“A beacon of hope": a qualitative study on migrants' mental health needs and community-based organisations' responses during the COVID-19 pandemic in Antwerp, Belgium

Background: The COVID-19 pandemic has highlighted the need for structurally informed mental health services that are sensitive to social inequalities and cultural differences. Community-level services and organisations are often referred to as having the potential to play a key role in providing such services to migrants, yet not many studies have documented how these types of services have been organised and experienced during the COVID-19 pandemic. The objective of our case study in Antwerp’s districts of Borgerhout and Antwerpen-Noord (Belgium) was to explore how community-level responses to the mental health impact of the COVID-19 crisis were organised and experienced by rst-generation migrants and members of community-level organisations. Methods: Semi-structured qualitative interviews were conducted with rst-generation migrants in Borgerhout and Antwerpen-Noord (n=19) and with professionals in the local psycho-social care sector (n=13). Results: Our �ndings highlight the complex drivers of migrants’ mental health and the unique value and indispensability of local-level services and organisations in providing mental-health related services, particularly in a crisis context like the COVID-19 pandemic. Qualities that emerged to be particularly important included organisations’ awareness of local needs; their �exible nature which allows them to address bottlenecks and �ll gaps left by other services; their capacity to respond holistically to a broad spectrum of needs; their ability to offer culturally sensitive care and support; and their physical accessibility. However, our �ndings also demonstrate the fragility and fragmentation of these local-level services and initiatives. In the face of the COVID-19 crisis, this related to serious challenges to the necessary physical accessibility of organisations’ services; services and initiatives becoming overloaded; and widespread fragmentation and lack of oversight of the available services forming a real barrier for both service users and providers. Conclusions: This study underlines the importance of prioritising physical accessibility of mental health services at the community level, improving cultural


BACKGROUND
The COVID-19 crisis has had far-reaching direct and indirect consequences, including signi cant impacts on people's mental health.In the rst few months of the COVID-19 pandemic, there were predictions that the pandemic would create a 'tsunami' of mental health problems (1).Our current insight into the mental health impact of the COVID-19 pandemic is more nuanced.Rather than resembling a tsunami -a sweeping force that overpowers everything in its wake -the mental health impact of the COVID-19 pandemic can perhaps be more appropriately characterised as a series of localised oods.Speci c groups of people have been disproportionately affected by worsened mental health, including migrants (2,3).It is well-recognized that people who are historically disadvantaged in society, such as ethnic minorities and low-income groups, are typically among the people most affected by the immediate and long-term mental health shocks caused by crises (4).Drivers of the unequal burden of mental health problems linked to COVID-19 include the gendered distribution of domestic responsibilities during lockdown periods, the unequal economic repercussions of the crisis, and the overrepresentation of ethnic minority groups in stressful 'frontline' professions (2,5).For many people who were already marginalised in various ways prior to the pandemic, the pandemic has intensi ed the precariousness of maintaining good mental health.Furthermore, it worsened di culties in accessing appropriate support (2), which was for instance visible in the growing waiting lists for specialised mental health services.
The COVID-19 pandemic has highlighted the complex social determinants of mental health, which shape the unequal distribution of mental health issues across social fault lines (6)(7)(8).Some scholars and activists have argued that the increased attention for mental health problems during the COVID-19 pandemic should be channelled to tackle these social determinants of mental health.For example, Rose et al. (8) have advanced a "structurally informed rebuilding agenda" that spans economic policies to maintain safety nets of income; ensuring unequal access to health services; and investments to support mutual aid, community groups and voluntary sector organisations.Particularly for migrants and ethnic minorities, community-level organisations and initiatives are often described as having the potential to offer structurally informed mental health services that are sensitive to social inequalities and cultural differences (7,9,10).A study on common mental disorders and ethnicity in England, for instance, suggested that mental health services provided by local-level actors that are embedded in communities increase trust among ethnic minority communities (10).Similarly, a scoping review of community-centred interventions for improving public mental health concluded that community-based interventions "have potential to in uence the cultural and social factors that protect and promote mental health and wellbeing" (9).Apers and colleagues (11,12) found that including migrant groups' explanatory models of mental health in the design and implementation of mental health services and care is highly important, which may be easier to achieve at the community level.
A number of studies have documented the speci c drivers of mental health impact among migrants during the COVID-19 pandemic in Belgium (3,(13)(14)(15).These studies found that there was an additional need for support and mental health care among migrants, due to the disproportionate impact of governmental control measures, and the increased stigmatisation and experiences of racial and ethnic discrimination.A series of explorative studies conducted among several migrant and minoritized communities in Antwerp during the rst lockdown found that many migrant groups organised their own community responses to deal with the COVID-19 pandemic (13)(14)(15).For instance, bottom-up initiatives in response to the crisis among the sub-Saharan African community in Antwerp included translation of public health messaging, food distribution, and online spiritual support (13).Members of the Orthodox-Jewish community in Antwerp also experienced a high degree of internal solidarity that provided them with both material and mental support (15).Although these ndings highlight the mental health impact of the COVID-19 pandemic and coping strategies that were employed by migrant communities in Antwerp, limited research has focused on the potential value and shortcomings of community-based services and interventions responding to migrant communities' mental health needs in the COVID-19 context.
This case study addressed this research gap, by exploring how community-based initiatives have helped mitigate the negative mental health impacts of the COVID-19 pandemic in Borgerhout and Antwerpen-Noord, using semi-structured qualitative interviews with members of migrant communities in these districts and with professionals in the local psycho-social care sector.More speci cally, our aims were to explore the complex drivers of migrants' mental health needs during the COVID-19 pandemic; investigate which qualities and characteristics allow local-level organisations and initiatives to respond to these needs; and shed light on the main challenges faced by these local-level actors.

