A Qualitative Study Exploring the Psychosocial Needs of Male Undocumented Afghan Migrants in Istanbul , Turkey

(1) Background: Refugees and asylum-seekers from Afghanistan have been shown to be highly distressed as a result of preand post-resettlement traumas. However, little is known about the challenges that Afghan migrants endure while residing in Turkey, a population that has grown at unprecedented rates in recent years, and largely deemed illegal by Turkish asylum and settlement laws; (2) Methods: We conducted interviews with 15 Afghan males residing in Istanbul, Turkey in late 2015. A qualitative content analysis technique informed by Qualitative Description was used to analyze the data; (3) Results: Narratives revealed that motives for migrating to Turkey are driven by both a humanitarian need for protection against persecution and economic deprivation. While they are in transit, we observed that Afghan migrants are victimized, exposed to multiple traumas; and, in Turkey experience poverty, unemployment, and exploitation while living in poor conditions and receive no social assistance. Lastly, interviews revealed that their hopes reflect their motives for migrating, that is, to have a stable life and to support their families back home where ever they end up resettling; and (4) Conclusions: Our qualitative interviews clarified the harrowing and demoralizing transit experiences and the depth of exploitation and precarious living conditions that Afghans currently face. Findings have implications for asylum policies, and for delivering culturally-competent interventions that promote the overall well-being of Afghans in Turkey.


Introduction
The migration of Afghans to the European Union (E.U.) has increased dramatically in recent years with 176,000 asylum claims being made by Afghans by the end of 2015, ranking just second to claims made by Syrians [1].Factors explaining these trends include socio-economic challenges and a prolonged conflict in Afghanistan, as well as deteriorating job conditions and policy shifts calling for the expulsion of existing (undocumented) Afghan refugees in Iran and Pakistan [2].Turkey, a major transit corridor for Afghans seeking to reach E.U. countries [3], is also a place of resettlement for thousands of Afghans lodging asylum claims in recent years [4].In addition to being a transit base for Afghans, Alimia [5] suggests that a major pull factor for irregular migration to Turkey is because the country has become a hub for cheap labor, needed to contribute to its rapid development and modernization projects.Alimia's interviews with young Afghan men in Turkey and in Pakistan (en route to Turkey) show that migration patterns are also shaped by various push factors, that is, constructions of selfhood, dignity, masculinity and the need to provide for their families.Displaced Afghans resettled in industrialized nations are shown to be highly distressed as a result of being exposed to war-related traumas, and post-resettlement difficulties that encompass an array of unmet psychosocial needs [6], or stressors related to multiple losses and challenges.These challenges include adapting to a new and unfamiliar setting, for example, dealing with the loss of traditional support networks, facing a lack of income-generation opportunities, being subject to unfair treatment by members of the host society, and the lack of access to essential health, educational, and economic resources [7].These factors explain the high prevalence of poor mental health outcomes, including depression and posttraumatic symptoms, documented among Afghan refugees [6].However, new research suggests that moral injury, defined by Litz et al. [8] as 'potentially morally injurious events, such as perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations' affects the mental health of refugees over and above the impact of trauma exposure and post-migration stressors, as recently shown in a diverse sample of traumatized refugees in Switzerland [9].Afghan men may be at particular risk of moral injury especially when transgressions involve dishonorable behavior (e.g., sexual violence) toward Afghan women (who carry family honor) that men are characteristically prepared to die protecting [10].Their mental health, along with their dignity and morale, may further be affected by their inability to meet gender-role expectations of sustaining the economic well-being of their families.
But in Turkey, their lack of economic well-being can be attributed to the fact that Afghan migrants are a population that is largely considered illegal according to Turkish asylum and settlement laws that grant protection to refugees from Europe and to those of Turkish ancestry [11].Consequently, most Afghan migrants arriving in Turkey have no residence status or path to citizenship, and thus no right to work.Like many Syrian refugees, Afghans may be victim to great hostility by locals who often blame asylum seekers and refugees for driving up rents, competing with local populations for jobs, driving wages down by working illegally, and making public services such as health care less accessible to the local population [12].
In the E.U., legal challenges with regard to asylum processes prolong economic uncertainty and family separation, which have been shown to contribute to psychiatric disorders [13,14] and to poor overall health and quality of life [15,16].Underlining the continuing illegal status of Afghan refugees in Turkey, the March 2016 agreement between Turkey and the E.U. ("E.U.-Turkey Statement") provides support in Turkey for Syrian refugees and paths for their resettlement in E.U. countries, yet has no provisions for Afghans [17].Our recent cross-sectional survey of Afghan migrants in Istanbul shows that exclusionary legal processes for claiming residency, without which one cannot be gainfully employed, may be the basis for the high rates of post-migration living difficulties (poverty, isolation, unemployment, fears of being sent home, asylum challenges) that negatively impact the health and well-being of Afghans [18].And in a later study, we found that despite their poor mental and physical health status, the precarious conditions in which they live were a plausible reason for their low reported use of professional health services [19].This paper is an attempt to use qualitative, in-depth interviews to contextualize and expand on these quantitative findings in order to deepen our understanding of the migration experiences and needs of male Afghan migrants residing in Istanbul.Essentially, this study was guided by the following research question: what are the psychosocial needs of male Afghan migrants residing in Istanbul, Turkey?
The significance of this study rests on various factors.First, Afghans can be expected to continually seek safety and economic prosperity in Turkey and elsewhere so long as socio-political conditions in Afghanistan do not improve.And in Turkey, where they are essentially deemed unlawful migrants and barred from any type of assistance, their unmet psychosocial needs are likely tremendous.Therefore, understanding their motives for migrating, whether it be for safety, economic prosperity or both; their current challenges in Turkey; and, relatedly the factors that contribute to their overall mental health and well-being is needed to deliver culturally-competent community-based interventions that promote their resilience in the face of their current struggles.

