1. Introduction

The COVID-19 pandemic continues to have an unprecedented global impact. While adolescents are less impacted clinically by the virus [1–3], this 10–19 year old age group [4] has been directly and indirectly affected by the pandemic through measures to control the virus, including quarantine policies, school closures and the shift to remote learning [5–7]. As lockdowns and school closures went into effect around the world, schools across all 50 U.S. states closed in March 2020 and millions of adolescents shifted to remote learning. As of December 2020, more than two thirds of U.S. students were still not attending school fully in person, contributing to learning loss across all grade levels [8]. These measures to curb the spread of the COVID-19 virus led to prolonged periods of social isolation, which can be particularly detrimental for adolescents due to the importance of peer groups and connectedness during this critical developmental period [9, 10]. Throughout the U.S., adolescents spent more time at home and had less access to external support services. Households experienced significant stress, often resulting in reduced family functioning. Physical and psychological maltreatment from household members and caregivers increased throughout the pandemic [5, 7, 11–15].

Adolescents in the U.S. have also been indirectly impacted by the pandemic in numerous ways. As of early 2022, the U.S. has reported in excess of 57 million cases of COVID-19 and over 827,000 associated deaths, with a cumulative confirmed case rate of 16,708 cases per 100,000 persons since the onset of the pandemic. [16, 17] As of April 30, 2021, more than 100,000 minors in the United States had lost at least one primary caregiver to COVID-19 [6]. In addition, many children and adolescents have described the impact of caregivers’ stressors due to the pandemic, including financial insecurity, unemployment, health concerns, intimate partner violence, and substance use, on their wellbeing [18]. Mental health in adult and young adult populations has declined considerably with symptoms of depression and anxiety spiking in the first months of the pandemic; [19] increases in or new onset of substance use have also been observed [19] All of these pandemic-related phenomena have imposed new and evolving challenges upon adolescents, their education, their family and peer relationships, and their mental health.

Immigrants and refugees in the U.S. and other high-income countries have been particularly impacted by the COVID-19 pandemic, facing numerous and distinct risks that have compromised their health and welfare. Immigrant populations face especially high risks of infection by COVID-19, due largely to the compounding challenges of limited English proficiency, increased risk of exposure to COVID-19 due to employment in front-line services, and vulnerability to misinformation. [20–22] During the pandemic, immigrants and refugees in the U.S. often fell through the gaps in the social safety net, and did not receive many of the services intended to support vulnerable people in the U.S., including federal relief aid [23–25]. Parental unemployment, according to a 2021 study of five cities in the U.S., increased in migrant populations with 30% of immigrants included in the survey reporting losing a job during the pandemic [12]. These persistent and intensifying socioeconomic disadvantages, lower levels of health literacy, limited health care access, and higher risk of exposure to COVID-19 have made the pandemic a particularly precarious time for refugee and immigrant households.

These general dynamics of refugee and immigrant health during the COVID-19 pandemic have had distinct impacts for adolescents in refugee and immigrant households, particularly with respect to mental health. Adolescence is a life stage replete with risks and opportunities and when important physical, social and cognitive changes occur [26, 27]. Many mental health and psychosocial challenges have their onset during this developmental stage [28, 29]. During the COVID-19 pandemic, adolescents have seen rising rates of anxiety and less adequate sleep [30], and adolescents who were forced to isolate or quarantine experienced decreases in overall mental health and increased feelings of helplessness, worry, and fear [26]. Additionally, social isolation, which has increased due to quarantines and school closures, has been found to increase the risk of depression in adolescents [10]. This isolation and lack of social connection can lead to stress [31], and throughout the pandemic, rates of youth mental health conditions, including suicidal ideation, have increased [32]. Although research on COVID-19’s impact on refugee mental health is limited, there is some evidence which suggests that COVID-19 has triggered traumatic memories in refugees, worsening their overall mental health [33], while some adolescent refugees, particularly those from the Middle East and North Africa (MENA) region already face higher risks of experiencing suicidal ideation associated with migration and stressful life events [34]. Alongside reinforcing existing health and social inequities, there is a risk that COVID-19 school closures disproportionately impact students who are already disadvantaged in terms of material support and personal and academic preparedness for home learning [24, 35, 36]. Disproportionate learning loss and educational attainment largely attributed to language barriers may contribute to the phenomenon of non-English speaking students in English-dominant communities being 50% more likely to be categorized as academically low-performing during the COVID-19 pandemic [24, 36–39].