Study setting
Our case study was carried out in the Antwerp districts of Borgerhout and Antwerpen-Noord.Located in Dutch-speaking Flanders, Antwerp is the capital of the Antwerp province and had a little over half a million (539,000) inhabitants in 2023.Antwerp's residents have diverse backgrounds, and this diversity is even more pronounced in Borgerhout and Antwerpen-Noord.A quarter of Borgerhout's population (25%) consists of rst-generation migrants, while in Antwerpen-Noord, this gure is even higher at 39%.In 2023, a notable percentage of residents in Borgerhout (30%) and Antwerpen-Noord (16%) have a North African migration background, including the origin of their parents.There are also signi cant numbers of rst or second-generation West Asian and Eastern European migrants in both neighbourhoods.Compared to the average yearly net income per resident (€17,160) in the City of Antwerp in 2020, yearly incomes in Borgerhout were €2,376 lower, and €4,674 lower in Antwerpen-Noord (16).

Study design
This study was part of the European Horizon 2020 project COVINFORM researching the impact of COVID-19 on vulnerable populations in 11 different countries.This qualitative case study engages with members of migrant communities themselves, as well as with local (mental) health professionals, social workers, and representatives from local Civil Society Organisations (CSOs) and other relevant community-level organisations and initiatives.The rst stage of the case study consisted of exploratory expert interviews with n=13 professionals, while the second stage involved n=19 in-depth qualitative interviews with rst-generation migrants living in Borgerhout or Antwerpen-Noord who arrived in Belgium at least 5 years ago (Table 1).

Recruitment
For the rst stage of the case study, we pursued convenience sampling by compiling a list of relevant organisations and services in Borgerhout and Antwerpen-Noord through online searches and then contacting representatives of those organisations and services.Although most of the organisations and individuals we contacted work directly on mental health-related issues (e.g.psychologists and psychosocial care providers), some have a more indirect link to mental health service provision (e.g. a local community centre which offers a range of services and which has an in-house psychologist).We contacted organisations in the two districts who have migrant communities as (one of) their main target groups.Our convenience sample included organisations that received funding from the City of Antwerp in the context of the Coronababbels ('Corona chats') scheme, which were funds awarded to seven community organisations in Antwerp in 2021 to organize activities with the aim of providing psychosocial support, strengthening people's social networks, engaging in dialogue about these groups' concerns, and providing feedback signals to policymakers during the COVID-19 pandemic.The professional pro les of the experts included three functionaries of the municipality of Antwerp, a coordinator of a local community centre, and a coordinator of a local psycho-social care organisation branch.In addition, we interviewed three clinical psychologists and ve professionals with training in psycho-social work or related elds whose expertise ranged from youth work to assisting undocumented migrants.
For the qualitative interviews with migrants, participants were recruited through organisations working with migrants in Borgerhout and Antwerpen-Noord, as well as via snowball sampling.Recruitment occurred rst through local CSOs or NGOs that work with the target population and provide practical, psychological, or nancial assistance.The majority of those interviewed were low-income migrants, although some residents interviewed held 'white collar jobs' with a higher income.Within the heterogeneous group of ' rst-generation migrants in Borgerhout and Antwerpen-Noord', we aimed to include variation in terms of the length of stay in Belgium (providing it was over ve years), gender, age, and country of origin.Further recruitment strategies that were used included engaging with community health workers as gatekeepers, who were typically individuals that were well-trusted by members of the target communities.

