Introduction
Global displacement hit an all-time record, with 35 million people forced to leave their countries and seek refuge in other countries (United Nations High Commissioner for Refugees, 2023). Following Syria and Ukraine, Afghanistan is among the top three countries where most refugees originate. As a torn-apart country by foreign and local forces, Afghanistan has an intricate story of displacement over more than 40 years. After the religious forces seized power in 2021, the humanitarian crisis was further accelerated, putting millions of people in need of humanitarian assistance (United Nations High Commissioner for Refugees Refugee Statistics, 2023). Türkiye is one of the main destinations for Afghans, who represent the second-largest group seeking asylum, followed by Syrians (Presidency of Migration Management, 2023).
Refugees are at higher risk of poor mental health and functioning due to traumatic experiences and stressors before, during and after migration (Patanè et al., Reference Patanè, Ghane, Karyotaki, Cuijpers, Schoonmade, Tarsitani and Sijbrandij2022). A recent meta-analysis revealed that the prevalence of depression, anxiety and post-traumatic stress disorder among refugees and asylum seekers is 31.5%, 31.4% and 11%, respectively (Blackmore et al., Reference Blackmore, Boyle, Fazel, Ranasinha, Gray, Fitzgerald, Misso and Gibson-Helm2020). Similar prevalence rates were also reported among Afghan refugees and asylum seekers living in neighbouring and high-income countries (Gerritsen et al., Reference Gerritsen, Bramsen, Devillé, van Willigen, Hovens and van der Ploeg2006; Hosseini Divkolaye and Burkle, Reference Hosseini and Burkle2017; Slewa-Younan et al., Reference Slewa-Younan, Yaser, Guajardo, Mannan, Smith and Mond2017; Walther et al., Reference Walther, Kröger, Tibubos, T, Von Scheve, Schupp, Hahn and Bajbouj2020). Resource-based models of refugee adaptation (Ryan et al., Reference Ryan, Dooley and Benson2008) consider mental health an indispensable resource facilitating participation and successful integration. Therefore, mental health problems might hinder refugees’ social and cognitive capacities and skills necessary during the integration process (Nickerson et al., Reference Nickerson, Liddell, Keegan, Edwards, Felmingham, Forbes, Hadzi-Pavlovic, McFarlane, O’Donnell, Silove, Steel, Van Hooff and Bryant2019; Schick et al., Reference Schick, Zumwald, Knopfli, Nickerson, Bryant, Schnyder, Muller and Morina2016). Socio-cultural integration, one of the dimensions of integration, is the combination of social capital that refugee communities maintain or develop after the resettlement and cultural adaptation (Pennix, Reference Pennix, Miroslav, MacDonald and Haug2005). According to the Social Capital Theory (Putnam, Reference Putnam1993), social relationships provide crucial capital to people whereby they can obtain resources, access emotional and instrumental support and maintain healthy functioning. Both social bonds (contact with own ethnic group) and social bridges (contact with host community members) are necessary for successful adaptation (Ager and Strang, Reference Ager and Strang2008). On the other hand, cultural adaptation is often investigated during the acculturation process, which changes people’s values, behaviours and identities when they encounter a new culture. During intercultural contact, people might prefer maintaining their heritage culture and adopting the host community culture to a different degree (Berry, Reference Berry1997). Both social capital and cultural adaptation are conducive to mental health and functioning among refugee communities (Chen et al., Reference Chen, Ling and Renzaho2017; Niemi et al., Reference Niemi, Manhica, Gunnarsson, Ståhle, Larsson and Saboonchi2019; Tartakovsky and Saranga, Reference Tartakovsky and Saranga2022). However, conflict-related traumatic experiences and post-displacement stressors can pose a significant threat to acquiring or maintaining relationships and successfully integrating into the host community (Kurt et al., Reference Kurt, Acar, Ilkkursun, Yurtbakan, Acar, Uygun and Acarturk2021) (Tartakovsky and Saranga, Reference Tartakovsky and Saranga2022). So far, existing studies have predominantly focused on economic integration among refugees in high-income countries (Bakker et al., Reference Bakker, Dagevos and Engbersen2014; Stempel and Alemi, Reference Stempel and Alemi2021; Walther et al., Reference Walther, Kröger, Tibubos, T, Von Scheve, Schupp, Hahn and Bajbouj2020). There is a dearth of studies examining the sociocultural integration among refugees in low- and middle-income countries where the majority live in. Further, evidence on the mental health and integration of Afghan refugees is extremely limited, albeit much needed in a given socio-political atmosphere.
