Results from the VIOLIN Study: Verbal violence against migrants in German public institutions, discrimination and their association with mental health – an online cross-sectional study

Results from the VIOLIN Study: Verbal violence against migrants in German public institutions, discrimination and their association with mental health – an online cross-sectional study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Results from the VIOLIN Study: Verbal violence against migrants in German public institutions, discrimination and their association with mental health – an online cross-sectional study Meret Jäschke, Andrea Borho, Eva Morawa, Felicitas Hauck, Lucia Romero Gibu, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4790467/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 27 Aug, 2025 Read the published version in BMC Public Health → Version 1 posted 4 You are reading this latest preprint version Abstract Theoretical background: Discrimination is a psychological stressor for migrants and increases the likelihood of mental illnesses. This cross-sectional online survey examined the frequency of experiences of verbal violence in institutions (VVI) and discrimination among voluntary migrants and refugees (N = 525) in Germany, as well as their association with mental health. Methods: The measurement instruments included the Everyday Discrimination Scale (EDS), the Patient Health Questionnaire 2 (PHQ-2), the Generalized Anxiety Disorder Scale 2 (GAD-2), and the self-developed 24-item VVI questionnaire. Voluntary migrants were compared to refugees. Results: The data of 137 refugees and 388 migrants in Germany were evaluated. Since living in Germany, migrants experienced VVI most frequently in public transport (53%), immigration offices (53%), doctors' offices (48%), hospitals (41%), and city council/district offices (38%). A comparison of the sum score of the questionnaire on VVI among voluntary migrants shows that females experienced VVI significantly more often than males (p = 0.018). There were no significant differences between refugees and voluntary migrants (p = 0.50), nor gender differences among refugees (p = 0.69) in their experiences of VVI. Experiences of discrimination were reported on a frequency of less than a yearly basis. Refugees showed significantly more depressive symptoms than voluntary migrants (p < 0.001), but the generalized anxiety symptoms were comparable in both groups (p = 0.08). In multiple regression analyses, being a refugee, low life satisfaction, frequent experiences of VVI and discrimination were significantly associated with increased symptoms of depression. Significant predictors for elevated symptoms of generalized anxiety were low life satisfaction, experiences of VVI and discrimination, as well as a low sense of belonging to the country of origin. Conclusion: The results show the need for additional action to reduce VVI against migrants, especially in the identified public institutions. Verbal Violence Migrants Refugees Germany Discrimination Mental Health Institution 1. Introduction The project Verbal Violence against Migrants in Institutions (VIOLIN) is the first one in Germany to examine the experiences of verbal violence in institutions (VVI) of migrants and refugees and its interrelationship with their mental health. Verbal violence (VV) is a non-physical form of discrimination and is hard to be detected in comparison to the bodily forms of violence. Discrimination refers to the unequal treatment of people on the basis of characteristics such as origin, skin color, nationality, gender, sexual orientation, culture or religious practice [ 1 ]. International research has identified discrimination as the most important factor impairing mental health for migrants after resettlement [ 2 ]. There is strong empirical evidence for the link between discrimination and poor mental health [ 3 ] in form of development and persistence of depression and anxiety [ 4 , 5 , 6 , 7 , 8 , 9 ]. In scientific research in Germany the definition of the Federal Statistical Office of Germany is mostly used, which characterizes people to have a migration background if they themselves or at least one parent was born without German citizenship [ 10 ]. Refugees are persons who have fled their home country because of their race, religion, nationality, membership in a particular social group, or on grounds of war and political conflicts [ 11 ]. Voluntary migrants, in contrast, leave their country of origin of their own decision [ 11 ]. In Germany, there is the Federal Anti-Discrimination Agency and research groups that investigate discrimination. They have published the following key information on discrimination against migrants: Every second migrant reports experiences of discrimination [ 12 , 13 ]. Refugees´ experiences of discrimination are slightly more frequent than the average migrant population in Germany [ 14 ]. Discrimination acts as a psychological stressor as it is uncontrollable and increases the likelihood of mental illnesses [ 9 , 15 ]. In surveys, discrimination is usually measured in terms of personally perceived discrimination, which can also be caused by physical violence. Migrants whose physical or physiognomic characteristics allow conclusions to be drawn about their migration history report discrimination in 48% of cases. If they also have an accent of language, 59% report discrimination. Without differences in physiognomy, only 17% report discrimination [ 16 ]. Black people name their skin color as the most common reason for discrimination [ 9 ]. Country of origin and religious affiliation also have an influence [ 9 , 12 , 16 , 17 ]. In general, migrants most frequently report discriminatory experiences when on the search for a job or apprenticeship, as well as during interactions with authorities [ 13 ]. More specifically, highest occurrences of discrimination are mentioned on the housing market, followed by offices/authorities, work, shops/services and health services [ 12 ]. Particularly, in these institutions the discriminated person is in a dependent role [ 18 ]. We have focused on verbal discrimination, a subtle linguistic form of violence, as this has not been sufficiently investigated to date. Verbal violence was investigated in the context of public institutions because the observations can be objectified there, but not in the private sphere. We would also like to make recommendations to public institutions on how they can improve their communication. In linguistics, VV is defined as “linguistic behavior that has detrimental effects on the interlocutor” [ 19 ]. In addition to the interlocutors experiences, it is also important to look at the consequences of VVI but this association has not yet been examined. The aim of the project VIOLIN was to document and understand VVI against migrants and refugees in Germany. Since migrants are a heterogeneous group [ 20 ], the frequency and form of experiences of VVI could differ between refugees and voluntary migrants, e.g. migrant workers. We specifically aimed to understand the association between VVI and mental health. On the basis of these objectives we made two hypotheses: VVI has a negative impact on the mental health of migrants. Refugees show higher prevalence scores for depression and anxiety symptoms compared to voluntary migrants. 2. Materials and methods VIOLIN is an interdisciplinary project of the Friedrich-Alexander University Erlangen-Nürnberg (FAU), with the participation of the departments of regional research, linguistics, health psychology and psychosomatics. For this cross-sectional online survey, a questionnaire was developed by members of the named departments and translated by native speakers into the following nine languages: German, English, Spanish, French, Arabic, Polish, Farsi, Pashto and Turkish. The questionnaire consists of a main module and four submodules, covering specific political, linguistic and psychological issues, which are not subject of this manuscript. The survey was presented using the academic online survey tool Unipark ( www.unipark.com ; Tivian, Germany) and, took 30 minutes to complete on average. Using snowball sampling, recruitment was done through various channels, such as social media (Facebook, Instagram), clubs and associations of ethnic groups, churches and public institutions, e.g. integration councils and anti-discrimination bodies. The data collection period was from October 21, 2021 to April 01, 2022. A total of 899 migrants fulfilling the above mentioned definition of migration background voluntarily participated in the survey. The study was approved by the Ethics Committee of the Medical Faculty of the Friedrich-Alexander University Erlangen-Nürnberg (FAU) (project identification code: 451_19B). 2.1. Measurement instruments The following sociodemographic and migration-specific variables were collected: sex, age, educational degree, current occupation, language skills, residence status, duration of stay and reason to migrate. In addition, the survey focused on VVI, experiences of discrimination and mental health. 