The impact of the COVID-19 pandemic on the mental health and wellbeing of refugees and asylum seekers-A Narrative Review of the Literature.

OBJECTIVE: To identify the factors affecting refugees and asylum seekers mental health and wellbeing during the COVID-19 pandemic.
METHODS: A narrative review of available international research literature from January 2020 to June 2021 was conducted to identify these factors.
RESULTS: Seven factors were identified: pre-existing physical health vulnerabilities, pre-existing mental health vulnerabilities, environmental, social, cultural-specific, economic and legal/welfare challenges.
CONCLUSION: Multiple interacting bio-psycho-socio-economic-cultural-ecological factors lead to greater impact of COVID-19 pandemic on refugee and asylum seekers wellbeing than the general population.

The United Nations High Commissioner for Refugees (UNHCR) defines a refugee as someone, or a group of people, who has fled war, violence, conflict or persecution and has crossed an international border to find safety in another country.[1] Additionally, an asylum seeker is a person who has sought protection as a refugee, but whose claim for refugee protection has not yet been finalised.[2]

Few studies have identified specific factors that contribute to the direct and indirect impact of the COVID-19 pandemic and associated policy changes and restrictions on refugee and asylum seeker mental health and wellbeing. Current literature suggests that factors such as poor living conditions, financial disadvantage, poor access to healthcare, stigma, social isolation and COVID-19 contagion are variables that influence the impact of COVID-19 on the health and wellbeing of asylum seekers and refugees.[3] Asylum seekers and refugees are at increased risk of mental illness due to exposure to multiple adversities including trauma, dispossession, poverty and acculturation challenges.[4] Therefore, it would be appropriate to hypothesise that impact of COVID-19 pandemic on mental health and wellbeing of refugees and asylum seekers is more severe in comparison to other populations. However, it is critical to examine what specific variables might contribute to the exacerbation of this symptomology. This information can then be used to inform future clinical practice and policy.

The specific research question examined in the project was: what factors affect the mental health and wellbeing of refugees and asylum seekers during the COVID-19 pandemic?

Method

Nine databases were utilised including: CINAHL, Cochrane, Healthy Policy Reference Centre, Medline, ProQuest, PsychInfo, Psychology and Behavioural Sciences Collection, PubMed and SocIndex. The literature search was limited to articles published between January 2020 and June 2021. Figure 1 presents a PRISMA diagram of the initial screening process.

Figure 1.

PRISMA flow diagram.

Keyword sutilised during the initial literature search included: asylum seekers, refugees, COVID-19, mental health, wellbeing, quarantine, social distancing, lockdown and SARS-CoV-2. For inclusion criteria, the titles and abstracts of all retrieved manuscripts were screened, then exclusion criteria were applied if (a) studies used data that was outside the proposed timeline, (b) had focus topics or keywords that were not pertinent to the aim of the current study and (c) were not in English. Studies were selected and the results were analysed to make the present narrative review. A total of 48 articles were collected and screened using a title-abstract analysis. A total of 33 articles were included in the final narrative review which comprised of 15 narrative reviews, nine editorials, five systematic reviews, five quantitative research projects and two qualitative research projects.

Results

Review of the available international literature identified seven core themes emerging in relation to asylum seekers and refugees and the impact on their wellbeing due to COVID-19. These challenges include pre-existing physical health vulnerabilities, pre-existing mental health vulnerabilities, environmental, social, cultural-specific, economic and legal/welfare factors.

Pre-existing physical health vulnerabilities

Multiple factors place asylum seekers and refugees at elevated risk for exposure to COVID-19, increased severity of COVID-19 and ongoing symptoms following acute illness, including having increased rates of pre-existing physical health vulnerabilities and co-morbidities.[5] Review suggests that this population is more likely to experience respiratory diseases linked with their prior travel or living conditions,[6] as well as the high prevalence of chronic respiratory diseases within this population, such as tuberculosis, making them increasingly vulnerable to the physical health impacts of COVID-19.[6]

Pre-existing mental health vulnerabilities

The COVID-19 pandemic is being identified as having a significant impact on the mental health and psychosocial wellbeing of asylum seekers and refugees.[7] Research suggests that the COVID-19 pandemic may be triggering past traumatic experiences, including through confinement and increased isolation, exacerbating mental health problems and undermining daily functioning.[8] Additionally, people from similar backgrounds as asylum seekers and refugees experience compounding anxieties regarding elderly family members in their country of origin and being unable to return to the country of origin in an emergency to support those family members or attend funerals.[9]

