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COVID-19 and Mental Health Among People Who Are Forcibly Displaced: The Role of Socioeconomic Insecurity

Published Online:14 Jul 2022https://doi.org/10.1176/appi.ps.202200052

Abstract

Objective:

Forcibly displaced persons may be at elevated risk for poor mental health outcomes because of the COVID-19 pandemic. This study sought to examine associations between COVID-19–related socioeconomic insecurity and mental health outcomes among asylum seekers.

Methods:

The authors evaluated the association between the degree of food, housing, and income insecurity related to the pandemic and mental health outcomes among East African asylum seekers in a high-risk, postdisplacement setting in the Middle East (i.e., Israel).

Results:

Anxiety symptom severity (p=0.03) as well as the rate of suicidal ideation among women (odds ratio [OR]=2.81, p=0.016) were significantly elevated in a community sample of asylum seekers during the COVID-19 pandemic (N=66) relative to a similar sample (N=158) from the same community and context assessed before the pandemic. No differences between the two groups were observed for severity or rate of probable depression or posttraumatic stress disorders. In addition, among the sample assessed during the pandemic, socioeconomic insecurity due to the pandemic was strongly associated with elevated symptom severity and probable anxiety, depression, and posttraumatic stress disorders as well as suicidal ideation (R2 range=0.19–0.35; OR range=4.54–5.46).

Conclusions:

Findings are consistent with growing evidence of a mental health crisis among asylum seekers that is linked to COVID-19 control policies and residential status policies. The results highlight the risk for suicidal ideation linked to intersectional marginalization among female asylum seekers. These findings may inform postdisplacement policy making, social justice advocacy, humanitarian aid, and clinical science and practice to mitigate poor mental health outcomes associated with COVID-19 among forcibly displaced persons.

HIGHLIGHTS

  • The authors examined associations between COVID-19–related socioeconomic insecurity and mental health outcomes among asylum seekers in a high-risk postdisplacement setting.

  • Anxiety symptom severity and the rate of suicidal ideation among women were significantly elevated during the COVID-19 pandemic.

  • Pandemic-related socioeconomic insecurity was associated with elevated symptom severity and rates of probable anxiety, depression, and posttraumatic stress disorders as well as suicidal ideation.

  • Findings may inform policy-level interventions, humanitarian aid and nongovernmental organization services, and social justice advocacy work, as well as public health and clinical interventions.

The COVID-19 pandemic and related stressors (e.g., lockdowns, uncertainty, social isolation, and socioeconomic insecurity) have led to a variety of poor mental health outcomes, including elevated incidence and exacerbation of depression, anxiety, and suicidal ideation (1, 2). Furthermore, growing evidence indicates that critical disparities place many marginalized people and communities at elevated risk for poor mental health outcomes linked to the COVID-19 pandemic (3, 4). For example, pandemic control policies in the United States have been associated with poor mental health outcomes among women, particularly women experiencing various forms of socioeconomic and related insecurity, as well as women and men with preexisting psychiatric disorders (2, 5, 6). Racial and ethnic minority populations, as well as other marginalized populations, may face additional preexisting and systemic stressors (e.g., socioeconomic insecurity, racism, social isolation, limited access to health and mental health services, chronic stress, and past trauma) thought to contribute to poor mental health and stress-related outcomes associated with the COVID-19 pandemic (3, 4, 6). Building on emerging research into social inequities and related health disparities among marginalized populations during the pandemic, in this study we focused on mental health among the large and fast-growing, yet understudied, populations of forcibly displaced persons (FDPs) seeking sanctuary.

Forced Displacement During the COVID-19 Pandemic

For the >82 million FDPs worldwide (7), the stressors and sequelae of the pandemic may be magnified significantly (4, 8–10). Before the pandemic, risk for poor mental health among FDPs was linked to pre- and peri-migration trauma and stress as well as postmigration living difficulties (11, 12) characteristic of high-risk postdisplacement settings (e.g., resettlement communities) (13–15). Such postmigration difficulties include insecure residential status; food, housing, and income insecurity; limited access to social, general, and mental health services; social isolation; and other chronic stressors (11, 12). The COVID-19 pandemic has been theorized to exacerbate these preexisting chronic stressors and inequalities among FDPs (16) and thereby result in poor mental health outcomes (16–18).

