The Impact of COVID-19 Pandemic Lockdowns on Refugee Mental Health: A Narrative Review.

With over 80 million persons around the world forcibly displaced from their homes, 26.3 of whom are refugees, recent estimates indicate that the number of forced migrants has reached an all-time high (UNHCR, 2020). Already at a disadvantage, the closures of schools and key community resources aimed at combating the spread of the virus during the early stages of the pandemic contributed to further distress on the well-being of refugees. Recognizing that forced migrants are a vulnerable and underserved population and that the COVID-19 virus and the lockdowns put in place to reduce its spread severely worsened their multidimensional stressors, the authors used a qualitative narrative review with attention to the thematic analysis model to explore the impact of lockdowns on refugees' mental health by reviewing publications from April 2020 through May 2021. The review findings are categorized under three themes: (a) negative impact on mental health, (b) suggested intervention approaches/strategies, and (c) recommendations. Implications for counseling and research are discussed.

The impact of COVID-19 pandemic lockdowns on Refugee Mental Health: a narrative review

Refugees are a vulnerable population group where persecution, conflict, violence, human rights violations, or events seriously disturbing force them to displace from their home countries (United Nations High Commissioner for Refugees, UNHCR, 2020). A refugee is any person who owing to a well-founded fear of persecution due to race, nationality, religion, or membership in a particular social group is outside a country of nationality and is unwilling to avail of the protection of that country (UNHCR, 2000). In comparison to the general population, COVID-19 lockdowns and closures of important community resource centers were problematic and complicated for some refugees due to their pre-existing mental health challenges. Before the lockdowns, refugees’ mental health was widely overlooked and less prioritized (UNHCR, 2020). With the global pandemic, attention was devoted to the physical health of citizens with a focus on refugees’ mental health left to lag (Wang et al., 2021). We provide a narrative review of publications since the outbreak of the COVID-19 virus with a specific focus on the impact of pandemic lockdowns on the mental health of refugees. The end goal is to understand factors that increased refugees’ susceptibility to mental health issues, strategies, and/or interventions during pandemic times and beyond and address the challenges in meeting refugees’ mental health needs.

Impact of Migration on Mental Health of Young and Adult Refugees

In comparison to migrant groups who may choose to leave their home countries and have the option of returning, refugees are forced to leave (UNHCR, 2016) and have minimal options to return to their home countries of origin. The refugees’ experiences and challenges during various migratory phases make it difficult to realize their overall mental health (Hajak et al., 2021). Specifically, pre-, trans-, and post-migration phases comprise risk factors contributing to the mental health problems in refugees such as anxiety, conduct, and sleep disorders among younger refugees, post-traumatic stress disorder (PTSD), and depression (Stuart & Nowosad, 2020). Pre-migration experiences may include exposure to atrocities, like forcibly witnessing or participating in killings (Fino et al., 2020). Trans-migration experiences occur during flight, such as living in congested refugee camps with limited basic human needs (Meda, 2017). For school-going refugee children and adolescents, there is a disruption to the continuation of schooling in refugee camps due to minimal resources and less established educational infrastructure (Dridi et al., 2020). Post-migration experiences comprise ongoing challenges and stressors during and upon resettlement in the host country including culture shock and acculturative stress, language barriers, as well as unemployment or underemployment (Bemak & Chung, 2017). Other experiences are financial challenges, incidences of racism and discrimination, isolation, hopelessness, and helplessness that may result from uncertainties related to immigration and legal statuses (Sangalang et al., 2019).

In addition, younger refugees are at particularly high risk for mental health problems as they must navigate critical normative developmental processes (e.g., identity development and relationship formation with peers) while also dealing with migration challenges (Meda, 2017). For instance, adolescent refugees reported instances of discrimination, racism, othering, exclusion, and bullying, which made adjustment and adaptation challenging during the post-migration transition in schools in host countries (Baak, 2019; Frounfelker et al., 2020) showed evidence of high levels of PTSD and depression during the examination of the mental health and psychosocial well-being of refugee children. Further, limited research studies are conducted to evaluate symptomatology in young refugees in low-to-middle-income countries (LMICs) where the prevalence of mental health challenges is more severe (Blackmore et al., 2020a; Frounfelker et al., 2020). In LMICs settings, common mental health problems in refugee children and adolescents include PTSD, depression, anxiety, and behavioral challenges (Blackmore et al., 2020a; Frounfelker et al., 2020), with unaccompanied refugee minors at a high risk of mental health problems such as abuse and exploitation (Frounfelker et al., 2020; Hanewald et al., 2020).

