60 2 0 2 4 D V E D O M O V I N I • T W O H O M E L A N D S 6 0 • 2 0 2 4 Glavni urednici / Editors-in-Chief Kristina Toplak, Marijanca Ajša Vižintin Odgovorna urednica / Editor-in-Charge Marina Lukšič Hacin Tehnični urednik / Technical Editor Tadej Turnšek Mednarodni uredniški odbor / International Editorial Board Synnove Bendixsen, Ulf Brunnbauer, Aleš Bučar Ručman, Martin Butler, Daniela l. Caglioti, Jasna Čapo, Donna Gabaccia, Jure Gombač, Ketil Fred Hansen, Damir Josipovič, Aleksej Kalc, Jernej Mlekuž, Claudia Morsut, Ikhlas Nouh Osman, Nils Olav Østrem, Lydia Potts, Maya Povrzanović Frykman, Francesco Della Puppa, Jaka Repič, Rudi Rizman, Matteo Sanfilippo, Annemarie Steidl, Urška Strle, Adam Walaszek, Rolf Wörsdörfer, Simona Zavratnik, Janja Žitnik Serafin Lektoriranje in korektura / Copyediting and proofreading Jana Renée Wilcoxen (angleški jezik / English) Tadej Turnšek (slovenski jezik / Slovenian) Oblikovanje / Design Anja Žabkar Prelom / Typesetting Inadvertising d. o. o. Založila / Published by ZRC SAZU, Založba ZRC Izdal / Issued by ZRC SAZU, Inštitut za slovensko izseljenstvo in migracije / ZRC SAZU, Slovenian Migration Institute, Založba ZRC Tisk / Printed by Birografika Bori, Ljubljana Naklada / Printum 150 Naslov uredništva / Editorial Office Address INŠTITUT ZA SLOVENSKO IZSELJENSTVO IN MIGRACIJE ZRC SAZU p. p. 306, SI-1001 Ljubljana, Slovenija Tel.: +386 (0)1 4706 485; Fax +386 (0)1 4257 802 E-naslov / E-mail: dd-th@zrc-sazu.si Spletna stran / Website: https://ojs.zrc-sazu.si/twohomelands Revija izhaja s pomočjo Javne agencije za znanstvenoraziskovalno in inovacijsko dejavnost Republike Slovenije in Urada Vlade Republike Slovenije za Slovence v zamejstvu in po svetu / Financial support: Slovenian Research and Innovation Agency and Government Office for Slovenians Abroad ISSN 0353-6777 ISSN 1581-1212 21 D V E D O M O V I N I • T W O H O M E L A N D S • 6 0 • 2 0 2 4 C C B Y 4 . 0 | h t t p s : / / d o i . o r g / 1 0 . 3 9 8 6 / 2 0 2 4 . 2 . 3 I Master of psychology; ZRC SAZU, Sociomedical Institute, Ljubljana; dino.manzoni@zrc-sazu.si; ORCID https://orcid.org/0000-0003-0597-4675 II PhD in medical sciences; ZRC SAZU, Sociomedical Institute, Ljubljana; lilijana.sprah@zrc-sazu. si; ORCID: https://orcid.org/0000-0002-5363-3309 @language: sl, en @trans-language: sl, en @publisher-id: id @doi: 10.3986/2024.2.3 @article-type: 1.01 @article-category: S 260 @pages: 21–48 @history-received: 10. 12. 2023 @history-accepted: 09. 05. 2024 * * * Ž u r n a l m e t a * * * @issue: 60 @volume: 2024 @pub-year: 2024 @pub-date: 01. 08. 2024 * * * O p r e m a * * * @avtorji: Dino Manzoni, Lilijana Šprah @running-header: The Impact of the COVID-19 Pandemic on the Mental Health of Refugees THE IMPACT OF THE COVID-19 PANDEMIC ON THE MENTAL HEALTH OF REFUGEES: A SYSTEMATIC LITERATURE REVIEW Dino Manzoni,I Lilijana ŠprahII COBISS: 1.02 ABSTRACT The Impact of the COVID-19 Pandemic on the Mental Health of Refugees: A Systematic Literature Review As part of a systematic literature search, the authors independently reviewed 256 articles and included 12 papers in the final selection. The synthesis of the results showed that the psychological distress of refugees increased significantly following the outbreak of the COVID-19 pandemic. The main mental health difficulties of refugees addressed in the analyzed studies were stress, anxiety, depression, and post-traumatic stress disorder. The mental health of refugees during the pandemic appeared to be closely related to their poor living conditions and socioeconomic situation, social exclusion, unemployment, inadequate housing, lack of access to health and social services, discrimination, and lack of essential goods. KEYWORDS: COVID-19, mental health, refugees, systematic literature review, stress IZVLEČEK Vpliv pandemije bolezni COVID-19 na duševno zdravje beguncev: Sistematični pregled literature V procesu sistematičnega pregleda literature smo pregledali 256 člankov in jih 12 med njimi vključili v končni izbor. Sinteza rezultatov je pokazala, da so begunci po izbruhu pandemije COVID-19 doživljali znatno večjo psihološko stisko. Ključne težave, povezane z duševnim zdravjem beguncev, ki so jih obravnavale analizirane raziskave, so bile stres, anksioznost, depresija in posttravmatska stresna motnja. Pokazalo se je, da je bilo duševno zdravje beguncev med pandemijo tesno povezano z njihovimi slabimi življenjskimi pogoji in socialno-ekonomskim položajem, socialno izključenostjo, brezposelnostjo, neustrezno namestitvijo, pomanjkanjem dostopa do zdravstvenih in socialnih storitev, diskriminacijo ter dostopom do osnovnih potrebščin. KLJUČNE BESEDE: COVID-19, duševno zdravje, begunci, sistematični pregled literature, stres 22 D V E D O M O V I N I • T W O H O M E L A N D S • 6 0 • 2 0 2 4Dino Manzoni, Lilijana Šprah INTRODUCTION The COVID-19 pandemic, caused by the novel coronavirus SARS-CoV-2, has posed unprecedented challenges to global health, and led to widespread concern and scientific scrutiny. Among the myriad consequences of the pandemic, the impact on mental health has become an important area of study, as vulnerable populations such as refugees have been exposed to particular and increased stressors (Alarcão et al., 2022). Previous studies have already shown that refugees have a higher risk of mental disorders compared to the general population (Steel et al., 2009). In addi- tion, studies by Li et al. (2016) and Porter & Haslam (2005) emphasize the persistent psychological effects of displacement and the complex socio-cultural factors that influence the mental well-being of refugees. The COVID-19 pandemic was characterized by its scope, scale, and duration. It can be classified as an extreme event with unfavorable, unpredictable, and life-threatening interventions in normal activities over which individuals have no control. This situation led to people around the world experiencing negative stress, mistrust, fear, and uncertainty (Morganstein, 2022). One of the consequences of the lockdown during the COVID-19 epidemic in England, for example, is that around 10% of the population suffered from long-term stress (Fancourt et al., 2021), which is related to the fact that a severe reaction to an extreme event is associated with a greater experience of stress and is more likely to lead to mental health difficul- ties (Dohrenwend, 2000). Changes in mental health have been observed in many countries, particularly an increase in depression, anxiety, and post-traumatic stress disorder (Manchia et al., 2022; Papadopoulou et al., 2021). Shortly after the World Health Organization declared a pandemic on March 11, 2020, concern arose in professional circles about a possible parallel mental health crisis due to the danger posed by the virus itself, which also affects the central nervous system (Pfefferbaum & North, 2020; Taquet et al., 2021), as well as the restrictive health precautions (Haider et al., 2020; Jin et al., 2021). Refugees, who are already struggling with the psychological consequences of displacement and trauma, face particular challenges that the COVID-19 pandemic exacerbated. In addition to increasing insecurity, limited access to basic services, and increasing social isolation, the potential deterioration of mental health was one of the main concerns of refugee aid professionals (Hoffman et al., 2023; Kiteki et al., 2022). In addition, a recent report by the World Health Organization indicates that fear of deportation is one of the main reasons why refugees do not seek medical care for symptoms of COVID-19 (WHO, 2020). The literature shows that there is a link between stressors in the post-migration phase and poorer mental health outcomes in refugees (Li et al., 2016). Resettled refugees often experience severe isolation and loneliness, which affect mental well-being and the adjustment process to life in the host country (Wu et al., 2021). This is particularly evident in exceptional situations such as a pandemic, as shown in 23 6 0 • 2 0 2 4 The Impact of the COVID-19 Pandemic on the Mental Health of Refugees the study by Filosi et al. (2022). Their interviewees, asylum seekers and beneficiaries of protection living in the Trento asylum system, experienced “collective isolation” during the COVID-19 outbreak. Filosi et al. (2022, p. 85) were certain that “staying in a collective facility exposed them more to the virus generated anxiety and distrust among interviewees.” These kinds of difficulties and experiences are specific to marginalized and vulnerable social groups such as refugees or asylum seekers. In the past, refugees have shown remarkable resilience in the face of adver- sity, overcoming the complex circumstances of forced migration with strength and perseverance. However, the confluence of pre-existing mental health issues, stress- ors before, during, and after migration, and the additional stresses of the COVID-19 pandemic raises questions about the well-being of this marginalized population. Understanding the complex interplay between the COVID-19 pandemic and the mental health of refugees is important to develop targeted interventions to promote resilience and prevent the long-term consequences of poor mental health in this vulnerable group. The present study was motivated by the assumption that the COVID-19 pandemic has a disproportionately greater impact on the mental health of marginal- ized groups such as refugees (El Tatary & Gill, 2022; Kluge et al., 2020). In this context, a systematic review was conducted to capture the research conducted, summarize the findings from the methodologically and disciplinary heterogeneous body of knowledge in this area, and identify existing knowledge gaps to adequately plan much-needed further research. This review aims to provide a systematic overview of the current literature on the impact of the COVID-19 pandemic on the mental health of refugees. In this context, we sought answers to the following questions: 1. Has the COVID-19 pandemic impacted the mental health of refugees as a vulnerable group? 