Characteristics of the participants
A total of 19 participants (12 stakeholders, 7 ARMs) completed the FL interviews (Table 1).
Stakeholders were 4 men and 8 women. The age range was 26 to 43. ARMs included 5 men and 2 women with different professional backgrounds. One of them had no job, one was an interpreter, two were workers, one participant was a farmworker and two were cultural-mediators. Their ages ranged from 25 to 46 years. In terms of country of origin, three participants were from Nigeria, two from Morocco, one from Afghanistan and one from Pakistan. The time since resettlement ranged from 2 to 10 years. In terms of their legal status, three participants were regular and documented migrants, three were asylum seekers and one was a refugee.
Twelve stakeholders and eight ARMs attended separated sessions of FG discussion (Table 1). Stakeholders included 5 men and 7 women, with age ranging from 26 to 45 years. ARMs were 5 men and 3 women, with age ranging from 25 to 43 years. In terms of country of origin, four were from Nigeria, one from Afghanistan and three from Pakistan. The time since resettlement ranged from 2 to 10 years. Five participants were regular and documented migrants, one was an asylum seeker and two had a refugee status. In terms of job position, one participant was a driver, three were workers, three were cultural mediators and one was an assistant chef.
Three ARMs and five stakeholders participating in the free listing interviews were considered knowledgeable about the topic and were invited to contribute to FG discussions.
Free listing interviews
Problems and functions, and stakeholders’ difficulties in working with ARMs.
Salient problems and functions in response to each question are summarised in Table 2.
Frequency reflects the number of times a term was stated among ARMs and stakeholders in response to a question. The Additional file includes the descriptions of each problem mentioned by participants during the FL interviews and the comparison of salient problems and functions, and stakeholders’ difficulties in working with ARMs. Salient issues and themes that emerged during the FL interviews with ARMs and stakeholders were discussed during the FGs, as reported below.
Focus group discussions
Main themes
During FG, we asked participants to discuss and comment on answers provided not only by stakeholders themselves but also by ARMs, in order to stimulate a discussion on the results and to compare any discrepancies. The main themes emerged during the FG discussion with stakeholders and ARMs are summarised in Table 3 and discussed as follows.
Stakeholders
Job Issue. The concept of “job” had different meanings to stakeholders compared to ARMs: if for the latter the job seems to be essentially linked to an immediate and urgent economic issue, for stakeholders it represents the first step of a long-term project. The professionals’ difficulty was to make this project acceptable, because often ARMs could not understand it in the way it was originally conceived for them. In relation to job, a worker said:
“We ask ourselves a series of questions and we see certain problems because we are in a different system of life, because certain primary needs are already satisfied and, therefore, we can take care of other problems and notice other things, which take a backseat when there are no work and no documents” (O6, social worker).
Precarious living circumstances. ARMs often struggle with many living difficulties in the resettlement country – job, housing, documents – leading to inevitable consequences on mental health. The lack of a document, the delay of an appointment, the absence of a response from institutions, could represent a matter of life or death, real or symbolic, with intense emotional reactions. Sometimes stakeholders acknowledge to underestimate ARMs’ essential needs to be satisfied and their attempt to prioritise them, especially while developing projects to improve social inclusion and integration.
Housing and sharing spaces. Basic needs also included finding a home. Housing was a challenging factor due to administrative and racial issues. In some cases, ARMs were forced to live in shared and overcrowded contexts, where living difficulties and conflicts could emerge more frequently.
Isolation during the pandemic. Stakeholders considered social isolation as an important issue for ARMs. Nevertheless, they acknowledged it was not reported as a main problem by ARMs. Regarding this point, a worker said:
“During lockdown I suffered from loneliness, I couldn’t see my family and friends. People with a migration background were required to leave their family of origin and friends. Maybe they have already faced it up. They felt loneliness but maybe in a different way, because in general we always have the possibility to be close to the people we love” (O2, legal worker).
Thus, in stakeholders’ perspective, ARMs had already dealt with the distance from their beloveds, allowing them to tolerate and accept loneliness to an extent during the pandemic.