2.1.1. Verbal violence in German public institutions A qualitative study with Latin American migrants [ 19 ], focus groups with pupils with a migration background [ 21 ] and interviews of refugees from Afghanistan served as preliminary studies. Through an expert consensus group the relevant items as well as the institutions where VVI was experienced most frequently were extracted from the preliminary studies for the present questionnaire Finally 24 items aimed to determine the form and frequency of VVI. The items consisted of examples of uncomfortable situations that people had experienced. For example, “The person ignored me when I spoke to him“, “The person insisted that I speak only German”, “The person spoke to me particularly fast, so I could not understand him/her well”, “The person did not look at me when I spoke“, “The person was making fun of me”, or “The person refused to listen to me”. Frequency was measured using a 5-point Likert scale, ranging from “never” (0) to “very often” (4). The impact of the experience was measured on a 5-point Likert scale, ranging from “not at all” (0) to “very much” (5). For the analysis, the average sum scores were computed. The internal consistency measured by Cronbach’s alpha was very high (0.94). In addition, it was determined in which public institutions VVI was experienced. For this purpose, 14 examples were given, i.e. public transport, doctors’ offices, immigration offices, police, school. 2.1.2. Perceived discrimination Perceived Discrimination was assessed using the Everyday Discrimination Scale (EDS). It is a well-established psychometric questionnaire that can capture temporary or long-term and relatively low levels of discrimination experienced in daily life [ 22 ]. Participants were asked to report how often they had been treated unfairly in their everyday life in the past 12 months using a 6-point Likert Scale from “never” (0) to “almost daily” (5) for each out of the 9 items. The following item was added: “Are you treated worse than others in authorities?”. Higher scores indicated a higher level of perceived discrimination. The internal consistency measured by Cronbach’s alpha was very high (0.92). 2.1.3. Depression and Generalized Anxiety Disorder: PHQ-4 (Patient Health Questionnaire) To assess depression and generalized anxiety symptoms, PHQ-4 (Patient Health Questionnaire) [ 23 ], as an abbreviated form of the Patient Health Questionnaire (PHQ-D), was utilized. PHQ-4 can be subdivided into a module for depressive symptoms (PHQ-2) and a module for generalized anxiety symptoms (GAD-2). The PHQ-2 [ 24 ] questioned the frequency of depressed mood and anhedonia in the past two weeks. On a 4-point Likert scale from “not at all” (0) to “almost every day” (3) participants indicated the frequency of experiencing “little interest or pleasure in things” and felt “dejection, melancholy or hopelessness “. Clinically relevant depressive symptoms were defined as a sum score greater than or equal to 3. The Generalized Anxiety Disorder Scale 2 (GAD-2) [ 25 ] as a screening instrument for clinically relevant symptoms of generalized anxiety disorder asks about the frequency of feelings of “nervousness, anxiety, or tension” and “not being able to stop or control one’s worry” during the past 2 weeks on a 4-point Likert scale ranging from “not at all” (0) to “present almost daily” (3) with a cut-off score greater than or equal to 3 of the sum score indicating clinically relevant symptom severity. For this sample, the Cronbach’s Alpha was 0.82 for PHQ-2 and 0.86 for GAD-2. 2.1.4. Life satisfaction in Germany Life satisfaction with participants’ lives in Germany was measured by a visual analogue scale consisting of following manifestations “not satisfied at all” (0) to “very satisfied” (10). 2.2. Statistical analysis IMB SPSS Statistic 29 (IBM Corporation, Armonk, NY, USA) was applied for the statistical analysis. Means, standard deviation, range and frequencies were calculated for the descriptive analyses. Participants who did not complete the relevant questionnaires were excluded from the sample. The sample of 899 participants was reduced to 528 due to missing answers for items relevant to the research question. In addition, three persons were excluded due to implausible answers. The investigated sample of 525 migrants in total was again divided into two subgroups, 137 refugees and 388 voluntary migrants. Based on the available cut-off values, the prevalence rates for assessing clinically relevant symptoms of depression and generalized anxiety were calculated for each questionnaire. For the analysis of differences between refugees and voluntary migrants and between female and male migrants in terms of their mental health (PHQ-2 and GAD-2), experiences of VVI, experiences of discrimination (EDS) and life satisfaction, we conducted T-tests for independent samples after checking the normal distribution of the characteristic examined. The effect size was calculated using Cohen‘s d (d ≥ 0.2 = small, d ≥ 0.5 = medium and d ≥ 0.8 = large effect size). Multiple linear regression analyses were calculated, in which the results point to a significant association of VVI experience and discrimination experiences with depressive and generalized anxiety disorder symptoms. Due to multicollinearity with a correlation coefficient of 0.75 between experiencing discrimination and VVI, we conducted two regression analyses for each outcome variable. The significance level was set at p ≤ 0.05 in all analyses. For the regression analysis, we excluded three participants who had indicated “trans” as their gender as they could not be assigned to either the female or male gender group based on the information provided. 3. Results 3.1. Sample characteristics (Socio-demographic and migration-specific variables) The sample consisted of refugees (N = 137) and voluntary migrants (N = 388) from 60 different countries. Among the voluntary migrants, 372 were first-generation and 61 were second-generation migrants. There were more women among the sample of voluntary migrants (70%) than among the refugee sample (32%). The average age of the total sample was 38.22 years (SD = 11.64; range 18–78). One hundred and eight refugees (79%) and 353 (91%) voluntary migrants had completed secondary school with a degree. 75% of the sample had a high (at least level B2) German language proficiency. The three most frequently mentioned reasons for migration were family/partnership (30%), flight/forced migration (28%) and studying (24%). On average, refugees had lived in Germany for 9.35 years (SD = 10.12) and voluntary migrants for 15.20 years (SD = 13.27). Further sociodemographic and migrant-specific variables are listed in Table 1 . Table 1 Socio-demographic and migration-specific characteristics of the total sample. Variables Total (N = 525; 100%) refugees (N = 137; 26%) Volunteer Migrants (N = 388; 74%) Women (N = 316; 60%) Men (N = 206; 39%) Sex Female Male Diverse 316 (60%) 206 (39%) 3 (1%) 44 (32%) 92 (67% 1 (1%) 272 (70%) 114 (29%) 2 (1%) 316 (100%) 206 (100%) Age in years Range 18–78 M = 38.2 (SD 11.6) M = 36.0 (SD 11.9) M = 39.0 (SD 11.5) M = 37.9 (SD 10.95) M = 38.9 (SD 12.6) Marital status Single Permanent partnership Married Divorced Widowed 139 (27%) 74 (14%) 275 (52%) 34 (6%) 3 (1%) 53 (39%) 8 (6%) 70 (51%) 6 (4%) 0 (0%) 86 (22%) 66 (17%) 205 (53%) 28 (7%) 3 (1%) 77 (24.5%) 54 (17%) 157 (50%) 25 (8%) 3 (1%) 62 (30%) 18 (9%) 117 (57%) 9 (4.5%) 0 (0%) Educational degree Left school without graduation Compulsory school finished with a diploma Finished secondary school with a diploma 12 (2%) 52 (10%) 461 (88%) 8 (6%) 21 (15%) 108 (79%) 4 (1%) 31 (8%) 353 (91%) 4 (1%) 24 (8%) 288 (91%) 7 (3%) 28 (14%) 171 (83%) Vocational training Completed Started, but not yet completed Started, but canceled No 234 (45%) 21 (4%) 5 (1%) 265 (50%) 53 (39%) 9 (7%) 3 (2%) 72 (52%) 181 (46%) 12 (3%) 2 (1%) 193 (50%) 133 (42%) 11 (3.5%) 2 (0.5%) 170 (54%) 100 (48.5%) 10 (5%) 2 (1%) 94 (46%) Age at immigration in years (N = 464; 136 R 1 , 328 VM 2 , 183 W 3 , 183 M 4 ) M = 25.1 (SD 9.1) M = 26.5 (SD 10.1) M = 24.6 (SD 8.7) M = 24.8 (SD 9.3) M = 25.6 (SD 8.9) Duration of stay in years (N = 463; 136 R 1 , 327 VM 2 , 183 W 3 , 182 M 4 ) M = 13.4 (SD 12.7) M = 9.4 (SD 10.1) M = 15.1 (SD 13.3) M = 13.9 (SD 12.4) M = 13.0 (SD 13.2) Five most common countries of origin (N = 523; 137 R 1 , 386 VM 2 , 312 W 3 , 205 M 4 ) 61 (12%) Germany 53 (10%) Afghanistan 53 (10%) Poland 48 (9%) Syria 41 (8%) Mexico 45 (33%) Syria 44 (32%) Afghanistan 14 (10%) Iran 6 (4%) Poland 5 (4%) Turkey 61 (15%) Germany 47 (12%) Poland 41 (11%) Mexico 25 (6%) Ecuador 24 (6%) Turkey 39 (12.5%) Germany 36 (11.5%) Mexico 29 (9%) Poland 19 (6%) Iran 17 (5.5%) Ecuador 45 (22%) Afghanistan 32 (15.5%) Syria 24 (12%) Poland 22 (11%) Germany 14 (7%) Turkey German citizenship by birth 46 (9%) 4 (3%) 42 (11%) 27 (8.5%) 19 (9%) Asylum application (N = 382; 117 R 1 , 265 VM 2 , 225 W 3 , 155 M 4 ) 109 (28%) 109 (93%) 0 (0%) 31 (14%) 77 (50%) Residence status (N = 382; 117 R 1 , 265 VM 2 , 225 W 3 , 155 M 4 ) Permanent Temporary No title Other Not specified 207 (54%) 126 (33%) 14 (4%) 10 (3%) 25 (6%) 33 (28%) 61 (52%) 13 (11%) 5 (4.5%) 5 (4.5%) 174 (65%) 65 (24.5%) 1 (0.5%) 5 (2%) 20 (8%) 143 (64%) 62 (28%) 2 (1%) 2 (1%) 16 (7%) 64 (41%) 63 (41%) 12 (8%) 8 (5%) 8 (5%) Reason to migrate (N = 465; 137 R 1 , 328 VM 2 , 278 W 3 , 184 M 4 ) Flight/Forced Migration Work Education/Further education Study Family and partnership reasons Economic reasons Other 129 (28%) 72 (15%) 35 (7%) 111 (24%) 139 (30%) 48 (10%) 33 (7%) 127 (93%) 4 (3%) 4 (3%) 7 (5%) 4 (3%) 7 (5%) 11 (8%) 0 (0%) 68 (21%) 31 (9%) 104 (32%) 135 (41%) 41 (12%) 22 (7%) 43 (15.5%) 46 (16.5%) 23 (8%) 69 (25%) 113 (41%) 30 (11%) 12 (4%) 86 (47%) 26 (14%) 11 (6%) 42 (23%) 