Sample and Setting
A purposive sample of 15 undocumented Afghans participated in brief interviews conducted in the Dari language by the first author.Of the 15 participants, 12 had taken part in mental health surveys implemented by the study authors; an additional two were directly solicited, and a third respondent voluntarily approached the investigator.Participants were all male ranging in age from 17 to 37 years, were mostly unmarried (n = 11), with overall low levels of education (two possessed college degrees), mostly unemployed, and a length of residence in Turkey ranging from one week (n = 1), a few months to a year (n = 12) to 13 years (n = 2).Interviews lasted up to 60 min and were conducted in local cafés and public areas within the Zeytinburnu district of Istanbul over a 10-day period in September 2015.While holding interviews in public places may have potentially posed a privacy risk to participants, or discomfort for those recalling traumatic experiences, this was considered the most appropriate means of carrying-out interviews given that is was presumably most convenient for participants already congregating in the Zeytinburnu area.Conducting interviews in more private spaces such as their living quarters may have not guaranteed privacy given that migrants often live in cramped quarters, in addition, this may have posed a safety risk for the investigator as living arrangements for migrants are facilitated by people smugglers who seem to have a strong presence in Istanbul [3].

Interview Procedures
Verbal consent was obtained from participants using an information sheet approved by the first author's Institutional Review Board, which explained their rights and protections along with the purpose of the study as one that seeks to understand the 'health needs and life experiences of Afghans in Turkey'.We advertised the study in this manner to avoid presenting it as a "mental health study", which may have been perceived as stigmatizing for some.Upon gaining (verbal) consent, interviews were initiated using an interview-guide querying participants on: the factors that lead them to leave Afghanistan (e.g., "Tell me what life was like for you in Afghanistan?"),their experiences while in transit (e.g., "How did you get to Turkey?"), their migration and settlement experiences (e.g., "What life difficulties do you currently face here in Turkey?"), and their personal expectations with regard to their relocation (e.g., "What do/did you hope to gain by relocating here/relocating to England)/Germany?").Moreover, based on our prior research with Afghan refugees in southern California [20], we found that audio-recording devices were in no means helpful in increasing the receptivity of Afghans to take part in individual interviews given fears and uncertainty with regard to how their data would be used.Given their illegal residency status, we assumed that Afghans in Istanbul may have shown similar apprehension in participating.Instead, we took copious notes during interviews, documented verbatim expressions, and reflected on our findings within a reasonable time-frame afterwards to optimize recall.