The present study aimed to investigate the socio-cultural integration among Afghan refugees in Türkiye by considering the role of conflict and displacement stressors. Building on the resource-based model of refugee adaptation (Ryan et al., Reference Ryan, Dooley and Benson2008), we examined the role of mental health in explaining the relationship between those stressors and socio-cultural integration. We posited that traumatic events and post-displacement stressors would be positively associated with mental health symptoms and negatively with socio-cultural integration outcomes. Mental health symptoms, then, would predict lower socio-cultural integration outcomes.
Method
Procedure
A cross-sectional, web-based survey study [2020.423.IRB3.161] was conducted between April and June 2021 (Kurt et al., Reference Kurt, Ventevogel, Ekhtiari, Ilkkursun, Ersahin, Akbiyik and Acarturk2022). Participants were recruited through a non-governmental organization providing services to Afghan refugees in Türkiye. The online survey link was shared via the social media platforms of this organization. The study inclusion criteria were (1) being above 18 years, (2) being literate in the Dari language, (3) having Afghan origin and (4) fled to Türkiye due to political and economic unrest in Afghanistan. Two screening questions (Are you forcibly displaced due to political and economic unrest in Afghanistan? and Are you coming from Afghan origin?) were asked at the beginning of the survey. Those who said yes to both were allowed to proceed with the rest of the survey. Flow chart of the participants’ recruitment is given in Fig. 1.
Figure 1. Participant flow.
Completion of the survey lasted approximately half an hour. To compensate for time and effort of the participants, they were asked to provide their contact information (either their email addresses or phone numbers) at the end of the survey. Research assistants contacted participants and sent the digital grocery check of 3.75 US dollars.
Measures
Potentially traumatic events
Part one of the Harvard Trauma Questionnaire (Mollica et al., Reference Mollica, Caspi-Yavin, Bollini, Truong, Tor and Lavelle1992) was used to measure the potentially traumatic events (PTEs) that the participants have experienced before, during and or after migrating to Türkiye. The instrument includes 17 items (e.g., “lack of food or water,” “combat situation,” “imprisonment”), each rated on a 0 (no – absent) to 1 (yes – present) scale. Sum scores are calculated as ranging from 0 to 17. Higher scores indicate a higher number of PTEs experienced by the participants. We used the validated Dari version (Wind et al., Reference Wind, van der, de la Rie and Knipscheer2017). As the items are answered on a categorical scale, internal consistency was evaluated by calculating Omega, which was 0.82 in the present study.
Post-displacement stressors
Post-Migration Living Difficulties Checklist (Schick et al., Reference Schick, Zumwald, Knopfli, Nickerson, Bryant, Schnyder, Muller and Morina2016; Silove et al., Reference Silove, Sinnerbrink, Field, Manicavasagar and Steel1997) is a 17-item scale that measures the wide range of challenges such as social, economic and legal stressors that participants have been experiencing in the last 12 months. Items are rated on a 5-point Likert Scale, ranging from 0 (not a problem) to 4 (very serious problem). Higher scores indicate a higher level of post-displacement stressors experienced in the last 12 months. The scale was translated and back translated by bilingual researchers in the present study. Any inconsistencies between the original and back-translated document were resolved by relying on the original version. The Cronbach’s alpha for this study was 0.89.