There is also a high prevalence of PTSD and depression among older refugees (Blackmore et al., 2020b; Silove et al., 2017), with the acknowledgment of the problematic nature of generalizations of the prevalence of mental health problems (Giacco et al., 2018). Researchers revealed a need for consideration of other factors, such as country of origin and whether there are ongoing conflicts, involuntary repatriation, socio-demographic characteristics, and prior socioeconomic status (Giacco et al., 2018; Silove et al., 2017). Other varying factors include the political, social, and economic contexts of the host country as well as the degree of acceptance or lack thereof for specific refugee groups (Giacco et al., 2018). For example, discriminatory experiences (e.g., employment, neighborhood, and public transportation) of adult refugees from Africa, the Middle East, and Southeast Asia are risk factors for refugees’ emotional well-being (Ziersch et al., 2020). Overall, risk factors during migration experiences increase refugees’ vulnerability in new environments, a reality that worsened with the pandemic. Although this health crisis had negative physical and mental health impacts on global populations, lockdowns (i.e., during which residents were forbidden to leave their homes) aimed at mitigating the spread of the virus contributed to more unexpected challenges for refugees.

Global impact of lockdowns on Mental Health of the General Population

Globally, the COVID-19 virus and accompanying lockdowns resulted in adverse mental health consequences. In a systematic review using eight countries representing Asia, Europe, the Middle East, and North America researchers found high rates of symptoms of anxiety, depression, post-traumatic stress disorder, psychological distress, and stress (Xiong et al., 2020). Some risk factors associated with distress included unemployment, chronic psychiatric illnesses, student status, and exposure to social media or news related to Covid-19. In another study using seven middle-income countries in Asia, Wang et al., (2021) cited risk factors for adverse mental health as age (less than 30 years), relationship status, discrimination, and close contact with people infected by the virus; protective factors include gender, employment, living with other people or family members, spending limited time on health-related information, and hope for survival. Other mental health impacts include the psychological burden on the general population especially older females in some contexts (Khatatbeh et al., 2021), health and financial strain on families (Knolle et al., 2021), and the likelihood of anxiety, posttraumatic stress disorder, and depression (Semo & Frissa, 2020). Similarly, mental health problems were related to fear and uncertainty about the future leading to anxiety and psychological stress, stigma, and discrimination due to prolonged quarantine, as well as aggression and obsessive-compulsive disorder (Shujan et al., 2020; Torales et al., 2020).

Method

A qualitative approach was plausible to address the goal of this study “because some research questions cannot be answered using (only) quantitative methods” (Busetto et al., 2020). Specifically, we used a literature review, not to present new data, but to assess the published literature and provide the currently available evidence (Busetto et al., 2020). We relied on a non-systematic or narrative review that seeks to identify and summarize what has been published on a topic of inquiry, and with the avoidance of duplications to determine novel areas not addressed to guide future inquiries (Connlley & Clandinin, 1990; Derish & Annesley 2011; Grant & Booth, 2009; Cronin et al., 2008). Data analysis was conducted using narrative thematic analysis – one of the four approaches of narrative analysis that focuses on the content of the text (Butina, 2015; Riessman, 2005).

Researcher reflexivity

The research team consisted of three researchers—two assistant professors and one undergraduate student who was a research assistant at the time of the study. The first and third authors have experience conducting qualitative research with underserved populations while the second author has experience conducting literature reviews as well as coding qualitative data. All authors have varying degrees of interest in underserved and minority populations such as refugees. For instance, the first author’s previous experience involves closely working with refugee youth and adults. Due to the degree of familiarity with the refugee population, the authors were aware of their own beliefs, assumptions, biases, and thought processes during the research project as well as how these have the potential to affect the analysis, theme development, and interpretation. As a safeguard, the authors were open to addressing these aspects during debriefings.