2. What were the most common mental health difficulties of refugees during the COVID-19 pandemic? METHOD Search strategy, protocol, and eligibility criteria The databases of the Web of Science were used for the systematic literature search. During the literature search, the Web of Science proved to be a suitable database for conducting a scoping and systematic review of mental health research. However, Scopus has a larger database in the social sciences and humanities (Xiong et al., 2020). The authors independently reviewed the titles and abstracts of the studies (n = 256) from the database search. Studies that were repetitive (n = 1) and records that had previously been excluded by the quick filter (n = 25) were excluded. Studies were included if they met the following selection criteria: 1) studies published in 24 D V E D O M O V I N I • T W O H O M E L A N D S • 6 0 • 2 0 2 4Dino Manzoni, Lilijana Šprah peer-reviewed journals between January 1, 2020, and September 8, 2023; 2) studies primarily focused on the refugee population; 3) published in English; 4) mental health studies conducted in any country; 5) related to the COVID-19 pandemic. Quantita- tive, qualitative, and mixed-methods studies were included that addressed various aspects of measuring psychosocial problems in refugees. Studies were excluded if they did not fit the conceptual framework of the study and did not focus primarily on the refugee population and their mental health during the COVID-19 pandemic. The PRISMA flowchart system was used as a reference when selecting the stud- ies. According to the defined inclusion criteria, the two researchers independently performed the title and summary control (n  =  256), discussed the results, and continuously updated the data collection form in an iterative process. In case of ambiguities, the results were discussed and finally reconciled. The same method was used for the full-text reviews of the included studies (n = 81). Studies that were not directly related to mental health and irrelevant studies that did not meet the inclusion criteria were excluded from the full-text review. A total of 12 studies were eligible for the systematic literature review (Figure 1). The synthesis of information is the most useful and important contribution of the systematic literature review. Based on the literature, we decided that the most appropriate approach for synthesizing qualitative, quantitative, and mixed-method research findings was narrative synthesis (Popay et al., 2006). Quality assessment The Newcastle-Ottawa Scale (Wells et al., 2014) and the checklist developed by Kmet et al. (2004) were used to assess the quality of the studies. We used the NOS to assess the quality of cohort studies. Studies can receive a maximum score of 9 from the NOS. For one study that included mixed methods—both quantitative and qualita- tive—we used the Mixed Methods Appraisal Tool (Hong et al., 2018). The MMAT is a critical appraisal tool developed for the assessment phase of systematic reviews of mixed studies. We used only four of five categories of study design, namely Qualita- tive, Quantitative randomized controlled trials, Quantitative descriptive, and Mixed methods. Together, they resulted in a maximum score of 22 points. Some studies used cross-sectional designs, and two studies were purely qual- itative. A checklist of 10 questions was used to assess the quality of the two study types. We used the JBI Checklist for Qualitative Research & JBI Checklist for Analytical Cross-Sectional Studies (JBI, 2023). The purpose of this assessment is to evaluate the methodological quality of a study and to determine the extent to which the possibility of bias was considered in the design, conduct, and analysis of a study. We independently conducted a quality assessment of the research articles identified in the study. 25 6 0 • 2 0 2 4 The Impact of the COVID-19 Pandemic on the Mental Health of Refugees Figure 1: The adapted PRISMA flow diagram system (source: Page et al., 2021). RESULTS Methodological characteristics of the studies Table 1 provides an overview of the studies included in the systematic literature review. Twelve studies were included, conducted in Italy (n  =  1), Uganda (n  =  1), Jordan (n = 2), Turkey (n = 2), Canada (n = 2), Indonesia (n = 1), Australia (n = 1), and Bangladesh (n = 2). Most of the refugees were from Syria and Myanmar, but there were also refugees from Afghanistan, Iraq, Somalia, Nigeria, etc. 26 D V E D O M O V I N I • T W O H O M E L A N D S • 6 0 • 2 0 2 4Dino Manzoni, Lilijana Šprah The included studies were quantitative cross-sectional studies (n  =  5), cohort studies (n  =  4), mixed methods studies (n  =  1), and studies that used qualitative research methods (n = 2). In studies using qualitative methods (n = 2), data were collected using a semi-structured interview. Other data were collected using established psychological instruments; only some of these have been validated cross-culturally, with the exception of one study conducted in Canada, which used only the National Community Health Survey Questionnaire. All studies used differ- ent scales that measure mental health with high validity and reliability. Most of the data was collected between 2019 and 2021, i.e., before and during the COVID-19 pandemic. However, for some studies, the screening and baseline assessment process was already initiated in 2018. Due to COVID-19 measures and restrictions, data was collected online (n = 5), by telephone and/or online (n = 2), by telephone call (n = 1), and in person (n = 4). Three studies examined the mental health of adolescents, and one study examined the mental health of older adult refu- gees aged 60 years and older. The remaining studies (n = 8) examined the mental health of refugees aged 18 years and older. One study examined how COVID-19 affects the mental health of resettled Syrian refugee women in the postpartum period, and one study examined mental health difficulties due to the difference between the local population and refugees. One study aimed to investigate and compare symptoms of depression, anxiety, and PTSD in refugees and local patients of End-Stage Renal Diseases receiving hemodialysis during COVID-19. Other studies examine the impact of the current pandemic on the mental health of refugees. Only one study, conducted in Italy, included refugees alongside migrants, asylum seekers, and stakeholders in its sample. The impact on mental health can be divided into four main categories, namely stress, anxiety, depression, and post-traumatic stress disorder (PTSD), as well as an additional category in which the data is collected under the heading “Other find- ings.” The choice of these categories is logical, as this is the simplest and clearest way to analyze and summarize the most common psychosocial problems of refugees. Mental health outcomes and effects on individuals: synthesis of results Category: Stress Almost all of the selected studies (n = 10) came to results related to stress. Palit et al. (2022) found that 94.7% of Rohingya refugees living in Bangladesh were already suffering from psychological distress at the beginning of the study. They documented higher levels of psychological distress at baseline in partici- pants who were over 30 years old compared to young adults (≤30 years), in married compared to single participants, and in participants with bronchial asthma, isch- emic heart disease, or diabetes mellitus (when all participants were included). The results of Part I (items 1–14) and Part II (distress thermometer) were significantly 27 6 0 • 2 0 2 4 The Impact of the COVID-19 Pandemic on the Mental Health of Refugees higher in women than in men (p < 0.05). They found that participants with one or more chronic diseases were more distressed. Diabetes, in particular, was associated with higher levels of distress both at the start of the study and at follow-up. The follow-up survey was conducted around 15 months later, in November 2020, during the pandemic. A total of 342 Rohingya refugees who had participated in the first survey took part in the follow-up survey. A significant increase in stress was found from pre-pandemic to pandemic, as assessed by the RHS-15 scale (RHS-15 Part I: 22.96 ± 8.43 vs. 46.72 ± 1.87, p < 0.001; and RHS-15 Part II: 4.43 ± 1.59 vs. 6.91 ± 1.49, p < 0.001). Participants’ mean COV19 QoL score was 4.47 ± 0.15 (out of 5), indicating a perceived negative impact of the pandemic on their lives. In the multiple regres- sion analysis, female gender (β = 0.604, p = 0.017) and COV19 QoL score (β = 2.537, p = 0.003) were significantly associated with higher perceived distress among partic- ipants. At follow-up, all participants had developed psychological distress. In the study conducted in Indonesia by Hoffman et al. (2023), the stressors most frequently mentioned by refugees from Afghanistan (n = 227, 24.9%), Iraq (n = 224, 24.5%), Somalia (n = 162, 17.7%), Iran (n = 69%), Sudan (n = 49, 5.4), Other (n = 182, 19.9%) were concerns about resettlement (70.3%), memories of previous trauma/ stressors (60.4%), access to protection from COVID-19 (57.7%), limited access to basic necessities (57.2%), and concerns about childcare (55.9%). Yalcin et al. (2021) reported in their study conducted in Turkey that the levels of anxiety and traumatic stress was significantly higher in refugee patients than in local patients receiving hemodialysis. The results of the study conducted by Nakhaie et al. (2022) in Canada show that young refugees and immigrants are exposed to negative stressors such as poverty, unemployment, occupational segregation, downward occupational mobil- ity, inadequate housing, and homelessness, barriers to accessing social services, discrimination, and racism during the pandemic. Food insecurity has had by far the greatest impact on the mental health of newly arrived refugees and young immi- grants during the pandemic. 