Empirical studies of FDPs’ mental health during the pandemic are now emerging. Several studies, conducted in various populations and postdisplacement settings, have documented that the COVID-19 pandemic, COVID-19–related socioeconomic factors, and the pandemic as a reminder of past traumatic life events were associated with poor mental health outcomes such as depression, anxiety, and stress among refugees (19–21). In the largest study of its kind to date, the World Health Organization carried out a large online screening survey (ApartTogether) among migrants (N=28,853) in approximately 170 countries over the initial months of the COVID-19 pandemic (April–October 2020). A large majority of respondents were from high-income countries, had higher education, lived in secure accommodations, and had secure residency status. The survey was used to measure several pandemic-related experiences and stressors, including perceived worsening of mental health outcomes related to the pandemic through single-item screening questions (e.g., “feeling anxious” and “feeling depressed”). The most elevated rates of perceived worsening of mental health due to the COVID-19 pandemic were observed among migrants living in refugee camps, asylum centers, or on the streets and in insecure accommodations (22). A follow-up analysis among a subsample of survey respondents (N=20,742) documented that women, as well as men and women struggling with basic needs, reported particularly elevated rates of worsening of mental health due to the pandemic (23).

Building on this work, research is now needed regarding unrecognized asylum seekers and other FDPs living in fast-growing and unstable postdisplacement settings, wherein risk for poor mental health and its exacerbation during the pandemic may be most prevalent and severe (10, 15, 23). Specifically, studies and data are needed to help specify the stress- and trauma-related mental health outcomes (i.e., posttraumatic stress [PTS], depression, anxiety, and suicidality) exacerbated by the pandemic among FDPs. To do so, it is important to measure mental health outcomes with psychometrically reliable and valid measures. Likewise, studies are needed regarding malleable risk factors (e.g., sociocontextual factors) linked to the COVID-19 pandemic (17) that may be readily targeted by policy-level interventions (18, 22).

Study Aims

Aim 1

We sought to test whether stress- and trauma-related mental health outcomes, specifically, severity and probability of anxiety, depression, and PTS disorders as well as suicidal ideation, were significantly elevated in the months after the beginning of the COVID-19 pandemic relative to the months before the pandemic. To do so, we compared well-established measures of stress- and trauma-related mental health issues between two independent community samples of East African asylum seekers residing in a high-risk, postdisplacement setting in the Middle East (i.e., Israel) before and during the initial months of the COVID-19 pandemic.

Aim 2

We sought to test whether food, housing, and income insecurities due to COVID-19 control policies were associated with stress- and trauma-related mental health outcomes during the initial months of the pandemic. The rationale for this focus was twofold. Preliminary findings from large survey studies have pointed to the potential key role of sociocontextual factors linked to a role of insecurity in higher risk for poor mental health during the pandemic among migrants (22, 23) and other marginalized populations (4). Furthermore, such socioeconomic factors are malleable and may be systemically affected by policy-level interventions (24, 25).

Methods

Participants

The pre–COVID-19 sample consisted of 158 Eritrean asylum seekers (mean±SD age=31.8±5.2 years; 46% [N=73] female), collected between May 2018 and May 2019 before the onset of the COVID-19 pandemic. The COVID-19 sample consisted of 66 Eritrean asylum seekers (mean age=35.3±4.6 years; 53% [N=35] female; one participant in this sample was from Sudan), collected between September 2020 and January 2021 during the COVID-19 pandemic national lockdowns and socioeconomic closures in Israel. Both studies and samples were collected in an ambulatory laboratory in the same unstable, postdisplacement setting in Israel (26). In both studies, participants were recruited via public flyers, community recruitment, and local nongovernmental organizations (NGOs) and municipal organizations working with asylum seekers. Exclusion criteria in both studies were past suicide attempt, acute risk for committing suicide, or current mental health treatment (psychotherapy or psychosocial support group). Notably, the pre–COVID-19 study also excluded psychotic symptoms (26), and no probable cases of psychosis were observed in the COVID-19 sample. Baseline (preintervention) data for the pre–COVID-19 sample were from a preregistered, single-site randomized controlled trial of a mindfulness-based intervention (26). Identical baseline assessment (preintervention) data for the COVID-19 sample were from a preregistered, single-site, open-trial study of a digital mobile adaptation of the mindfulness-based intervention.