25 (14%) 17 (9%) 15 (8%) German language skills (N = 461; 130 R 1 , 331 VM 2 , 274 W 3 , 184 M 4 ) No knowledge A1 A2 B1 B2 C1 C2 First language 4 (1%) 24 (5%) 29 (6%) 59 (13%) 95 (21%) 119 (26%) 108 (23%) 23 (5%) 1 (1%) 11 (8%) 9 (7%) 22 (17%) 38 (29%) 32 (25%) 14 (11%) 3 (2%) 3 (1%) 13 (4%) 29 (6%) 37 (11%) 57 (17%) 87 (26.5%) 94 (28.5%) 20 (6%) 2 (1%) 14 (5%) 18 (6.5%) 33 (12%) 48 (17.5%) 75 (27.5%) 70 (25.5%) 14 (5%) 2 (1%) 9 (5%) 11 (6%) 25 (13.5%) 46 (25%) 44 (24%) 38 (21%) 9 (5%) Recognition of the degree Complete Partial None Not applicable 198 (38%) 96 (18%) 96 (18%) 135 (26%) 36 (26%) 32 (23%) 34 (25%) 35 (26%) 162 (42%) 64 (16%) 62 (16%) 100 (26%) 123 (39%) 61 (19%) 62 (20%) 70 (22%) 74 (36%) 35 (17%) 33 (16%) 64 (31%) Occupation German course Integration course Work/occupation School Study Vocational training/apprenticeship Internship Housewife/househusband (Early) retirement Job search Other None of the above 35 (7%) 12 (2%) 339 (65%) 8 (1%) 88 (17%) 30 (6%) 15 (3%) 41 (8%) 13 (2%) 38 (7%) 11 (2%) 19 (4%) 22 (16%) 8 (6%) 58 (42%) 5 (3.5%) 24 (17.5%) 14 (10%) 9 (6.5%) 6 (4.5%) 5 (3.5%) 12 (9%) 5 (3.5%) 5 (3.5%) 13 (3.5%) 4 (1%) 281 (66%) 3 (1%) 64 (16%) 16 (3%) 6 (1.5%) 35 (9%) 8 (2%) 26 (7%) 38 (10%) 14 (3.5%) 12 (4%) 7 (2%) 214 (68%) 6 (2%) 56 (18%) 14 (4.5%) 8 (2.5%) 36 (11.5%) 2 (0.5%) 22 (7%) 6 (2%) 7 (2%) 23 (11%) 5 (2.5%) 124 (60%) 2 (1%) 32 (15.5%) 16 (8%) 7 (3.5%) 5 (2.5%) 10 (5%) 15 (7%) 2 (1%) 11 (5%) Form of employment (N = 310; 54 R 1 , 256 VM 2 , 195 W 3 , 115 M 4 ) Full-time employment Part-time employment Marginal employment Occasional or irregular employment 217 (70%) 76 (24%) 12 (4%) 5 (2%) 42 (78%) 10 (18%) 2 (4%) 0 (0%) 175 (68%) 66 (26%) 12 (5%) 3 (1%) 116 (59.5%) 65 (33.5%) 11 (5.5%) 3 (1.5%) 101 (88%) 11 (10%) 1 (1%) 2 (2%) Sense of belonging to country of origin from 0–3 M = 1.99 (SD .91) M = 1.86 (SD .96) M = 2.04 (SD .88) M = 2.07 (SD .86) M = 1.89 (SD .95) Sense of belonging to Germany from 0–3 M = 1.74 (SD .85) M = 1.76 (SD .88) M = 1.73 (SD .85) M = 1.69 (SD .88) M = 1.83 (SD .81) Future in Germany Yes No Partly 260 (49%) 67 (13%) 198 (38%) 90 (65.5%) 9 (6.5%) 38 (28%) 170 (44%) 58 (15%) 160 (41%) 139 (44%) 46 (14.5%) 131 (41.5%) 120 (58%) 21 (10%) 65 (31.5%) Life satisfaction from 0–10 M = 7.1 (SD 1.94) M = 6.7 (SD 2.05) M = 7.2 (SD 1.89) M = 7.18 (SD 1.89) M = 7.91 (SD 2.01) 1 R: refugees; 2 VM: voluntary migrants; 3 W: women; 4 M: men 3.2.1. Verbal violence in German public institutions The average sum score of the total sample for the 24 items was 25.15 (SD = 18.09). There was no significant difference (t(524) = 0.67; p = 0.50; d = 0.07) between refugees (M = 26.04; SD = 18.46) and voluntary migrants (M = 24.84; SD = 17.97). However, female voluntary migrants experienced significantly more VVI (M = 26.42; SD = 18.02) than male voluntary migrants (M = 20.51; SD = 16.56; t(385) = 3.01; p = 0.003; d = 0.34). There were no significant differences in the frequency of VVI experienced by female (M = 26.70; SD = 16.16) and male (M = 25.38; SD = 19.34) refugees (t(135) = 0.39; p = 0.69; d = 0.07). VVI was most experienced in the following settings: public transport (53%), immigration offices (53%), doctors’ offices (48%), hospitals (41%), and city council/district offices (38%). No significant differences were found in frequency, occurrence and location of VVI neither between voluntary migrants and refugees, nor between women and men. 3.2.2. Discrimination The participants reported perceiving discrimination (EDS) in Germany less than once a year (M = 11.97; SD = 9.63) without a significant difference (t(524) = 0.97; p = 0.33; d = 0.10) between refugees (M = 12.66; SD = 10.27) and voluntary migrants (M = 11.73; SD = 9.40). Gender differences were not significant (t(135) = -0.48; p = 0.63; d = -0.09) for female (M = 11.95; SD = 8.62) and male (M = 12.86; SD = 10.98) refugees. There were also no significant differences in the experience of everyday discrimination (t(385) = 1.16, p = 0.25; d = 0.13) for female (M = 12.03; SD = 9.15) and male voluntary migrants (M = 10.82; SD = 9.90). 3.2.3 Depression One hundred and sixty-five of the 525 participants (31%) showed clinically relevant depressive symptoms (PHQ-2 ≥ 3), 42% of refugees and 28% of voluntary migrants. The average value for depressive symptoms was 2.09 (SD = 1.70). Refugees (M = 2.53; SD = 1.72) presented significantly more depressive symptoms than voluntary migrants (M = 1.94; SD 1.66; t(524) = 3.51; p < 0.001; d = 0.35). The results revealed no significant differences in the prevalence of depressive symptoms between female (M = 2.36; SD = 1.56) and male (M = 2.60; SD = 1.80; t(135) = -0.74; p = 0.46; d = -0.14) refugees. There were no significant differences regarding depressive symptoms between female (M = 1.96; SD = 1.67) and male (M = 1.87; SD = 1.64; t(385) = 0.47; p = 0.64; d = 0.05) voluntary migrants. Among the nine most common countries of origin, Syria (M = 2.63; SD = 1.79), followed by Iran (M = 2.19; SD = 1.90), revealed the highest mean for depressive symptoms. In an additional file [see Additional file 1] further mean values for the nine most common countries of origin in the study sample are provided. 3.2.4. Generalized anxiety symptoms One hundred and fifty-four of 525 participants (29%) in the total sample had clinically relevant anxiety (GAD-2 ≥ 3), constituting 34% of refugees and 28% of migrants. The mean score of the total sample was 2.05 (SD 1.76) on the GAD-2 scale. The T-test indicated no significant differences between refugees (M = 2.28; SD = 1.77) and voluntary migrants (M = 1.97; SD = 1.76; t(524) = 1.75; p = 0.08; d = 0.17) or between female (M = 2.11; SD = 1.77) and male (M = 2.38; SD = 1.77; t(135) = -0.82; p = 0.41; d = -0.15) refugees or female (M = 2.04; SD = 1.76) and male (M = 1.78; SD = 1.73; t(385) = 1.31; p = 0.19; d = 0.15) voluntary migrants. However, when looking at the mean scores for the individual countries of origin, differences are detectable. Migrants from countries such as Syria (M = 2.54; SD = 1.92), Iran (M = 2.19; SD = 0.67) or Afghanistan (M = 2.10; SD = 1.76) demonstrated the highest levels of anxiety disorder symptoms in our sample. Mean scores for the nine most common countries of origin can be found in an additional file [see Additional file 1]. 3.2.5. Life satisfaction On a scale of 0 to 10, voluntary migrants (M = 7.20; SD = 1.89) showed significantly higher life satisfaction compared to refugees (M = 6.70; SD = 2.04; t(524) = -2.61; p = 0.009; d = 0.26). The results revealed significant differences in terms of life satisfaction between female (M = 7.14; SD = 1.62) and male (M = 6.46; SD = 2.18; t(135) = 2.04; p = 0.04; d = 0.34) refugees. There were no significant differences between female (M = 7.18; SD = 1.92) and male (M = 7.27; SD = 1.80; t(385) = -0.42; p = 0.68; d = -0.05) voluntary migrants. 3.3. Predictors of depression and generalized anxiety symptoms We conducted multiple regression analyses to examine the association between VVI and mental health. Sociodemographic and migration-specific variables such as migrant group (refugee or voluntary migrant), experience of VVI, gender, age, marital status, educational degree, occupation, knowledge of German, sense of belonging to the country of origin, sense of belonging to Germany, and life satisfaction were considered. The results are presented in Table 2 . Because of the high correlation between VVI and perceived discrimination, separate multiple regression analyses to examine the relationship between perceived discrimination and psychological well-being were conducted. These can be found in an additional file [see Additional file 2] as the results are similar to those of the regression analysis with VVI as a predictor variable. Table 2 Multiple linear regression analyses including VVI and socio-demographic and migration-related characteristics as predictor variables. Predictors of Depressive Symptoms 1 B 3 SE 4 β p 95% CI 5 Migrant group 6 − .442 .184 − .116 .017 − .80 to − .08 Verbal violence in public institutions 7 .014 .004 .152 .002 .01 to .02 Life satisfaction 8 − .228 .046 − .263 < .001 − .32 to − .14 Sex 9 .111 .162 .032 .493 − .21 to .43 Age − .005 .008 − .032 .514 − .02 to .01 Marital status 10 .029 .165 .008 .861 − .30 to .35 Educational degree 11 − .714 .509 − .061 .162 .29 to .95 Occupation 12 − .071 .207 − .016 .732 − .48 to .34 German language skills 13 < .001 .051 < .001 .994 − .10 to .10 Sense of belonging to the country of origin 14 − .129 .084 − .067 .123 − .29 to − .04 Sense of belonging to Germany 15 − .166 .109 − .082 .129 − .38 to .05 Predictors of GAD Symptoms 2 Verbal violence in public institutions 7 .023 .005 .238 < .001 .01 to .03 Sense of belonging to the country of origin 14 − .181 .084 − .091 .032 − .35 to − .02 Life satisfaction 8 − .213 .046 − .236 < .001 − .30 to − .12 Migrant group 6 − .181 .185 − .046 .330 − .55 to .18 Sex 9 .032 .163 .009 .846 − .29 to .35 Age − .007 .008 − .043 .365 − .02 to .01 Marital status 10 − .107 .166 − .028 .519 − .44 to .22 Educational degree 11 − .359 .513 − .030 .484 -1.37 to .65 Occupation 12 .258 .209 .055 .217 − .15 to .67 German language skills 13 − .093 .051 − .082 .071 − .19 to .01 Sense of belonging to Germany 15 − .182 .110 − .087 .097 − .40 to .03 1 PHQ-2: Patient Health Questionnaire—Depression Module, sum score, range: 0–6 (higher values are linked to higher symptom severity); 2 GAD-2, Generalized Anxiety Disorder Scale, sum score, range: 0–6 (higher values are linked to higher symptom severity); 3 B: regression coefficient; 4 SE: standard error; 5 CI: confidence interval; 6 0: refugee; 1: voluntary migrant; 7 verbal violence in German institutions, average sum score, range: 0–96 (higher values are linked to higher experience of verbal violence in institutions); 8 life satisfaction, sum score, range: 0–10 (higher values indicate higher life satisfaction); 9 1: female; 2: male; 10 0: single; 1: relationship; 11 0: no; 1: yes; 12 0: no; 1: yes; 13 German language skills, sum score, range: 0–8 (higher values are linked to higher German language skills) 14 sense of belonging to the country of origin, sum score, range: 0–3 (higher values are linked to higher sense of belonging); 15 sense of belonging to Germany, sum score, range: 0–3 (higher values are linked to higher sense of belonging). 