Credibility and trustworthiness

Several strategies are proposed to ensure validity and reliability in qualitative research including journaling, peer review/debriefing; triangulation, rich/thick description of data, member checks, using external audits, and prolonged observation (Morrow, 2005; Creswell, 1997). In keeping with Creswell’s (1997) recommendation that researchers utilize at least two strategies in a qualitative study, about credibility, the first two authors conducted the analysis independently and engaged in ongoing peer debriefings/discussions during this process. This included discussions related to coding such as agreement on the creation of new codes and discarding others to minimize redundancies as well as determination of overarching themes. Second, the third author (with experience conducting qualitative research) audited the findings from the analytic process in the context of the title and literature review and provided insights that were taken into consideration, especially in the development of themes and interpretation of findings. For reliability, the authors follow the steps in the narrative thematic analysis (Creswell, 1997).

Selection of studies

The first stage of this review involved searching the following database collections: Directory of Open Access Journals, PubMed Central, Academic Search Complete, Journals@Ovid, IngentaConnect Journals, SpringerLink Contemporary, SAGE, Wiley Online Library, Springer Journals Complete, BioMedCentral Open Access, Science Direct Journals, SocINDEX, Freely Accessible Medical Journals, and Single Journals. To identify relevant articles, the second author utilizes all combinations of the following search terms: COVID-19, coronavirus, COVID-19 pandemic, refugees, refugee youth, mental health, mental illness, impact of COVID-19/coronavirus, effect of COVID-19/coronavirus, psychological effects of COVID-19/coronavirus. To reflect the timeline of the onset of coronavirus and the urgency of the situation, we include publications from 2020 to 2021. To complete a comprehensive search, the second author manually reviewed all search results. The inclusion criteria for the review include: (a) publications that examined the mental health impact of COVID-19 and its associated factors on refugee populations and (b) available full texts accessible in English. The exclusion criteria were publications that (a) that were unrelated to mental health, refugees, and COVID-19, (b) addressed populations beyond refugees, and (c) did not have full texts accessible in English.

The initial search identified 1062 potentially relevant publications. The author removed duplicate sources, resulting in manually screening 408 unique publications by title and abstract. Next, the author identified, assessed, and read the entirety of 40 articles for eligibility. The final inclusion consisted of 16 publications. Figure 1 illustrates the search process of identification, screening, eligibility, exclusion, and inclusion.

Fig. 1

Identification, Selection, Eligibility, and Inclusion Criteria

Data Analysis

A qualitative approach was used for this review study because it takes into consideration specific ways of understanding a particular phenomenon at a given time (Figgou & Paviopoulos, 2015). Considering the newness of the topic of focus, a narrative analysis (NA) thematic model was feasible in order “to present a non-systematic summation and analysis of available literature on a specific topic of interest” (Gregory et al., 2018, p. 893). We used the narrative thematic model that focuses on the content (i.e., in the context of this review the available content/text on the topic) as opposed to the structure/composition of the topic (Figgou & Paviopoulos, 2015; Riessman, 2005). The thematic model incorporates the common features in content and what is reported (Riessman, 2005). To this end, the authors followed the five steps in narrative thematic analysis namely: (a) organization and preparation of the data, (b) obtaining a general sense of the information, (c) the coding process, (d) categories or themes, and (e) interpretation of data (Creswell,1997). The data analysis process was conducted as follows after the second author completed the literature search using the inclusion/exclusion criteria and summarization of all the 16 selected studies. The first two authors conducted the first two steps; organization and preparation of the data as well as obtaining a sense of the information by reading and re-reading the summaries in their entirety of the selected articles for review. During this process, the authors noted and highlighted the developing patterns or themes and recurring key ideas across the articles. In the second phase, the authors independently conducted the third and fourth steps of analysis – coding and development of logical categories. In doing so, the authors read and re-read through each of the article summaries, again, highlighting the recurring messages, keywords, and notable ideas. For easier identification and designation of the categories, the authors documented these in Word. To determine themes, the authors assigned the codes into logical categories or specific words or phrases that described sections of the data (Rossman & Rallis, 2003). These categories reflected the themes that had become evident and representative of the study findings. The final step, interpretation or making meaning of the data, was a simultaneous procedure infused with the coding and theme development processes. The interpretation involved studying the categories and corresponding codes to ascertain underlying themes that provided an understanding of the impact of lockdowns on refugees’ mental health. This process culminated in the following themes in this study: (a) negative impact of lockdowns on mental health or refugees namely – the impact on school-going refugee children and adult refugees, (b) fears, triggers, and flashbacks, (c) stress, anxiety, and depression, (d) impact on mental health due to economic challenges, poor living conditions, and legal status, (e) approaches to address refugees’ mental health during COVID-19 and, (f) recommendations.