Discrepancy of meanings in needs. Another emerging theme concerned the distance between stakeholders and ARMs in health needs. Regarding this topic, some professionals acknowledged a difficulty in matching their own and ARMs’ expectations, especially about mental health. Some problems concerned both the different ways to express suffering, and the identification of their actual distress, without anticipating and taking for granted others’ requirements.
“There are categories that are purely ours, I mean Western, and that many times migrants are not able to name as we name them because we invented those names” (O1, social worker). “Maybe we have the inclination…no, surely we have it … to project our categories on migrants, both cultural and personal categories, but the problems migrants perceive are much more concrete, less idealized. Sometimes … More than a priority, mental health needs are our projection because we identify ourselves with the migrant.” (O4, mental health professional).
Psychological suffering/distress. Even though stakeholders found it difficult to combine different perspectives on needs and requirements, they recognized psychological suffering actually exists. They acknowledged pain feelings in ARMs such as sadness, anger, frustration, hopelessness and worries experienced in everyday life.
Life project concepts. The difficulty to combine different perspectives also concerned governmental reception and integration projects for ARMs and the pathways of care within mental health services.
“The reception project is complex and concerns many aspects…health, work, learning the language…it’s a rigid structure that is necessary to live in this context, but it is also necessary from a bureaucratic point of view for reporting. But this rigid structure is not always adaptable to all people…the model we propose is like: learn the language so that you can find a job, so that you can have training and contracts, so then you can have the documents… They are channelled into this track where there are various objectives to be achieved and I think it is a bit suffocating as a structure” (O6, social worker).
In addition, a mental professional stated:
“It is difficult to go further, even if they came for a visit…time after time someone could find a sense in the care we offer, but at the beginning it’s difficult because we are not able to reflect their needs” (O3, mental health professional).
Therefore, stakeholders realised how important it is to signify the project and to make it shareable with ARMs so it can be turned from “theory into practice”. Sometimes, conflicts on expectations could emerge, making it difficult to understand who is lost.
Taking care of oneself. Compared with the way ARMs reported caring for themselves, stakeholders noted that not all the activities matched with those they mentioned. What struck them most was the “waiting for” theme. It does not always coincide with a passive attitude as they thought, but on the contrary it seems to require a great effort to be carried on:
“Waiting and being patient can be seen as a way of caring. We ask them to be patient so many times… I’m surprised that they put it in this section, that they connect it to a kind of exercise of caring and patience” (O1, social worker). This new consciousness had a cathartic value for stakeholders because they realized something they were not completely aware of before: “When I’m in front of someone with a passive attitude I get angry, I get frustrated, but now I realized that this is a way of caring, so I will have a different approach and relate them in a different way” (O5, legal worker).
Vulnerability. Stakeholders also reflected on how often they think about ARMs as a fragile person, thus implementing an assumption of over-vulnerability:
“When I was asked the question, I didn’t think to answer that many people are empowered by telling themselves that they are leaders of their own lives, that they will guide their life, that there is hope and a future.” (O4, linguistic-cultural mediator).
Moreover, the pandemic has created a condition of “shared vulnerability”, involving all human beings. This condition made it possible to establish a greater empathic closeness with the condition of ARMs, opening up to numerous questions:
“If this emergency situation reflected a universal human weakness, how did migrants feel before? Does it mean that vulnerability before was greater on one side than on the other?” (O4 mental health professional).
Being invisible. During the pandemic, social professionals’ perception of their role was “to be invisible” for institutions. This invisibility was manifold: it affected professionals, ARMs and all the vulnerable groups, as the “last of the last”. An example of this perception concerns both the absence of proper prevention and control measures for ARMs, and the lack of protection and guidance for professionals.
Bureaucracy and access to services. Public services do not represent a reference point for ARMs, and all stakeholders agreed on this topic. This was perceived largely during pandemic, when all services limited their access and slowed down their activities, leading to a general disorganisation. These difficulties had consequences on major practical issues for ARMs, such as the renewal and the release of documents, developing strong feelings of frustration, anger and confusion.
Digitalization. Due to the pandemic, “digitalization” of services further complicated access because all activities required online procedures. Not all ARMs had digital literacy and many lacked the possibility to have devices and a good internet connection. For example, distance learning for ARMs families has been a challenge because of the struggle in finding tools and using technology. Digitisation had consequences even in terms of preventing the face-to-face relationships, that are essential in fostering processes of mutual understanding.