We focused on this population because it represents a large group of asylum seekers in the Middle East region and a large and rapidly growing population of FDPs worldwide living in high-risk urban postdisplacement settings (7). Currently, <0.5% of asylum requests in Israel are recognized (27), and none of the participants had recognized refugee status. They were under a “group protection” status, which functionally entitles them to a temporary right not to be deported. Additionally, like millions of other at-risk FDPs, this population has been exposed to extensive and severe traumatic stress experiences linked to their forced displacement (26, 28), including torture and trafficking, as well as ongoing chronic stress tied to a wide range of postmigration living difficulties (e.g., residential status and chronic daily stressors) (29, 30). Thus, this population is at high risk for stress- and trauma-related mental health outcomes (31, 32).

Procedure

Participants were screened by telephone for eligibility to participate and assured confidentiality and anonymity. Participants completed verbal and written informed consent in their native language. Both studies received human subjects research ethics approval by the University of Haifa Institutional Review Board. Participants completed the preintervention assessment, including self-report questionnaires assessing mental health outcomes. Data were collected in an ambulatory laboratory space within a local NGO, located in the urban center of the asylum-seeker community.

Measures

All measures were translated and back-translated to the participants’ native language of Tigrinya; measures were also psychometrically evaluated and validated in earlier research of these specific African refugee populations (30–33) and through cognitive interviewing to ensure linguistic as well as sociocultural meaning (26, 34). The nine-item Patient Health Questionnaire (PHQ-9) (35) was used to assess symptom severity and rate of depression and suicidality; scores range from 0 to 27, with higher scores indicating greater depression symptom severity. To identify a probable categorical (diagnostic) symptom status of depression, a PHQ-9 cutoff score ≥10 is commonly used (36). We herein refer to this categorical status as “probable depression.” The Harvard Trauma Questionnaire (HTQ) (37) was used to measure traumatic stress exposure as well as symptom severity and rate of posttraumatic stress disorder (PTSD) (according to DSM-IV-TR criteria); scores range from 1 to 4, with higher scores indicating greater posttraumatic stress symptom severity. To identify a probable categorical (diagnostic) symptom status of PTSD, an HTQ cutoff score ≥2 is commonly used (38). We herein refer to this categorical status as “probable PTSD.” A short version of the Beck Anxiety Inventory (BAI) (39) was used that included six items (unable to relax, dizzy or lightheaded, heart pounding and racing, terrified or afraid, nervous, and shaky and unsteady) that loaded most strongly on total BAI scores in previous studies among this population (26); BAI scores range from 0 to 3, with higher scores indicating greater anxiety symptom severity. Because of the use of this short version of the BAI, no validated, categorical (diagnostic) cutoff is available, only a continuous symptom severity score. The Post-Migration Living Difficulties Scale (40) was used to assess postmigration stressors; scores on this scale range from 0 to 9, with higher scores indicating greater postmigration stressors. Finally, the COVID-19 Socioeconomic Insecurity Index, developed for the purpose of this study, included three questions measuring influence of the COVID-19 pandemic on housing security (e.g., “Did your housing change because of COVID-19?”), food security (e.g., “Did you lose access to food because of COVID-19?”), and income security (e.g., “Did your employment change because of COVID-19?”). These three questions were used to assess and quantify COVID-19–related impacts on three key forms of socioeconomic insecurity (ranging from 0=no insecurity to 3=severe insecurity). (The COVID-19 Socioeconomic Insecurity Index is available as an online supplement to this article.)