Data Analysis
To contextualize and understand the experiences and needs of Afghan migrants in Istanbul a qualitative descriptive [21] approach was applied.Qualitative Description, or QD, is a method of choice when a presentation of the facts of the informants' experiences in everyday language is desired, rather than thick description and theory development.While QD stays close to the data and describes informants' experiences in a language similar to the informants' own language, researchers can "move away" from the data by providing interpretations of their findings, according to Sandelowski [22].Our qualitative content analysis technique, informed by Elo and Kyngäs [23] called for organizing data according to coherent categories informed by our interview guide, as well as subcategories informed by emerging data.For example, we created categories to include (1) 'pre-migration stressors'; (2) 'transit-related experiences'; (3) 'post-migration stressors'; and (4) 'future desires' while emergent subcategories included 'economic stress', 'witnessing atrocities', 'poverty and unemployment', and 'education', respectively.We systematically applied these sets of codes to our notes, reflections, and verbatim expressions.This assisted in identifying commonalities in the data or similar patterns and phrases through counting the number of respondents endorsing specific contents related to each topic.This process assisted in determining emerging common themes, building a story line, deciding on patterns that hold true for the data, and examining patterns in light of existing data [24].
For ensuring credibility in our findings, we used guidelines proposed by Shenton [25].These guidelines call for promoting honesty in participant responses by assuring them confidentiality as part of the informed consent process, and further, by supporting participant narratives through the provision of extensive verbatim statements (translated from Dari).Member-checking was not feasible in this setting, given the already hard-to-reach nature of this population who likely view authority figures with suspicion.

Results
Below we present qualitative findings according to key thematic categories, which were derived from topics covered in the semi-structured interview guide.These include: (1) 'motives for migrating to Turkey'; (2) 'traumatic transit experiences'; (3) 'life difficulties in Turkey'; and (4) 'hopes for the future'.Exemplary verbatim statements are presented in accordance with each theme.

Theme 1: Motives for Migrating to Turkey
Nearly all participants cited having no hope for a safe and productive future in Afghanistan due to poverty and economic distress as well as a lack of security (n = 13), given the government's inability to create jobs and the rise in suicide bombings, respectively.One individual and his entire family had fled Iran to avoid deportation after spending 10 years there.Moreover, the pessimism about conditions in Afghanistan is exemplified in one participant's statement that "it will take a miracle to fix Afghanistan" (age 27).Others (n = 3) cited direct threats from the Taliban due to prior employment as translators with the U.S. military (n = 2), or for being enlisted in the Afghan National Army (n = 1).The statements below emphasize these narratives: "I worked for the Americans in Helmand and Kandahar, and recently when the Taliban took over Kunduz, they asked people like me to turn themselves in".
"Me and my uncle had a small convenience store . . .after he was shot in the chest and killed, I sold the store, and used the money to leave"."I fled Iran with my whole family after spending 10 years there . . .they wanted to deport us back to Afghanistan".

