

Methods

Individuals from different countries (N = 99) seeking asylum in Germany were assessed for homesickness, migration-related variables (e.g., number of losses and stage of the asylum proceedings), and mental health symptoms (symptoms of depression, posttraumatic stress and prolonged grief). After exploratory factor analysis, standardized mean factors scores were fed into subsequent correlational and regression analyses to identify the most prominent predictors of homesickness scores.

Results

The participants showed substantial levels of homesickness. We found a three-factor solution that implied distinct factors regarding (1) adjustment difficulties and loneliness, (2) ruminations about home, and (3) missing family and/or friends. The total homesickness score was associated with mental health but regression analyses with the three mean factor scores showed differential associations with mental health and migration-related variables. While adjustment difficulties and loneliness were-besides time since arrival in Germany-associated with mental health problems (depressive and posttraumatic stress symptoms), ruminating about home was predicted by migration-related variables (number of losses and asylum status). For the factor scores regarding missing family and/or friends, the regression model was not significant.

Conclusion

The assessment of homesickness in refugee populations is feasible and of clinical importance, especially when distinguishing between separation distress and difficulties with adjusting to the new situation.

Estimated prevalence rates and risk factors for common mental health problems among Syrian and Afghan refugees in Türkiye

BACKGROUND

Türkiye hosts 4 million refugees and asylum seekers, with Syrians and Afghans being among the largest refugee groups in country. There are limited comparative data on the conflict- and displacement-related experiences of these groups and the relation with mental health status.

AIMS

To assess the mental health status of Syrians and Afghans in Türkiye, identify risk factors and explore to what extent differences in mental health conditions are related to potentially traumatic events and post-displacement stressors.

METHOD

Two parallel online survey studies were conducted between April and June 2021 among 798 Syrians and 785 Afghans in Türkiye. Data were collected on sociodemographic characteristics, traumatic events (Harvard Trauma Questionnaire), post-displacement stressors (Post-Migration Living Difficulties Checklist), symptoms of depression and anxiety (Hopkins Symptoms Checklist-25) and post-traumatic stress disorder (PTSD) (Post-Traumatic Stress Disorder Checklist for DSM-5, short form).

RESULTS

For Syrian and Afghan participants respectively, estimated prevalence rates were: 41.1% and 50.3% for depression; 39.6% and 41% for anxiety; and 41.6% and 46.5% for PTSD. In both groups, significant predictors were female gender, exposure to potentially traumatic events, and structural and socioeconomic post-displacement stressors. Additional risk factors were older age for Afghans and higher education for Syrians.

CONCLUSIONS

Self-reported symptoms of common mental health problems are highly prevalent among Syrian and Afghan refugees and associated with a wide range of risk factors. After controlling for conflict- and displacement-related experiences, Afghans reported higher anxiety symptoms than Syrians, which is likely related to their legal status in Türkiye.

Living a frozen life: a qualitative study on asylum seekers' experiences and care practices at accommodation centers in Sweden

BACKGROUND

Forced migrants fleeing conflict and violence face a high risk of mental health problems due to experiences before displacement, perilous journeys, and conditions in the new host societies. Asylum seekers seem to be in particularly vulnerable situations, indicated by higher prevalence rates of mental health problems compared to resettled refugees. Asylum seekers' mental health is highly influenced by the conditions they face in host countries while awaiting a decision on their case. In Sweden, 40% of asylum seekers reside in state-provided accommodation centers during the asylum process. Collective accommodation centers for asylum seekers have been said to impose restrictive social conditions and to be associated with poorer mental health outcomes than other housing forms (e.g., self-organized housing). However, there seems to be a scarcity of qualitative studies exploring the experiences of asylum seekers in different contexts. The aim of this study was therefore to explore the experiences of asylum seekers and how they manage their mental wellbeing while living at accommodation centers in Sweden.

METHODS

Fourteen semi-structured interviews with asylum seekers were conducted at two accommodation centers in Sweden. Participants were recruited using purposeful sampling and represented a diverse group of asylum seekers regarding age, background, and gender. The data was analyzed using content analysis.

RESULTS

Three overarching categories were identified; 1) Frozen life, 2) Constant worrying and "overthinking", and 3) Distractions and peer support. Participants experienced a state of being that could be characterized as a frozen life, which was associated with intense feelings of psychological distress, mostly described as manifesting itself in consuming patterns of ruminative thoughts, for instance overthinking and constant worrying. However, despite high levels of distress, participants demonstrated agency in managing negative mental health outcomes through self-care practices, peer support, and the development of care practices in caring for others in need.