Data collection
In-depth interviews with professionals in the local psycho-social care sector were carried out in Dutch in May-July 2022.Interviews with migrants took place in June-November 2022 in Dutch or English, and in some cases interviews were accompanied by a translator.For both types of interviews, an interview guide was used that included main questions following the logical ow anticipated in the interview, as well as follow-up questions and probes which helped move the discussion to a deeper level by asking for additional details.Out of the expert interviews, nine interviews took place privately at respondents' workplaces, and the remaining four interviews were done virtually using Microsoft Teams.Interviews with migrants were conducted in CSO spaces or in cafes in the respondent's neighbourhood, which helped facilitate their willingness to talk openly.Interviews were audio-recorded and transcribed shortly following the interviews.The duration of interviews ranged from 20 to 95 minutes each.Notes on non-verbal clues, as well as any interruptions to the interview, were written down and incorporated into the transcriptions.
Interviews were conducted by the rst and second author (JM and HR), who are both young, white, female researchers with a university education.Both have a Western-European background and were not born in Belgium, but currently live in Borgerhout.Interview transcripts were translated from Dutch to English by JM and HR.

Data analysis
Re exive thematic analysis of the transcripts was undertaken by JM and HR (17).An initial stage of analysis involved open coding of transcripts to identify preliminary themes and sub-themes.A codebook developed through this initial stage of coding was then used to re-code all interviews in NVivo, with codes being re ned and renamed along the course of coding.Our analysis was informed by a conceptualisation of mental health as being shaped by complex social determinants and was undoubtedly in uenced by the authors' own lived experiences, positionality and contextual understanding of the study setting.
Discussions within the study team helped identify the main themes in relation to the study objectives and shaped the selection of data fragments presented in the write-up.Some quotations were revised to remove any pauses or repetitions, denoted by […], provided it would not alter meaning.

Ethical considerations
Written consent was obtained from all participants.Researchers orally explained the goals of the study and provided an information sheet.Participation was voluntary and participants were free to withdraw their participation at any time.To protect con dentiality, participants are only described in this paper in terms of their gender and country of origin (for migrant interviews) or by a generic description of their professional position (for professionals in the psycho-social care sector).Ethical approval was granted for this study by the University of Antwerp Ethics Committee for the Social Sciences and Humanities (reference SHW_21_93).

RESULTS
The interviews provided rich accounts of the diverse and multifaceted impact the COVID-19 crisis has had on migrants in Borgerhout and Antwerpen-Noord, as well as on the working realities of the professionals in the local psycho-social care sector.We present our ndings in three sections.First, we summarise the severe impact of the COVID-19 pandemic among migrants, to understand how mental health was inextricably interlinked with broader hardship and precarity across life domains.Second, we discuss how the interviews are testament to the unique value and indispensability of local-level services and organisations in providing mental-health related services, particularly in a crisis context like the COVID-19 pandemic.Qualities and characteristics of local-level organisations and initiatives that emerged to be particularly important included their awareness of local needs; their exible nature which allows them to address bottlenecks and ll gaps left by other services; their capacity to respond to a broad spectrum of needs; their ability to offer culturally sensitive care and support; and their physical accessibility.Third, we discuss the fragility and fragmentation of these local-level services and initiatives.In the face of the COVID-19 crisis, this related to serious challenges to the necessary physical accessibility of organisations' services; services and initiatives becoming overloaded; and lack of oversight of the available services forming a real barrier for both service users and providers.