Theme 2: Traumatic Transit Experiences
Discussions with participants uncovered the key role that smugglers play in getting Afghans to Turkey (through Iran).Many indicated being connected to smugglers in Afghanistan or in Pakistan.Participants recounted paying smugglers an initial down payment of roughly 400 Euros in order to get them to Turkey, while the remaining balance, upwards of 8000 Euros would be paid upon arriving to their final destination in Europe.When asked how they would come up with the money to pay smugglers, one participant (age 17) recounted using moneys from selling a small convenience store, run by him and his uncle, after his uncle was shot and killed by the Taliban right before his eyes.In addition, a few cited family savings and money made through sold property in Afghanistan, others cited working and saving money in Turkey.Two individuals described that their families allowed smugglers to place liens on their properties in Afghanistan to avoid the potential harm that might result from unpaid debts.
All participants recounted perilous 36-hour treks by foot through Iranian deserts, mountain passes, rough terrain, and also being locked in vehicle trunks and large containers for days in order to evade Iranian authorities.Some described beatings by smugglers (n = 5) when merely asking to rest, and being deprived of food and water during transit (n = 6).Such journeys apparently lead to the death of several fellow migrants.One participant recalled individuals shot at and killed by Iranian border police, two participants recalled seeing corpses, presumably of Afghans, lying in the desert.Also, others reported that women are sexually victimized by smugglers (n = 3), with one participant (age 27) stating that "one is better off being a pimp than taking this journey with their wife."Further, participants mentioned: "I walked 2 nights through the desert with smugglers and thought I was going to die.We had no food and smugglers would beat us when we didn't keep up with the rest of the group or when we asked to rest.We saw dead bodies of people with their backpacks still on.I witnessed others drinking their own urine . . .I regret coming to Turkey because of all the troubles I experienced".
"One night when our group stopped to sleep in the desert, the smugglers took the women to a different location against their will, telling the men that traveled with them that they were taking the women to a safer place to spend the night".

Unmet Psychosocial Needs in Turkey
Unemployment, difficulty learning the Turkish language, high cost of living, and low wages, which most participants indicated were not enough to support family back home in Afghanistan, were challenges common to all participants.Respondent's did not take the decision to leave Afghanistan lightly, requiring them to weigh bad options with another set of bad options.Many described sleeping in parks or in cramped quarters arranged by smugglers where one participant (age 18) described how he and others ate food out of a single bowl, and that a fellow Afghan made sexual advances toward him.Others mentioned: "We sleep in parks and have no food to eat . . .we have to find food . . .we don't have jobs to become self-sufficient".
"Money goes quick here when you don't know the language".Since all Afghans in this study were living illegally in Turkey and did not have the right to work, narratives of exploitation also resounded as some participants (n = 4) described working long and strenuous shifts in steel mills and local restaurants.One individual (age 28) summed up their sentiments stating that "Turkish businesses are taking advantage of young Afghans."Indeed, two participants described the common practice they experienced of working for a period of time without compensation, only to be terminated by their employers who threatened to alert local law enforcement for trespassing, as exemplified by the following statements: "When I first got here I felt like turning myself in [to the immigration authorities] . . .a friend of mine wanted to kill himself because he worked for a while for someone and did not get paid because he didn't speak the language"."We have no power over these [Turkish] people, after working for them they will call the police on us and tell them that they don't know us".
Although not specifically asked about the source of support, not a single individual mentioned knowing of, or they themselves receiving any sort of social assistance from the Turkish government, charity, or any other local entity.Two participants (n = 2), who had lived in Turkey for 13 years, expressed their frustrations with not getting support from anyone including the local Afghan consulate.Indeed, both accused consulate employees of demanding bribes in exchange for assistance, that any health services they needed had to be paid out of pocket, and that their children are barred from enrolling in schools because of their legal status.