3.3.1. Regression analysis PHQ-2 In the regression analysis with VVI as predictor variable and PHQ-2 as outcome variable, being a refugee (β = -0.11; p = 0.03), low life satisfaction (β = -0.29; p < 0.001) and a higher amount of experiencing VVI (β = 0.17; p < 0.001) were significantly associated with increased symptoms of depression. The explained variance was 23%. 3.3.2. Regression analysis GAD-2 Variables significantly associated with increased symptoms of generalized anxiety were a lower sense of belonging to the country of origin (β = -0.10; p = 0.03), lower life satisfaction (β = -0.25; p < 0.001) and more frequent experiences of VVI (β = 0.26; p < 0.001). The explained variance was 26%. 4. Discussion Currently, 24.9 million people with migration background live in Germany (as of December 31, 2023) [ 26 ]. They make up 29.7% of the German population, and their number is increasing [ 26 ]. To our knowledge VIOLIN is the first study investigating migrants’ experiences of VVI in Germany and its association with their mental health states. We were able to reveal that migrants experienced VVI most frequently in public transport, immigration offices, doctors’ offices, hospitals, and city council/district offices. Among voluntary migrants, females experienced VVI significantly more often than their male counterparts. There were no significant gender differences between female and male refugees in their experiences of VVI. Refugees showed significantly more depressive symptoms than voluntary migrants. In multiple regression analyses, being a refugee, low life satisfaction and frequent experiences of VVI were significantly associated with increased depressive symptoms. Regarding generalized anxiety disorder, life satisfaction, experiences of VVI as well as a low sense of belonging to the country of origin were significant predictors for elevated symptom severity. In terms of sociodemographic factors, migrants form a heterogeneous group. This makes comparisons within our sample difficult. With an average age of 38.2 years, our sample is older than the average age of migrants in Germany in 2019, which was 35.6 years [ 27 ]. We suppose that the exclusion of children and adolescents in our survey contributes to this. Thirty-two percent of asylum applications in Germany in 2022 were submitted by women [ 28 ]; in our sample, 32% of refugees are female. Yet, the proportion of women in the group of voluntary migrants is above average at 70% in our sample. In 2022, 49% of people with migration background in Germany were women [ 29 ]. In addition, our sample has an above-average level of education, with 71% holding a university degree, whereas in Germany in 2022, 38.5% of people with migration background aged 15 or older held a qualifying academic school degree [ 30 ]. These aspects must be considered in the following. On average, migrants from our sample experience VVI rarely and discrimination less frequently than once a year, which can be regarded as positive. In the institutional context, studies about the situation in Germany mostly examined migrants’ experiences of discrimination [ 14 , 18 ]. As VV is a linguistic construct the studies did not focus on VVI. Since the 2014s, surveys have reported low levels of discrimination against migrants and refugees in Germany [ 16 , 31 ]. However, people with a migration background experience discrimination significantly more often than people without [ 16 , 31 ]. Furthermore, migrants’ experiences of discrimination in Germany seem to have increased in recent years [ 17 , 32 ]. In a 2022 study 35% of migrants reported having been discriminated sometimes or often in the past year [ 17 ]. The German Centre for Integration and Migration Research examined in 2022 the experiences of discrimination of more than 21.000 people in Germany [ 9 ]. Using the EDS, around 90% of the visually recognizable people in the sample reported having experienced at least one of the forms of discrimination recorded in the scale in their everyday lives [ 9 ]. In general, awareness of the various forms of discrimination has also increased [ 32 ]. We could demonstrate that there are no significant differences in the experience of VVI and discrimination between refugees and voluntary migrants. Whereas female migrants, especially voluntary migrants, experience significantly more VVI compared to male migrants. This gender-specific difference was not found in the experiences of discrimination. This means that a larger group is detected as affected by hostile interactions when verbal violence is used as a measure. In contrast, the report of the National Discrimination and Racism Monitor 2023 by the German Center for Integration and Migration Research even reports that women experience less subtle discrimination on average than men [ 9 ]. But the level of actual discrimination differs from the level of perceived discrimination [ 33 ]. The results on institutions where VVI is experienced, confirm the results of earlier studies, the areas where discrimination is perceived are agencies, authorities and the healthcare sector [ 9 , 12 , 18 ]. Compared to discrimination, including physical or sexual violence, VVI is more difficult to detect and establish retrospectively, as it does not leave any physical damage and is more difficult to objectify [ 19 ]. Moreover, in the context of migration, it can be masked by aspects such as language barriers and cultural differences [ 19 ]. The victim may assume that the manner of address corresponds to the customs of the country. As a result, the perpetrator has fewer inhibitions about practicing this form of discrimination. Fortunately, our findings indicate that migrants experience VVI not on a daily base. However, mental distress may be caused by VVI in the reported institutions such as public transport, immigration authorities and health care. The country of origin also plays a decisive role. In our study migrants from Iran, Mexico and Syria experienced the most VVI. When differentiating migrants by country of origin, various sociodemographic and migration-specific aspects must also be considered [ 34 ]. In Germany, especially people with a Turkish migration background feel discriminated [ 31 ]. The latter is often explained by the fact that certain nationalities are more often identified as migrants due to visible characteristics, accent or religious affiliation [ 16 ]. This visibility provides more targets for perpetrators. However, it should be noted here that in the case of VVI, i.e. the immigration departments, every migrant is identified as such by his or her counterpart. Prejudices and visual differences seem to play an additional role in the social interactions of migrants and refugees. We could demonstrate by our regression analyses that the experience of VVI is related to reduced mental health of migrants. This finding is also consistent with previous studies that have reported discrimination to be negatively associated with mental health [ 4 , 5 , 6 , 7 , 8 ]. In multiple regression analyses [see Table 2 and Additional file 2], the effect of discrimination is slightly higher compared to the effect of the experience of VVI. One consideration would be that the EDS investigates everyday life [ 22 ], while the VVI questionnaire includes questions about specific situations in German institutions. By surveying a broader spectrum (not only institutions, not only verbal violence) it may be possible to capture stronger effects on mental health. Manifestations of mental distress, depression and anxiety are significantly higher in our study population than in the German general population [ 35 ]. In line with our results, in the 2016 and 2017 IAB-BAMF SOEP survey of refugees in Germany, refugees had more depressive symptoms in PHQ-4 compared to the German population average [ 36 ]. As has been shown in numerous studies ,prevalence scores for depression and anxiety among migrants vary by host country [ 37 , 38 ], country of origin [ 34 , 39 , 40 ], migrant subgroup [ 41 ], and generation [ 40 ]. Displaced persons are more likely to exhibit psychological distress [ 37 , 42 ], which was also the case in our survey. In our sample, the prevalence scores for refugees of 42% for depression and 34% for anxiety disorders are slightly higher than the prevalence scores for refugees in similar studies [ 43 , 44 ]. Selection effects of the online study may have played a role here, so that those migrants and refugees affected with a high symptom burden were more likely to participate in the anonymous study. Refugees are