Mental health symptoms
Mental health symptoms as an indicator of psychological resources were evaluated using Hopkins Symptom Checklist (Mollica et al., Reference Mollica, Wyshak, Marneffe, Khuon and Lavelle1987) with 25 items focusing on symptoms of anxiety and depression. Participants are asked to indicate how much they are bothered or distressed by the given symptoms (e.g., feeling fearful and trembling for anxiety symptoms and feeling low in energy, slowed down and feeling lonely for depressive symptoms) in the last week, including today. Each item is rated on a 4-point Likert Scale (1 = not at all, 4 = extremely), which higher scores indicate a higher level of mental health symptoms. The scale was previously validated with displaced Afghans (Wind et al., Reference Wind, van der, de la Rie and Knipscheer2017). The Cronbach’s alpha for this study was 0.92 for anxiety and 0.94 for depression. We used the overall mean score of the scale as an indicator of mental health symptoms.
Integration outcomes
Social integration
Following the conceptualization by Ager and Strang (Reference Ager and Strang2008) on different domains of integration, we focused on assessing social bonds (contact with co-ethnic group members) and social bridges (contact with the host community) as the indicators of social integration. We used four items to measure quantity (frequency of contact) and quality of contact (valence of contact) with their own ethnic group and host community members (Barlow et al., Reference Barlow, Paolini, Pedersen, Hornsey, Radke, Harwood, Rubin and Sibley2012). Social bonds consist of the following items: How frequently do you contact people from your ethnic group? and How frequently do you have positive contact with people from your ethnic group? Social bridges consist of the following items: How frequently do you contact Turkish people? and How frequently do you have positive contact with Turkish people? Items were translated and back-translated by bilingual researchers. We combined the items for quality and quantity of contact with own ethnic group as social bonds and with Turkish people as social bridges. The Cronbach’s alpha was 0.84 for social bonds and 0.76 for social bridges in the present study.
Cultural integration
As indicators of cultural integration, acculturation orientations as maintenance of heritage culture and adoption of destination culture were measured by the Vancouver Index of Acculturation (Ryder et al., Reference Ryder, Alden and Paulhus2000). Participants are asked to rate on a 9-point Likert scale (1 = strongly disagree, 9 = strongly agree) to what extent they agree to maintain the values and norms of their heritage culture and embrace the culture of the destination country in different domains of life such as private and public domains. It has 20 items mirroring each other, with the only difference about reference to the heritage or destination culture. Example items are “I often participate in my heritage cultural traditions” (maintenance of heritage culture) and “I often participate in mainstream cultural traditions” (adoption of destination culture). Ten items referring to heritage culture are averaged to the maintenance of heritage culture, and 10 items referring to destination culture (Turkish culture) constitute the adoption of destination culture. Items were translated and back-translated by bilingual researchers. The scale has often been used for culturally diverse communities to understand their integration process in the resettlement context (Testa et al., Reference Testa, Doucerain, Miglietta, Jurcik, Ryder and Gattino2019; Zhang et al., Reference Zhang, Mandl and Wang2010). Higher scores indicate greater endorsement of the respective culture’s values, norms and practices. The Cronbach’s alpha for heritage culture maintenance was 0.83, and 0.81 for adopting destination culture in the present study.
Data analysis
Descriptive and bivariate correlations were performed using SPSS Statistics 28.0 (IBM Corp, 2021). Confirmatory factor analysis (CFA) and structural equation modelling were conducted to estimate the parameters for the hypothesized model with Mplus Software 8 (Muthén and Muthén, 1998-Reference Muthén and Muthén2003). To prevent sample size reduction and subsequent loss of power, full information maximum likelihood estimation was employed to handle missing data at random (Enders, Reference Enders2010).
We used a two-step approach in our analysis. As we used best proxy indicators for social and cultural integration outcome, we conducted a CFA in the first step to test whether the indicators adequately reflected the proposed latent factors for cultural and social integration constructs. In our model, we included cultural and social integration as latent variables and PTEs, post-displacement stressors and mental health symptoms as manifest variables. In the second step, we tested the structural equation model by using top-down model building where we included all the relevant covariates (age, sex, education, marital status, income, legal status and length of stay) and then removed non-significant paths one at a time to preserve model parsimony (Wang and Wang, Reference Wang and Wang2012). The significance of indirect predictor role of traumatic events and post-displacement stressors on integration outcomes via mental health symptoms was tested using the bootstrapping technique (1000 resampling) with 95% confidence intervals (MacKinnon et al., Reference MacKinnon, Fairchild and Fritz2007). Standardized coefficients were presented in the final model. Following model fit indices were used to evaluate the overall goodness of model fit: chi-square goodness of fit test, comparative fit index (CFI) >.90, root mean square error of approximation (RMSEA) <.08 with 90% CI and standardized root mean square residual (SRMR) <.08 (Brown, Reference Brown2006; Kline, Reference Kline2011; MacCallum et al., Reference MacCallum, Browne and Sugawara1996).