Hopes for the Future
In a positive conclusion to the interviews, it was a common feature that participants were hopeful that their exodus from Afghanistan would ultimately allow them a more peaceful/stable and comfortable life (n = 6), the ability to financially support their families, wherever they might end up resettling (n = 5), and to pursue an education (n = 5), allowing them a brighter future.Aside from one participant of Turkmen origin indicating that he wanted to resettle in Turkey by stating that "Turkey is a good place for me . . .I want to live here, work, and live like a Turk" (age 18), others viewed their stay in Turkey as short-term, something they would do to work and save enough money to pay smugglers for arranging their journey into the E.U. through Greece.Two individuals planned to end up in the United Kingdom, while others ultimately planned to resettle in Germany, where they claimed to have family connections, as emphasized here: "We want to go to a place where they will accept us . . .we will sacrifice for our two children . . .we want our kids to make something of themselves and do something for their country [Afghanistan], if not, to at least contribute to wherever they live, that's all we want".
"If I make money I will leave, but for now I will stay [in Turkey] until money is made . . .I want to study diplomacy and political science in the future".
"Turkey is a good place for me . . .I want to live here, work, and live like a Turk".
"I want to go to Germany where my uncle is and get an education . . .after all, a person has to establish their dignity somehow . . .". "I just want 10% of what I could have potentially done in my profession, I studied engineering in Kabul and I can't use my degree from Afghanistan here . . .I want to work for 2 to 3 years here then go to Europe".