more likely to experience depression compared to voluntary migrants [ 37 , 45 ]. In our sample they exhibited significantly more depressive symptoms than voluntary migrants in our sample. Studies show, that compared to voluntary migrants, refugees are exposed to more pre-migratory stressors such as war and persecution, the flight itself, and post-migratory stressors such as procedures of residence permission which put a strain on their mental health. [ 15 ]. The meta-analysis by Blackmore et al. [ 43 ] showed prevalence scores for refugees of 31.5% for depression and 11% for anxiety. For refugees exposed to an armed conflict, Mesa-Vieira et al. [ 44 ] reported in a meta-analysis prevalence rates of 25% for major depression and 14% for general anxiety disorders. The meta-analysis by Lindert et al. found prevalences for anxiety disorder between 6% and 44% for migrant workers and between 5% and 90% for refugees [ 46 ]. Regarding anxiety disorders the comparison between refugees and voluntary migrants in our sample was not significant, but a tendency was evident. With a mean of 2.09 in the PHQ-2 and of 2.05 in the GAD-2, our total sample revealed significantly more symptoms of depression and anxiety than the German general population with a mean of 0.97 in the PHQ-2 and of 0.83 in the GAD-2 [ 35 ]. In scientific literature unfortunately only few studies can be found that differentiate between refugees and voluntary migrants [ 47 ]. However, prevalence values are known to vary widely across studies, as migrants represent a very heterogeneous group [ 46 , 48 ]. Yet, some studies didn´t find a difference between the mixed migrants population (voluntary migrants and refugees) and the general German population [ 49 ], especially not for voluntary migrants considering prevalences for depression and anxiety [ 50 ]. Certain factors such as cultural adjustment stress, discrimination in the host country, pre-migration trauma and displacement or uncertain immigration status [ 5 ] may contribute to an increased level of distress symptoms among migrants in our sample and could also explain the increased prevalence of depressive symptoms among refugees compared to voluntary migrants. Low overall life satisfaction is also statistically predictive of a prevalence of depression and anxiety disorders. With a mean of 6.7 among refugees and 7.2 among voluntary migrants, our results are comparable to those of the IAB-BAMF-SOEP survey, with mean values of 6.86 among refugees and 7.55 among migrants in Germany collected in 2015 [ 14 ]. The life satisfaction of refugees in Germany is related to their family situation, their residence status, their work and housing situation, their health situation, their feeling of being welcome in Germany, and the extent of their social contacts with Germans [ 51 ]. Higher levels of feeling to be welcome in Germany and social support were also significantly associated with lower levels of depression and generalized anxiety in a study with 136 Syrian students in Germany [ 52 ]. Gender was surprisingly not a significant predictor in our analysis. In literature female migrants showed significantly higher depression [ 37 , 53 ] and anxiety symptoms [ 54 ] compared to males. The gender differences for depression [ 55 ] and generalized anxiety symptoms [ 56 ] are also evident in the general German population. It is also possible that gender is no longer significantly associated with poorer mental health in our study population when other socio-demographic characteristics such as education level are considered. According to a meta-analysis by Brance et al. [ 57 ] social identification, both with the host country and with the home country community, protects ethnic minorities and migrants from depression and anxiety. The feeling of migrants of belonging to their country of origin, as a form of group affiliation, is also a negative significant predictor of anxiety disorders in our analysis (in the regression analysis with VVI as a predictor variable). One could assume that this feeling is a form of social identification, which acts as a protective factor against anxiety symptoms [ 57 ]. Social identification also correlates with other factors such as trauma and persecution [ 57 ], which in turn have a negative impact on mental health. Strengths and Limitations First of all, due to the cross-sectional design of the study, no causal conclusions can be drawn. The strength of the study is the size of the sample and the recruitment through different channels such as social media (Facebook, Instagram), churches and public institutions, e.g. integration councils and anti-discrimination bodies. In addition, the questionnaire could be answered in nine different languages and an equal access was ascertained for most ethnic groups. The questionnaire on VVI included 24 questions. This increases the likelihood that different aspects of experiences with VVI were made measurable. One weakness was the long time needed for completion of the questionnaire. Thus, some participants did not complete the survey. In addition, the questionnaire on VVI is not validated yet and we have used the sumscores. Therefore, comparison with other groups was not possible. The high proportion of participants with a high level of education and the high proportion of women in the group of voluntary migrants limit the representativeness of our sample. Recruitment also took place through university networks, which could be one reason why mainly young, well-educated migrants were reached. In an average composition of the cohort, different values of perceived VVI are to be assumed. Future research on the experience of VVI and its impact on mental health is needed to confirm recent findings and collect new results. For this, prospective studies need to be conducted so that the impact of VVI can be examined. In addition to the association with depression and generalized anxiety disorder, other disorders such as PTSD should also be considered. Gender differences must be looked at as well. In this context, it is also important to distinguish gender differences in the experience of VVI between female and male migrants as well as between women and men in the general population. 5. Conclusion VVI is highly associated with the state of migrants’ mental health. This is of high importance as migrants, especially refugees, in Germany have a significantly higher risk of depressive and anxiety symptoms compared to the general population. To gain further insight specifically on VVI, further studies should be conducted in individual institutions, focusing on gender differences. Special attention should be paid to immigration offices, health care institutions and city councils/district offices. To reduce VVI in the future and to raise awareness and sensitize on the issue, courses could be set up for employees in these institutions. To minimize VVI in public places, for example in public transport, citizens could be reached directly, i.e. through advertising campaigns. Society benefits from such measures, but perhaps there is not yet sufficient awareness for this. Abbreviations VVI Verbal violence in institutions VV Verbal violence VIOLIN Verbal Violence against Migrants in Institutions Declarations Ethics approval and consent to participate The study was approved by the Ethics Committee of the Medical Faculty of the Friedrich-Alexander University Erlangen-Nürnberg (FAU) (project identification code: 451_19B). Consent for publication – Not applicable Availability of data and materials The dataset analyzed during the current study is available from the corresponding author on reasonable request. Competing interests No potential conflict of interest was reported by the authors. Funding The presented study was supported by the STAEDTLER Foundation and the Emerging Fields Initiative (EFI) of the Friedrich-Alexander-Universität Erlangen-Nürnberg. The funders did not have any further role in the design of the study and collection, analysis, interpretation of data, or writing the manuscript. Authors' contributions MJ, AB, EM, FH, LRG, MA, NR, SJ, PB and YE designed the study concept. AB, FH, LRG and MA conducted the study. AB and MJ analyzed the data. MJ drafted the manuscript with corrections and commentaries from AB, EM and YE. All authors reviewed and approved the final draft of the manuscript. Acknowledgment We thank all migrant organizations, associations and institutions for their support in the recruitment process. Authors' information MJ performed the present work in fulfilment of the requirements for obtaining the degree „Dr. med.”. References Federal Agency for Civic Education. [Discrimination/anti-discrimination - terms and basics]. https://www.bpb.de/shop/zeitschriften/apuz/221573/diskriminierung-antidiskriminierung-begriffe-und-grundlagen/ . Accessed 1 March 2023. Erim Y, Schellong J. Special issue flight and migration. J Psychosom Res. 2020. 10.1016/j.jpsychores.2020.110260 . Berger M, Sarnyai Z. More than skin deep: stress neurobiology and mental health consequences of racial discrimination. Stress. 2015. 10.3109/10253890.2014.989204 . Paradies Y, Ben J, Denson N, Elias A, Priest N, Pieterse A, et al. Racism as a Determinant of Health: A Systematic Review and Meta-Analysis. PLoS ONE. 2015. 10.1371/journal.pone.0138511 . Hajak VL, Sardana S, Verdeli H, Grimm S. A Systematic Review of Factors Affecting Mental Health and Well-Being of Asylum Seekers and Refugees in Germany. Front Psychiatry. 