Data Analysis

First, to test how well the pre–COVID-19 and COVID-19 samples of asylum seekers were matched on key demographic factors, including gender and education as well as traumatic stress history and postmigration living difficulties, we conducted chi-square tests, Fisher’s exact tests, and independent-samples t tests, respectively. Second, to test aim 1, we conducted a two-way analysis of variance to assess the association among COVID-19; gender; and symptom severity of anxiety, depression, and PTS. We also used logistic regression to test the association among COVID-19, gender and suicidal ideation, and probable depression and PTSD. Third, to test aim 2, we conducted a multiple linear hierarchical regression to assess the association among COVID-19 socioeconomic insecurity; gender; and symptom severity of anxiety, depression, and PTS. In the first step of the regression, COVID-19 socioeconomic insecurity and gender were entered, and their interaction was added in the second step. Additionally, a logistic regression was conducted to study the association among COVID-19 socioeconomic insecurity, gender and suicidal ideation, and probable depression and PTSD. We conducted analyses with IBM SPSS Statistics, version 25.

Results

Pre–COVID-19 and COVID-19 Demographic Characteristics, Trauma History, and Postdisplacement Stressors

Table 1 shows the descriptive statistics for each sample. The pre–COVID-19 and COVID-19 samples did not differ significantly on education level, gender, traumatic stress exposure history, or postmigration living difficulties.

TABLE 1. Descriptive characteristics of the East African asylum seekers before and during the COVID-19 pandemica

CharacteristicBefore COVID-19 (N=158)During COVID-19 (N=66)
N%N%
Age (M±SD years)31.8±5.235.3±4.6
Gender
 Male85543147
 Female73463553
Education (years)b
 1–644281625
 7–1298624163
 13–16149812
 >16210—
Traumatic stress exposure history (M±SD HTQ score)7.1±2.96.7±3.5
Postmigration living difficulties (M±SD PMLD score)7.9±1.27.9±1.1

aHTQ, Harvard Trauma Questionnaire (possible scores range from 0 to 10, with higher scores indicating higher traumatic stress exposure); PMLD, Post-Migration Living Difficulties Scale (possible scores range from 0 to 9, with higher scores indicating higher postmigration stressors).

bData for one participant in the COVID-19 cohort were missing.

TABLE 1. Descriptive characteristics of the East African asylum seekers before and during the COVID-19 pandemica

Enlarge table

Aim 1: Mental Health Before and During COVID-19 Among Asylum Seekers

Table 2 shows the descriptive statistics by sample and gender. The individuals in the COVID-19 sample reported significantly higher levels of anxiety symptom severity (assessed with the BAI; F=5.04, df=1 and 166, p=0.03) as well as suicidal ideation among women (multiple logistic regression interaction statistics: B=1.27, standard error [SE]=0.63, odds ratio [OR]=3.55, 95% confidence interval [CI]=1.04–12.12, p=0.04; simple effects by gender: women: B=1.03, SE=0.43, OR=2.81, 95% CI=1.21–6.49, p=0.016; men: B=0.24, SE=0.46, OR=0.79, 95% CI=0.32–1.94, p=0.61) relative to the pre–COVID-19 sample. However, relative to the pre–COVID sample, the COVID-19 sample did not report statistically significantly higher levels of depression (assessed with the PHQ-9), PTS (assessed with the HTQ) symptom severity, or elevated rates of probable depression or PTSD.

TABLE 2. Descriptive statistics of mental health outcomes among East African asylum seekers before and during the COVID-19 pandemica

Mental health outcomeBefore COVID-19 (N=158)During COVID-19 (N=66)
Male
(N=85)		Female
(N=73)		Male
(N=31)		Female
(N=35)
N%N%N%N%
Anxiety symptoms (M±SD BAI score).98±.95.85±.791.03±.711.42±.93
Depression symptoms (M±SD PHQ-9 score)8.8±6.97.9±6.48.7±6.311.6±7.7
Probable depression (PHQ-9 score ≥10)3440233213421646
Suicidal ideation (on PHQ-9)293420279291851
Traumatic stress symptoms (M±SD HTQ score)2.24±.722.18±.732.03±.592.36±.61
Probable PTSD (HTQ score ≥2)5261395315481954

aBAI, Beck Anxiety Inventory (possible scores range from 0 to 3, with higher scores indicating higher anxiety symptoms); HTQ, Harvard Trauma Questionnaire (possible scores range from 1 to 4, with higher scores indicating higher traumatic stress exposure); PHQ-9, nine-item Patient Health Questionnaire (possible scores range from 0 to 27, with higher scores indicating more severe depression symptoms).

