An exploratory follow-up study on the relationship between asylum application outcomes, language competence, psychological well-being, and social integration in Chinese fleeing religious persecution

Massimiliano Aragona1, Miriam Castaldo1

1The Italian National Institute for Health, Migration and Poverty (INMP), Rome, Italy.

Summary. Aims. This study explores the long-term outcome of Chinese refugees arrived in Italy fleeing reported religious persecution. Methods. Post-migration living difficulties (PMLD), psychological well-being and language proficiency about 9 years after the first arrival are the outcomes compared in two groups. One group includes persons that had not yet received a form of international protection, still living in Italy without visa (undocumented asylum seekers - UAS). The comparison group includes persons that had received a visa for international protection (refugees - R). The Chinese versions of the World Health Organisation - Five Well-Being Index (WHO-5) and the List of Migration Experiences (LiMEs) were administered. Results. Three UAS and three R were compared. R reported higher pre-migration traumas and PMLD in the two years after the arrival in Italy. At the evaluation about 9 years later, UAS reported lower scores at the psychological well-being and more PMLD. Moreover, they had not learned Italian, while R were fluent in the host language. Conclusions. Considering that the main difference between the two groups was having or not received a visa recognizing the reliability of their asylum request, we hypothesize that this is a key variable explaining the long-term well-being and social adjustment of these persons.

Key words. Asylum seekers, mental health, migration studies, refugees, resettlement, social disadvantage.

Uno studio esplorativo di follow-up sulla relazione tra esiti delle domande di asilo, competenza linguistica, benessere psicologico e integrazione sociale nei cinesi in fuga dalla persecuzione religiosa.

Riassunto. Obiettivi. Questo studio esplora gli esiti a lungo termine dei rifugiati cinesi arrivati in Italia in fuga da riferite persecuzioni religiose. Metodi. Le difficoltà di vita post-migratorie (PMLD), il benessere psicologico e la competenza linguistica a circa 9 anni dal primo arrivo sono gli esiti confrontati nei due gruppi. Un gruppo comprende persone che non hanno ancora ricevuto una forma di protezione internazionale e di conseguenza senza permesso di soggiorno (richiedenti asilo senza documenti - UAS). Il gruppo di confronto comprende le persone che hanno ricevuto un visto per la protezione internazionale (rifugiati - R). Sono state somministrate le versioni cinesi dell’OMS-5 per il benessere e del LiMEs per le esperienze traumatiche e le difficoltà di vita pre e post-migratorie. Risultati. Sono stati confrontati tre UAS e tre R. I R hanno riportato maggiori traumi pre-migrazione e più PMLD nei due anni successivi all’arrivo in Italia. Alla valutazione di circa 9 anni dopo, gli UAS hanno riportato punteggi più bassi nel benessere psicologico e un maggior numero di PMLD. Inoltre, non avevano imparato l’italiano, mentre i R stavano meglio, avevano meno PMLD e parlavano correntemente la lingua del paese di approdo. Conclusioni. Considerando che la principale differenza tra i due gruppi era l’aver ricevuto o meno un permesso di soggiorno che riconoscesse l’attendibilità della loro richiesta di asilo, ipotizziamo che questa sia una variabile chiave per il benessere a lungo termine e l’adattamento sociale di queste persone.

Parole chiave. Disuguaglianze sociali, immigrazione, richiedenti asilo, rifugiati, salute mentale, stress.

Introduction

Refugees and asylum seekers tend to have high rates of mental health problems, including post-traumatic stress disorder (PTSD) and depression1. The literature is mainly concentrated on PTSD and trauma-related symptoms2, which are primarily due to the traumatic and stressful events occurring in the refugees’ life. However, while in the first years of resettlement sufferance due to PTSD is the main problem, five years later depressive and anxiety disorders are also increased3. Evidence suggests that initial high rates of PTSD are related to exposure to traumatic events before migration, which often represent the reasons for leaving the country of origin4, during the migratory journey5 or in migratory landing countries6, while poor social integration, problems in having regular visas7, and difficulties in accessing health services may contribute to higher rates of mental disorders in the long-term3. The politics of migration in the countries where refugees are resettled are also crucial. For example, a study showed that two years after their arrival, refugees with high social protection and permanent protection visas (PPVs) were healthier than those who had arrived without valid visas. The latter were detained for unauthorized arrivals and received only temporary protection visas (TPVs), and after two years they had more overall distress, anxiety, worries, depression, and PTSD symptoms, than refugees with PPVs. Moreover, they also showed less improvement in their English language skills, social withdrawal, and higher levels of distress in relation to a wide range of post-migration living difficulties (PMLD)8. Interestingly, PMLD have a negative impact not only in adjustment conditions, leading to anxious-depressive reactions. They are a significant risk factor also for PTSD, probably through a re-traumatizing effect on individuals who are already vulnerable and with a low capacity to handle resettlement stress due to their previous traumatic history9.

