**1. Introduction**

In 2015, the ongoing wars and conflicts in the Middle East and Africa led to a dramatic increase in refugees making their way to Europe crossing the Mediterranean [1]. Most of the refugees originated from Syria, Afghanistan, Iraq, and Central Africa. Many of them have been subjected to stressful and adverse experiences on the individual, family, and community level, as reflected in high rates of mental health issues during the postsettlement period [2–5]. There is a large body of literature showing that refugees experience mental rather than physical impairments [5–7]. A study published by the German Federal Chamber of Psychotherapists showed that about half of adult refugees residing in Germany suffered from mental illnesses such as post-traumatic stress disorder (PTSD) and depression [2]. In addition, the literature reveals that prevalence rates in mental disorders were frequently increased in war refugees, even many years after resettlement [8]. Therefore, it seems important to understand the factors that predict postmigration stress and adverse mental health in order to promote refugees' long-term mental health.

Many refugees are dealing with loneliness and the experience of loss [9,10]. Refugee families are often separated by conflict-induced displacement [11,12] or the migration policies of the host country [13]. In some cases, family members are left behind to seek asylum in the hope of eventual reunification [12]. In Germany, family reunification is linked to a residence or settlement permit [14]. Due to the growing number of asylum applications in 2015 and 2016 [1], the duration for the decision-making in asylum procedures increased

**Citation:** Belau, M.H.; Becher, H.; Kraemer, A. Impact of Family Separation on Subjective Time Pressure and Mental Health in Refugees from the Middle East and Africa Resettled in North Rhine-Westphalia, Germany: A Cross-Sectional Study. *Int. J. Environ. Res. Public Health* **2021**, *18*, 11722. https://doi.org/10.3390/ ijerph182111722

Academic Editor: Paul B. Tchounwou

Received: 13 September 2021 Accepted: 29 October 2021 Published: 8 November 2021

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from 8 months on average in 2015 [15] to 18 months on average in 2018 [16], which in turn led to delays in family reunification applications. This situation can be seen as a serious threat leading to high levels of psychological stress, as those affected have limited coping capacities in the host country, e.g., family support resources, which is in line with Lazarus' psychological stress and coping theory [17]. Consistent with Hobfoll's conservation of resources theory [18], which focuses on the change and conservation of resources in the context of environment and social processes, we argue that refugees separated from their family experience time pressure as a type of psychological stress. Time pressure occurs when a person has less time available (real or perceived) than is necessary to complete a task or obtain a result [19], such as family reunification. Evidence suggests that the presence of a family member in an individual's postmigration country has a positive effect on postmigration stress [20]. In contrast, family separation is shown to be associated with reduced health-related quality of life (HRQoL) [21,22]. Furthermore, a lack of information about family members left behind is associated with mental illnesses such as depression, somatization, anxiety, and PTSD, while information about family members left behind is associated with better self-rated health [3]. Thus, we hypothesized that refugees who are separated from their family members (particularly from spouse or partner and/or child or children) experience adverse mental health and time pressure as a type of psychological stress after resettlement.

Time pressure has one objective dimension and one subjective dimension [23]. The objective dimension embraces a measurable time shortage, e.g., not having time for an activity, while the subjective dimension is a predominantly subjective emotional experience of fragmented time, demands to do things faster, or feeling rushed. To the best of our knowledge, no study so far aimed to explore the association between family separation and subjectively perceived time pressure, a potential social determinant of health [24], in refugee populations. Previous research on subjective time pressure showed associations with mental health problems such as anxiety and depression [25,26], and a causal relationship in either direction is conceivable [19,27].

Several studies show that family separation may affect refugees' mental health [22,28,29] and well-being [30]. A previous study conducted amongst adult refugees resettled in Australia [31] focused on the impact of family separation and worry about family and friends on post-traumatic stress symptoms and psychological distress. The study also examined the contributions of demographic and postmigration stressors, with older age and female sex found to be more consistent predictors than family separation and worry about family and friends. An older study has also shown that a long asylum procedure and a longer stay in the host country can have a negative impact on refugees' overall health situation and well-being [32]. Concurrently, there are often barriers to receiving medical services and accessing the social system [33]. Although a study by Wetzke et al. [34] shows that primary care is most needed directly after arrival, refugees in Germany still have limited access to medical care during their asylum process [35]. From a public health perspective, information is needed on factors that promote and impair health among refugees seeking protection in Germany.

Thus, the goal of our study was to investigate the impact of separation from spouse or partner and/or child or children as a nuclear family on mental health and subjective time pressure, as it may be a stressor involved in the stress–distress relationship, among refugees in North Rhine-Westphalia, Germany, considering sociodemographic and postmigration factors as the main relevant confounders.

#### **2. Materials and Methods**

#### *2.1. Sample Description and Procedure*

Data come from the FlueGe Health Study (FHS), a cross-sectional study administered by Bielefeld University, conducted on refugees from the main countries of origin that contributed to the European refugee crisis in 2015 and 2016 in the region of East Westphalia-Lippe in North Rhine-Westphalia, Germany. The data were collected between February and

November 2018 and included personal interviews and physical examinations, carried out by trained interviewers. Informed consent forms, information letters, and the questionnaire were translated into the following five languages by Kantar Public, a consulting and market research institute: Arabic, Farsi, Kurmanji, English, and German. Participants were recruited from shared and private accommodation in eight different locations in East Westphalia-Lippe, with municipal cooperation partners and social workers providing access to potential participants. The FHS included all participants who were willing to participate (convenience sampling) and signed informed consent, excluding those who were younger than 18 years of age; could not speak Arabic, Kurmanji, Farsi, English, or German; or had been in Germany for more than five years. Prior to the interviews, all potential participants were personally informed by the field team about the aims and procedure of the study during an on-site visit with an invitation to participate. The field team consisted of an academic researcher and trained interviewers in the required languages. All potential participants who could not be contacted in person received a letter informing them of the study aims and procedure and asking them to contact the field team by telephone. Approval from the Ethics Commission of Bielefeld University was obtained before the data were collected to ensure ethical and data protection guidelines were followed.

A total of 827 men and women aged 18 to 75 years were assessed for eligibility and invited to the study. Of these, *n* = 130 had an inadequate language level, and *n* = 371 refused to participate in the study. The main reasons were personal reasons and no interest in the research. A total of 326 men and women signed informed consent (recruitment rate, 46.8%) and completed the study. Prior to data analysis, the FHS study population was reduced to individuals with a spouse or partner and/or a child or children (*n* = 208).

#### *2.2. Measures*

### 2.2.1. Time Pressure

Subjectively perceived time pressure was assessed using a single-item question from the German Socioeconomic Panel (SOEP): "Please think about the last four weeks. How often did it occur within this period of time that you felt rushed or pressed for time?" with five possible responses: "Always", "Often", "Sometimes", "Seldom", and "Never" [36]. In order to identify associated factors, time pressure was dichotomized with participants who rated "always" or "often" being categorized into the time-stressed group, whereas those who rated "sometimes", "seldom", or "never" were categorized into the not time-stressed group, which is consistent with the literature [37].