Complex drivers of mental health impact
Looking back on the years following the outbreak of the pandemic, the respondents note how the mental health impact of the COVID-19 crisis has been heterogeneous yet far-reaching.Key drivers of poor mental health that emerged from the interviews included social isolation and loneliness; health concerns related to the COVID-19 virus; working conditions; nancial hardship; housing and the built environment; and increasing digitisation related to COVID-19 measures and restrictions.
The interviews highlighted that a key driver of poor mental health among migrants during the pandemic was social isolation.Some migrants in particular were severely impacted by the social restrictions associated with the pandemic, such as those who lived alone or far from their families, were unable to access online support, and faced language barriers.For many migrants, efforts to integrate and nd their place in Belgium were halted by the pandemic.For example, a man from India pointed out that: "It is hard to learn a language when you live alone and have to stay at home every day, not talking to other people, especially as I have no internet at home and no laptop.Then I started drinking alcohol.I like to talk to people.Not stay at home.I have problems if I stay at home." Since many rst-generation migrants typically have more limited support systems and networks, closure of childcare facilities and other support organisations also disproportionately impacted them and this has created a lot of stress and anxiety.A woman from Somalia explained: "I was home alone with my sons.I had nothing to do, I couldn't go outside.I thought I was really going to die.I thought, no I have two kids.It was so hard, 2020, 2021.I was always crying.I'm going to die, I thought.And then what are my kids going to do?" In addition to an exacerbation of experiences of loneliness and isolation, the impact of COVID-19 on employment was also a key driver of poor mental health.Some of the interviewed migrants were laid off as a result of the pandemic, while others' search for work was made more di cult because of the economic consequences of the pandemic.A woman from Uzbekistan who used to work in a restaurant explained that she was not eligible for government compensation when the restaurant closed: "I could not get money because I worked 'in interim', it was a day contract."The nancial impact of the COVID-19 crisis was even more challenging for undocumented migrants without papers, who cannot work legally or access unemployment bene ts.Unemployment caused nancial worries for those interviewed, and many migrants also described lacking structure, routine and purpose, which impacted negatively on their mental health.Consequently, due to people's own di culties, it was sometimes more di cult to support people in one's near social circles, as illustrated by this quote from a man from Morocco: "I have my own problems with my papers, my health… everything.But I always remain happy.Problems, pfff, yes (laughs).I will speak with you and listen a few times, but if it is constant, then no.I don't want it to become my own problem.I will just leave.I have many problems of my own.If it was my girlfriend, okay, but if it is another person, sorry no.Just once or twice I would speak to you, no more." Ability to cope with the impact of the COVID-19 crisis was also challenged by migrants' living situation and the built environment.For many respondents living in cramped housing, public spaces such as parks are particularly important: "Normally after school we can go to the park with the kids for basketball together, cycling, soccer.But then everything stopped" (Man, Afghanistan).Conversely, for those interviewed who lived in a bigger house, had a garden or close access to a park, expressed that these factors signi cantly contributed to their mental well-being.
Although some of the mental health drivers of migrants were similar to those experienced pre-pandemic, access to resources to help deal with these problems was severely hampered by the COVID-19 crisis.One issue which was frequently mentioned related to di culties caused by increased digitalisation from COVID-19 and the closure of physical spaces.For parents with children studying from home, accessing the internet and providing equipment was a problem.In addition, making appointments online was very di cult for some migrants with limited language or computer skills.A Somali woman explained: "I am bad with computers.To make appointments is di cult when everything is online.There were no more appointments during corona, I couldn't come here [to local wellbeing organisation].It was very di cult." In short, many structural drivers of mental health problems were exacerbated during the COVID-19 pandemic.Increased isolation, combined with stressors related to work, nances, and caring responsibilities, negatively impacted respondents' mental health.In addition, the physical spaces and organisations that could typically provide assistance were often closed or more di cult to reach.