2021. 10.3389/fpsyt.2021.643704 . Schmitt MT, Branscombe NR, Postmes T, Garcia A. The consequences of perceived discrimination for psychological well-being: a meta-analytic review. Psychol Bull. 2014. 10.1037/a0035754 . Borho A, Viazminsky A, Morawa E, Schmitt GM, Georgiadou E, Erim Y. The prevalence and risk factors for mental distress among Syrian refugees in Germany: a register-based follow-up study. BMC Psychiatry. 2020. 10.1186/s12888-020-02746-2 . Voglino G, Gualano MR, Lo Moro G, Forghieri P, Caprioli M, Elhadidy HSMA, et al. Mental health and discrimination among migrants from Africa: An Italian cross-sectional study. J Community Psychol. 2022. 10.1002/jcop.22685 . German Centre for Integration and Migration Research. [Racism and its symptoms: Report of the National Monitoring of Discrimination and Racism with a focus on health]. 2023. https://www.rassismusmonitor.de/publikationen/rassismus-und-seine-symptome/ . Accessed 10 November 2023. German Federal Statistical Office. [Migration background]. https://www.destatis.de/DE/Themen/Gesellschaft-Umwelt/Bevoelkerung/Migration-Integration/Glossar/migrationshintergrund.html?view=getColorboxEntry . Accessed 20 October 2023. Federal Ministry for Economic Cooperation and Development. [Flight and Migration: Basics and Terms]. https://www.bmz.de/de/themen/flucht/fachbegriffe#lexicon=21872 . Accessed 20 October 2023. Federal Anti-Discrimination Agency. [Risks of discrimination for refugees in Germany]. 2016. https://www.antidiskriminierungsstelle.de/SharedDocs/forschungsprojekte/EN/Studie_DiskrRisiken_fuer_Gefluechtete_en.html . Accessed 1 January 2024. Institute for Employment Research. [The IAB-SOEP Migration Sample: Living, learning, working - how migrants are doing in Germany]. 2014. https://doku.iab.de/kurzber/2014/kb2114.pdf . Accessed 13 November 2023. Institute for Employment Research, Federal Office for Migration and Refugees, Panel S-E. IAB-BAMF-SOEP Refugee Survey: overview and first results. 2016. https://www.bamf.de/SharedDocs/Anlagen/EN/Forschung/Forschungsberichte/fb29-iab-bamf-soep-befragung-gefluechtete.html?nn=283560 . Accessed 1 January 2024. Matheson K, Foster MD, Bombay A, McQuaid RJ, Anisman H. Traumatic Experiences, Perceived Discrimination, and Psychological Distress Among Members of Various Socially Marginalized Groups. Front Psychol. 2019. 10.3389/fpsyg.2019.00416 . The Expert Council on Integration and Migration. So, where are you originally from? Experiences of discrimination and phenotypic differences in Germany. 2018. https://www.svr-migration.de/en/publication/experiences_of_discrimination/ . Accessed 1 January 2024. Wieland U, Kober U. [Discrimination in the immigration society: perceptions and attitudes in the population]. 2023; 10.11586/2023020 [Experiences of discrimination in Germany: Results of a representative survey and a survey of the people affected]. 2017. https://www.antidiskriminierungsstelle.de/SharedDocs/downloads/DE/publikationen/Expertisen/expertise_diskriminierungserfahrungen_in_deutschland.html . Accessed 1 January 2024. Jansen S, Romero L. Verbal violence – a first approximation based on Latin American migrants’ experiences in German institutions. The Mouth. Crit J Lang Cult Soc. 2021;ISSN:2513–X101. Erim Y, Morawa E. [Psychotherapy with Immigrants and Traumatized Refugees] PPmP - Psychotherapie ·. Psychosom · Medizinische Psychologie. 2016. 10.1055/s-0042-115412 . Borho A, Morawa E, Schug C, Erim Y. Perceived post-migration discrimination: the perspective of adolescents with migration background. Eur Child Adolesc Psychiatry. 2023. 10.1007/s00787-022-02084-6 . Williams DR, Yu Y, Jackson JS, Anderson NB. Racial Differences in Physical and Mental Health:Socio-economic Status, Stress and Discrimination. J Health Psychol. 1997. 10.1177/135910539700200305 . Löwe B, Wahl I, Rose M, Spitzer C, Glaesmer H, Wingenfeld K, et al. A 4-item measure of depression and anxiety: Validation and standardization of the Patient Health Questionnaire-4 (PHQ-4) in the general population. J Affect Disord. 2010. 10.1016/j.jad.2009.06.019 . Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care. 2003. 10.1097/01.Mlr.0000093487.78664.3c . Kroenke K, Spitzer RL, Williams JB, Monahan PO, Löwe B. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007. 10.7326/0003-4819-146-5-200703060-00004 . Federal Agency for Civic Education. [Population with a migration background]. https://www.bpb.de/kurz-knapp/zahlen-und-fakten/soziale-situation-in-deutschland/61646/bevoelkerung-mit-migrationshintergrund/ . Accessed 10 June 2024. German Federal Statistical Office, WZB Berlin Social Science Center, Federal Institute for Population Research. [Data Report 2021 - Social Report for Germany, complete edition]. 2021. https://www.destatis.de/DE/Service/Statistik-Campus/Datenreport/Downloads/datenreport-2021.html . Accessed 9 November 2023. Federal Agency for Civic Education. [Demographics of asylum seekers in Germany]. https://www.bpb.de/themen/migration-integration/zahlen-zu-asyl/265710/demografie-von-asylsuchenden-in-deutschland/ . Accessed 20 April 2023. Statista Research Department. Number of persons with migration background in Germany in 2022, by gender https://www.statista.com/statistics/891857/number-persons-migrant-background-by-gender-germany/ . Accessed 1 January 2024. Distribution of the. population with and without a migrant background in Germany as of 2022, by school education. https://www.statista.com/statistics/921215/national-and-migrant-population-by-school-education-germany/ . Accessed 1 January 2024. Expert Council on Integration and Migration. Germany's Transformation to a Modern Immigration Country: Annual Report 2014 with Integration Barometer. 2014. https://www.svr-migration.de/en/publication/annual-report-2014/ . Accessed 1 January 2024. Antidiskriminierungsstelle des Bundes. [Annual report 2022]. 2023. https://www.antidiskriminierungsstelle.de/SharedDocs/downloads/DE/publikationen/Jahresberichte/2022.html . Accessed 24 October 2023. Diehl C, Liebau E, Mühlau P. How Often Have You Felt Disadvantaged? Explaining Perceived Discrimination. Cologne J Sociol Social Psychol. 2021. 10.1007/s11577-021-00738-y . Morawa E, Erim Y. [The interrelation between perceived discrimination, depressiveness, and health related quality of life in immigrants of Turkish and Polish origin]. Psychiatr Prax. 2014. 10.1055/s-0033-1343221 . Wicke FS, Krakau L, Löwe B, Beutel ME, Brähler E. Update of the standardization of the Patient Health Questionnaire-4 (PHQ-4) in the general population. J Affect Disord. 2022. 10.1016/j.jad.2022.06.054 . Institute for Employment Research. Second wave of the IAB-BAMF-SOEP Survey: Language skills and employment rate of refugees improving with time. 2019. https://nbn-resolving.org/urn:nbn:de:0168-ssoar-77905-9 . Accessed 1 January 2024. Bedaso A, Duko B. Epidemiology of depression among displaced people: A systematic review and meta-analysis. Psychiatry Res. 2022. 10.1016/j.psychres.2022.114493 . Gkiouleka A, Avrami L, Kostaki A, Huijts T, Eikemo TA, Stathopoulou T. Depressive symptoms among migrants and non-migrants in Europe: documenting and explaining inequalities in times of socio-economic instability. Eur J Public Health. 2018. 10.1093/eurpub/cky202 . Jurado D, Alarcón RD, Martínez-Ortega JM, Mendieta-Marichal Y, Gutiérrez-Rojas L, Gurpegui M. Factors associated with psychological distress or common mental disorders in migrant populations across the world. Revista de Psiquiatría y Salud Mental (English Edition). 2017. 10.1016/j.rpsmen.2017.02.004 . Beutel ME, Jünger C, Klein EM, Wild P, Lackner KJ, Blettner M, et al. Depression, anxiety and suicidal ideation among 1st and 2nd generation migrants - results from the Gutenberg health study. BMC Psychiatry. 2016. 10.1186/s12888-016-0995-2 . Levecque K, Van Rossem R. Depression in Europe: does migrant integration have mental health payoffs? A cross-national comparison of 20 European countries. Ethn Health. 2015. 10.1080/13557858.2014.883369 . Turrini G, Purgato M, Ballette F, Nosè M, Ostuzzi G, Barbui C. Common mental disorders in asylum seekers and refugees: umbrella review of prevalence and intervention studies. Int J Mental Health Syst. 2017. 10.1186/s13033-017-0156-0 . Blackmore R, Boyle JA, Fazel M, Ranasinha S, Gray KM, Fitzgerald G, et al. The prevalence of mental illness in refugees and asylum seekers: A systematic review and meta-analysis. PLoS Med. 2020. 10.1371/journal.pmed.1003337 . Mesa-Vieira C, Haas AD, Buitrago-Garcia D, Roa-Diaz ZM, Minder B, Gamba M, et al. Mental health of migrants with pre-migration exposure to armed conflict: a systematic review and meta-analysis. Lancet Public Health. 2022. 10.1016/S2468-2667(22)00061-5 . Close C, Kouvonen A, Bosqui T, Patel K, O'Reilly D, Donnelly M. The mental health and wellbeing of first generation migrants: a systematic-narrative review of reviews. Global Health. 2016. 10.1186/s12992-016-0187-3 . Lindert J, Brähler E, Wittig U, Mielck A, Priebe S. [Depression, anxiety and posttraumatic stress disorders in labor migrants, asylum seekers and refugees. A systematic overview]. Psychother Psychosom Medizinische Psychologie - PSYCHOTHER PSYCHOSOM MED PSYC. 2008. 10.1055/s-2008-1067358 . Carroll HA, Kvietok A, Pauschardt J, Freier LF, Bird M. Prevalence of common mental health disorders in forcibly displaced populations versus labor migrants by migration phase: A meta-analysis. J Affect Disord. 