Results

This systematic narrative review shows the publications were mainly discussion papers or reports (n = 8), commentaries (n = 5), qualitative study (n = 1), qualitative and quantitative pilot study (n = 1), and an editorial letter (n = 1). Following, the results are categorized into three key themes: (a) the negative impact of lockdowns on refugees’ mental health, (b) approaches/strategies to address refugees’ mental health, and (c) recommendations.

Impact of lockdowns on Mental Health of Young and Adult Refugees

Of the total 26.3 million refugees globally, nearly half are children below 18 years of age, a population considered one of the at-risk refugee groups (UNHCR, 2020). Due to COVID-19, school-going refugee children face unique challenges with disruption of their day-to-day lives – changes in schedule, loss of structure, transitioning to remote education, boredom, and isolation from peers (Edmonds & Flahault, 2021; Fouad et al., 2021; Karajerjian, 2021). Also, language acquisition for young refugees through peer relationships with host country peers is an important part of their adjustment (Beißert et al., 2020). With school closures, there was a disruption in the fostering of these relationships, as isolation from peers limits the ability to grow linguistically, which leaves young refugees with language barriers that impede their ability to integrate into host communities, a possible cause for psychological stress (Edmonds & Flahault, 2021). For example, in a study not included in the review isolation in addition to other pandemic outcomes contributes to traumatic experiences in young refugees (Endale et al., 2020).

Additionally, the transition to remote learning was a challenge for some refugee children because of poor housing conditions and lack of access to or unreliable internet connections in countries with limited electricity (Karajerjian, 2021). Refugee children lacking computers or technological literacy were unable to participate (Edmonds & Flahault, 2021; Fouad et al., 2021). Furthermore, with more time spent at home, mental health providers raised concerns about issues related to hidden child labor, early marriages, abuse, and neglect (Nisanci et al., 2020). These occurrences have the potential for the onset of mental health problems in refugee children, especially with the closures of religious institutions that serve as mental health support systems for refugees. Researchers show that religious institutions provide structured activities and role modeling that enhance young refugees’ school and cultural adjustment in resettlement (Wilkinson et al., 2017). During lockdowns, many refugee children had limited options to replace these institutions in their lives. This led to uncertainties related to the completion of schooling causing stress and anxiety for the children and their parents (Karajerjian, 2021).

Related to adult refugees, before the pandemic, researchers reported a persistent prevalence of post-traumatic stress disorder, anxiety, and depression (Kartal et al., 2019; Stuart & Nowosad, 2020). For refugees with pre-migration experiences of war trauma (Fino et al., 2020), lockdown measures reignited traumatic memories. For instance, the quietness and emptiness on the streets were potential triggers of negative memories in refugees, such as hiding from rival groups or government authorities (Mattar & Piwowarczyk, 2020). Then, to enforce stay-at-home orders in many places, some countries had an increased military and/or police presence in the streets (Rees & Fisher, 2020). Such was the case among Rohingya refugees in Malaysia as they reported experiencing flashbacks when witnessing law enforcement on the streets (Verghis et al., 2021). Lockdowns also triggered memories of living under oppressive or dangerous regimes where refugees may have experiences of forced detainment, captivity, or imprisonment that was accompanied by helplessness, as well as physical or psychological torture (Kizilhan & Noll-Hussong, 2020; Rees & Fisher, 2020). Lockdowns were also socially isolating, leading to concerns that the stress related to social isolation and limited social engagement was a possible trigger of past traumatic experiences (Nisanci et al., 2020). In addition to triggers, lockdowns contributed to refugees’ – children and adults’ stress and anxiety as they grappled with transitions into a “new normal” in their living environments.

Stress, anxiety, and Depression

During lockdowns, there is a heightened sense of fear and stress of contracting the virus and possible death (Rees & Fisher, 2020; Verghis et al., 2021). Besides the fear of death from the virus, in South Africa, refugee women’s fears were related to testing procedures and possible forced quarantine away from their families, leading to anxiety and stress (Mutambara et al., 2021). For those with pre-existing chronic conditions, the lockdown was stressful and anxiety-provoking as some refugees could not receive treatments leading to worry and depression. Additionally, stress and anxiety for other refugees were related to various tracing technologies and apps that were threatening to refugees who viewed them as invasions of privacy (Rees & Fisher, 2020).