Unique value and indispensability of community-based organisations and initiatives
Although our case study revealed the disproportionate mental health impact faced by migrants in Borgerhout and Antwerpen-Noord, their resilience and the importance of support from community-based organisations working directly with them also clearly emerged from the interviews.Firstly, the interviews highlighted that community-level actors are knowledgeable about the direct and indirect effects of the COVID-19 crisis on their target groups and have a thorough understanding of the various needs that have emerged as a consequence.For example, a social worker working at a local CSO branch noted the increased need for psychological support immediately following the outbreak of the COVID-19 pandemic in 2020: "We saw a large increase in psy-requests, a lot of people with stress complaints… really an increase with the period before".
Professionals in the local psycho-social care sector agreed that their organisations' accessibility was key in allowing them to be closely in touch with the impact of the crisis.A coordinator of a local psychosocial care organisation branch pointed out that the array of mental health services on offer is complex, and that many people struggle to navigate the system: "when it comes to mental health problems, nding your way around that entire landscape is not easy.I think they come to us more easily, especially people with little nancial means".Another respondent, who is a trained psychologist and founder of a local drop-in centre for young people and women, emphasised accessibility as a key strength of her organisation: "For example, a woman might pass by who is not feeling well at the time, who has never come here before.But she sees a dynamic, so she comes in and says, 'what is it all about, what do you all do?' Then we start telling her, and all at once a very big story emerges.'I've been through this and this, and I'm alone, and I don't feel so good and I don't know which organisations I can turn to.'" A shared sentiment among the respondents working in the psycho-social care sector was that a core strength of their organisations is their capacity to respond to a broad spectrum of needs.Many of the professionals interviewed take a coaching approach to mental-health related issues.Particularly in the COVID-19 crisis, when many support services became more di cult to access, respondents felt one of their key responsibilities was to link clients to support across different life domains.A psychologist working with children and families explains that this includes not only professional services, but also people's personal networks: "That is our vision, to try to activate people's own network.Can someone be approached, someone at school, a neighbour, or someone else?We work with people to see how support can be strengthened in different life domains." As such, helping people improve their psychological wellbeing was widely recognized as requiring an approach tailored to a person's unique situation and their social network.Respondents underline the psychosocial nature of their work, which frequently combines offering practical and therapeutic support.
A social worker at a local CSO branch said: "Yes, it really is psycho-social work, even with people who are not speci cally looking for psychological support.People have a lot of baggage and have a need to talk [...], to just feel heard." Most of the community-level organisations had already been in existence for several years prior to the pandemic and had built up strong ties with the neighbourhood, which was a signi cant asset in the COVID-19 crisis situation.National and regional governments focused heavily on vulnerability in terms of physical health status, particularly in the early stages of the pandemic, yet professionals attuned with their local neighbourhood had a more nuanced understanding of which groups of migrants were particularly vulnerable.This included an understanding of gendered differences, such as the caring responsibilities shouldered predominantly by women, as well as the unique challenges faced by undocumented migrants in the neighbourhood.A social worker at a local CSO branch noted that "the government was busy with other things", and grassroot organisations were left to pull a lot of weight in working with people "who do not appear in government statistics, but who are actually there" such as undocumented migrants and other marginalized groups.
Apart from their proximity and long-standing embeddedness in their locality, a unique value of community-level organisations is their relatively exible nature and ability to rapidly adapt their services in response to changing needs.This quality turned out to be particularly important in a crisis context, as it allowed organisations to address bottlenecks and ll gaps left by other services and governmental agencies.Particularly at the beginning of the pandemic, when many governmental services closed their front-o ces, community-level organisations found themselves having to adapt the scope of their work.A psychologist and founder of a local CSO explains: "At that time, we were no longer just doing youth work, but we also became social services... and we tried to deal with all the questions that came in as best we could".She feels that lling this gap was much needed: "I think that with our open drop-in house, we really were a beacon of hope.People said: 'we can go there, we can talk, we can get help, at least they are physically open.We don't have to call or talk to them online, we can really go to them.'At the very beginning there was nothing open at all, but we gave them a bit of perspective." As many of the local-level organisations and initiatives are relatively small, it was easier for them to rapidly adjust their services to meet their target groups' needs.Several respondents remarked that the City of Antwerp government facilitated tailored responses through providing funding for a diverse array of psycho-social support measures through the Coronababbels ("Corona chats") scheme: "All kinds of organisations were given the chance to develop initiatives, for example around the theme of loneliness" (Psychologist who established a CSO during the COVID-19 pandemic).Indeed, the Coronababbels funding scheme exempli ed how grassroots level funding for psychosocial support interventions can facilitate the promotion of initiatives that share a common vision while adopting targeted approaches.
The interviews also highlight the importance of culturally sensitive support when dealing with the mental health impact of the COVID-19 pandemic.This includes awareness of the stigma surrounding mental health issues, which can impede support seeking.A psychologist and founder of a local CSO points out that "many people are very ashamed of their situation", and might not seek social support from friends and family because "it always has to go well for you, it is not OK if it goes badly for you".It should be noted that there was signi cant diversity in the type of care and support the interviewed migrants perceived as appropriate.Although many of the interviewed migrants conceptualised mental distress during the COVID-19 pandemic primarily as a normal reaction to di cult circumstances, rather than a distinct psychological condition requiring professional support, others did endorse biomedical labels for mental distress: "If a friend was feeling depressed, I would recommend they speak to a specialist, a doctor.[...] Depression is a sickness.It is di cult to advise without knowing the causes, because there are many crises now.Are you depressed because of the pandemic?Why? Financial, less freedom?These problems also need to be addressed.I can't give general advice that would work for everyone."(Man, Syria) As highlighted by this quote, many migrants felt mental health issues were most appropriately tackled by understanding and addressing their underlying causes.Assisting with structural challenges could then also provide an opening to discuss mental health issues, regardless of how someone might label them.
One of the psychologists interviewed underlined that culturally sensitive support often requires a move away from "the Western model of how psychopathology works", and being open to the different ways in which people make sense of their mental health.Many community-level services represent the diversity of the neighbourhood, helping them to offer culturally sensitive care and support and overcome language barriers, as shown by this quote of a psychologist and founder of a local CSO: "There are many people here in Borgerhout who do not speak the language and who cannot nd their way in the services on offer.People really seek us out, because we work in a culturally sensitive way.
[…] We have a Ghanaian working with us, we have Belgian people working with us, we have Moroccan, Turkish people working with us, so we are actually very diverse in our team.This means that we really reach the different target groups and can help them, because we are approachable and we know the language." Working with a multi-lingual team, sometimes including interpreters, was described as a key prerequisite for offering culturally sensitive services.Combined with organisations' nuanced awareness of a broad spectrum of local needs and their exible nature, this was considered a key strength of community-level initiatives.