Migrants, asylum seekers and refugees
Access to services. The first problem ARMs discussed was “access to services” and the immediate consequences on their administrative status (release and renewal of identity documents). Locally, the lack of documents has consequences on the possibility to obtain regular employment contracts and to approach new job opportunities:
“…everything was closed, it was not possible to work…administrative services were almost closed and moreover police headquarters, banks, the post office, the tax agency…everything was closed” (M3, male). Another participant said: “My documents were expiring, I had an appointment at police headquarters but they postponed it, so they expired…without documents I cannot renew my job contract…” (M2, female).
Digitalization. The perception of services’ disorganisation was related to the sudden implementation of digital access. However, “digitalization” also had a positive value. In fact, many recognised the importance of this “digital revolution” because those people who previously had difficulties in using technology were forced to adapt and to learn new skills:
“This is a telematics revolution, thanks to the pandemic. This is a positive aspect that allowed the development of technology in Italy. People who didn’t even know how to turn on a computer or go on the Internet to see their personal files…had to learn how to do it!” (M1, male).
Limitation during pandemic. Another problem concerned movement restrictions within the Italian context and towards the Country of origin. For example, a Moroccan participant said:
“…our COVID-19 deaths were buried here in Italy, without being able to be transferred to the country of origin. Their corpses had to stay here because Morocco didn’t accept them coming from a red zone like Italy” (M6, male). Due to limitations and reductions in services, some migrants were not able to exploit opportunities that had been offered by the Government before the pandemic (e.g., language and profession classes).
Cultural and linguistic barriers. A discussion arose around the language barrier and the experience of isolation that sometimes is generated due to the impossibility to communicate their view point in their native language and adopting their cultural background:
“There are some situations where you feel isolated, in dealing with others to communicate your view point, maybe it’s because the language barrier…also because normally I tend to speak English, even when I speak Italian…I think, I need and I want and always tend to communicate my view point in my own language, in my own ground” (M3, male).
Racism. Racism emerged during individual interviews as a widespread problem, although they reported experiences of racism described as “moderate” in the European context. However, racism is condemned in all its forms mainly as a manifestation of the difficulty to accept diversity:
“…racism is a very heavy word…discrimination hurts a lot, it depends on culture, on life people lead, which can generate this feeling and this behaviour. Unfortunately, it’s a language that we find everywhere, it doesn’t include only one Country, we sometimes find it within the same culture, religion, doctrine. Racism can be named as an element of survival…to survive you have to be very rude, violent, hateful… all these terms can create a vocabulary that is called racism…” (M6, male).
The circumstances in which people live could make the person a victim of racism. Being in a vulnerable situation, like ARMs, could represent one of these circumstances, leading to discrimination experiences:
“not every finger is the same in my hands, similarly all people are also not in the same category. It depends only on circumstances and situations…” (M7, female).
Human vulnerability. The pandemic made the vulnerability “universal and shared” (M6, male). On a global level, it connected Italy with other countries in the world; on a local level it equalizes the local population and ARMs as human beings. In the COVID-19 emergency all people are vulnerable in the same way and unified by the uncertainty of the situation.
Psychological suffering and distress. The pandemic generated strong feelings of fear, frustration and confusion even among ARMs about what was happening:
“both migrants and Italian citizens had not understood the game… we had not understood anything…there is the coronavirus, people are dying, we were scared…” (M5, female).
One participant also reported that coronavirus assumed “the meaning of death”, generating extreme fear. However, during the discussions, it also emerged that the initial confusion about what was happening led some people to distrust the information that media was passing on, producing denialist ideas:
“…but the ways it is here in Italy is making me and other people to be confused … to understand if what is telling us is real or not…” (M4, male). All participants agreed that this emergency situation was an additional source of stress further exacerbating their already insecure and unstable situation: “…there are also your personal problems, your personal issues, your health issues, you are depressed, you are frustrated…” (M7, female).