Results
Participants’ characteristics
The current sample consisted of 785 Afghans (33.8% female). The mean age of the participants was 29.60 years (SD, 9.50 years), ranging from 18 to 67 years. Among the participants, half were married (49.9%), had at least one child (50.3%) and were asylum seekers (55.2%). The mean duration of stay in Türkiye was 36.32 months (SD, 24.43 months), and the mean number of years of education was 11.35 years (SD, 4.24 years). Most participants’ monthly household income (80%) was under 300 US dollars. Demographic characteristics of the current sample (e.g., age, gender, education, legal status) are similar to those reported in a large-scale national survey in Türkiye (Eryurt and Koc, Reference Eryurt and Koç2017).
The most frequently reported PTEs were “living in a combat situation (66.4%)” and “lack of food or water (56.1%)” while “brainwashing (5.4%)” and “rape or sexual abuse (6.6)” were the least reported incidents. The details are given in Table 1.
Table 1. Sample characteristics (n = 785)
Descriptive statistics
Table 2 presents the descriptive statistics and bivariate correlations. Female gender and older age were negatively correlated with social bridges and adoption of the destination culture and positively correlated with mental health symptoms. Higher education and income level were positively correlated with social bridges, and higher income was positively correlated with social bonds. Income level was also negatively correlated with mental health symptoms. Compared to holding a legal status, asylum-seeking was negatively correlated with social bridges and positively correlated with mental health symptoms. Having no legal status was negatively associated with the adoption of the destination culture compared to holding a legal status.
Table 2. Descriptive statistics and bivariate correlations among study variables
* p < 0.05, **p < 0.01, ***p < 0.001.
Measurement model testing
CFA results indicated an overall good model fit for both social and cultural integration outcomes. The results supported our initial conceptualization of two dimensions of social integration, namely social bonds and bridges. Allowing two factors to covary (Hayduk and Littvay, Reference Hayduk and Littvay2012), the model was just identified with factor loadings ranging from 0.75 to 0.95, indicating acceptable loadings. Further, the original two factors structure of cultural integration (maintenance of heritage culture and adoption of destination culture) were supported. The final model for this measure fit the data well (χ2(168) = 469.776, p < 0.001, CFI = 0.911, RMSEA = 0.052 (90% CI = 0.047-0.058), SRMR = 0.053) with factors loading ranging from 0.49 to 0.73, indicating acceptable loading values.
Structural equation model testing
The model fit the data well, (χ2(356) = 829.104, p < 0.001, CFI = 0.908, RMSEA = 0.042 (90% CI = 0.038-0.046), SRMR = 0.052). PTEs (β = 0.267, p < 0.001) and post-displacement stressors (β = 0.452 p < 0.001) positively predicted mental health symptoms. There was a negative association between PTEs and maintenance of heritage culture (β = −0.119 p < 0.05), but positive association with adoption of destination culture (β = 0.127 p < 0.05) and social bridges (β = 0.259, p < 0.001). Mental health symptoms negatively predicted social bridges and adoption of destination culture (β = −0.342, p < 0.001, β = −0.266, p < 0.001, respectively).
The relation of PTEs and post-displacement stressors on adoption of destination culture via mental health symptoms were significant (β = −0.071, 95% CI: [−0.112 to −0.038], β = −0.120, 95% CI: [−0.175 to −0.067], respectively). That is, in our model, traumatic events and displacement stressors positively predicted a higher level of mental health symptoms, negatively predicting the adoption of the destination culture. Further, mental health symptoms predicted the relationship of traumatic events with social bridges (β = −0.091, 95% CI: [−0.136 to −0.055]) and of post-displacement stressors with social bridges (β = −0.155, 95% CI: [−0.208 to −0.097]). Similar to the adoption of destination culture, traumatic events and post-displacement stressors were associated with higher mental health symptoms, predicting a lower level of adoption of destination culture. Significant paths are depicted in Fig. 1, and Table 3 includes the direct and indirect predictions the tested model.