Fragility and fragmentation
Community-level organisations and initiatives also faced challenges during the COVID-19 pandemic.
Fragility and fragmentation were related to physical accessibility and digitalisation; services and initiatives becoming overloaded; and lack of oversight of the available services forming a real barrier for both service users and providers.
The interviews with community-based organisations highlighted how physical accessibility is an absolute must for these services to function and reach their target groups, yet the pandemic seriously challenged this.One issue which was frequently mentioned by migrant residents of Antwerpen-Noord and Borgerhout related to di culties caused by increased digitalisation from COVID-19 and the closure of physical spaces, as illustrated by an Afghan man: "My [language] school was online, that is why I didn't pass.Because sometimes my Wi-Fi works, sometimes it doesn't work.This was a problem.[...]You always had to make an appointment.Everything was closed.To come here [local wellbeing organisation], became more di cult." A social worker at a local CSO branch explained how digitisation poses a big threshold particularly "for people who are vulnerable, who do not speak the language, or who are illiterate".She notes that the digitalisation trend which accelerated during the COVID-19 pandemic now seems to continue: "I can also see that the digitalisation of the COVID pandemic is now continuing, and a very large number of people simply fall by the wayside.They end up with social services or with a voluntary organisation that has to do it for them, because they cannot do it themselves." Professional respondents described how particularly in the early stages of the pandemic, organisations encountered signi cant di culties in remaining in touch with their target groups while respecting physical distancing rules.This caused frustration, since many did not consider digital communication to be effective.A psychologist and founder of a local CSO mentioned: "The only thing we could do was to talk to them online or via WhatsApp, but we noticed very quickly that that didn't really do much".Indeed, a key take-away of the pandemic for many respondents is that face-to-face contact with their target groups is absolutely essential, as indicated by a coordinator of local community centre: "What has become clear to me is that even when things are complicated, when there are restrictive measures, personal contact must be maintained.
[…] The loss of personal contact has been very di cult for many people here, so the main challenge is to nd ways to make personal contact possible, in any way possible." The relatively small size of many local-level organisations and services also meant that they quickly became overloaded, especially when demand increased due to the COVID-19 pandemic impact.The closure or digitalisation of other (governmental) services put more pressure on community-level services that did remain open.In the face of a deluge of questions for help, which were frequently outside of organisations' regular scope of work, many respondents described feeling overwhelmed.A social worker at a local CSO branch recalls: "A lot of organisations and social services were closed, so we saw a very high demand.Organising access to healthcare is our organisation's core business, but if a client says: 'I have received a reminder from the bailiff and there will be additional costs if I don't respond within fteen days", then I'm not going to say: 'It's not my job to help you with that'.Of course I will take that on."-Social worker at a local CSO branch The quote above demonstrates how holistic support was not always o cially part of organisations' mission, which meant its provision depended on the personal commitment of professionals, sometimes at a personal cost.Professional respondents were acutely aware that they were unable to meet the needs of all the people who sought support, let alone those who did not reach their organisations.Indeed, many respondents expressed a sense of powerlessness to help their target groups tackle the underlying causes of mental health issues.They prioritise supporting people in the short term, which a psychologist characterised as "an intermediate step, a bit of a re-ghting exercise", but are often unable to offer the holistic long-term support they feel people require.
Finally, the interviews showed how fragmentation and lack of oversight of the available services is a real barrier for both service users and providers.Some respondents felt the COVID-19 crisis had boosted collaboration between different organisations working on similar issues: "During COVID, because we were so limited in our possibilities, we asked each other for advice, we talked to each other more, we worked together more.That sounds very, very basic, but we did rely on each other more.Like: 'it's not going well here, can I refer this person to you?' There was much more consultation."-Psychologist and founder of a local CSO Nonetheless, the consensus arising from the interviews was that signi cant fragmentation remains.A psychologist expressed how she sometimes refers to psychosocial support services that she knows, but that she feels it is hard to get a grasp of all the relevant services on offer: "But the thing is, I don't know exactly what's out there.[…] For example, I recently referred a mother with postnatal depression to an organisation where I know they have Arabic-speaking staff, and she can go there with her baby to a support group and meet other mothers.So I thought that was good, but that was because I happened to have been there myself and I knew how it works." The need to build bridges and break down walls was a frequently expressed wish for the future.
Respondents noted that particularly when you aim to reach speci c groups like migrant communities, a collaborative network of partners with local know-how is essential.A coordinator of a local community centre expressed the need for an increased focus on facilitators and building bridges, "because there are often walls and everyone just works within their own eld, not looking beyond those walls".
Two of the respondents work for organisations that 'share' staff with different agencies in the social and health services.Although this allows these organisations to have an excellent local network and pursue a multi-sectoral approach, it also poses organisational challenges: "So for example, they work in their home team for 9 hours and then another 9 hours with us.And there are people who get lost in that, they feel they can't focus enough when they are working here and there.We're still learning about how best to tackle that, it is a challenge."-Coordinator of local psycho-social care organisation branch The locally tailored nature of the work of many community-level organisations thus also has downsides, as it leads to a fragmented landscape which is di cult to navigate and poses human resource challenges.Although this issue predates the COVID-19 pandemic, this fragility was highlighted during the pandemic when the everyday working realities of professionals in the psycho-social care sector were heavily disrupted.