34.5, 23.3, and 21.1 percent of youth in this study reported that nervousness, helplessness, and/or depression affected them “well” and “extremely,” respectively, during COVID-19. Akhtar et al. (2021) documented that among the participants, refugees in Jordan, the most common COVID-19 concerns were the financial impact (82.9%), lack of essentials (72.9%), infecting others (60.8%), the health of family members outside the camp (55.3%), being infected themselves (52.8%), being confined to their own caravan (47.2%), being quarantined (39.7%), the stigma of infection (39.2%), the government’s management of the pandemic (36.2%), and the capacity of the local healthcare system (32.7%). Anwar et al. (2023) found that the overall prevalence of perceived stress among refugees living in Bangladesh was 93%. It should be added that most refugees in the sample also reported difficulties in accessing food (81%), earning money (90%), and routine medical care (73%). 28 D V E D O M O V I N I • T W O H O M E L A N D S • 6 0 • 2 0 2 4Dino Manzoni, Lilijana Šprah The participants—Syrian refugee women who have settled in Canada—in the qualitative study conducted by Cameron et al. (2021) indicated that COVID-19 has changed their access to and utilization of health services. They reported restrictions in hospital care, restrictions in childcare, changes in service provision, and lack of access to doula services. COVID-19 restrictions also led to the closure of schools and daycare centers. As a result, all participants stated that they had between one and seven additional children at home after giving birth, which they cared for full-time. They spoke about the stress and exhaustion they experienced when they had to organize homeschooling or childcare for their additional children on top of caring for their new baby. Liddell et al. (2021) found in their study conducted in Australia that the most commonly reported stressors were related to COVID-19 infection, with the most common being worrying about being infected themselves (66.5%), worrying that a loved one is infected (72.1%), or infecting others (47.7%). Social stressors as a result of the COVID-19 pandemic were also common, including school closures (46.7%), restricted social activities (46.6%), and the need to stay at home (41.3%). Of the respondents, 41.1% said the COVID-19 pandemic reminded them of a previ- ous trauma. The sample of the study conducted by Lotito et al. (2023), which included adult asylum seekers, refugees, and migrants (ARMs), and actors with migration experi- ence, reported increased psychological stress among asylum seekers, refugees, and migrants residing in Italy. They spoke of feelings of pain, sadness, anger, frustration, hopelessness, and worry that they experience in everyday life. The pandemic also triggered strong feelings of anxiety, frustration, and confusion, which exacerbated their already insecure and unstable situation. One of the biggest problems they faced was the precarious living conditions. Restrictions on movement and cuts to services also reduced their employment opportunities. The language barrier led to a sense of isolation as they were unable to express their point of view. The inability to “access services” directly affected their administrative status and prevented them from obtaining a regular employment contract. All public services restricted their access and slowed down their activities, resulting in general disorganization, e.g., in the renewal and release of documents, which caused strong feelings of frustration, anger, and confusion. Due to the pandemic, the “digitalization” of services made access even more difficult, as all activities had to be carried out online. A discussion arose about the language and cultural barriers and the experience of isolation that sometimes results from not being able to communicate your point of view in your native language and include your cultural background. In the individual interviews, racism emerged as a widespread problem. Their difficulties, therefore, encompassed both basic (physiological, safety) and emotional needs (feeling safe, well-being). The quantitative results of the recent mixed-methods study conducted in Jordan by Jones et al. (2022) show that two-thirds of all adolescents in the sample (66.8%) experienced increased stress at home during the pandemic. The qualitative 29 6 0 • 2 0 2 4 The Impact of the COVID-19 Pandemic on the Mental Health of Refugees findings showed that a number of youth, particularly boys, sought exit options from Jordan—including migration through brokers—due to the extreme vulnerability to which they were exposed. Many youth felt that violence had increased since the start of the pandemic, with more than 50% of youth who had experienced some form of violence stating that it had increased during the pandemic, particularly among unmarried girls. The qualitative findings also show that increased levels of stress in households—due to economic pressures, unemployment, and the fact that fathers and brothers are at home significantly more than before the pandemic—have led to an increase in domestic violence. Qualitative data also revealed the emotional depri- vation that young people experience when separated from their peers at work or school. Of the young people surveyed, almost a third (29.4%) had not had any face- to-face or online contact with friends in the last seven days, which is very concerning given the importance of peer interactions in the teenage years. The results show that virtually all refugees were exposed to relatively high levels of stress during the COVID-19 epidemic, mainly due to poor living and socioeco- nomic conditions. In the studies, stress levels were measured using various data collection instruments. Category: Depression More than half, i.e., seven out of twelve studies, found results related to depression. The results of a study conducted by Logie et al. (2022) in Uganda showed that the overall prevalence of depression before the declaration of the COVID-19 pandemic was 27.5%, with 19.6% reporting moderate depression, 7.1% mild depression, and 0.8% severe depression. In the period after the COVID-19 pandemic was declared, the prevalence of depression was slightly higher at 28.9%; however, there was no significant difference in overall depression in the population between the two peri- ods (p = .583). Taken together, these results suggest that a substantial proportion of urban youth refugees suffer from chronic depression. Among urban youth refugees in Kampala, depression was associated with widespread and chronic food insecurity, affecting two-thirds of participants. Similar results were found in a Turkish study by Yalcin et al. (2021), in which the prevalence of depression symptoms did not differ between the groups of refugees and local patients receiving hemodialysis. Kurt et al. (2021) found that half of the participants met the criteria for proba- ble depression (52.9%), which was higher than previously reported prevalence rates among Syrian refugees in Turkey. Statistical analysis shows that loss of resources and perceived discrimination during the pandemic significantly and positively predicted depression symptoms among refugees. In the qualitative study conducted by Cameron et al. (2021) in Canada, young mothers reported that the COVID-19 environment also impacted their mental health in the postpartum period, leading to increased feelings of anxiety, isolation, and 30 D V E D O M O V I N I • T W O H O M E L A N D S • 6 0 • 2 0 2 4Dino Manzoni, Lilijana Šprah disappointment. The study showed that there is a link between increased depressive symptoms and low levels of social and informal support among refugee women. Liddell et al. (2021) found that 17.3% of the sample met DSM-5 criteria for prob- able depression (in the Australian general population, the prevalence of depressive symptomatology is 4.1%). Statistical analysis shows that social difficulties due to COVID-19 specifically predicted increased depression symptoms and disability. The results of a study conducted by Jones et al. (2022) show the following: 19.3% of adolescents in the Jordanian sample had symptoms indicative of moderate to severe depression as measured by the PHQ-8. 