Environmental challenges

Asylum seekers and refugees are more vulnerable to contracting COVID-19 as they are more likely to live in conditions that disproportionately increase their risk of contagion due to inability to physically distance in dense multigenerational residential settings and difficulties with self-isolation if they or other household members are experiencing symptoms or have contracted the disease.[7] Some countries utilise closed detention environments, for example, closed community and hotel detention in Australia, thereby increasing the overcrowding and hindering physical distancing.[10] Visitor limits increase sense of isolation. Additionally, many have been forcibly displaced and are over-represented in the homelessness communities and other community supported arrangements where population density is high making precautionary practices, such as physical distancing and consistent hygiene practices, difficult to implement.[11]

Social challenges

Pre-existing racism and xenophobia appear to be compounded in the COVID-19 context. The experience of this can exacerbate distrust in health authorities, delay early detection and treatment and reduce the likelihood of compliance with preventive and treatment advice. This can prolong illness and delay recovery.[7] Lack of culturally appropriate information and poor health literacy hinder help-seeking.[10] It was also identified that self-stigma and perpetuation of misconceptions related to concerns about denial of services or worries of deportation to an individual’s country of origin also decreased help-seeking for COVID-19 symptomology in this population.[12] Ongoing efforts should be aimed towards the reduction of social stigma including within health and social support services by enhancing awareness at the community level and building trust in health services and preventive measures, social cohesion and non-discriminatory practical measures to support this population.[13]

Culture-specific challenges

The most prominent difficulties faced in access to healthcare related to language barriers, accessibility of information and discrepancies in healthcare practices that did not align with specific cultural or religious beliefs. These factors lead to decreased adherence with preventive policy measures.[2] The scarcity of culturally and linguistically accessible information about COVID-19 and how to engage in preventive health behaviours, increases risk to this population as well the community within which they live, through higher risk of infection, delayed or limited access to health care and negative consequences of illness.[13] Even when supportive language services in place, asylum seekers and refugees are often identified as having less access to preventive healthcare due to legal or health insurance status, and the prioritisation of services for citizens from the host nation resulting in significant delays in accessing healthcare.[6]

Economic challenges

Many individuals within this population work in casual employment in front-line service roles such as cleaners and security and have job insecurity. This leads to ongoing financial insecurity and worry, inability to take time off work even when sick, inability to work from home and inability to pay for the ongoing cost of healthcare services.[13] This lack of financial resources to sustain support networks may lead to higher risk of infection and spread of infection. Additionally, those working in informal labour markets are often unable to access welfare services from the government such as job retention schemes or subsidies during workplace closures due to the COVID-19 pandemic.[14]

Legal/welfare challenges

Legal constraints in relation to residency status and permanent protection can reduce access for this population to government welfare and healthcare services. During COVID-19 pandemic, this has compromised financial and food security, accommodation and access to healthcare.[14] There have also been policy and legal changes related to international and domestic travel that have a compounding effect on isolation and anxiety as when observing from a cultural lens, as many asylum seekers and refugees are unable to travel to support family members and many have little sense of connection to their host country during periods of prolonged isolation and/or their own illness.[7] In addition to difficulties with initial access to support services due to COVID-19 impacts, there were reductions in services, including under-staffed and over-stretched mental health services and non-government organizations which decreased opportunities to access care and practical support during COVID related restrictions.[10]

Conclusion

Narrative review and analysis of the literature identified seven key factors that contribute to decreased mental health and wellbeing for asylum seekers and refugees during the COVID-19 pandemic. These are: pre-existing physical health vulnerabilities, pre-existing mental health vulnerabilities, environmental, social, cultural-specific, economic and legal/welfare challenges.

Asylum seekers and refugees appear to be significantly and cumulatively impacted through these individual and interacting bio-psycho-socio-economic-cultural-ecological factors above and beyond other cultural population groups.[5] Due to the ongoing nature of the COVID-19 pandemic it is unclear how these domains will continue to be impacted or effect this vulnerable population. Overwhelming evidence suggests that these should be target areas for intervention to reduce pre-existing vulnerabilities and barriers to care so as to ensure equitable access to health and social services now and in the future at both the clinical practice and policy levels.[15]

The most important themes derived from the current analysis were that during the COVID-19 pandemic environmental, social, cultural-specifical, economic and legal and welfare challenges are likely to have had and continue to have significant impact on development and/or exacerbation of mental health issues in asylum seekers and refugees. Future research must include further quantitative analysis to formally identify variables that contribute to the development of mental health difficulties and disorders in particular populations in the wake of the COVID-19 pandemic. This can be used to inform policy, practice, service development and advocacy for extra resources to support intervention to reduce the impact of COVID-19 pandemic on the mental health and wellbeing for asylum seekers and refugees.