DISCUSSION
The ndings from this study demonstrate how the mental health impact of the COVID-19 pandemic among migrants was particularly severe (3,6), and underline it cannot be understood in isolation from the pandemic impact on other life domains.Key drivers of poor mental health that emerged from the interviews included social isolation and loneliness; health concerns related to the COVID-19 virus; working conditions; nancial hardship; housing and the built environment; and increasing digitisation related to COVID-19 measures and restrictions.For people living in socially disadvantaged situations, mental distress typically resulted from a combination of pre-existing chronic stressors and acute pandemicrelated stressors (18).Although many drivers of the mental health impact identi ed in this study are not speci c to migrants, they were disproportionately felt.For example, employment-related stressors were more common among migrants who were precariously employed, rendering them more easily "dispendable" during the pandemic (19,20).An intersectional perspective thus reveals that the experiences of migrants in the COVID-19 context were shaped by prevailing sociocultural and socioeconomic systems (21).By concentrating on the neighbourhood level, we were able to investigate how these systemic factors are evident on a local scale, contributing to the varied needs of diverse migrant populations in Borgerhout and Antwerpen-Noord.For most of the migrants and professionals interviewed, a response limited to specialist mental health services does not su ce to address these needs.They emphasized the importance of a psycho-social lens to comprehensively address root causes at individual, interpersonal, community, and structural levels (22).
This case study also illuminated migrants' resilience in the face of the COVID-19 crisis, as well as the crucial role of community-based organisations active in the neighbourhoods.Our ndings show how the exible nature of local-level initiatives allowed them to address bottlenecks and ll gaps left by other services during the pandemic, resonating with previous reports that grassroots-level actors often go the extra mile to ensure essential needs are met in a crisis context, surpassing the limitations imposed by legal restrictions and bureaucratic regulations (23).Respondents in the psycho-social care sector emphasized the strength of their organisations in taking a coaching approach to mental health, with a key responsibility of connecting clients to support in various life domains and activating own social networks where Similarly, ndings from a scoping review by Baskin et al. (9) suggest ethnic minority populations might bene t from improved mental health through interventions aiming to mitigating social isolation by fostering peer-to-peer support and cultivating social networks.Several studies in the UK context have pointed to the importance of facilitating linkages to complementary or additional services for migrants and ethnic minorities in particular, also referred to as 'signposting' or 'social prescribing' (24)(25)(26).As community-level organisations are typically more trusted by migrant groups, they are uniquely placed to foster awareness of mental health issues and facilitate access to mental health services (9).In addition, our ndings highlight the importance of culturally sensitive support when dealing with the mental health impact of the COVID-19 pandemic.This aligns with the results of a recent scoping review conducted by Apers et al. (11) on interventions aimed at enhancing the mental health and well-being of migrants and ethnic minority groups in Europe.This review noted the signi cance of establishing a culture-appropriate therapeutic alliance, which can be achieved through the involvement of professionals who share a similar background or native language pro ciency with the target group (11).
Despite their unique strengths, community-level organisations and initiatives encountered various challenges during the COVID-19 pandemic.As documented elsewhere, COVID-19-related challenges faced by community-based organisations included restrictions on movement, closure of physical spaces, reduced capacity for in-person services, and limited face-to-face interactions due to social distancing measures (27)(28)(29).Considering the importance of physical accessibility and provision of tailored personal guidance, many organisations tried their best to stay operational.Yet due to their relatively small scale, many local-level organisations and services in Borgerhout and Antwerpen-Noord experienced overload as demand surged in response to the impact of the COVID-19 pandemic.Indeed, embedding comprehensive mental health services at the community level can be challenging when small grassroots organisations are confronted with human resource limitations and infrastructure constraints (30).Local psycho-social care professionals recognized the need to tackle structural hardships underlying mental health issues, yet their ability to alleviate these systemic drivers is constrained.While some professionals may extend their support beyond their o cial responsibilities, this approach is unlikely to be viable in the long term as it results in overload and burn-out.
Digitalisation emerged as a key challenge from interviews with both migrants and professionals.The interviews revealed evidence of accelerated digitalisation during the COVID-19 pandemic, resulting in exacerbated information inequality and the emergence of additional barriers to accessing suitable support.Indeed, the 'digital divide' undoubtedly widened during the COVID-19 pandemic (31).Our results are in line with ndings from a qualitative study with refugees and support organisations conducted by Aigner & Bešić (32) in Vienna, which underscored how language learning, job searching and overall integration became more di cult during the pandemic as support systems were digitised and personal interaction was reduced.Isolation and lacking a sense of routine and purpose in turn impact negatively on mental health.As such, although digitalisation and the use of digital technology has been put forward as "e cient and cost-effective" to improve coverage of mental health services and support globally during the COVID-19 pandemic (33), our study found that migrants and professionals alike considered inperson interaction irreplaceable.Therefore, it is crucial to carefully evaluate the barriers that exist in implementing digital solutions and consider the potential for exacerbated social and information inequality.