34.5, 23.3. Of adolescents in the study conducted by Nakhaie et al. (2022) in Canada, 21.1% stated that nervousness, helplessness, and/or depression during COVID-19 applied to them “well” or “very well.” The proportion of people with depression in the quantitative studies ranged from 19.3% to 52.9%. Interestingly, the results of two studies showed that depressive symptoms did not increase during COVID-19. In some studies, different scales were used to measure the extent of depression, and their mean values were reported. Category: Anxiety Half, i.e., six out of twelve studies, showed results related to anxiety. The results of a study conducted by Anwar et al. (2023) in Bangladesh showed that the overall prevalence of COVID-19-related anxiety among participants was 68%. Kurt et al. (2021) found that almost half of the participants met the criteria for anxiety (42.9%), which is higher than previously reported prevalence rates among Syrian refugees in Turkey. In the qualitative study conducted by Cameron et al. (2021) in Canada, young mothers reported anxiety related to systemic barriers to postnatal care and loss of informal support. They also reported heightened levels of anxiety triggered by fear of the virus. The women were particularly concerned about their child’s health and felt particularly vulnerable to the virus. Liddell et al. (2021) found that 23.3% of the sample met the criteria for health anxiety, and 19.8% met the criteria for probable generalized anxiety disorder (in the general Australian population, the prevalence of generalized anxiety disorder is 2.7%). Fears about the future (including visa application processes and future life in Australia) were associated with an increase in symptoms of health anxiety and disability. Fears related to contracting COVID-19 (for self, family, or risk of infecting others) led to symptoms of health anxiety. Yalcin et al. (2021) found that anxiety levels were significantly higher in the Turkish refugee sample than in the sample of local patients receiving hemodialysis (29.6% vs. 12.9%, p < 0.05). Jones et al. (2022) reported that 12.4% of adolescents in the Jordanian sample suffered from moderate to severe anxiety symptoms, with higher rates in older 31 6 0 • 2 0 2 4 The Impact of the COVID-19 Pandemic on the Mental Health of Refugees adolescents (4.5%, p < 0.01) and females (4.5%, p < 0.001) than in their peers. It was found that loss of resources and perceived discrimination during the pandemic significantly and positively predicted anxiety symptoms. The qualitative data showed that anxiety was also associated with strong feel- ings of social isolation and, in some communities, the breakdown of social cohesion. In the quantitative studies, the percentage of people with anxiety ranged from 12.4% to 68%. In the studies, the level of anxiety was measured using various data collection tools. Category: Post-traumatic stress disorder (PTSD) Three of the studies came to conclusions related to post-traumatic stress disorder. The first study by Akhtar et al. (2021) found that refugees hosted in Jordan had less severe PTSD symptoms than before the pandemic (27.69 ± 15.76 vs. 24.92 ± 13.08, p = 0.06). Nevertheless, the data collected shows the following difficulties of the refugees: 1) financial worries (82.9%); 2) lack of basic needs (72.9%); and 3) insuf- ficient capacity of the local healthcare system (32.7%) in Jordan. In the second study by Yalcin et al. (2021), 33.3% of refugees accommodated in Turkey reported PTSD symptoms and had significantly higher PTSD symptom scores than local patients (16.1%, p < 0.05). In terms of psychiatric comorbidity, anxiety and PTSD were more common in refugees than in local patients receiving hemodialysis. Fear of contracting COVID-19 (for self, family, or risk of infecting others) predicted PTSD symptomatology. Among refugees, somatic anxiety and PTSD were the most common psychiatric disorders (33.3% each). In the study by Liddell et al. (2021), 32.9% of the sample met DSM-5 criteria for probable PTSD (in the Australian general population, the prevalence of PTSD symptomatology is 6.4%). Although it was not the most common problem (41.1%), difficulties due to COVID-19 triggering memories of past traumatic events was the strongest predictor of PTSD. The percentage of people with PTSD symptoms ranged from 26.65% to 32.9% in the quantitative studies. Interestingly, the results of one study showed that PTSD symptoms decreased during COVID-19. Category: Other findings Nakhaie et al. (2022) found that the second most important predictor of mental health is resilience. This finding could indicate that refugees should not be patholo- gized and patronized, as they, too, have strong adaptive capacities and can cope with adversity. However, sustainable living conditions and access to the universal rights, both socioeconomic and health, that we advocate for in the West must be ensured. Jones et al. (2022) found that most young people seek solace and guidance in religion to cope with the situation (90.7% in the quantitative survey). This information 32 D V E D O M O V I N I • T W O H O M E L A N D S • 6 0 • 2 0 2 4Dino Manzoni, Lilijana Šprah is vital for mental health professionals who provide psychological interventions and prevention programs that help improve the mental health of vulnerable popula- tions. Jones et al. (2022) also highlighted the significant role that family relationships played for some young people in managing their psychosocial well-being and mental health during the pandemic. This is also an important protective factor to keep in mind when considering mental health programs or interventions in crises, but of course, only under certain conditions. Young people also pointed out that stress in the household (and economic pressures in particular) had increased since the pandemic, which had translated into an increase in violence in the household, including violence against young people. Jones et al. (2022) also documented that the patterns of stressors reinforce exist- ing social and economic inequalities, with girls—and particularly married girls and adolescents from the poorest households and those not attending school—being more disadvantaged. More than 15% of the sample—mainly older girls—suffered from moderate to severe symptoms of depression and anxiety. The qualitative data suggest that the higher levels of anxiety among adolescent girls compared to adolescent boys are at least partly due to limited privacy, particularly in relation to menstrual hygiene (which is highly culturally taboo), as male family members are more likely to be at home during confinement. These challenges in terms of cultural norms were compounded by limited economic resources, inadequate water supplies, and a lack of understanding by male family members of the needs of girls, both in terms of privacy and ensuring care, as their mobility is more restricted than that of boys and men. The survey data also confirm these findings: 52% of unmarried women see access to menstrual hygiene products as a challenge, with 60% of these adolescents stating that this challenge has increased during the pandemic. In the Canadian qualitative study conducted by Cameron et al. (2021), partic- ipants stated that they were not provided with interpreters and were forced to navigate the healthcare system in English during COVID-19. Primary care services and home-based postnatal support, as provided by doulas and nurses, were offered virtually. Telehealth appointments presented some challenges for interpreting and had both positive and negative effects on participants. 33 6 0 • 2 0 2 4 The Impact of the COVID-19 Pandemic on the Mental Health of Refugees Year / Author(s) Country Type of Study No. of participants Sam ple Data Data Collection Instrum ents Data Collecting Method / Date Mental Health Outcom es Quality Assessm ent Lotito et al., 2023 Italy Qualitative 19 Free listing interviews: 12 stakeholders, 7 refugees. Focus group: 12 stakehold - ers, 8 refugees Age (mean): 34 years (SD = 7) Semi-structured interview Online / Feb–Apr 2021 Psychological distress, strong feelings of fear, insecurity, and frustration, which are also related to unemployment, housing, difficult access to health care, isolation, and racism. 8/10 Akhtar et al., 2021 Jordan Quantitative (longitudinal) 410 Female: 71.5%, Male: 28,5%. Age (mean): 40.4, SD = 7.1. Married (n = 203). 48.5% of the sample completed follow-up assessments Kessler Psychological Distress Scale (K10); Hopkins Symptom Checklist-25 (HSCL-25); PTSD Checklist for DSM-5 (PCL-5) 1) Screening: Aug–Dec 2019; 2) Baseline assessments: Sep 2019–Jan 2020; 3) 6-week online assessments: Nov 2019– Mar 2020; 4) 18-week online assessments: Jan–Jun 2020 Refugees had less severe PTSD symptoms than those assessed before the pandemic. Financial worries (165, 82.9%), shortages of essential supplies (145, 72.9%), local health care system capacity (65, 32.7%) 6/9 Kurt et al., 2021 Turkey Quantitative (cross-sectional) 345 Female: 165, Male: 10. Age (mean): 33.4, SD = 9.11. Previously diagnosed psychiatric difficulties 8% Generalized Anxiety Scale; Patient health questionnaire-9; Multi - dimensional scale of perceived social support; Everyday discrim- ination scale (short version); The conservation of resources evalua- tion (modified version) Online / Sep–Oct 2020 High levels of depressive and anxiety symptoms were reported. Resource loss and perceived discrimination significantly and positively predicted depressive and anxiety symptoms. 6/8 Jones et al., 2022 Jordan Mixed-method 3311 Two cohorts: aged 10–12 years and 15–17. 