Throughout implementation of the Study of Adolescent Lives after Migration to America [SALaMA] project, researchers have investigated the mental health and wellbeing of adolescents who come from–or who have parents who came from–the MENA region and settled in the U.S. Findings from the study indicate that alongside high levels of resilience and effective approaches to coping with challenges in resettlement contexts [40, 41], there are significantly increased levels of suicide ideation amongst adolescents born outside of the United States compared to U.S.-born students in quantitative studies in Detroit, Michigan and Harrisonburg, Virginia [34]. These students may be particularly vulnerable to the dynamics of COVID-19 and its impacts on economic stability, education quality and access, and mental health status. However, in the emerging evidence-base on the social, economic and mental health impacts of COVID-19 on students in the U.S., there is limited research focused specifically on refugee and immigrant youth, and nothing focused on youth from the MENA region. Some research has explored teachers’ perspectives on the shift to remote learning, however, the specific challenges of supporting MENA-background students through the challenges of the pandemic have not been documented. Moreover, perspectives on the impact have primarily focused on the education sector and mental health system separately, rather than exploring how mental health supports usually in place through formal and informal practices in education were impacted by the pandemic.

The COVID-19 pandemic began during ongoing data collection for SALaMA. Interviews with teachers and other service providers for adolescent refugees in Chicago, Illinois, Harrisonburg, Virginia and Detroit Metropolitan Area [DMA], Michigan, indicated the centrality of disruptions to education and services wrought by the COVID-19 pandemic, and the research team therefore incorporated additional questions focused on impacts of COVID-19 on resettled adolescent refugees into in-depth interviews conducted with educators and other service providers. The objective of this analysis, based on two phases of qualitative data collection for SALaMA, is to describe the perspective of educators and other school-affiliated service providers regarding experiences of the COVID-19 pandemic on mental health and wellbeing amongst adolescent resettled refugees and access to and quality of education and support services for adolescent resettled refugees.

2. Methods

Data were collected as part of the SALaMA study, a mixed methods study of mental health and psychosocial wellbeing of adolescent students from the MENA region, conducted in several cities across the U.S.

Sample

Key informants in all sites were involved in provision of education or mental health services for students, particularly students from the MENA region. Key informants included school administrators, managers of English language learning services and programs, teachers, therapists, staff of non-governmental organizations and/ or community-based organizations, and case workers. The sample was identified through a combination of purposive sampling and snowball sampling. In all sites, connections with specific schools and relevant organizations had been made in prior phases of SALaMA. In the first stage of research in Chicago, the research team conducted key informant interviews with school contacts as a first step, following which the school contacts provided names of services providers whom they knew of or worked with, both within and outside schools. In the second phase of interviews in Chicago, we revisited the list of key informants and conducted a follow-up interview with one key informant, while targeting more mental health service providers through key contacts in the community and local organizations. For the key informant interviews in Harrisonburg and DMA, the research team put together a list of relevant key informants who had participated in a previous phase of data collection in each site (2019 in DMA and 2018 in Harrisonburg), reached out to these key informants, and asked key study contacts in each site to add relevant individuals or update the list. Each potential respondent was reached via e mail. The research team sent a minimum of two follow-up emails to potential respondents who did not respond initially. Potential respondents sometimes indicated a colleague who would be better placed to participate in an interview on the study topics. Throughout data collection, each key informant was asked if they could think of additional relevant key informants, and the research team reached out to these recommended individuals to request an interview. A total of 46 key informants were included in the two phases of data collection in Chicago, and in data collection in DMA and Harrisonburg (see Table 1).

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Table 1. Key informants by location, position and sex.

https://doi.org/10.1371/journal.pone.0283599.t001

Data analyses

Data analysis was conducted in several phases. Based on the objectives of the study, the research team employed directed content analysis. Directed content analysis was selected as the analytic method as it fit the objectives of the study; one of the benefits of this approach is that it can be used to expand on or further describe a phenomenon or set of phenomena about which there is already some theory or research [43]. In the case of this study, there was some prior research conducted as part of the SALaMA project that indicated the relevance of these research questions. While directed content analysis may result in bias due to use of a predetermined theory or categories, in the case of the present analysis, the initial codes were drawn directly from data.