CONCLUSION

This study offers new insights into the everyday challenges that asylum seekers at accommodation centers face. Furthermore, it offers valuable observations of how asylum seekers at accommodation centers cope through self-care practices, peer support, and care practices in caring for peers in need. In order to enable sustainable and empowering support, mental health and psychosocial support services must identify and address both challenges and strengths, be grounded in the lived reality of asylum seekers, and build on existing resources. Moreover, further policy work needs to be done to enable faster asylum processes.

Adaptive performance in refugees after trauma: how relevant are post-traumatic stress and post-traumatic growth?

Purpose

Wars can lead to massive migration waves, e.g. the Syrian Civil War that began in 2011 led to the European refugee crisis. Discussions about labour integration often accompany huge spikes in asylum applications. Since many refugees experience traumatic events, such as torture, health problems must be considered in the work context. Unfortunately, the relevance of the post-traumatic experiences of refugees to specific job performance facets has mainly been ignored. To close the research gap, a study with refugees living in Germany was conducted to examine to what extent trauma-related variables are relevant to performance variables.

Design/methodology/approach

The relationship between post-traumatic stress (PTS), post-traumatic growth (PTG) and adaptive performance (social and task-oriented adaptive performance) was examined as, nowadays, many activities require dealing with changes (e.g. new colleagues, new technologies). Sixty-nine people met the inclusion criteria (e.g. refugee status, traumatic experiences) and completed the survey. Data were analysed using the Bayesian approach.

Findings

Bayesian analyses revealed that PTG might promote both social and task-oriented adaptive performance. In contrast, PTS was negatively related to task-oriented adaptive performance. Furthermore, there was no substantial evidence that PTG moderates the relationship between PTS and adaptive performance. Furthermore, there is preliminary evidence that refugees do not differ substantially from the general population with respect to social adaptive performance.

Originality/value

The present study demonstrates for the first time the relevance of post-traumatic experiences to the adaptive performance of refugees.

Preventing the mental health consequences of war in refugee populations

The refugee experience is associated with several potentially traumatic events that increase the risk of developing mental health consequences, including worsening of subjective wellbeing and quality of life, and risk of developing mental disorders. Here we present actions that countries hosting forcibly displaced refugees may implement to decrease exposure to potentially traumatic stressors, enhance subjective wellbeing and prevent the onset of mental disorders. A first set of actions refers to the development of reception conditions aiming to decrease exposure to post-migration stressors, and a second set of actions refers to the implementation of evidence-based psychological interventions aimed at reducing stress, preventing the development of mental disorders and enhancing subjective wellbeing.

Post-Migration Stressors and Health-Related Quality of Life in Refugees from Syria Resettled in Sweden

The link between post-migration stressors and mental ill health is well documented in refugees resettled in high-income host countries, but the consequences of these stressors on refugees' health-related quality of life (HRQoL) are less known. This study examined the association between post-migration stressors and HRQoL among Syrian adult refugees resettled in Sweden using a preference-based value set obtained from the general Swedish population. A total of 1215 Syrian adults, ages 18-64 years, granted residency in Sweden, responded to a postal questionnaire in 2016 regarding various aspects of their resettlement. The European Quality of Life Five Dimensions Five Level (EQ-5D-5L) questionnaire was used to assess HRQoL through an EQ-5D-5L index score (range; 0=dead to 1=full health). The index score was preference weighted using a Swedish population value set. Predictors were four self-reported post-migration stressors related to daily living in the host country: financial strain, social strain, competency strain and perceived discrimination divided into low, medium and high levels of experienced stress. Multivariable linear regression models were employed to assess the association between post-migration stressors and HRQoL index score, adjusting for potentially traumatic events in the pre- and peri-migration phase as well as sociodemographic confounders/covariates (sex, age, education, civil status, immigration year). The Syrian refugees had a mean EQ-5D-5L index score of 0.863 (SD = 0.145). There was strong evidence of a negative dose-response association in both unadjusted and adjusted models between HRQoL and the post-migration stressors financial strain and social strain-i.e., there was a stepwise, and statistically significant, decrease in HRQoL when going from low to medium to high strain. Competency strain and discrimination were only associated with lower HRQoL when experienced at high levels in fully adjusted models. High exposure to potentially traumatic experiences before or during flight was also associated with lower HRQoL. Syrian refugees resettled in Sweden reported a lower HRQoL than the general Swedish population and lower than age-matched Swedish adults. The present study results point to the possible adverse effects of post-migration stressors on HRQoL.