2023. 10.1016/j.jad.2022.10.010 . Lindert J, von Ehrenstein OS, Wehrwein A, Brähler E, Schäfer I. [Anxiety, Depression and Posttraumatic Stress Disorder in Refugees - A Systematic Review]. Psychother Psychosom Med Psychol. 2018. 10.1055/s-0043-103344 . Glaesmer H, Wittig U, Brähler E, Martin A, Mewes R, Rief W. [Are migrants more susceptible to mental disorders?]. Psychiatr Prax. 2009. 10.1055/s-2008-1067566 . Lindert J, Ehrenstein OSv, Priebe S, Mielck A, Brähler E. Depression and anxiety in labor migrants and refugees – A systematic review and meta-analysis. Soc Sci Med. 2009. 10.1016/j.socscimed.2009.04.032 . Refugees are improving their German language skills and continue to feel welcome in Germany: The third wave of the IAB-BAMF-SOEP Survey of Refugees. 2020. https://www.bamf.de/SharedDocs/Anlagen/EN/Forschung/Kurzanalysen/kurzanalyse1-2020_iab-bamf-soep-befragung-sprache.html?nn=404000 . Accessed 1 January 2024. Hosari RR, Borho A, Morawa E, Erim Y. Which Protective Factors Are Associated with the Mental Health of Syrian Students in Germany? A Register-Based Cross-Sectional Study. Int J Environ Res Public Health. 2022. 10.3390/ijerph192316200 . Morawa E, Brand T, Dragano N, Jöckel KH, Moebus S, Erim Y. Associations Between Acculturation, Depressive Symptoms, and Life Satisfaction Among Migrants of Turkish Origin in Germany: Gender- and Generation-Related Aspects. Front Psychiatry. 2020. 10.3389/fpsyt.2020.00715 . Georgiadou E, Zbidat A, Schmitt GM, Erim Y. Prevalence of Mental Distress Among Syrian Refugees With Residence Permission in Germany: A Registry-Based Study. Front Psychiatry. 2018. 10.3389/fpsyt.2018.00393 . Busch MA, Maske UE, Ryl L, Schlack R, Hapke U. [Prevalence of depressive symptoms and diagnosed depression among adults in Germany: results of the German Health Interview and Examination Survey for Adults]. Fed Health Bull - Health Res - Health Prot. 2013. 10.1007/s00103-013-1688-3 . Hinz A, Klein AM, Brähler E, Glaesmer H, Luck T, Riedel-Heller SG, et al. Psychometric evaluation of the Generalized Anxiety Disorder Screener GAD-7, based on a large German general population sample. J Affect Disord. 2017. 10.1016/j.jad.2016.12.012 . Brance K, Chatzimpyros V, Bentall RP. Increased social identification is linked with lower depressive and anxiety symptoms among ethnic minorities and migrants: A systematic review and meta-analysis. Clin Psychol Rev. 2023. 10.1016/j.cpr.2022.102216 . Additional Declarations No competing interests reported. Supplementary Files Additionalfile1.docx Additional file 1.docx. Mean values of the nine most frequent countries of origin for PHQ-4, PHQ-2, GAD-2, verbal violence in institutions and EDS. Additionalfile2.docx Additional file 2.docx. Multiple linear regression analyses including perceived discrimination and socio-demographic and migration-related characteristics as predictor variables, and depression and generalized anxiety symptoms as dependent variables. Cite Share Download PDF Status: Published Journal Publication published 27 Aug, 2025 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 29 Jul, 2024 Editor assigned by journal 29 Jul, 2024 Submission checks completed at journal 26 Jul, 2024 First submitted to journal 23 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4790467","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":333065477,"identity":"12829849-ed22-42aa-89ff-18609bbfd6b4","order_by":0,"name":"Meret Jäschke","email":"","orcid":"","institution":"Friedrich-Alexander University Erlangen-Nürnberg (FAU)","correspondingAuthor":false,"prefix":"","firstName":"Meret","middleName":"","lastName":"Jäschke","suffix":""},{"id":333065478,"identity":"b6a6dea6-6aaa-4e23-a865-514e7064853e","order_by":1,"name":"Andrea Borho","email":"","orcid":"","institution":"Friedrich-Alexander University Erlangen-Nürnberg (FAU)","correspondingAuthor":false,"prefix":"","firstName":"Andrea","middleName":"","lastName":"Borho","suffix":""},{"id":333065479,"identity":"0215b577-58ef-41de-bb41-bbd6651bc5bc","order_by":2,"name":"Eva Morawa","email":"data:image/png;base64,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","orcid":"","institution":"Friedrich-Alexander University Erlangen-Nürnberg (FAU)","correspondingAuthor":true,"prefix":"","firstName":"Eva","middleName":"","lastName":"Morawa","suffix":""},{"id":333065480,"identity":"41280a21-59fd-4079-a10b-ada5712ef9d4","order_by":3,"name":"Felicitas Hauck","email":"","orcid":"","institution":"Friedrich-Alexander University Erlangen-Nürnberg (FAU)","correspondingAuthor":false,"prefix":"","firstName":"Felicitas","middleName":"","lastName":"Hauck","suffix":""},{"id":333065481,"identity":"05b7fab1-b00c-4d9d-a46c-d100aad0ddb0","order_by":4,"name":"Lucia Romero Gibu","email":"","orcid":"","institution":"Friedrich-Alexander University Erlangen-Nürnberg (FAU)","correspondingAuthor":false,"prefix":"","firstName":"Lucia","middleName":"Romero","lastName":"Gibu","suffix":""},{"id":333065482,"identity":"c03b1292-2d49-44a5-9b02-85ab2b127107","order_by":5,"name":"Mojib Atal","email":"","orcid":"","institution":"Friedrich-Alexander University Erlangen-Nürnberg (FAU)","correspondingAuthor":false,"prefix":"","firstName":"Mojib","middleName":"","lastName":"Atal","suffix":""},{"id":333065483,"identity":"1e339a86-4440-42dd-8ff8-e8e900ebadec","order_by":6,"name":"Nicolas Rohleder","email":"","orcid":"","institution":"Friedrich-Alexander University Erlangen-Nürnberg (FAU)","correspondingAuthor":false,"prefix":"","firstName":"Nicolas","middleName":"","lastName":"Rohleder","suffix":""},{"id":333065484,"identity":"68ea0c1f-cbe1-436e-9f0e-ca6b969fc024","order_by":7,"name":"Silke Jansen","email":"","orcid":"","institution":"Friedrich-Alexander University Erlangen-Nürnberg (FAU)","correspondingAuthor":false,"prefix":"","firstName":"Silke","middleName":"","lastName":"Jansen","suffix":""},{"id":333065485,"identity":"f617a3d6-e1a6-48e3-beda-c28a2282e37d","order_by":8,"name":"Petra Bendel","email":"","orcid":"","institution":"Friedrich-Alexander University Erlangen-Nürnberg (FAU)","correspondingAuthor":false,"prefix":"","firstName":"Petra","middleName":"","lastName":"Bendel","suffix":""},{"id":333065486,"identity":"1d92796e-c971-49d4-9a26-9a2b124a843a","order_by":9,"name":"Yesim Erim","email":"","orcid":"","institution":"Friedrich-Alexander University Erlangen-Nürnberg (FAU)","correspondingAuthor":false,"prefix":"","firstName":"Yesim","middleName":"","lastName":"Erim","suffix":""}],"badges":[],"createdAt":"2024-07-23 17:09:40","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4790467/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4790467/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-025-24363-y","type":"published","date":"2025-08-27T15:57:12+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":90344925,"identity":"e224c531-7574-4add-9cb3-3517276b14e1","added_by":"auto","created_at":"2025-09-01 16:07:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1287531,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4790467/v1/220d98cd-456f-4cde-8129-fe1036f2ceb0.pdf"},{"id":63059584,"identity":"4cd60767-cf41-479d-aa81-e2df602d2c02","added_by":"auto","created_at":"2024-08-22 15:55:49","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":17501,"visible":true,"origin":"","legend":"\u003cp\u003eAdditional file 1.docx. Mean values of the nine most frequent countries of origin for PHQ-4, PHQ-2, GAD-2, verbal violence in institutions and EDS.\u003c/p\u003e","description":"","filename":"Additionalfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-4790467/v1/692f527691889854395dd800.docx"},{"id":63059582,"identity":"13bca8fc-738e-4feb-80f1-111298a07c79","added_by":"auto","created_at":"2024-08-22 15:55:49","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":20622,"visible":true,"origin":"","legend":"\u003cp\u003eAdditional file 2.docx. Multiple linear regression analyses including perceived discrimination and socio-demographic and migration-related characteristics as predictor variables, and depression and generalized anxiety symptoms as dependent variables.\u003c/p\u003e","description":"","filename":"Additionalfile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-4790467/v1/ea7d1ce1639a23bf398f9a17.