1,603 boys, 1,708 girls. Age: 15-21 (n = 1,639), 10-14 (n = 1,672). Qualitative sample: 104 girls, 74 boys Patient Health Questionnaire 8; Generalized Anxiety Disorder 7 scale; Brief Resilient Coping Scale; Household Food Insecurity Access Scale; COVID-19-related quantita - tive surveys Phone call and online / 1) Oct 2018– Mar 2019; 2) May 2020 and Jan 2021 19.3% reported symptoms of moderate to severe depression, 12.4% reported moderate to severe anxiety symptoms. 2/3 reported increasing stress at home. 17/22 Logie et al., 2022 Uganda Quantitative (longitudinal) 450 Age: 16–24 years. Male (n = 185), Female (n = 182), Age (mean): 20.0, SD: 2.4. 75 (16.7%) were lost to follow-up Patient Health Questionnaire-9 (PHQ-9) Face-to-face / Feb–Dec 2020 The prevalence of depression was high, but there was no significant difference before (27.5%) and after (28.9%) the pandemic. 8/9 34 D V E D O M O V I N I • T W O H O M E L A N D S • 6 0 • 2 0 2 4Dino Manzoni, Lilijana Šprah Ye ar / A ut ho r(s ) Co un try Ty pe of St ud y No . o f pa rti cip an ts Sa m pl e D at a Da ta Co lle cti on In str um en ts Da ta Co lle cti ng M et ho d / D at e Me nt al He alt h O ut co m es Qu ali ty As se ssm en t Lid de ll e t a l., 20 21 Au str ali a Qu an tit ati ve (lo ng itu din al) 65 6 Ma le: 50 .8% . F em ale s: 4 9.2 %. Ag e (m ea n): 42 .85 , S D =  12 .22 . M arr ied (n  =  50 3, 76 .9% ) Pa tie nt He alt h Q ue sti on na ire ; Po st- tra um ati c D iag no sti c S ca le; Bo dil y P reo ccu pa tio n S ca le of th e I lln ess At tit ud e S ca le; W orl d He alt h O rga niz ati on Di sab ilit y As ses sm en t S ch ed ule 2. 0; RA S Ha ras sm en t a nd Bu lly ing Su rve y; Ha rva rd Tra um a Q ue sti on na ire ; Ge ne ral ize d A nx iet y D iso rde r As ses sm en t On lin e / Ju n 2 02 0 41 .1% of re fug ee s r ep ort ed th at th e p an de mi c CO VID -1 9 r em ind ed th em of pa st tra um as. CO VID -1 9 M em ori es of pa st tra um ati c e ve nts we re th e s tro ng est pr ed ict or of PT SD , h ea lth an xie ty, de pre ssi on , a nd di sab ilit y. 7/ 9 Na kh ai e et a l., 20 22 Ca na da Q ua nt ita tiv e (c ro ss -s ec tio na l) 24 4 Ag e < 19 (6 0. 2% ). M al e: 43 .8 % . F em al e 56 .2 % Ca na di an C om m un ity He al th S ur ve y Q ue st io n- na ire - 20 17 -1 8 Ph on e ca ll / J ul 2 2– N ov 26 , 2 02 0 Fo od in se cu rit y ha d by fa r t he gr ea te st im pa ct o n th e ps yc ho - lo gi ca l d ist re ss o f n ew ly a rri ve d ad ol es ce nt re fu ge es . 5/ 8 Ho ffm an e t a l., 20 23 In do ne sia Q ua nt ita tiv e (c ro ss -s ec tio na l) 91 3 M al e (n  =  6 30 ). Fe m al e (n  =  2 81 ). Ag e (m ea n) 3 0. 85 , SD  =  9 .4 5. M ar rie d (n  =  4 11 , 45 % ). Af gh an ist an (n  =  2 27 , 24 .9 % ), Ira q (n  =  2 24 , 2 4. 5% ), So m al ia (n  =  1 62 , 1 7. 7% ), Ira n (n  =  6 9% ), Su da n (n  =  4 9, 5 .4 ), O th er (n  =  1 82 , 1 9. 9% ) Ha rv ar d Tr au m a Q ue s- tio nn ai re ; P os ttr au m at ic Di ag no st ic S ca le –I V; Pa tie nt H ea lth Q ue s- tio nn ai re –8 ; G en er al ize d An xi et y Di so rd er –7 sc al e; D im en sio ns o f An ge r R ea ct io ns –5 ; M ed ic al O ut co m es Su rv ey –S ho rt F or m ; A lis t o f 1 2 st re ss or s re la te d to C O VI D -1 9, cr ea te d fo r t hi s s tu dy ; so ci al su pp or t q ue st io ns us ed b y Ar ay a et a l. (2 00 7) O nl in e (K ey S ur ve y pl at fo rm ) / M ay 2 9– O ct 29 , 2 02 0 Th e re fu ge es ’ g re at es t c on ce rn w as h ow th e pa nd em ic C O VI D -1 9 w ou ld a ffe ct re se ttl em en t. Fe ar o f de po rt at io n m ay b e re fle ct ed in th e se co nd m os t f re qu en tly ci te d st re ss or . 6/ 8 35 6 0 • 2 0 2 4 The Impact of the COVID-19 Pandemic on the Mental Health of Refugees Year / Author(s) Country Type of Study No. of participants Sam ple Data Data Collection Instrum ents Data Collecting Method / Date Mental Health Outcom es Quality Assessm ent Yalcin et al., 2021 Turkey Q uantitative (cross-sectional) 58 Syrian refugee (n = 27). Local (n = 31). Age (m ean) 48, SD = 15.2, M ale: 44.4% . Fem ale: 55.6% Patient Health Q ues - tionnaire Som atic, Anxiety, and D epressive Sym ptom s (PHQ -SADS); Post-traum atic Stress Disorder Checklist for DSM -5 (PCL-5) Face-to-face / Jul 2021 Scores for anxiety and traum atic stress w ere significantly higher in refugee patients. They had signifi- cantly higher som atic sym ptom scores than local patients. They also had significantly higher PTSD scores than local patients. 6/8 Anw ar et al., 2023 Bangla - desh Q uantitative (cross-sectional) 864 Age ≥ 60. M ale 57% . The m ajority of the participants w ere aged 60–69 years (72% ). M arried: 79% . Living alone (67% ). Currently unem ployed or retired (89% ). Household size > 4 m em bers: 57% . Currently suffering from any chronic diseases: 50% Bengali version of the five-point Coronavirus Anxiety Scale (CAS); 10-item Perceived Stress Scale (PSS), validated am ong the Bangladeshi population Face-to-face / Nov–D ec 2021 The prevalence of CO VID -19- related anxiety w as 68% , and perceived stress w as 93% . M ost participants reported diffi culty accessing food (81% ), earning m oney (90% ), and receiving routine m edical care (73% ). 7/8 Cam eron et al., 2021 Canada Q ualitative 8 M arried (n = 8). 1–2 children: 1. 3–4 children: 2. 5–6 chil - dren: 3. 7–8 children: 2 Sem i-structured inter- view form m ade for the purpose of the survey Telephone interview or online / M ar–Aug 2020 Three them es em erged: system ic barriers to postnatal care, loss of inform al support, grief, and anxiety. 8/10 Palit et al., 2022 Bangla - desh Q uantitative (longitudinal) 732 Age (m ean): 32.25 ± 14.01 years (SD). Fem ale: 61.1% , M ale: 38.9% . 342 participated in the follow -up survey The Refugee Health Screener 15 (RHS-15); The CO VID -19-Im pact on Q uality of Life (CO V19- Q oL) scale v 1.5 Face-to-face / 1) Base - line survey Jul 5, 2019, and 2) Nov 10, 2020 The pandem ic had a significant im pact on the quality of life and stress levels am ong refugees. W om en w ere significantly m ore affected than m en. 6/9 Table 1: Sum m ary of study types, sam ple characteristics, study design, assessm ent instrum ents, m ental health outcom es, and quality assessm ent. 36 D V E D O M O V I N I • T W O H O M E L A N D S • 6 0 • 2 0 2 4Dino Manzoni, Lilijana Šprah DISCUSSION AND CONCLUSIONS It is already known that the environment of the epidemic has had a long-term nega- tive impact on people’s mental and psychological state, so we must continue to worry about the impact of COVID-19 on mental health (Zhu et al., 2023). It is also very well documented that refugees are a vulnerable group and are more likely to have mental health difficulties than the local population due to the stressful circum- stances before, during, and after migration (Alarcão et al., 2022; Li et al., 2016). The most recent World Health Organization report on refugees (WHO, 2023, p. 5) also emphasizes and states that refugees (and migrants) can be “the most vulnerable members of society and often face xenophobia, discrimination, poor living, hous- ing and working conditions, and inadequate access to health services, despite frequently experiencing physical and mental health problems.” The prevalence of common mental disorders such as depression, anxiety, and post-traumatic stress disorder (PTSD) tends to be higher among refugees than in the host population (WHO, 2023). Furthermore, in crises such as the COVID-19 pandemic, the system of restrictions and the consequences of crises have a differentiated impact on the population. As Della Puppa & Perocco (2022, pp. 9–10) state in their study: “This new system of restrictions has added the limitation of the movement of the poor (now also considered ‘infected’) as well as to the war on migrants and the poor that has been going on for years. These groups, considered undesirable, are often confined in buffer zones, liminal zones—a sort of ‘new sacrifice zones’—in very harsh conditions and with high health risks.” In this study, a systematic review was conducted to examine the impact of the COVID-19 pandemic on refugee mental health from an international perspective. As a result of the search in the Web of Science database, we compiled the results of 12 studies that met the inclusion criteria. As explained in the methods chapter, based on the literature, we decided that the most appropriate approach for synthesizing qualitative, quantitative, and mixed methods research findings was narrative synthesis (Popay et al., 2006). In all of the studies included in the review, the results showed that the patterns of stressors rein- forced pre-existing social and economic inequalities. In the refugee context, with pre-existing poverty, social exclusion, hardship, and a lack of adequate immediate social and health support, the COVID-19 pandemic significantly exacerbates the stressors and, consequently, the mental health difficulties of refugees. In this respect, the study shows that the empirical results on a global level support the hypothesis put forward in the literature. The study shows that these problems arise from indirect situations such as unemployment and precarious living conditions during the isolation and quarantine process. The language barrier leads to a sense of isolation as refugees are often unable to express their feelings and communicate appropriately with those around them, meaning that their social envi- ronment does not recognize them. The inability to “access services”—including the 37 6 0 • 2 0 2 4 The Impact of the COVID-19 Pandemic on the Mental Health of Refugees healthcare system—has a direct impact on