Furthermore, higher levels of domestic and gender-based violence as well as an increase in cases of refugees engaging in self-harm, harm to others, sexual abuse, and divorce contributed to mental health problems (Karajerjian, 2021). Refugee women noted increased levels of family conflict, both due to and resulting in increased levels of stress. These problems seem to have dramatically increased during the pandemic (Karajerjian, 2021; Mutambara et al., 2021). Victims of sexual abuse and violence are likely to struggle with mental health problems, such as depression, stress, and anxiety (Mutambara et al., 2021). In South Africa, with the lockdown keeping men at home from work, refugee women reported psychological stress from the violence towards their children, and arguments within their households (Mutambara et al., 2021).

In addition, the closure of community and religious centers, coupled with social isolation meant that integrating socially into host communities was an even larger challenge for refugees during the pandemic (Edmonds & Flahault, 2021). Social isolation due to preventative measures and limited social connections posed challenges to the mental resiliency and well-being of refugees (Browne et al., 2021). In another study, stories of Syrian refugee women in Lebanon revealed fear and anxiety problems associated with the trauma of war and forced migration as well as the challenges of the pandemic (Karajerjian, 2021). In this context pre-pandemic, the women were chronically anxious, stressed, and scared, often manifested in somatic ways, such as regular nightmares, challenges completing daily activities, hair loss, and loss of hope. The pandemic measures worsened their vulnerability and existing burdens that negatively affected their emotional, psychological, and social well-being (Karajerjian, 2021).

Further, pre-pandemic interview assessments of the psychological impact of pre-migration experiences on Yazidi refugees in Iraq showed the prevalence of symptoms related to depression, anxiety, somatoform, dissociation, post-traumatic stress disorder, and suicidal ideation, with all mental health problems increasing significantly from the first to the second interview (Kizilhan & Noll-Hussong, 2020). In Uganda, there were concerns that factors related to the pandemic were likely to compound South Sudanese refugees’ existing mental health difficulties (McKague, 2020). While social support is integral to facilitating refugees’ mental health (Hynie, 2018), this was nearly impossible and potentially dangerous during COVID-19 lockdowns. At the same time, enormous economic and financial challenges during the pandemic lockdowns were stressors that negatively affected many refugees’ mental health well-being.

Impact due to Economic Challenges, Legal Status, and poor housing

Although employability of refugees in resettlement countries is generally a challenge (Curry et al., 2018), the lockdowns led to considerable levels of economic hardship through loss of employment, difficulty accessing financial relief, and a decreased ability to financially support family members who still lived overseas (Brickhill-Atkinson & Hauch, 2021; Mattar & Piwowarczyk, 2020). Loss of employment and income amounted to difficulties paying rent, as well as refugee parents’ expressions of helplessness, which led to an increase in mental health problems (Fouad et al., 2021; Karajerjian, 2021; Verghis et al., 2021). The difficulty in accessing financial relief was a factor in increased anxiety in some refugees (Brickhill-Atkinson & Hauch, 2021). In other situations, refugees’ economic challenges were more complex due to their legal status in the host country, where “illegals” lacked the legal right to work even before the pandemic (Verghis et al., 2021). The refugees’ non-citizen and illegal statuses meant they did not receive financial assistance during the pandemic. This added to their vulnerability with mass arrests that took place while obtaining the COVID-19 tests, which led to deportations and intense feelings of fear, stress, anxiety, and uncertainty for those left behind.

The non-citizenship status also negatively affected refugee women in South Africa as employers prioritized South African citizens for government financial assistance (Mutambara et al., 2021). Coupled with this was the state of uncertainty about the UNHCR’s process toward legalization of some refugees’ immigration status (Fouad et al., 2021; Karajerjian, 2021) as well as the stress of the suspension of resettlement and related services (Mutambara et al., 2021). The uncertainty related to resettlement immigration processes, economic insecurities (Brickhill-Atkinson & Hauch, 2021), and not knowing what the future held was stressful and anxiety-inducing. Also, with minimal options during the pandemic, some refugees found employment in hazardous, exploitative, and difficult environments (Brickhill-Atkinson & Hauch, 2021; Mutambara et al., 2021; Verghis et al., 2021). This included working in high-risk occupations/industries, such as providing home health services (Clarke et al., 2021; Mattar & Piwowarczyk, 2020). While these options may have temporarily eased refugees’ economic insecurities, they also increased their fears, anxiety, and worries related to contracting the virus at a time when due to their legal statuses, some encountered difficulties accessing medication or health care appointments (Brickhill-Atkinson & Hauch, 2021; Karajerjian, 2021).