Table 3. Direct and indirect effects
* p < 0.05; **p < 0.01; ***p < 0.001. TE: Traumatic experiences, PMLD: Post-displacement stressors, MS: Mental health symptoms, MHC: Maintenance of the heritage culture, ADC: Adoption of the destination culture, Sbridge: Social bridges, Sbond: Social bonds.
a Confidence intervals of standardized results are reported. LLCI: lower level confidence interval. ULCI: upper level confidence interval.
Given the cross-sectional nature of the present study, the alternative model where mental health was the outcome variable and social and cultural integration were the intervening variables was tested. The model did not fit the data well, CFI = 0.847, RMSEA = 0.054, 90% CI 0.050–0.057, SRMR = 0.097. Therefore, the initially proposed model was supported and explained in the following section.
Discussion
We found that traumatic events and post-displacement stressors significantly predicted higher mental health symptoms among Afghan participants. Traumatic events also predicted a higher level of social bridges and adoption of Turkish culture but a lower level of maintenance of Afghan culture. Mental health played a significant role in the relationship between traumatic experiences, post-displacement stressors and social bridges and adoption.
Compared to the large body of research on refugee mental health, evidence on the refugee integration process is sparse, especially among those resettled in low- and middle-income countries. Therefore, our findings provide novel insights into the socio-cultural integration processes of refugees in those countries. This is the first study in a low- and middle- income country to explore the relationship between mental health and integration, considering the role of conflict and displacement-related stressors. Unlike the studies conducted in high-income income countries (Kartal et al., Reference Kartal, Alkemade, Eisenbruch and Kissane2018; Tartakovsky and Saranga, Reference Tartakovsky and Saranga2022), we found that experiencing traumatic incidents do not necessarily hamper the capacity of refugees to develop a relationship with host community members. Yet, consistent with the previous findings (Kurt et al., Reference Kurt, Acar, Ilkkursun, Yurtbakan, Acar, Uygun and Acarturk2021), they are likely to hinder maintaining heritage culture. These findings might be explained by the notion that stressful life events mobilize various coping strategies to help deal with associated psychological distress, ultimately determining the aftermath of PTEs (Lazarus and Folkman, Reference Lazarus, Folkman, Lazarus and Folkman1984). Meta-analytic evidence attests that flexibility in using different coping strategies provides an advantage in terms of psychological adjustment after stressful life events (Cheng et al., Reference Cheng, Lau and Chan2014). As such, those who experienced a higher level of traumatic events might have chosen to integrate into the host society as a coping strategy to deal with negative feelings related to traumatic events. Concurrently, they might have engaged in avoidance coping strategy and eschewed their heritage culture as it is likely to reinvigorate those excruciating traumatic memories. After experiencing traumatic events related to group membership, individuals might choose to maintain or disregard their group identity, depending on whether their group provides resources to combat stressors (Muldoon et al., Reference Muldoon, Haslam, Haslam, Cruwys, Kearns and Jetten2019). While maintaining heritage culture may not help Afghans to cope with stressors, adopting Turkish culture might provide the necessary resources to adjust to a new life. On the other hand, post-displacement stressors were not associated with any of the integration outcomes. Conflict-related traumatic events seem to play a major role in shaping the integration process, while post-displacement stressors are a more potent risk factor for mental health (Hou et al., Reference Hou, Liu, Liang, Ho, Kim, Seong, Bonanno, Hobfoll and Hall2020).