their administrative and socioeconomic status, as they are also prevented from obtaining a regular employment contract or adequate treatment. During the COVID-19 pandemic, all public services restricted their access and slowed down their operations, leading to a general disorganization. However, the pandemic also served as a political pretext for the isolation, inaction, and inhumane treatment of refugees. Due to the specific nature of the refugee population, certain specificities must be considered, such as the fact that refugees are, by definition, “on the move.” Stud- ies such as the one by Cukut Krilić & Zavratnik (2023, p. 26) warn that: “The COVID-19 pandemic put people on the move in an additional vulnerable position because the usual spatial routes were disrupted and the restricted mobility—i.e., the lockdowns of societies—further increased the insecurity of continuing the route—although, of course, mobility could not be stopped completely.” It has also been shown that refugees’ previous experiences with national and international laws, rules, practices, and interventions have led them to visibly distrust the social and health systems of the countries in which they find themselves. Thus, they showed feelings of fear of possibly being left to die. This has widened the gap between the host society and the refugees, pointing to systemic barriers to integra- tion and the resulting structural reinforcement of segregation and discrimination. Research findings on the mental health of children and adolescents show that special attention should be paid to the conditions under which refugees will grow up in the future. They have shown that children and adolescents face extremely diffi- cult situations and, as a result, have difficulties with their mental health (Jones et al., 2022; Logie et al., 2022; Nakhaie et al., 2022). During the pandemic, they have been exposed to deteriorating living conditions, leading to severe stressors such as poverty, occupational segregation, inadequate housing, and homelessness, barriers to accessing social and health services, discrimination, and racism (Nakhaie et al., 2022). Research shows that although we live in the twenty-first century, the lack of essential goods and food insecurity during the pandemic had a significant impact on the psychological distress and well-being of refugees and young immigrants. The abovementioned extrapsychic problems, as well as social and political oppression, threaten to overwhelm the refugees’ coping capacities. Therefore, the social determinants of mental health should be recognized so that the social causes that exacerbate the symptoms of mental disorders and overall mental well-being can be adequately addressed. We can add that the social psychiatric approach is more appropriate than a purely biomedical model when it comes to the mental health and psychological difficulties of refugees. In fact, social psychiatry is particularly associated with developing therapeutic communities and highlighting the impact of socioeconomic factors on mental illness. “Social psychiatrists strive to pay close attention to their patient’s cultural milieus and to their ‘Idioms of Distress’ which are the characteristic way in which members of different cultures describe what is wrong 38 D V E D O M O V I N I • T W O H O M E L A N D S • 6 0 • 2 0 2 4Dino Manzoni, Lilijana Šprah and which may differ from the expressions found in mainstream [American] culture,” according to the American Association for Social Psychiatry homepage (AASP, 2024). Interestingly, in one of the studies examined during the pandemic, refugees reported a lower intensity of PTSD symptoms than before the COVID-19 outbreak. This finding was unexpected in the context of numerous studies predicting that pre-existing mental health difficulties would be a major risk factor for poorer mental health during the pandemic (Lancet, 2020). The hypothesis could be that the symp- toms of some mental health difficulties, such as PTSD and depression, temporarily subside during a severe crisis and reappear after the state of emergency ends. Akhtar et al. (2021) also hypothesize that the restricted freedom of movement due to quar- antine reduces the likelihood of encountering stimuli that trigger PTSD symptoms, such as flashbacks and anxiety due to traumatic events. However, it should be noted that the context of resettlement plays a crucial role in the mental health of refugees. As Hynie (2018) notes, although pre-migration trauma can predict mental disor- ders and PTSD, the post-migration context can be an equally strong determinant of mental health. Mental health is highly influenced by the conditions in which they live post-migration and is therefore strongly shaped by the socioeconomic factors of daily life (Li et al., 2016). In addition, two studies (Logie et al., 2022; Yalcin et al., 2021) have shown that although symptoms of depression are more common in the refugee population than in the general population, they did not increase during the epidemic itself. One possible hypothesis could be that the crisis has increased coping readiness, as evidenced by increased anxiety and stress response, and that depressive symp- toms—and possibly even suicidal behavior—increase after the epidemic ends, as the body’s responses that prepared for the extreme struggle subside and commu- nities move into the recovery or mourning phase. Since social ties or networks are one of the most important protective factors to prevent the development and exac- erbation of mental health difficulties, intervention programs and policies should pay special attention to the effects of discrimination and segregation. However, Oliveros et al. (2022) point out that the biggest problem is not the lack of social ties but rather the fact that existing social ties place the affected individuals outside of society as a whole. Nakhaie et al. (2022) find that the second most important predictor of mental health is resilience. This could suggest that refugees should not be pathologized and patronized as they, too, have strong adaptive skills and can cope with adver- sity. As refugees’ mental health is also determined by the local political climate in the post-migration phase, we find that moral, politically correct victimization and paternalism in the form of pity only portray traumatized people as helpless, passive subjects of events or victims of unfortunate circumstances, isolating the subject’s victimization mechanism in its dual function from the actual context (Manzoni, 2023). Nonetheless, sustainable living conditions and access to the universal rights, both socioeconomic and health-related, that we advocate for in the West must be 39 6 0 • 2 0 2 4 The Impact of the COVID-19 Pandemic on the Mental Health of Refugees guaranteed. With the words of Anholt & Sinatti (2019), we add the emphasis that putting refugee resilience into practice depends on the systemic factors, local context, and political interests of the actors involved. With this in mind, refugees should have access to all social services offered by the host country through legis- lative changes and improvements to the country’s bureaucratic and social systems. LIMITATIONS AND FUTURE RESEARCH The first obvious limitation of our study is that we only considered the Web of Science database. In addition, the systematic review should be extended with articles from the Scopus database. The second limitation of our study is that the studies included in the system- atic literature review were geographically dispersed. This dispersion means that they only provide a global overview of refugee mental health during the COVID-19 pandemic. Uganda, Jordan, and Lebanon are the most critical global humanitarian hotspots. Only one study from the geographical area of Europe was added. However, data from two studies conducted in Turkey were also included. Therefore, further systematic literature reviews should focus particularly on the geographical area of Europe, which has a common sociopolitical context and whose numerous political struggles are fought at the expense of refugees’ mental and physical health. The third limitation of our study is that we focused only on the refugee popula- tion. The latter are associated with groups that have a different status or are defined differently in different countries, such as migrants and asylum seekers. Researchers Crawley & Skleparis (2017) argue that these dominant categories do not adequately capture the complex relationship between political, social, and economic driv- ers of migration. Furthermore, the assessment should consider that the measures implemented do not differ from country to country and that the health of refu- gees, asylum seekers, and migrants is affected by the measures at different levels. In complementary systematic studies, an additional focus should be placed on the female population and age-differentiated population groups, such as young or elderly people, as research shows that these groups have specific problems that often remain hidden and unspoken. Finally, we should add that new research should also examine which factors have had the greatest impact on refugee mental health during the epidemic so that we are better prepared to address them with direct interventions and prevention programs in the future. Considering the evidence that some mental health difficulties only increase after an acute crisis, research should continue for some time after the end of the crisis. A