TABLE 2. Descriptive statistics of mental health outcomes among East African asylum seekers before and during the COVID-19 pandemica

Enlarge table

Aim 2: COVID-19–Related Socioeconomic Insecurity and Mental Health Outcomes

Figure 1 and Table 3 show descriptive statistics for socioeconomic insecurity due to the pandemic and mental health outcomes. Among FDPs in the COVID-19 sample, degree of COVID-19–related socioeconomic insecurity was significantly associated with elevated anxiety symptom severity (assessed with the BAI) (R2=0.22, F=5.58, df=3 and 60, p=0.02; β=0.47, p=0.006), depression symptom severity (assessed with the PHQ-9) (R2=0.19, F=4.62, df=3 and 60, p=0.006; β=0.50, p=0.004), PTS symptom severity (assessed with the HTQ) (R2=0.35, F=9.47, df=3 and 52, p<0.001; β=0.66, p<0.001), as well as elevated rates of probable depression (PHQ-9) (B=1.51, SE=0.57, OR=4.54, 95% CI=1.49–13.80, p=0.008), PTSD (HTQ) (B=1.70, SE=0.62, OR=5.46, 95% CI=1.63–18.28, p=0.006), and suicidal ideation (B=1.62, SE=0.68, OR=5.10, 95% CI=1.34–19.44, p=0.017).

FIGURE 1.

FIGURE 1. Mental health outcomes by degree of socioeconomic insecuritya

aThe COVID-19 Socioeconomic Insecurity Index score was calculated by giving 1 point to each of three measures (i.e., housing, food, and employment status) affected by COVID-19; scores range from 0 (no insecurity) to 3 (severe insecurity). The y-axis represents standardized scores of these measures, with negative scores indicating low symptom levels and positive scores indicating high symptom levels. BAI, Beck Anxiety Inventory (possible scores range from 0 to 3, with higher scores indicating higher levels of anxiety symptoms); HTQ, Harvard Trauma Questionnaire (possible scores range from 1 to 4, with higher scores indicating higher traumatic stress exposure). PHQ-9, nine-item Patient Health Questionnaire (possible scores range from 0 to 27, with higher scores indicating higher depression symptoms); PTS, posttraumatic stress.

TABLE 3. Descriptive statistics of mental health outcomes by level of socioeconomic insecurity in the COVID-19 sample (N=66)a

No insecurity (N=4)Low insecurity (N=13)Moderate insecurity (N=25)Severe insecurity (N=24)
Male
(N=3)		Female
(N=1)		Male
(N=8)		Female
(N=5)		Male
(N=9)		Female
(N=16)		Male
(N=11)		Female
(N=13)
Mental health outcomeN%N%N%N%N%N%N%N%
Anxiety symptoms (M±SD BAI score).67±.58.17±.0.65±.411.17±1.29.7±.471.33±.921.67±.681.69±.81
Depression symptoms (M±SD PHQ-9 score)4.3±3.80±.05.9±3.911.8±10.56.1±4.810.7±6.514.1±6.213.3±7.7
Probable depression (PHQ-9 score ≥10)0—0—225240222638982862
Suicidal ideation (on PHQ-9)0—0—113360111850764754
Traumatic stress symptoms (M±SD HTQ score)1.33±.341.50±.01.77±.271.92±.561.92±.382.48±.542.60±.582.47±.64
Probable PTSD (HTQ score ≥2)0—0—2252405561169873646

aBAI, Beck Anxiety Inventory (possible scores range from 0 to 3, with higher scores indicating higher anxiety symptoms); HTQ, Harvard Trauma Questionnaire (possible scores range from 1 to 4, with higher scores indicating higher traumatic stress exposure); PHQ-9, nine-item Patient Health Questionnaire (possible scores range from 0 to 27, with higher scores indicating more severe depression symptoms). The COVID-19 Socioeconomic Insecurity Index was used to assess insecurity and was calculated by giving 1 point to each of three measures (i.e., housing, food, and employment status) affected by the COVID-19 pandemic; scores range from 0 (no insecurity) to 3 (severe insecurity).