Another challenge was refugees’ poor housing in refugee camps, which was worsened by the pandemic. The camps, usually overcrowded and congested with limited basic needs and poor sanitation, resulted in a high prevalence of outbreaks of diseases or even death (Brickhill-Atkinson & Hauch, 2021; Junior et al., 2020; Vonen et al., 2021). Pointing to the possibility of a humanitarian crisis since refugee camps host more individuals than they can accommodate, the camps were dangerous during the pandemic with a high likelihood to foster the rapid transmission of diseases (Vonen et al., 2021). Overcrowding in the camps made social distancing difficult (Junior et al., 2020; Raju & Aveb-Karlsson, 2020; Vonen et al., 2021), a situation that can lead to fear and anxiety among refugees. To mitigate refugees’ mental health problems during the lockdown, researchers suggested implementing various interventions and policies at different levels or systems in service provision.

Approaches to address Refugees’ Mental Health

While many of the publications reviewed highlighted the negative impact on refugees’ mental health, other research included multifaceted and creative approaches to address those problems. There was an emphasis on collaboration among multiple government and community partners in efforts to promote the mental well-being of refugees (Clarke et al., 2021). Additionally, some authors noted additional provider monitoring and reevaluation of PTSD patients, especially those who had been in remission before the pandemic (Brickhill-Atkinson & Hauch, 2021; Mattar & Piwowarczyk, 2020). As an avenue for service providers during the lockdown, some healthcare providers delivered telemental health (TMH) synchronously in the form of therapy or asynchronously in the form of psychoeducation with the latter as a better choice in some contexts due to challenges related to inconsistent electricity and unstable internet connection (Fouad et al., 2021). Other suggestions for mental health professionals working with refugee patients included asking refugee patients specific questions about the impact of the pandemic to understand the fears of coming to the hospital, job and economic stability or lack thereof, safety and preventative health measures taken, access to food, and safe housing (Mattar & Piwowarczyk, 2020). Despite closures of some service locations due to the lockdown, mental health care providers’ knowledge was critical in directing refugee patients to available local resources, such as information for local food banks, shelters, and financial support. Given the link between refugees’ mental health and the effects of the lockdown, strategies, and interventions to ameliorate these problems also have direct or indirect impacts on refugees’ mental health.

Discussion

We reviewed sixteen publications that discussed the impact of the COVID-19 virus pandemic lockdowns on the mental health of refugees during a global health crisis. Given the timing of this review – April 2020 to May 2021, the selected studies and publications represented perspectives that ranged from immediate responses from refugee service providers to reports, commentaries, editorial letters, and challenges and recommendations for intervention strategies. These were mainly from authors in the United States, Canada, East Asia, the Middle East, and two representations from sub-Saharan Africa. Findings from the review show that while the mental health issues in refugees during the COVID-19 virus seem like pre-pandemic times (Silove et al., 2017), the issues were exacerbated, or in part, created by the ripple effects of the lockdown. In the publications that addressed younger refugees, because of lockdowns, disruptions negatively affected this age with loss of routine and structure. The implications of closures added to the challenges for refugee children because of challenges to young refugees’ education, such as age limit restrictions, lack of funding to support programs, and lack of trained personnel to meet this population’s needs (Koehler & Schneider, 2019). As the COVID-19 virus lingered on with ever-changing mandates and restrictions, younger refugees’ psycho-social-emotional wellbeing, particularly those living in refugee camps, seemed an area of much-needed attention in the immediate and aftermath of the pandemic.

The lockdowns greatly affected adult refugees, as the lockdown was a constant reminder of pre-migration experiences or having lived during a virus pandemic in their own country. Because of this, consideration of each refugee’s past trauma and torture, using telehealth options, and assessment of mental health problems become especially critical in service provision. In addition, unemployment is one of the post-migration challenges for refugees (Curry et al., 2018) and researchers realized the economic impact of the lockdowns on the general population globally (McBride et al., 2021). The mental health implications for refugees were more evident partly because of the nature of jobs and their legal statuses in host countries (Mukumbang, 2021) as many had minimal choices during the lockdown and opted to work in risky environments leading to heightened stress and fear of either infections or death from the virus. Hence, even beyond the pandemic, there is a need to determine ways to provide refugee financial assistance as well as overall health and mental health.