recommendation for practice can, therefore, primarily be to allocate more resources to in-depth research on vulnerable groups, which can be used to develop high-quality prevention programs. In addition to prevention programs and access to health services, sustainable living conditions, access to the material goods 40 D V E D O M O V I N I • T W O H O M E L A N D S • 6 0 • 2 0 2 4Dino Manzoni, Lilijana Šprah that we collectively produce as a society, and an accepting or inclusive social envi- ronment are necessary prerequisites for normal coexistence with people of different cultural and social backgrounds. The recent WHO report on refugees (2023, p. 68), also recommends that policies and programs for refugees and migrants should “recognize and address the social determinants of mental health and prioritize basic needs including food, housing, safety and education or employment.” Such a focus should promote a shift in the treatment of mental disorders, away from the tradi- tional psychiatric biomedical model of mental disorders and their treatment toward a social psychiatric model that explains how social factors contribute to the main- tenance of mental well-being. With this type of problem definition, host countries and the various programs can promote the understanding that social factors play a central role in all mental health difficulties. Only in this way can policies and prac- tices be formulated on the basis of which appropriate and effective measures can be taken in the field of refugee mental health. ACKNOWLEDGMENTS AND ADDITIONAL INFORMATION This presentation was prepared within the framework of the research program group Studies on Distress and Being Well (code: P5-0115-23) and the research project Mental health difficulties among migrants: experiences of recognition and treatment (code: L5-3183), co-funded by the Research and Innovation Agency and the Slovenian Academy of Sciences and Arts. There were no sponsors that would have caused a potential conflict of interest for the authors of the review. 41 6 0 • 2 0 2 4 The Impact of the COVID-19 Pandemic on the Mental Health of Refugees REFERENCES AASP – American Association for Social Psychiatry (2024, March 25). What IS Social Psychiatry? AASP. https://www.socialpsychiatry.org/column/ what-is-social-psychiatry Akhtar, A., Bawaneh, A., Awwad, M., Al-Hayek, H., Sijbrandij, M., Cuijpers, P., & Bryant, R. A. (2021). A longitudinal study of mental health before and during the COVID- 19 pandemic in Syrian refugees. A longitudinal study of mental health before and during the COVID-19 pandemic in Syrian refugees. European Journal of Psychotraumatology, 12(1), 1991651. https://doi.org/10.1080/20008198.2021.1 991651 Alarcão, V., Virgolino, A., Stefanovska-Petkovska, M., & Neves, J. (2022). Exploring the Effects of the COVID-19 Pandemic on Mental Health and Well-Being of Migrant Populations in Europe: An Equity-Focused Scoping Review. Behavioral sciences, 12(10), 393. Anholt, R., & Sinatti, G. (2019). Under the guise of resilience: The EU approach to migration and forced displacement in Jordan and Lebanon, Contemporary Security Policy, 41(2), 311–335. Anwar, A., Yadav, U. N., Huda, M. N., Das, S., Rosenbaum, S., Ali, A. R. M. M., Mondal, P. K., Rizwan, A. A. M., Hossain, S. F. A., Das Shuvo, S., & Mistry, S. K. (2023). Anxiety and Stress Related to COVID-19 Among the Community Dwelling Older Adults Residing in the Largest Refugee Camp of the World. Community Mental Health Journal, 59, 1181–1192. Cameron, E. S., Ramos, H., Aston, M., Kuri, M., & Jackson, L. (2021). “COVID affected us all”: The birth and postnatal health experiences of resettled Syrian refugee women during COVID-19 in Canada. Reproductive Health, 18, 256. Crawley, H., & Skleparis, D. (2017). Refugees, migrants, neither, both: categorical fetishism and the politics of bounding in Europe’s ‘migration crisis.’ Journal of Ethnic and Migration Studies, 44(1), 48–64. Cukut Krilić, S., & Zavratnik, S. (2023). Structural Vulnerabilities and (Im)Mobilities Amidst the Covid-19 Pandemic: People on the Move along the Balkan Route, Posted and Agricultural Workers. Central and Eastern European Migration Review, 12(2), 15–31. Della Puppa, F., & Perocco, F. (2022). Introduction: Migrants and Migration in the Eco-Pan-Syndemic Era. Dve domovini / Two Homelands, 56, 7–20. Dohrenwend, B. P. (2000). The role of adversity and stress in psychopathology: some evidence and its implications for theory and research. J Health Soc Behav, 41(1), 1–19. El Tatary, G., & Gill, N. (2022). The impact of the COVID-19 pandemic on the mental health and wellbeing of refugees and asylum seekers: A Narrative Review of the Literature. Australas Psychiatry, 30(6), 728–731. 42 D V E D O M O V I N I • T W O H O M E L A N D S • 6 0 • 2 0 2 4Dino Manzoni, Lilijana Šprah Fancourt, D., Steptoe, A., & Bu, F. (2021). Trajectories of anxiety and depressive symptoms during enforced isolation due to COVID-19 in England: a longitudinal observational study. Lancet Psychiatry, 8(2), 141–149. Filosi, N., Ioriatti, C., Pini, E., Serangeli, I., Storato, G. (2022). The Pandemic in the Trentino Asylum Reception System: Subjectivities Lost Within the “Health of the Facility”. Two Homelands, 56, 77–87. https://doi.org/10.3986/dd.2022.2.06 Haider, I. I., Tiwana, F., & Tahir, S. M. (2020). Impact of the COVID-19 Pandemic on Adult Mental Health. Pak J Med Sci, 36 (Covid19-s4), S90-s4. Hoffman, J., Liddell, B. J., Keegan, D., Kashyap, S., Diah Tricesaria, A. A. I., Pestalozzi, Z., Argadianti, R., Nandyatama, R. W., Khakbaz, M., Nilasari, N., & Nickerson, A. (2023). The Impact of COVID-19 Stressors on Refugee Mental Health and Well-Being in the Context of Sustained Displacement. American Journal of Orthopsychiatry, 93(2), 144–155. Hong, Q. N., Pluye, P., Fàbregues, S., Bartlett, G., Boardman, F., Cargo, M., Dagenais, P., Gagnon, M-P, Griffiths, F., Nicolau, B., O’cathain, A., Rousseau, M-C., & Vedel, I. (2018). Mixed Methods Appraisal Tool (MMAT), Version 2018: User Guide. McGill University. http://mixedmethodsappraisaltoolpublic.pbworks.com/w/file/ fetch/127916259/MMAT_2018_criteria-manual_2018-08-01_ENG.pdf Hynie M. (2018). The social determinants of refugee mental health in the post- migration context: A critical review. The Canadian Journal of Psychiatry, 63(5), 297–303. JBI (2023, December 3). Checklist for Qualitative Research & Checklist for Analytical Cross-Sectional Studies. JBI Critical Appraisal Tools. https://jbi.global/ critical-appraisal-tools Jin, Y., Sun, T., Zheng, P., & An, J. (2021). Mass quarantine and mental health during COVID-19: A meta-analysis. Journal of Affective Disorders, 295, 1335–1346. Jones, N., Baird, S., Abu Hamad, B., Bhutta, Z. A., Oakley, E., Shah, M., Sajdi, J., & Yount, K. M. (2022). Compounding inequalities: Adolescent psychosocial wellbeing and resilience among refugee and host communities in Jordan during the COVID-19 pandemic. PLoS ONE, 17(2), e0261773. Kiteki, B. N., Lou, S., & Liu, T. (2022). The Impact of COVID-19 Pandemic Lockdowns on Refugee Mental Health: A Narrative Review. Int J Adv Couns, 44(3), 95–413. Kluge, H. H. P., Jakab, Z., Bartovic, J., D’Anna, V., & Severoni, S. (2020). Refugee and migrant health in the COVID-19 response. Lancet, 395(10232), 1237–1239. Kmet, L. M., Lee, R. C., Cook, L. S. (2004). Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields. Alberta: Alberta Heritage Foundation for Medical Research. https://doi.org/10.7939/R37M04F16 Kurt, G., Ilkkursun, Z., Javanbakht, A., Uygun, E., Karaoglan-Kahilogullari, A., & Acarturk, C. (2021). The psychological impacts of COVID-19 related stressors on Syrian refugees in Turkey: The role of resource loss, discrimination, and social support. International Journal of Intercultural Relations, 85, 130–140. 43 6 0 • 2 0 2 4 The Impact of the COVID-19 Pandemic on the Mental Health of Refugees Lancet, T. (2020). Redefining vulnerability in the era of COVID-19. The Lancet, 395(10230), 1089. Li, S. S. Y., Liddell, B. J., & Nickerson, A. (2016). The Relationship Between Post- Migration Stress and Psychological Disorders in Refugees and Asylum Seekers. Current Psychiatry Reports, 18(9) 82. Liddell, B. J., O’Donnell, M., Bryant, R. A., Murphy, S., Byrow, Y., Mau, V., McMahon, T., Benson, G., & Nickerson, A. (2021). The association between COVID-19 related stressors and mental health in refugees living in Australia. European Journal of Psychotraumatology, 12(1), 1947564. Logie, C. H., Berry, I., Okumu, M., Loutet, M., McNamee, C., Hakiza, R., Musoke, D. K., Mwima, S., Kyambadde, P., & Mbuagbaw, L. (2022). The prevalence and correlates of depression before and after the COVID-19 pandemic declaration among urban refugee adolescents and youth in informal settlements in Kampala, Uganda: A longitudinal cohort study. Annals of Epidemiology, 66, 37–43. Lotito, C., Turrini, G., Purgato, M., Bryant, R. A., Felez-Nobrega, M., Haro, J. M., Lorant, V., McDaid, D., Mediavilla, R., Melchior, M., Nicaise, P., Nosè, M., Park, A-L., McGreevy, K. R., Roos, R., Tortelli, A., Underhill, J., Martinez, J. V., Witteveen, A., Sijbrandij, M., & Barbui, C. (2023). Views and experiences of migrants and stakeholders involved in social and health care for migrants in Italy during the COVID-19 pandemic: a qualitative study. BMC Psychology, 11, 164. Manchia, M., Gathier, A. W., Yapici-Eser, H., Schmidt, M. V., de Quervain, D., van Amelsvoort, T., Bisson, J. I., Cryan, J. F., Howes, O. D., Pinto, L., van der Wee, N. J., Domschke, K., Branchi, I., & Vinkers, C. H. (2022). The impact of the prolonged COVID-19 pandemic on stress resilience and mental health: A critical review across waves. Eur Neuropsychopharmacol, 55, 22–83. Manzoni, D. (2023). Kaj je travma?: od travme do posttravmatske stresne motnje. Problemi: revija za kulturo in družbena vprašanja, 61(2), 133–163. Morganstein, J. C. (2022). Preparing for the Next Pandemic to Protect Public Mental Health: What Have We Learned from COVID-19? Psychiatric Clinics of North America, 45, 191–210. Nakhaie, R., Ramos, H., Vosoughi, D., & Baghdadi, O. (2022). Mental Health of Newcomer Refugee and Immigrant Youth During COVID-19. Canadian Ethnic Studies, 54(1), 1–28. Oliveros, B., Agulló-Tomás, E., & Márquez-Álvarez, L. J. (2022). Risk and Protective Factors of Mental Health Conditions: Impact of Employment, Deprivation and Social Relationships. International journal of environmental research and public health, 19(11), 6781. Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L., Jennifer, Tetzlaff, J. M., Akl, E. A., Brennan, S. E., Chou, R. Glanville, J., Grimshaw, J. M., Hróbjartsson, A., Lalu, M. M., Li, T., Loder, E. W., Mayo-Wilson, E., McDonald, S., McGuinness, L. A., Stewart, L. A., Thomas, J., Tricco, A. C., Welch, V. A., Whiting, P., Moher, D. (2021). The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ, 372(71). https://doi.org/10.1136/bmj.n71 44 D V E D O M O V I N I • T W O H O M E L A N D S • 6 0 • 2 0 2 4Dino Manzoni, Lilijana Šprah Palit, S., Yang, H., Li, J., Khan, M. A. S., & Hasan, M. J. (2022). The impact of the COVID-19 pandemic on the mental health of Rohingya refugees with pre-existing health problems in Bangladesh. Conflict and Health, 16(1), 10. Papadopoulou, A., Efstathiou, V., Yotsidi, V., Pomini, V., Michopoulos, I., Markopoulou, E., Papadopoulou, M., Tsigkaropoulou, E., Kalemi, G., Tournikioti, K., Douzenis, A., Gournellis, R. (2021). Suicidal ideation during COVID-19 lockdown in Greece: Prevalence in the community, risk and protective factors. Psychiatry Research, 297, 113713. Pfefferbaum, B., & North, C. S. (2020). Mental Health and the Covid-19 Pandemic. The New England journal of medicine, 383(6), 510–512. Popay, J., Roberts, H., Sowden, A., Petticrew, M., Arai, L., Rodgers, N., & Britten, N. (2006). Guidance on the Conduct of Narrative Synthesis in Systematic Reviews. Lancaster University. https://www.lancaster.ac.uk/media/lancaster-university/ content-assets/documents/fhm/dhr/chir/NSsynthesisguidanceVersion1- April2006.pdf Porter, M., & Haslam, N. (2005). Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons: a meta-analysis. JAMA, 294(5), 602–612. Steel, Z., Chey, T., Silove, D., Marnane, C., Bryant, R. A., & van Ommeren, M. (2009). Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis. JAMA, 302(5), 537–549. Taquet, M., Luciano, S., Geddes, J. R., & Harrison, P. J. (2021). Bidirectional associations between COVID-19 and psychiatric disorder: retrospective cohort studies of 62 354 COVID-19 cases in the USA. Lancet Psychiatry, 8(2), 130–140. Wells, G. A., Shea, B., O’Connell, B., Peterson, J., Welch, V., Losos, M., & Tugwell, P. (2014). The Newcastle-Ottawa Scale (Nos) for Assessing the Quality of Nonrandomised Studies in Meta-Analyses. University of Ottawa. https://www.ohri.ca/programs/ clinical_epidemiology/oxford.asp WHO (2020). ApartTogether survey: preliminary overview of refugees and migrants self- reported impact of COVID-19. World Health Organization. https://www.who.int/ publications/i/item/9789240017924 WHO (2023). Mental health of refugees and migrants: risk and protective factors and access to care. WHO Press. Wu, S., Renzaho, A. M. N., Hall, B. J., Shi, L., Ling, L., & Chen, W. (2021). Time-varying associations of pre-migration and post-migration stressors in refugees’ mental health during resettlement: a longitudinal study in Australia. The Lancet Psychiatry, 8(1), 36–47. Xiong, J., Lipsitz, O., Nasri, F., Lui, L. M. W., Gill, H., Phan, L., Chen-Li, D., Iacobucci, M., Ho, R., Majeed, A., & Mclntyre, R. S. (2020). Impact of COVID-19 pandemic on 45 6 0 • 2 0 2 4 The Impact of the COVID-19 Pandemic on the Mental Health of Refugees mental health in the general population: A systematic review. Journal of Affective Disorders, 277, 55–64. Yalcin, M., Bashan, Y., Arpacioglu, S., Karas, H., Cebeci, E. (2021). Mental Health of the Refugee and Native Patients with End-Stage Renal Diseases Receiving Hemodialysis During COVID-19 in Istanbul: A Cross-Sectional Study from a Tertiary Center. Med Bull Haseki, 59, 363–370. Zhu, H-Y., Guo, Y-M., Pan, Z-M., Wang, Y., Zhang, M-L., Zhu, R-H., Li, ZP. (2023). Long- term effects of the COVID-19 pandemic on five mental and psychological disorders: in terms of the number of disease visits, drug consumption, and scale scores. BMC Psychiatry, 23, 677. 46 D V E D O M O V I N I • T W O H O M E L A N D S • 6 0 • 2 0 2 4Dino Manzoni, Lilijana Šprah POVZETEK VPLIV PANDEMIJE BOLEZNI COVID-19 NA DUŠEVNO ZDRAVJE BEGUNCEV: SISTEMATIČNI PREGLED LITERATURE Dino Manzoni, Lilijana Šprah Pandemija bolezni COVID-19, ki se je začela leta 2020, se je izkazala kot globalni zdravstveni in družbeni problem, ki je poglobil neenakosti in močno zaznamoval domala vsa področja življenja. V tem obdobju je prihajalo do neugodnih, nepred- vidljivih ter življenjsko ogrožajočih posegov v običajne dejavnosti, nad katerimi posameznik ni imel nadzora. Zaradi tega je večina ljudi doživljala negativni stres in velike negotovosti. Številne raziskave so pokazale, da je po razglasitvi epidemije in ukrepov za njeno obvladovanje v vseh prebivalstvenih skupinah prišlo do poveča- nega obsega težav na področju duševnega zdravja. Zlasti izrazite so bile povišane stopnje depresije in anksioznosti, posttravmatske stresne motnje (PTSM) ter različne čustvene stiske. Pandemija je imela še posebej negativen vpliv na duševno zdravje različnih ranljivih družbenih skupin, vključno z begunci. V članku je predstavljena raziskava, kjer smo proučili vpliv pandemije COVID-19 na duševno zdravje beguncev. V ta namen smo opravili sistematični pregled član- kov, objavljenih v bazi WOS. V analizo so bile vključene študije, ki so bile objavljene med 1. januarjem 2020 in 8. septembrom 2023, z vključeno ciljno skupino begun- cev, osredotočene na duševno zdravje ter povezane s pandemijo COVID-19. Od 256 raziskav, ki so ustrezale iskalnim kriterijem, smo po izločitvi dvojnikov, preglednih člankov, raziskav, katerih glavni namen ni bil proučevanje duševnega zdravja pri beguncih v kontekstu pandemije, ter raziskav, ki niso zadostile kriterijem metodolo- ške ocene kvalitete raziskave, v končno analizo vključili 12 raziskav. Analiza študij je pokazala, da se je po izbruhu pandemije med begunci znatno povečala psihološka stiska. Ključne težave, povezane z duševnim zdravjem begun- cev, ki so jih naslavljale analizirane raziskave, so bile stres, anksioznost, depresija in PTSM. Pokazalo se je, da je bilo duševno zdravje beguncev med pandemijo tesno povezano z njihovim slabim socialno-ekonomskim položajem, socialno izklju- čenostjo, brezposelnostjo, neustrezno namestitvijo, pomanjkanjem dostopa do zdravstvenih in socialnih storitev, diskriminacijo, rasizmom ter s težkimi in nego- tovimi življenjskimi razmerami, ki jih je pandemija še poslabšala. Simptomi PTSM, anksioznosti in depresije so bili pri beguncih bolj izraženi v primerjavi z avtohto- nimi prebivalci. Kot pomemben dejavnik tveganja za težave v duševnem zdravju beguncev se je izkazal negativni stres, ki je bil bolj izražen pri odraslih osebah (nad 30 let), poročenih, obolelih za kroničnimi boleznimi ter tistih s predhodnimi trav- matičnimi izkušnjami. Sistematični pregled literature je pokazal, da je pandemija bolezni COVID-19 dodatno povečala že obstoječe težave beguncev in prispevala k večji ranljivosti slednjih na področju duševnega zdravja. Prihodnje raziskave se bodo morale 47 6 0 • 2 0 2 4 The Impact of the COVID-19 Pandemic on the Mental Health of Refugees usmeriti v prepoznavanje ključnih dejavnikov, ki najbolj vplivajo na duševno zdravje beguncev v času kriznih razmer, kot je pandemija. Tako bi lahko vzpostavili ustrezne intervencije in preventivne programe, namenjene ranljivim skupinam. D V E D O M O V I N I • T W O H O M E L A N D S 6 0 • 2 0 2 4 UREDNIŠKI UVODNIK OB 60. ŠTEVILKI REVIJE DVE DOMOVINI, RAZPRAVE O IZSELJENST VU / EDITORIAL FOR THE 60TH ISSUE OF THE JOURNAL T WO HOMEL ANDS, MIGRATION STUDIES TEMATSKI SKLOP / THEMATIC SEC TION DUŠEVNO ZDRAVJE V KONTEKSTU MIGRACIJ / MENTAL HEALTH IN THE CONTEXT OF MIGRATION S a n j a C u k u t K r i l i ć Mental Health in the Contex t of M igrat ion: I ntroduc t ion to the Thematic Sec t ion D i n o M a n z o n i , L i l j a n a Š p ra h The I mpac t of the COVID -19 Pandemic on the Mental Health of Refugees : A Systematic L i terature Review M oj ca Va h J e v š n i k Navigat ing I ntegrat ion and Emotional Distress Dur ing Vulnerable Stages of L i fe : The Case of S lovenian Repatr iates From Venezuela M a r t i n a B o f u l i n Three’s a Crowd? 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Fra n ce s co D e l l a P u p p a Prac t ic ing Mult i -S i ted Ethnography : Ref lec t ions, Strategies, and Tools for Qual i tat ive Research on Transnat ional M igrat ion Ya s s i r A l i M o h a m m e d Sudanese M igrat ion and Dest inat ion Countr ies : Motivat ion Fac tors and the Role of Gender 602 0 2 4 9 7 7 0 3 5 3 6 7 7 0 1 3 ISSN 0353-6777 ISSN 1581-1212 D V E D O M O V I N I • T W O H O M E L A N D S 6 0 • 2 0 2 4