In the world, there are 36.4 millions of refugees, 6.1 millions of asylum-seekers, and 5.3 millions of people in need of international protection10. Interestingly, the mental health conditions of refugees are studied more extensively for those coming from some countries, while for other proveniences studies are very rare. For example, a rapid PubMed review (performed 31 January 2024) with the string [(“… refugees” OR “… asylum seekers”) AND “mental health”] retrieved 238 studies on Syrians, 48 on Iraqi, 41 on Afghans, 38 on Ukrainians, 34 on Somali, and only 4 on Chinese. Of the latter, two are not focused on our topic11,12, one is unavailable on the web13, and one is a recent study on Chinese asylum seekers14. Accordingly, the mental health problems of Chinese asylum seekers and refugees are largely understudied in current scientific research.

At present, available scientific research on Chinese asylum seekers and refugees is mainly based on worshippers of different religious communities including Evangelic domestic-Protestant churches unrecognized by the Chinese government, informal churches, and “new religious movements”, such as Almighty God Church15. They arrived in Europe around 2015 reporting oppression, discrimination, persecution, and human rights violations in China following their conversion to the Christian faith, as reasons for their forced migration16. In a sample of these asylum seekers, it was found a high prevalence of mental distress including PTSD, Depression, and Adjustment Disorders16. Moreover, in Chinese asylum seekers the likelihood of PTSD appeared to be significantly influenced by the modulation effect performed by three PMLD: “Feeling that you do not know where you will lend up tomorrow”, “Loneliness and boredom” and “Not being able to find work”14. Some years later, during the Italian lockdown due to the Covid-19 pandemic, an online ethnographic survey on the same group of Chinese refugees found a worsening of emotional conditions (most stated that they “felt bad” and “very bad” both for themselves and out of concern for their families who were in China during the epidemic), but also the protective function of religious communities with respect to the manifested malaise17. However, due to the rarity of studies on these populations, no data, apart from those mentioned, are presently available regarding the long-term development of these conditions in the host country.

This is a short descriptive report that presents the situation of six Chinese Christians belonging to domestic churches in China and who have applied for international protection in Italy for religious reasons. They arrived in Italy starting from 2015 but their asylum requests had different legal outcomes.

Three of them were finally recognized as refugees and received a visa to legally stay in Italy. On the contrary, three were not recognized as refugees and had to start a legal battle for not being repatriated, which is still ongoing about 9 years after their arrival in Italy.

Two main questions will be addressed in this study:

1. How are they now? Do they show signs of mental distress?

2. Being recognized as refugee and receiving a regular visa can be a protective factor from mental distress?

Methods

Sample

In 2023, three patients contacted for the first time our multidisciplinary Service for the Evaluation of Asylum Seekers. They were reported to our service by their lawyers, whose appeals in tribunals against the Italian governmental authorities’ decision not to recognize their request for international protection were rejected several times. According to the Italian laws, after the final rejection in tribunals, the last remaining chance for not becoming definitively an undocumented migrant is to try a new submission of the asylum request to the Italian governmental authorities. To do so, new evidence that was not considered at the time of the first evaluation must be presented. These three patients were compared to three former patients randomly selected from those that our group had evaluated during a study performed in the years 2015-2017. At the time of the original study their asylum requests had been rejected, but after our evaluations their applications were reconsidered and had received a visa for international protection: two visas as refugees and one protection for “humanitarian reasons”. The three “old” patients were contacted by one of us and asked to enter the study. In this study we will call “undocumented asylum seekers” (UAS) the three new patients and “refugees” (R) the three old patients included for the comparison. Both UAS and R kindly accepted to be involved in this study.

Interview

All selected individuals were interviewed in multidisciplinary settings with the following experts available (general practitioner, psychiatrist, psychologist, dermatologist, anthropologist, and cultural mediator). They were not all present during the interviews, being involved depending from the patients’ specific needs. During the clinical interviews, in all individuals medical and psychopathological information was collected, while the anthropologist organized her interview in specific and distinct settings.

Rating scales

All subjects were asked to fulfil the following instruments:

1. The List of Migration Experiences (LiMEs). It is a check-list of 59 events that migrants may have experienced in their lives18. Item responses are rated as presence/absence of the event, and, when present, the same experience can have occurred before leaving the country, during the migration journey, and/or in Italy. Multiple ticking is allowed. The items are clustered in two main groups, namely (a) traumatic experiences (e.g. intentional traumas including rape and torture, war/conflicts, witnessing of traumatic events occurred to family members and so on), and (b) living difficulties (e.g. poverty, unemployment, problems at work, problems in the legal procedure in the host country, cultural/social maladjustment, discrimination, barriers/difficult access to health assistance, and so on). Scoring of the two factors is computed by summing the number of events experienced by the subject. The Chinese version of the LiMEs was administered in this study. For this study, the LiMEs was adapted to rate the events occurred in Italy in two distinct phases: a) in the first two years after the arrival, and b) in the present time.

2. The World Health Organization-5 Well-Being Index (WHO-5) questionnaire. It is a five-item questionnaire exploring mood, calmness, energy, waking up rested, and enjoyment of life in the last two weeks. It is available in many languages and widely used to evaluate self-perceived psychological health status19. Each item is scored from 5 (all of the time) to 0 (none of the time), cumulative scores ranging from 0 (absence of well-being) to 25 (maximal well-being). The Chinese version of the WHO-5 was administered in this study.