Our findings highlight the importance of mental health as an important asset for integration, requiring forming new relationships and learning about a new culture. Mental health problems might hinder the attainment of new resources, such as learning a new language and navigating in a new setting which is essential for integrating into the host society (Ryan et al., Reference Ryan, Dooley and Benson2008). However, to maintain social ties with ethnic group members or preserve heritage culture, such resources requiring energy and skills may not be necessary. Thus, it is essential to provide mental health support to foster the integration of refugees in a new resettlement context. A growing body of evidence shows that cultural-adapted brief psychosocial interventions such as Self-Help Plus (SH+) and Problem-Management Plus (PM+) might be effective in preventing and treating mental health problems among refugees (Acarturk et al., Reference Acarturk, Uygun, Ilkkursun, Carswell, Tedeschi, Batu, Eskici, Kurt, Anttila, Au, Baumgartner, Churchill, Cuijpers, Becker, Koesters, Lantta, Nosè, Ostuzzi, Popa, Purgato, Sijbrandij, Turrini, Välimäki, Walker, Wancata, Zanini, White, van Ommeren and Barbui2022; Alemi et al, Reference Alemi, Panter-Brick, Oriya, Ahmady, Alimi, Faiz, Hakim, Hashemi, Manaly, Naseri and Parwiz2023). As most Afghans lack opportunities to use healthcare services due to their legal status in Türkiye (Eryurt and Koç, Reference Eryurt and Koç2017), future initiatives to provide such psychosocial interventions are urgently needed.
Our findings on socio-demographic characteristics are important to show at-risk groups to guide the efforts of policymakers and practitioners. Similar to previous research, female gender, older age, lower education and income level were found to be associated with worse mental health and integration outcomes (Alemi et al., Reference Alemi, James, Cruz, Zepeda and Racadio2014). Compared to holding a legal status, asylum-seeking or having no legal status was associated with mental health problems and integration difficulties in our sample. Uncertainty around the asylum-seeking process has prolonged adverse impacts on the psychological adjustment of refugees because of compounded living difficulties such as unstable housing and employment (Nickerson et al., Reference Nickerson, Steel, Bryant, Brooks and Silove2011). This finding highlights the importance of stable residency status for those fleeing from violence and persecution as it provides access to basic services that are conducive to mental health and integration (Posselt et al., Reference Posselt, Eaton, Ferguson, Keegan and Procter2019; Li et al., Reference Li, Liddell and Nickerson2016; Steel et al., Reference Steel, Momartin, Silove, Coello, Aroche and Tay2011).
The present study has some limitations. First, the cross-sectional design of the study does not allow us to make any causal inferences about the relationship between the study variables. Although our hypothesized model is based on theoretical considerations and the alternative model was tested, the directions of the relationships might change. Thus, longitudinal studies investigating the hypothesized relationship are warranted. Second, online data collection might have biased our sample by recruiting only those with access to the internet and technological devices. Yet, online tools became one of the most viable options to expand the reach of surveys, especially following COVID-19 (Dron et al., Reference Dron, Kalatharan, Gupta, Haggstrom, Zariffa, Morris, Arora and Park2022). The similarity of our sample characteristics to the large-scale, nationwide study of Afghans in Türkiye supports the representativeness of our sample, hence the potential of our results for generalizability.
Further, we only focused on the socio-cultural dimension of integration. In order to provide a complete picture of integration, a comprehensive investigation including other dimensions such as economic and political is required. Lastly, the present study only included the perspective of refugees. However, integration is a two-way process (Ager & Strang, Reference Ager and Strang2008). Host community members’ attitudes and preferences are important determinants of integration (Esses et al., Reference Esses, Hamilton and Gaucher2017). Therefore, future studies might consider investigating the impact of perceived or actual preferences of the host community on refugee integration.
Availability of data and materials
The data that support the findings of this study are available from the corresponding author (C.A.) on reasonable request.
Acknowledgments
We would like thank participants who shared their personal experiences with us. We are also grateful for Dr. Zakira Hekmat and Afghan Refugees and Solidarity Association (ARSA) for their support during this study. The opinions expressed in this paper are those of the authors and do not necessarily represent the decisions, policies or views of the organizations they serve or of the funder.
Financial support
This work was supported by Koc University’s Seed Fund granted to C.A. The study funders had no role in study design; collection, management, analysis and interpretation of data; writing of the report; or the decision to submit the report for publication.
Competing interests
None.
Ethical standards
This study was approved by university’s ethics committee. The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 200.
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