TABLE 3. Descriptive statistics of mental health outcomes by level of socioeconomic insecurity in the COVID-19 sample (N=66)a

Enlarge table

Discussion

We aimed to test the association between the COVID-19 pandemic, specifically, socioeconomic insecurity related to the pandemic, and stress- and trauma-related mental health outcomes among East African asylum seekers living in an unstable postmigration setting in Israel. First, during national lockdowns due to COVID-19 control policies, asylum seekers reported higher levels of anxiety and, among women, an elevated rate of suicidal ideation, relative to a sample of asylum seekers from the same community in the months before the COVID-19 pandemic. In contrast, no pre–post pandemic differences were observed for depression or PTS. These null effects, however, may be related to very high levels of symptomatology in the pre–COVID-19 participants who had been exposed to high levels of traumatic stress and postmigration living difficulties before the pandemic (26, 41–43). Notably, the two samples did not differ significantly in terms of demographic characteristics, trauma exposure history, or postmigration living difficulties. Accordingly, we are reasonably confident that differences, or the lack thereof, between the samples may be ascribed to effects associated with the pandemic.

Second, as predicted, the association between insecurities related to the COVID-19 pandemic and mental health outcomes among asylum seekers was strong and statistically significant. The greater the degrees of pandemic-related food, housing, and income insecurities, the greater the severities of anxiety, depression, and PTS symptoms and higher the rates of probable depression, PTSD, and suicidal ideation. For example, among asylum seekers experiencing food, housing, and income insecurities due to the pandemic, 58% (N=14 of 24) of the subsample reported current suicidal ideation, and 71% (N=17 of 24) reported probable depression. These rates were almost twice those observed among the pre–COVID-19 participants, who also had high levels of traumatization and chronic stress (31% [N=49 of 158] reported suicidal ideation, and 36% [N=57 of 158] reported depression); moreover, these rates were approximately six times higher for suicidal ideation and 10 times higher for depression than the rates observed in other nonclinical populations before the COVID-19 pandemic (26, 44, 45).

This study’s findings are important observations regarding the potential association between COVID-19–related socioeconomic insecurity and mental health outcomes among FDPs in this type of unstable postdisplacement context. Indeed, because anxiety was elevated in the COVID-19 sample, compared with the pre–COVID-19 sample, these findings are partially consistent with theory and recent findings in other marginalized populations for whom preexisting health disparities and inequities may be significantly exacerbated by COVID-19 control policies (3, 4, 20, 21). Our findings are also aligned with previous research documenting that marginalization, tied to unrecognized asylum status in high-risk postdisplacement settings, contributes to poor mental health outcomes (3, 10, 18, 46, 47). Furthermore, our findings are mostly consistent with and extend recent findings from the World Health Organization’s ApartTogether survey. Migrants with insecure residential status and limited access to basic needs due to COVID-19 reported the highest rates of perceived mental health concerns during the pandemic (22, 23). We also note that our findings highlight the potential mental health significance of intersectional marginalization for FDPs within the pandemic (48). Indeed, of particular urgency and global public health concern, we observed an elevated risk for suicidal ideation among female asylum seekers (23, 48, 49). Thus, COVID-19 and pandemic control policies, when paired with preexisting social marginalization and migration policies that do not provide a safety net postdisplacement (50), are likely to exacerbate stress- and trauma-related mental health outcomes among asylum seekers.

In light of the growing evidence base, this study’s findings may have tentative implications for postdisplacement policy making, social justice advocacy, humanitarian aid, and clinical science and practice. First, awareness among policy makers and promotion of public policy–based interventions oriented to guarantee basic human rights and socioeconomic security (51, 52) may be crucial to mitigating negative mental health outcomes among FDPs during the COVID-19 pandemic (53, 54). Policy relevant to residential status may be particularly important and effective because temporary status has been linked to poor socioeconomic integration postdisplacement (55). Second, humanitarian aid organizations and NGOs that provide services to ensure food, housing, and income security for FDPs during the ongoing COVID-19 crisis may be well suited to assess the incidence of poor mental health outcomes and deterioration and, specifically, guide efforts aimed at suicide prevention (56–58). Likewise, governmental organizations and NGOs facilitating food, housing, and income security may be an important part of social justice advocacy and public health care for FDPs (22, 52). Finally, to complement policies and services supporting socioeconomic security during the pandemic, clinicians working with FDPs can also aim to help prevent and mitigate the impact of COVID-19–related socioeconomic insecurity on mental health outcomes with intervention programs such as Self-Help Plus (51), Group Problem Management Plus (59), or Mindfulness-Based Trauma Recovery for Refugees or its mobile adaptation (26).