Using this approach, in the first phase, the research team reviewed all transcripts and identified preliminary themes [43]. Based on these themes, the team developed an initial codebook. To test and refine the codebook, the team employed deductive coding, which entailed selecting a single interview for all research team members to code, and in addition, pairs of research team members coded an additional interview, using Dedoose qualitative analysis software. Through this process, the team identified similarities and differences in utilization of the codebook and combined or added codes as needed. Following further revisions to the codebook, the research team re-coded the same interview, reviewed any additional discrepancies, and finalized the codebook based on further discussions. Following this, the research team–which included individuals with training in qualitative research methods, public health, social work and international development–applied the codebook to the entire dataset. At this stage, inductive coding was utilized, using the raw data to inform new or revised codes. The research team drew on Nowell et al.’s guidance regarding establishing trustworthiness through the process of thematic analysis in several ways [44]. For example, at the phase of data familiarization, the research team read and re-read interview transcripts, taking notes on potential codes, themes and interconnections. In the phase of generating initial codes, the research team kept a careful audit trail of all potential codes and codes that had been combined or deleted. In the phase of searching for themes, the team met and discussed how particular codes combined into larger themes, and all data analysis team members reviewed and approved the final coding and thematic scheme.

Based on emerging themes, frequency of code application and relevance to the key research questions, the following codes were exported from Dedoose for excerpt analysis: basic needs, caregiver engagement and supervision, online programming, student mental health, student engagement, family wellbeing, social isolation, decline in quality of programs; modes of delivery and outreach; innovative approaches; and psychosocial outreach (see Table 2 for primary thematic codes and sub-codes).

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Table 2. Primary codes and sub-codes.

https://doi.org/10.1371/journal.pone.0283599.t002

Results

Discussion

These qualitative data provide insight into the experiences of service providers offering education and mental health services to refugee and immigrant students during the first eighteen months of the COVID-19 pandemic in the U.S. Data for this study were collected at a time when return to in-person schooling seemed imminent. Participants who were expecting to return to ‘normal’ reflected on the impacts of COVID-19, thus they include perspectives of how experiences providing services during the pandemic could be brought forward towards improving teaching and engagement with students from the MENA region in the future. The findings emphasize the need for educators and mental health service providers to rebuild and strengthen relationships with students and families.

This analysis also explores service providers’ perceptions of the association between online programming and mental health challenges for refugee and immigrant students. Multiple contradictions emerged regarding online programming, participation and wellbeing; for some service providers, the pandemic spurred much-needed independence and self-sufficiency for MENA-background students, while for others, students’ nearly total lack of participation in online programming led to immense learning loss and social isolation. Nearly three years into the pandemic, there remains the dual challenge of protecting public health through measures to control the spread of the COVID-19 virus, while simultaneously supporting and promoting students’ mental health. The 2021 U.S. Surgeon General’s Advisory, Protecting Youth Mental Health, addressed the impact of the pandemic on youth mental health, stating that the “unfathomable number of deaths, pervasive sense of fear, economic instability, and forced physical distancing from loved ones, friends, and communities have exacerbated the unprecedented stresses young people already faced” [45]. Previous research conducted as part of SALaMA indicates that there are significantly increased levels of suicide ideation amongst adolescents born outside of the United States compared to U.S.-born students in Detroit, Michigan and Harrisonburg, Virginia [34]. Student help-seeking behaviors, integrated supports and mental health promotion provided in the classroom, and high-quality, targeted formal health services were significantly impacted by the pandemic. Critical factors influencing psychosocial health outcomes among this population–including school acceptance and belonging, language support and peer relationships–have been impacted and eroded during the pandemic. These findings highlight the need to ensure that acute needs that may have emerged during the pandemic are identified and addressed in the course of education and mental health service provision, whether in-person or online.

The refugee experience, intertwined with socio-economic status, compounded the negative impacts of COVID-19 for individuals and households. Prior research conducted as part of SALaMA and existing data show that prior to COVID-19, MENA-background students faced a range of stressors at school and at home and did not enter the pandemic with the same social, economic and cultural resources as other students. In this study, key informants reported that they recognized that MENA-background students were, prior to the pandemic, faced with significant challenges in integration into learning contexts. The pandemic brought to light how these challenges intersect with other inequities, and service providers reported that refugee adolescents were less able to engage in online learning and more likely to experience significant stressors at home, including challenges meeting basic needs. While the compounded impacts of the pandemic on the health and socioeconomic well-being of immigrants and refugees in the U.S. have been highlighted previously [46], the present data reveal the extent to which service providers struggled to identify and employ approaches to adequately address these challenges for their students. These findings are also echoed in research on adolescent resettled refugees’ experiences in Canada and Australia during the pandemic [36, 47], as well as other resettled refugee populations in the U.S, such as Rohingya refugees [48].