Trajectories of psychosocial symptoms and wellbeing in asylum seekers and refugees exposed to traumatic events and resettled in Western Europe, Turkey, and Uganda

Background: Longitudinal studies examining mental health trajectories in refugees and asylum seekers are scarce. Objectives: To investigate trajectories of psychological symptoms and wellbeing in refugees and asylum seekers, and identify factors associated with these trajectories. Method: 912 asylum seekers and refugees from the control arm of three trials in Europe (n = 229), Turkey (n = 320), and Uganda (n = 363) were included. We described trajectories of psychological symptoms and wellbeing, and used trauma exposure, age, marital status, education, and individual trial as predictors. Then, we assessed the bidirectional interactions between wellbeing and psychological symptoms, and the effect of each predictor on each outcome controlling for baseline values. Results: Symptom improvement was identified in all trials, and for wellbeing in 64.7% of participants in Europe and Turkey, versus 31.5% in Uganda. In Europe and Turkey domestic violence predicted increased symptoms at post-intervention (ß = 1.36, 95% CI 0.17-2.56), whilst murder of family members at 6-month follow-up (ß = 1.23, 95% CI 0.27-2.19). Lower wellbeing was predicted by murder of family member (ß  = -1.69, 95% CI -3.06 to -0.32), having been kidnapped (ß  = -1.67, 95% CI -3.19 to -0.15), close to death (ß =  -1.38, 95% CI -2.70 to -0.06), and being in the host country ≥2 years (ß =  -1.60, 95% CI -3.05 to -0.14). In Uganda at post-intervention, having been kidnapped predicted increased symptoms (ß = 2.11, 95% CI 0.58-3.65), and lack of shelter (ß  = -2.51, 95% CI -4.44 to -0.58) and domestic violence predicted lower wellbeing (ß  = -1.36, 95% CI -2.67 to -0.05). Conclusion: Many participants adapt to adversity, but contextual factors play a critical role in determining mental health trajectories.

Refugee Mental Health, Global Health Policy, and the Syrian Crisis

The most recent global refugee figures are staggering, with over 82.4 million people forcibly displaced and 26.4 million registered refugees. The ongoing conflict in Syria is a major contributor. After a decade of violence and destabilization, over 13.4 million Syrians have been displaced, including 6.7 million internally displaced persons and 6.7 million refugees registered in other countries. Beyond the immediate political and economic challenges, an essential component of any response to this humanitarian crisis must be health-related, including policies and interventions specific to mental health. This policy and practice review addresses refugee mental health in the context of the Syrian crisis, providing an update and overview of the current situation while exploring new initiatives in mental health research and global health policy that can help strengthen and expand services. Relevant global health policy frameworks are first briefly introduced, followed by a short summary of recent research on refugee mental health. We then provide an update on the current status of research, service provision, and health policy in the leading destinations for Syrians who have been forcibly displaced. This starts within Syria and then turns to Turkey, Lebanon, Jordan, and Germany. Finally, several general recommendations are discussed, including the pressing need for more data at each phase of migration, the expansion of integrated mental health services, and the explicit inclusion and prioritization of refugee mental health in national and global health policy.

The Impact of Pre- and Postarrival Mechanisms on Self-rated Health and Life Satisfaction Among Refugees in Germany

In this study, we focus on the evolution of refugees' well-being in the first years after their arrival in Germany. In contrast to other immigrants (e.g., labor migrants), refugees experience higher risks of unexpected and traumatic events and insecurity before and during their migration and face various legal and structural barriers in the receiving country. We contribute to the existing literature by exploring from a dynamic perspective possible pre- and postarrival determinants of refugees' life satisfaction and self-rated health upon arrival in Germany and the development of their life satisfaction and self-rated health in the process of becoming established. Applying linear regression and panel models with recent longitudinal data from the IAB-BAMF-SOEP Survey of Refugees in Germany, we find significant effects of prearrival factors, such as traumatic experiences and the complexity of migration, on both life satisfaction and self-rated health at the time of the first interview. Regarding postarrival factors, our results suggest that improvement in language proficiency and labor market status significantly shape refugees' life satisfaction and self-rated health. The time-dynamic analyses reveal substantial improvements in life satisfaction upon the approval of refugee status and the transition from shared housing to private accommodations. However, we find no improvements in self-rated health due to legal status but rather deterioration effects due to long-term residence in shared housing.