Although exibility and ability to develop tailored approaches at the grassroots level were a key asset of community-level organisations in times of crisis, our ndings suggest that it also contributes to a fragmented landscape that is challenging to navigate and presents human resource di culties.As noted by Kola (33), the signi cant demands placed by the pandemic further strained an already fragile and fragmented mental health care system.Some degree of fragmentation is arguably unavoidable, as a onesize-ts all approach is unlikely to meet the diverse needs of various migrant and ethnic minority populations (11).Yet considering that individuals are more likely to experience delays in receiving appropriate mental health support when mental health care delivery systems become more complicated (34), our study underlines the importance of striving to limit fragmentation and "knowing what's out there" so that local care systems remain navigable.
We propose three recommendations based on the ndings of this case study.Firstly, the ndings suggest that physical accessibility of community-level (mental health) services must remain a priority, even as societal digitalisation accelerates.Second, our ndings indicate that a holistic and culturally sensitive approach to community-based mental health services could be facilitated by training and employing more professionals who share a similar background and/or native language pro ciency as migrants.Finally, we encourage active efforts to "build bridges" and improve collaborations between communitylevel organisations, as well as with city governments.City governments have an important role to play in maintaining an overview of different organisations and stakeholders in the psycho-social care sector (e.g. through a publicly accessible database or directory), as well as facilitating cross-sectoral collaboration between organisations.
This case study had several limitations.Although the study started from a neighbourhood approach, it did not delve deeper into (informal) support mechanisms within migrant communities or the speci c role of community health workers.Future research could focus on how community-based organisations tackle similar issues across distinct neighbourhoods or cities.Second, it should be noted that most migrant participants in our sample tended to be younger or middle-aged, with the oldest participants interviewed 65 years old.As age impacts both mental health complaints and help-seeking behaviour and older people were particularly vulnerable to suffer from both physical and mental health impact during the pandemic, it would have been bene cial to interview older migrants as well.Third, recruitment was predominantly through organisations in the studied districts, which meant migrants not reached by these organisations were less likely to be included.Moreover, we were unable to compensate participants monetarily due to university regulations.This posed a limitation, as being able to compensate for time and energy might have allowed a more diverse range of participants to be interviewed.The power dynamics between researchers and participants, shaped by differences in education, language pro ciency, and ethnic backgrounds, also in uenced the results.We aimed to foster a comfortable environment by interviewing participants in spaces they were familiar with.Nonetheless, future research would bene t from more longstanding ethnographic eldwork in these neighbourhoods.Focusing on speci c migrant groups, utilizing native languages, and conducting focus groups to foster emotional support could be additional strategies to promote trust and gather in-depth insights.However, our study also revealed the fragility and fragmentation of these local-level services and initiatives.The COVID-19 crisis posed signi cant challenges, including impaired physical accessibility of services, overloading of existing initiatives, and a lack of coordination and oversight, creating barriers for both service users and providers.The study ndings highlight the need to prioritize physical accessibility of community-level mental health services; enhance culturally sensitive approaches by training and employing professionals who share a similar background or language pro ciency with migrants; and foster better collaborations between community-level organisations and city governments.These insights are valuable for guiding future crisis responses and mental health policy in similar communities and neighbourhoods.

CONCLUSIONS
This qualitative case study explored the organisation and experience of community-level responses to the mental health impact of the COVID-19 crisis among rst-generation migrants in the districts of Borgerhout and Antwerpen-Noord, Belgium.The ndings shed light on the importance and indispensability of local-level services and organisations in delivering psycho-social support and services, particularly during times of crisis such as the COVID-19 pandemic.Several key qualities and characteristics emerged as crucial for the effectiveness of these local-level initiatives, including their awareness of local needs, exibility in addressing gaps left by other services, holistic response to diverse needs, cultural sensitivity in care provision, and physical accessibility.

Table 1 :
Participant characteristics migrants and local psycho-social care professionals