Evidence indicates that student and caregivers’ engagement in the learning process and school environment is key to achieving positive developmental and desired academic outcomes [49–51]. Relationship-building–with teachers, peers and other trusted adults within and beyond the school system–is key for student engagement and wellbeing. The closure of schools and reduction in youth programs during the COVID-19 pandemic intensified challenges faced by service providers in supporting students’ engagement [52, 53]. In addition to challenges experienced by all students during the COVID-19 pandemic, refugee students face unique struggles with integration and engagement due to pre-existing educational challenges, potential trauma exposure, and stressors related to the resettlement process [54, 55]. Marginalized communities like refugee students have limited opportunities to form trustful relationships that could support their educational needs [56].

In the light of study findings and previous research, exploring ways to expand refugee students’ opportunities to form virtual, trustful, supportive relationships is an important area for future research. Interventions that promote family involvement and students’ engagement in offline and online school settings among refugees must be tailored, taking into consideration their unique contextual factors discussed above. Interventions with families, caring adults, and students to increase youth engagement in school have been implemented, including the Family Check-Up model, which focuses both on parent participation in education and youth academic achievements, resulting in improved youth self-regulation and decreased depression [57, 58]. Models developed to address student engagement, such as the Check and Connect model of “identification, treatment and skill building among individuals and families,” could be appropriate. This model includes core elements of relationship-building, ensuring active affiliation with the school, and encouraging a problem-solving approach to student wellbeing and achievement [58]; the core concerns voiced by service providers indicated that an active approach to identifying students at-risk of disengagement or dropping out of school will be needed in the transition back to in-person education. Such interventions could be adapted and piloted to contexts addressing MENA-background students’ and families’ needs in the context of COVID-19. In addition, educators and other school-affiliated staff reported high levels of stress due to the demands of teaching and providing other support services during school closures and concerns regarding the long-term impacts of the pandemic on their students’ learning and wellbeing. Emerging research indicates that teachers have struggled to engage students and keep them motivated, which has impacted their own perceptions of self-efficacy and reinforced feelings of isolation, and that burnout is a major concern as the pandemic, and its attendant impacts on education, continues [59]. Special attention should be paid to teachers’ and providers’ training in supporting and communicating with students and their families in the virtual learning context.

These data should be interpreted in light of some limitations. Firstly, given difficulties recruiting students and caregivers to participate in SALaMA during school closures, this sample consists solely of service providers. Therefore, results can be interpreted as service providers’ perceptions of the impact of the pandemic on student mental health, for example, whereas primary data collection with students and caregivers is key to validate these findings. Inclusion of perspectives from youth and caregivers may have indicated differences in experiences and relative importance of different factors for students. Secondly, the sites were selected purposively, based on prior relationships and ongoing data collection for SALaMA, and therefore results cannot be generalized to other contexts of service providers and refugee students during the pandemic. Future research could consider the challenges and strengths that were common across the three diverse study sites but must also consider the unique community needs and protective factors present for MENA students in their local context.

Conclusion

Evidence concerning the immediate and long-term impact of the COVID-19 pandemic on immigrant and refugee students’ well-being and learning outcomes is as yet not definitive, and will emerge in the coming years. Initial research indicates that vulnerable groups, including immigrants and refugees, in the United States, experienced increased impacts, including socio-economic stressors, loss of critical language learning and mental health supports in educational settings, and higher levels of disease and death, during the pandemic. This study explored the perspective of service providers and describe and analyze their efforts to provide high-quality educational and mental health services for immigrant and refugee students from the MENA region in Harrisonburg, Detroit and Chicago. These data indicate that service providers perceived significant impacts of the pandemic on the mental health and well-being of immigrants and refugees from the MENA region, and changes in access to and utilization of key services. Despite their best efforts to provide for, connect with and support students, service providers described a context of reduced services, social isolation and high levels of stressors for students and their families. In the context of acute and long-term effects of the pandemic on education systems in the United States, these data should inform policy and programming to support immigrant and refugee students’ wellbeing and learning.