Taking care. In order to cope with strong feelings and psychosocial problems, the participants stated that they try to rely on themselves, on their personal resources and adaptation skills:
“…because when we decided to leave our country, we were ready to deal with everything that could happen (…) An immigrant who came here is a person who has to sow if he wants to reap. He has to take care of himself, there is no one that gives him anything” (M6, male).
All participants fully agreed on this point:
“it all depends on me, it’s all up to me… you have to settle things by yourself, so you don’t have to depend on anybody” (M1, male) and “It’s a game of your mindset. How do you deal with the situation? How do you face the worst circumstance? It all depends on the human being” (M2, female). Despite the difficult circumstances, they try to “keep them motivated” (M6, male).
The role of context. There were barriers to personal caring and to the development of migration projects. Among these obstacles, participants named both practical aspects, including the lack of documents and the language barrier, and emotional aspects, including feelings of insecurity, fear and uncertainty. Participants emphasised the importance of the context in defining their own well-being.
“The person who has everything and the person who doesn’t have everything… it has an impact on their life and obviously when you don’t get the required answers… It definitely frustrates an individual. For example, if a person doesn’t qualify for their documents, it definitely affects them or the other person… all these things are absolutely relevant because it’s a psychological impact. Certainly, the environment and the situation play a very important role in building the personality of an individual… if you are happy certainly then things will be… I think they will have a new flavour, it will certainly have an impact on your physical life, it will have an impact on your mental life” (M4, male).
When ARMs read the use of drugs and alcohol among stakeholders’ answers, they underlined that this behaviour does not only arise in the host country, but it could already exist in the country of origin:
“It depends on the country and on the environment. As far as I know, immigrants who use drugs and alcohol are not people who use them to forget their problems. Some people were already addicted when they came to Europe and are continuing with the addiction” (M1, male).
During the discussion, some participants agreed that they rely on their social networks for problems that are difficult to manage on their own:
“you have to face small and big problems by yourself, sometimes the situation is out of your control, you need help from the people around, sometimes you need help from the people you are living with” (M2, female).
Bridging two worlds. A migrant who has been resettled for many years with documents and a job introduced the possibility to ask for help from services:
“Fortunately, we immigrants see Italy as a country which can solve our problems, and this is true. We are able to solve our problems in many ways but, if we are not able, there is always someone who gives us help, these people are maybe individuals, or it is the administration, the public services, the institutions” (M6, male).
For the participants, the host country enables them to solve practical aspects (document, job, housing, education). On the other hand, in order to deal with emotional problems, resorting to personal resources also implies a “return to their stranger side” (M3, male), the most familiar for themselves, the most unfamiliar for others in the host country. Their background remains essential whenever they need to obtain support. It is necessary to bridge and keep alive the connection between the two worlds they belong to: the host country and the country of origin:
“…the stranger part stays as a valid part always… for example, prayer is a psychological support to keep me calm. On the other hand, material salvation is given to me by the Italian community…” (M5, female).
Prayer and religion represent important ways to revive their belonging.
Based on the theoretical framework of the Social Ecological Model, the COVID-19 pandemic, as a part of the chronosystem, had a substantial effect among asylum seekers, refugees and migrants [17]. While this group was already confronting with substantial challenges, (i.e. in the access to public services, legal issues, and/or poor housing) the pandemic reshaped many aspects of the daily life. This sociohistorical public health emergency had a crosscutting impact on the well-being of these individuals. The emerged themes occurred at different levels from microsystem to macrosystem. At individual level, the pandemic generated strong feelings of fear, frustration and confusion, aggravating already insecure living situation. At the context level, there have been social, economic, and political measures impacting ARM’s immediate environment. Lockdown measures constituted barriers for communicating with families (also when based in the country of origin), for accessing workplaces and social and legal services, affecting at the same time the mesosystem. The exosystem was also impacted: the reduction of social networks limited the transition process for those planning to reach other countries. Finally, at macrosystem level, ARMs needed to reinforce the bridge between the host country and the country of origin as a way to manage emotional and practical aspects. In addition, the pandemic generated a global and local connection between countries around the world in terms of shared vulnerability as human beings. The interactions and connections between all these levels were recognized to be strong determinants of ARMs’ mental health.