Discussion
Based on our brief qualitative interviews with male Afghan migrants residing in Istanbul, we explored factors influencing respondents' exodus from their homeland, their traumatic migration and stressful resettlement experiences, as well as their future expectations.Our results show that the lack of safety and security in Afghanistan were important motives for their migration to Turkey.However, as opposed to prior migration waves from Afghanistan, which were motivated by the imminent threat of persecution, the exodus of Afghans at this time is also influenced by the dire need for prosperity or to improve their family' living standards by earning money abroad, and personal aspirations such as the desire to pursue an education.
The 'push and pull' forces operating here, that is, the unfavorable conditions in Afghanistan coupled with the perceived hope for a better future in the West, align with early theories of migration [26].However, akin to Alimia's study [5] of Afghans in Turkey and in Pakistan (en route to Turkey), push-pull factors are complicated such that they interact with the need for 'self-making' and masculinity to shape Afghan migratory patterns to Turkey.This is an important finding in the current contentious debate over the legitimacy of asylum claims made by Afghans, amid hostilities towards refugees in Turkey [11] and negative public sentiments toward economic migrants across many European nations [27].In fact, the E.U. has announced plans to repatriate the estimated 50-60% of Afghan migrants whose asylum claims are rejected [28].This level of uncertainty with regard to their residency status will likely perpetuate ongoing stress for Afghans, as demonstrated in previous studies of asylum-seekers in European nations [13][14][15].
In addition, our narratives reveal the perilous journey that Afghans make in order to enter Turkey's border.Participants experienced a vast array of traumas while in transit such as encountering starvation, beatings, and witnessing death.Our findings align with prior studies of Afghans [6] and other protection-seeking nationalities [29] documenting similar traumatic experiences, which have also been shown to exert a dose-response relationship with symptoms of depression and posttraumatic stress disorder (PTSD).Further lending credence to our findings is the fact that Afghans' conceptualizations with regard to the causal factors of depression and PTSD [20] relate to the harrowing pre-migration and transit experiences described in our narratives.
Though in contrast to other studies of Afghans accounting for such traumas, our narratives shed light on a type of trauma that has been largely understudied, that is, the occurrence of sexual assaults perpetrated against women sojourners by people smugglers.We contend that this type of trauma is especially harmful for Afghan men, who are accustomed to living in a gender-segregated society, where dignity is partly maintained by protecting women.However, in these circumstances we find that men are essentially powerless, at the mercy of smugglers, unable to protect women in their company and consequently face 'loss of dignity', as defined within Afghan culture.We recommend future research with female Afghan migrants to shed further light on these experiences.
Our findings point to the relevance of Nickerson et al.'s [9] finding that moral injuries may have a stronger and more lasting impact on the mental health of refugees, over and above the immediate impact of trauma exposure and post-migration stressors.These findings warrant further empirical attention on the effects that moral injuries have on both Afghan men and other protection-seeking populations.Culturally-competent interventions that reduce posttraumatic symptoms by building resiliency against such adversities are needed.
Among Afghans and other collectivistic cultures, a central challenge is how exactly to operationalize resiliency in ways that facilitate preventive interventions and that build on protective resources.Miller [30] suggests that interventions ought to be delivered through ecological frameworks that consider relationships between people and the settings they live in, the identification of naturally occurring resources within communities that can promote healing and healthy adaptation, and enhancement of coping strategies, for example, strengthening co-ethnic ties.Shared ethnic identity is protective when it provides psychological benefits such as a sense of belonging and continuity for refugees, as demonstrated in a recent study of Syrian refugees resettled in Turkey, which showed that strong ethnic identity moderates the effects of depression, PTSD and discrimination [31].The protective effects of co-ethnic ties are further exemplified in our recent quantitative survey of Afghans in Turkey where we found that Afghans who reported having family and relatives in Turkey were more likely to seek professional health services, which we attributed to established Afghans' knowledge of navigating local health clinics [15].This essentially demonstrated that personal and social resources were important enablers for seeking help within the formal health sector.
Also, the narratives captured in this study, further emphasize other findings from our structured survey [18] highlighting the great frequency with which Afghans in Istanbul have experienced a variety of stressors and deprivations.These include poverty and unemployment, no access to medical care, fear of being returned to Afghanistan, loneliness, isolation, concerns about family back home, and significant exploitation by employers.It is likely that their mental health problems may go unabated and their impairment levels will worsen due to their legal status that bars them from any professional psychological support; and, making matters worse is the fact that many are disconnected from their natural familial supports that Afghans traditionally rely on when in distress.However, because Afghans may not be able to access services within the formal medical sector and because mental health is an unattainable luxury, a necessary first step for helping Afghans to cope with post-migration stressors reported here may be to strengthen the social support networks within their own refugee community.
Interventions that aim to develop bonds between Afghan migrants and established Afghan communities in Turkey (or their social capital) could prevent large numbers of young people giving up and seeking other potential negative avenues to deal with the resulting increasing isolation and hopelessness.Such interventions that would allow Afghans to help each other is a promising ecological prevention framework that is realistic (monetarily) but represents an investment that would need to be intentionally implemented.Not doing anything, however, may in the end prove to be even more costly.
There are, of course, limitations to this study.First, the qualitative design limits generalizability, but on the other hand provided us with narratives that are easily missed by the reporting of survey data.Secondly, because the majority of our sample took part in interviews after completing questionnaires that assessed post-migration living difficulties, respondents may have been primed to answer interview questions in a certain way.Another limitation is that interviews were not audio-recorded, and despite best efforts in note taking, the possibility of inaccuracies cannot be ruled out.Moreover, because the aims of qualitative descriptive techniques are to stay close to the data while not emphasizing theory development, the analytic process becomes somewhat subjective as descriptions depend on the investigator's perceptions, inclinations, and sensitivities, according to Neergaard et al. [32].Lastly, despite the demographic makeup of our sample representing current migration trends from Afghanistan (mainly young men), women are not represented in this study, due to the hard-to-reach nature of this subgroup; therefore, findings can only apply to Afghan men.

Conclusions
This study revealed that male Afghan migrants do not leave their homes strictly by choice, but do so motivated by the need for safety and the promise of economic prosperity in the West.Our respondents spoke of virtually no options to make staying in Afghanistan a realistic choice-though many, if given an option would have happily stayed home versus their current reality.Our findings suggest the need for future research that further unpacks the concept of moral injury our respondents perceived when following what they see as their only realistic option, but then finding one door after another closed for them to "make it with hard work".Instead they experienced and observed multiple other stressors which result in them being beaten down, barely hanging on to their optimism for a better future in a safe place.As a result, we observed significant loss of hope and mental health decline; however, as our final theme suggested, Afghan migrants in Turkey continue to hold on to the hope for a better future.