Data analysis

Due to the small number of subjects involved, the data are presented descriptively, with means±standard deviation confronted in the two groups.

Ethical requirements

To be included in the study, all individuals signed an informed consent in accordance with the Declaration of Helsinki. The study on Chinese asylum seekers and refugees was approved by the Ethical Committee of the Italian National Institute of Health (PRE-549/17).

Results

The subjects involved in this study were 5 female and 1 male, mean age was 38.17±4.58, with medium-low education, and first arrival in Italy between 2015 and 2017. The general profile of the two groups at the time of this study was similar: both were working and living in rented apartments with other Chinese people. The main difference was related to their legal status: all new patients were still undocumented migrants (UAS) while all old patients (R) had received a visa for international protection.

Regarding psychological wellbeing, the total score at the WHO-5 was 16±1.73 in R and 9.33±6.11 in UAS. Four items scored higher in R than in UAS, respectively 2.67±0.58 vs. 2±1 (item 1: “I have felt cheerful and in good spirits”); 4±1 vs. 1.33±1.53 (item3: “I have felt active and vigorous”); 3.67±1.15 vs. 2±1.73 (item 4: “I woke up feeling fresh and rested”); 3.67±1.15 vs. 2±1 (item 5: “My daily life has been filled with things that interest me”). Item 2 (“I have felt calm and relaxed”) was the same in the two groups: ٢±١.

The most frequently reported pre-migration traumas were related to intentional violence during arrests and in detention structures. All patients reported isolation, deprivation of sleep and light, food and water. Torture was acted out in a timely manner after interrogations aimed at obtaining information about the organization of Christian house churches and their participants. Buckets of ice water thrown on the body and blows to the head and under the soles of the feet with blunt objects were frequent. Three women reported sexual violence. The number of pre-migration traumas was higher in the R group (9.33±1.53) than in UAS (4.67±0.58) (figure 1).




The number of living difficulties before leaving China was high and similar in the two groups (18.33±7.57 in UAS vs. 17±9.85 in R). After the arrival in Italy, their number was higher in R (19.33±4.62) than in UAS (15.33±2.08 in R). On the contrary, at the time of this study the number of living difficulties was much higher in UAS (14±2) than in R (9±7.81) (figure 1).

Finally, after about nine years after their first arrival in Italy, all R were fluent in Italian, while the three UAS had not learned enough Italian to communicate with people outside the Chinese community.

Discussion and conclusions

This is the first study exploring the long-term outcome of Chinese refugees arrived in Italy fleeing reported religious persecution.

In their personal experience, both R and UAS reported severe pre-migration traumas, higher in R than in UAS.

In the first year R reported also more post-migration living difficulties than UAS. Overall, the two groups were enough similar at the arrival, although the R group reported worse conditions in terms of pre-migration traumas and post-migration living difficulties. Despite these baseline conditions, at the follow-up it was the UAS group the one with more problems: indeed, they reported less overall psychological wellbeing, more current post-migration living difficulties and a worse knowledge of Italian.

Considering that the main difference between the two groups was having or not received a visa recognizing the reliability of their asylum request, we hypothesize that this could be a key variable explaining the long-term wellbeing and social adjustment of these persons.

This study is in line with previous evidence suggesting that post-migration living difficulties are fundamental for the wellbeing of traumatized migrants in general9 and of Chinese refugees in particular14. Moreover, it is in accordance with one of the few follow-up studies on the effect of receiving a regular visa on the mental wellbeing and the social integration of migrants8. To that survey, our study adds the following relevant information: a) it extends the exploration on Chinese refugees, a rarely studied population; b) it provides data on the outcome after a longer period (about nine years after the arrival vs. two years); c) while in Steel and coll. the migrants either received a definitive or temporary visa at the arrival in the host country, in our case all subjects’ requests of asylum were initially rejected, but R received a visa following their appeal in tribunal, while UAS requests were rejected again and after nine years their legal status was still undecided. Another recent study goes in the same direction, reporting that the transition from low-security visas to permanent visas is helpful for the wellbeing of migrants, permanent protection being associated with significant improvements in psychological and social functioning20.

The main limitation of the present study is the very small number of subjects. This prevented the possibility to analyse the information statistically. To avoid the dispersion of information, we also decided to use the total numbers of events reported in the LiMEs but not its subscales’ scores. Despite this limitation, we think that the descriptive presentation of these data is enough interesting to be shared with the scientific community. Moreover, it can be a stimulus for planning new research in the next years, because we expect that with the 2025 Catholic Jubilee, a new group of Chinese Christians reporting religious persecution could arrive. Finally, it is important to raise awareness among the Italian authorities responsible for evaluating asylum applications, to prevent the hasty rejection of new applications from triggering pathogenic mechanisms similar to those seen with this previous group.

In conclusion, if confirmed in further studies, this evidence suggests that rejecting asylum requests of Chinese reporting religious persecutions can be a key pathogenic factor leading to psychological suffering and scarce social integration many years after their first arrival in the host country.

Conflict of interests: the authors have no conflict of interests to declare.

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