Although our findings may inform the collective understanding of the magnitude of the emerging pandemic-related mental health crisis among FDPs, this study was limited in several ways, which should be addressed in future research. First, the COVID-19 sample was small, consisting of 66 asylum seekers. The sample size was restricted by the acute period during the COVID-19 crisis, restrictive pandemic control policies, and a required in-person assessment with a cultural mediator and translator. We have found that despite these logistic constraints, our assessment methodology yielded significantly more reliable and valid reporting than online assessments completed autonomously by asylum seekers in such highly unstable postdisplacement conditions. Thus, on balance, we believe that the sample size versus data collection integrity trade-off was necessary. Second, this study did not have a repeated-measures design. Although the pre- and postpandemic samples were closely matched on key demographic characteristics, trauma history, and postmigration living difficulties, inference about the impact of the COVID-19 pandemic on mental health outcomes must be interpreted cautiously. Although recruitment was from the studied community, larger-scale population data on unrecognized East African asylum seekers residing in this region of the Middle East are very limited. We therefore could not definitively evaluate to what degree the samples represented the population from which they were selected. It is therefore important for researchers in future studies to test whether these findings are relevant for other FDP populations and postdisplacement settings. Last, in this study, we relied on a self-reported measure to assess COVID-19–related socioeconomic insecurity. In future studies, researchers could also incorporate objective indices of these outcomes, although doing so may be more feasible in stable postmigration resettlement settings than in the present high-risk urban context in which such objective data are not likely to be available.

Conclusions

The findings of this study provide empirical evidence that unrecognized asylum seekers living in a high-risk postdisplacement setting in the Middle East are at elevated risk for poor mental health outcomes related to the COVID-19 pandemic. More specifically, we found that the degree of socioeconomic insecurity due to COVID-19 control policies, in the context of preexisting migration and residential status policies, was linked to significant elevations in stress- and trauma-related mental health problems, despite the already high rates and severity of these symptoms before the pandemic. In light of the scale and projected growth of forced displacement, and the still uncertain future and fast-evolving global health impact of the COVID-19 pandemic, there is an urgent need for systematic study, social justice advocacy, policy work, and public health intervention to protect FDP and related marginalized populations.

Department of Psychology, University of Haifa, Haifa, Israel.
Send correspondence to Dr. Bernstein ().

This study was funded by an Israel Science Foundation (grant 2046/17) and a Mind & Life Institute PEACE grant (awarded to Dr. Bernstein) and by the University of Haifa, Herta and Paul Amir Faculty of Social Sciences Idit Ph.D. fellowship (awarded to Ms. Zohar). The two COVID-19 studies described in this article are registered with ClinicalTrials.gov (NCT04380259 and NCT04761510).

The authors report no financial relationships with commercial interests.

The authors thank the asylum seekers who participated in the two studies, before and during a COVID-19 lockdown. For the pre–COVID-19 study, the authors thank Sendel Abraham, Dawit Weldehawariat Habtai, and Mogus Kidane for their assistance in translation and data collection; the team at the nongovernmental organization (NGO) Kuchinate for hosting the study, including Dr. Diddy Mymin-Kahn, Sister Azezet Habtezghi Kidane, Ruth Garon, Hewan Desta, Eden Gebre, Asmeret Haray, Fiori Yonas, and Achbaret Abraha; and Ron Peleg for his help in participant recruitment and data collection. For the COVID-19 study, the authors thank Yotam Phung, Michael Tesfahanes Afworki, and Alexandra Rzyanina for their help in data collection; the authors also thank the team at the NGO Assaf for collaborating and hosting the mobile lab to carry out the study, including Tali Ehrenthal, Sari Urim, Yael Federman, Miriam Meyer, and Michal Shechter. Finally, the authors thank Meital Gil Davis for coordination of logistics, research funding, and personnel for both studies; Ido Lurie, M.D., for pro re nata psychiatric consultation; and Yikealo Beyene for expert translation of study materials.

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