Overcrowded living environments are common characteristics for many refugees, like those in refugee camps (Blundell et al., 2019). Researchers revealed the close relationship between congested, unsafe, and poor living conditions in refugee camps and adverse mental health consequences in refugees (Van de Wiel et al., 2021). Thus, intervention strategies that target the improvement of living conditions in refugee camps can serve a dual purpose of improving refugees’ physical and mental health. Some publications also revealed an increase in cases of domestic and gender-based violence coupled with different forms of abuse particularly towards women and children. Such findings are consistent with the general populations across the globe during the pandemic (Bradbury-Jones & Isham, 2020; Pereda & Díaz-Faes, 2020). While women reported psychological stress from violence, it also has negative mental health implications on children. Lugova et al., (2020) indicated similar reports of psychological distress and negative socio-emotional well-being in internally-displaced women.

Results from this narrative review point to the different contributing factors to refugees’ mental health challenges during the pandemic lockdown. Publications in the review were reports from the field and commentaries related to refugees’ mental health. As an exception, Mutambara and colleagues’ (2021) qualitative study in South Africa provided rich narratives of women’s mental health issues in this context. However, given the snowball methodology, there was no guarantee of sample representation. A strength of Kizilhan and Noll-Hussong’s (2020) mixed-methods pilot study was the understanding of refugees’ mental health problems before and during the pandemic using a qualitative inquiry and psychometric measurements. Although the reviewed studies provided content on refugees’ mental health during a global health crisis, research studies using various methodological approaches and more qualitative studies might shed light on this topic.

Recommendations and implications for practice

Amid a global pandemic and the negative impact on refugees’ mental health, one of the important factors in the survival of this vulnerable population is their resilience. Resilience entails an individual’s ability to negotiate health-enhancing resources toward well-being through the family, community, and culture in a culturally significant manner (Ungar, 2008). Researchers have emphasized the need to acknowledge refugees’ resilience amid migration challenges (Sleijpen et al., 2016; Walther et al., 2021). Bearing this in mind, some authors reported a strengths-based resilience framework in the mental health of families during COVID-19 highlighting factors beneficial in promoting emotional and mental resiliency in refugees to include inoculating, buffering, repair, compensatory, promotive, and windows of opportunity (Browne et al., 2021). Inoculating factors refer to strategies and experiences refugees may have had in the past that helped promote resiliency, factors that may deploy coping strategies during the pandemic. Buffering and repair factors refer to the protective resources an individual has, such as family support, that at the onset of the pandemic may facilitate resiliency and factors related to practices that promote health. Compensatory and promotive factors are socio-cultural resources, such as faith, which help offset the stressors as well as social policies (e.g., health care or financial assistance) that exist within the countries for refugee resettlement. Windows of opportunity refer to individual and personal social services that help individuals cope, such as therapy. These intricately intertwined factors connect the immediate and external systems to refugees’ mental health. To harness refugees’ resilience, Browne and colleagues (2021) suggested program initiatives for interventions ought to be: (a) multileveled – organized, undertaken in multiple social locations, and include multiple family generations, (b) trauma-informed, (c) focused on the family, (d) culturally and linguistically sensitive, and (e) easily accessible. These initiatives focus on the important value systems that have relevance to the mental health of refugees. For instance, the inclusion of multiple family generations and focusing on the family are two common themes among refugee populations that act as building blocks and social support systems for their resilience and mental health (Sleijpen, 2016). Equally important are intervention strategies at the local and governmental levels.

In consideration of the integral roles of both local and governmental agencies in refugees’ wellbeing, at the local level, suggestions included forging partnerships among refugee service providers with the need to seek an understanding of the barriers to care and services (Kizilhan & Noll-Hussong, 2020). For instance, the challenge of language barriers for new arrivals compounds their communication and awareness of available resources (Clarke et al., 2021). Hence, partnerships and collaboration among refugee service providers have the likelihood of policy implementation focused on addressing barriers related to language and accessibility to services. Further, to alleviate some of the refugees’ physical and mental health challenges, some authors suggested the establishment of better long-term housing at refugee camps (Vonen et al., 2021). Addressing social concerns, such as housing, proper sewage disposal and sanitation, adequate nutrition, access to health care, and safety is imperative when considering the mental wellbeing of refugees during the time of the pandemic. In countries of refugee resettlement, there is urgency for government implementation of policies that not only address public health measures for its citizens but also the social realities and psychological support to benefit all individuals residing in their nations (Junior et al., 2020; Vonen et al., 2021).

In terms of implications, there is a need for longitudinal studies specifically focused on refugees across the lifespan to determine both the immediate and long-term pandemic mental health implications. Due to the diversity of countries of origin and resettlement, refugees’ mental health needs and problems are likely to differ. Due to these differences, context-specific studies focused on the impact of lockdowns and other pandemic-related factors, and refugees’ mental health is an area for further research inquiry. In the same vein, researchers may need to focus on refugees with pre-existing mental health problems.

Related to services provision, there is a need for service providers to have a working knowledge and understanding of the barriers to accessibility of available services and resources to refugees during difficult times. Before the pandemic, due to factors such as discrimination (Ziersch et al., 2020) and systemic inequities, refugees had limited access to resources (Stuart & Nowosad, 2020). Hence, mental health professionals must take on more active and action-oriented advocacy roles at local and governmental levels. That means, that mental health counselors working with refugees need to go beyond knowledge in basic counseling skills and cultural awareness of different refugee groups; they need to be knowledgeable and informed of the available resources to better address refugees’ physical and mental health needs. In addition, with most services transitioning to remote, the financial challenges with pandemic lockdowns, and unreliable electricity for some refugees, counselor advocacy roles could include engaging local electricity providers for subsidized or temporary free service. They are also to be aware of the differences within the refugee population such as significant language barriers and differing ethnicities/religions. These refugees are likely to encounter more stressors as they navigate ways to access basic needs that may linger beyond the pandemic. To meet their needs, counselors could provide individualized online tutoring and provision of other adjunct reading materials.

Strengths and Limitations

There are some limitations of this narrative review. First, given the global nature of COVID-19 virus lockdowns, it is likely with the exclusion of non-English language publications the authors missed important publication contributions. Second, because the pandemic is not over, there is a likelihood of new threats to refugees’ mental health from emerging variants such as the Delta variant. Third, the research databases utilized during the search process may not have included all studies on refugees’ mental health. Fourth, there is potential for bias in the inclusion and exclusion selection process. Fifth, the authors selected these studies in the review during the peak of the pandemic, a time when there was a sense of urgency to combat the spread of the virus and subsequent consequences. Hence, some of the suggested intervention strategies in the publications were within the context of other existing factors (e.g., political and humanitarian crises) and they might only fit those specific contexts. Sixth, some studies included interviews with refugees before and during the COVID-19 outbreak with consideration of other pre-existing factors. Hence, it is less practical to underpin the extent of mental health problems solely due to preexisting or the COVID-19 virus-related lockdown challenges. Despite the limitations, a key strength of the review study is that to our knowledge this is the first narrative review focusing on the impact of the COVID-19 virus lockdowns on the mental health of refugees. The findings provide implications for health and mental health providers with the refugee population during a global health crisis.

Conclusions

Refugees are a vulnerable population whose mental health problems and needs became more visible with the outbreak of the COVID-19 virus and the global implementation of lockdowns to contain its spread. Findings from the review show common mental health problems include depression, PTSD, anxiety, as well as stress and worry related to the prevailing circumstances during the pandemic. For younger school-going refugees, lockdowns leading to school closures exposed this age group to crippling effects on their schooling, and mental and psychological wellbeing. Isolation and loneliness, coupled with unstable home environments caused psychological stress, anxiety, and worry. For adult refugee parents or guardians, lockdowns led to the loss of employment and financial income. As a result of isolation from community members and the closure of resourceful agencies, there were increased cases of worry, stress, anxiety, violence, and depression. Although refugees’ mental health issues were like those experienced pre-pandemic, accessibility to needed resources made it more complex during lockdowns. To ameliorate refugees’ immediate and long-term mental health issues, a collaborative approach among various systems that serve this population could provide avenues for culturally-relevant and sensitive preventative and intervention measures to support recovery and renewal in a post-pandemic world.