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Results from the VIOLIN Study: Verbal violence against migrants in German public institutions, discrimination and their association with mental health – an online cross-sectional study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eThe project Verbal Violence against Migrants in Institutions (VIOLIN) is the first one in Germany to examine the experiences of verbal violence in institutions (VVI) of migrants and refugees and its interrelationship with their mental health. Verbal violence (VV) is a non-physical form of discrimination and is hard to be detected in comparison to the bodily forms of violence. Discrimination refers to the unequal treatment of people on the basis of characteristics such as origin, skin color, nationality, gender, sexual orientation, culture or religious practice [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. International research has identified discrimination as the most important factor impairing mental health for migrants after resettlement [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. There is strong empirical evidence for the link between discrimination and poor mental health [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] in form of development and persistence of depression and anxiety [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In scientific research in Germany the definition of the Federal Statistical Office of Germany is mostly used, which characterizes people to have a migration background if they themselves or at least one parent was born without German citizenship [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Refugees are persons who have fled their home country because of their race, religion, nationality, membership in a particular social group, or on grounds of war and political conflicts [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Voluntary migrants, in contrast, leave their country of origin of their own decision [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Germany, there is the Federal Anti-Discrimination Agency and research groups that investigate discrimination. They have published the following key information on discrimination against migrants: Every second migrant reports experiences of discrimination [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Refugees\u0026acute; experiences of discrimination are slightly more frequent than the average migrant population in Germany [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Discrimination acts as a psychological stressor as it is uncontrollable and increases the likelihood of mental illnesses [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In surveys, discrimination is usually measured in terms of personally perceived discrimination, which can also be caused by physical violence. Migrants whose physical or physiognomic characteristics allow conclusions to be drawn about their migration history report discrimination in 48% of cases. If they also have an accent of language, 59% report discrimination. Without differences in physiognomy, only 17% report discrimination [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Black people name their skin color as the most common reason for discrimination [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Country of origin and religious affiliation also have an influence [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In general, migrants most frequently report discriminatory experiences when on the search for a job or apprenticeship, as well as during interactions with authorities [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. More specifically, highest occurrences of discrimination are mentioned on the housing market, followed by offices/authorities, work, shops/services and health services [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Particularly, in these institutions the discriminated person is in a dependent role [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e We have focused on verbal discrimination, a subtle linguistic form of violence, as this has not been sufficiently investigated to date. Verbal violence was investigated in the context of public institutions because the observations can be objectified there, but not in the private sphere. We would also like to make recommendations to public institutions on how they can improve their communication.\u003c/p\u003e \u003cp\u003eIn linguistics, VV is defined as \u0026ldquo;linguistic behavior that has detrimental effects on the interlocutor\u0026rdquo; [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In addition to the interlocutors experiences, it is also important to look at the consequences of VVI but this association has not yet been examined.\u003c/p\u003e \u003cp\u003eThe aim of the project VIOLIN was to document and understand VVI against migrants and refugees in Germany. Since migrants are a heterogeneous group [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], the frequency and form of experiences of VVI could differ between refugees and voluntary migrants, e.g. migrant workers. We specifically aimed to understand the association between VVI and mental health. On the basis of these objectives we made two hypotheses:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eVVI has a negative impact on the mental health of migrants.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eRefugees show higher prevalence scores for depression and anxiety symptoms compared to voluntary migrants.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e"},{"header":"2. Materials and methods","content":"\u003cp\u003e VIOLIN is an interdisciplinary project of the Friedrich-Alexander University Erlangen-N\u0026uuml;rnberg (FAU), with the participation of the departments of regional research, linguistics, health psychology and psychosomatics. For this cross-sectional online survey, a questionnaire was developed by members of the named departments and translated by native speakers into the following nine languages: German, English, Spanish, French, Arabic, Polish, Farsi, Pashto and Turkish. The questionnaire consists of a main module and four submodules, covering specific political, linguistic and psychological issues, which are not subject of this manuscript. The survey was presented using the academic online survey tool Unipark (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003ca href=\"http://www.unipark.com\" target=\"_blank\"\u003ewww.unipark.com\u003c/a\u003e\u003c/span\u003e\u003cspan address=\"http://www.unipark.com\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e; Tivian, Germany) and, took 30 minutes to complete on average.\u003c/p\u003e \u003cp\u003eUsing snowball sampling, recruitment was done through various channels, such as social media (Facebook, Instagram), clubs and associations of ethnic groups, churches and public institutions, e.g. integration councils and anti-discrimination bodies. The data collection period was from October 21, 2021 to April 01, 2022. A total of 899 migrants fulfilling the above mentioned definition of migration background voluntarily participated in the survey.\u003c/p\u003e \u003cp\u003e The study was approved by the Ethics Committee of the Medical Faculty of the Friedrich-Alexander University Erlangen-N\u0026uuml;rnberg (FAU) (project identification code: 451_19B).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Measurement instruments\u003c/h2\u003e \u003cp\u003eThe following sociodemographic and migration-specific variables were collected: sex, age, educational degree, current occupation, language skills, residence status, duration of stay and reason to migrate. In addition, the survey focused on VVI, experiences of discrimination and mental health.\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003e2.1.1. Verbal violence in German public institutions\u003c/h2\u003e \u003cp\u003eA qualitative study with Latin American migrants [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], focus groups with pupils with a migration background [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] and interviews of refugees from Afghanistan served as preliminary studies. Through an expert consensus group the relevant items as well as the institutions where VVI was experienced most frequently were extracted from the preliminary studies for the present questionnaire Finally 24 items aimed to determine the form and frequency of VVI. The items consisted of examples of uncomfortable situations that people had experienced. For example, \u0026ldquo;The person ignored me when I spoke to him\u0026ldquo;, \u0026ldquo;The person insisted that I speak only German\u0026rdquo;, \u0026ldquo;The person spoke to me particularly fast, so I could not understand him/her well\u0026rdquo;, \u0026ldquo;The person did not look at me when I spoke\u0026ldquo;, \u0026ldquo;The person was making fun of me\u0026rdquo;, or \u0026ldquo;The person refused to listen to me\u0026rdquo;. Frequency was measured using a 5-point Likert scale, ranging from \u0026ldquo;never\u0026rdquo; (0) to \u0026ldquo;very often\u0026rdquo; (4). The impact of the experience was measured on a 5-point Likert scale, ranging from \u0026ldquo;not at all\u0026rdquo; (0) to \u0026ldquo;very much\u0026rdquo; (5). For the analysis, the average sum scores were computed. The internal consistency measured by Cronbach\u0026rsquo;s alpha was very high (0.94).\u003c/p\u003e \u003cp\u003eIn addition, it was determined in which public institutions VVI was experienced. For this purpose, 14 examples were given, i.e. public transport, doctors\u0026rsquo; offices, immigration offices, police, school.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003e2.1.2. Perceived discrimination\u003c/h2\u003e \u003cp\u003ePerceived Discrimination was assessed using the Everyday Discrimination Scale (EDS). It is a well-established psychometric questionnaire that can capture temporary or long-term and relatively low levels of discrimination experienced in daily life [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Participants were asked to report how often they had been treated unfairly in their everyday life in the past 12 months using a 6-point Likert Scale from \u0026ldquo;never\u0026rdquo; (0) to \u0026ldquo;almost daily\u0026rdquo; (5) for each out of the 9 items. The following item was added: \u0026ldquo;Are you treated worse than others in authorities?\u0026rdquo;. Higher scores indicated a higher level of perceived discrimination. The internal consistency measured by Cronbach\u0026rsquo;s alpha was very high (0.92).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003e2.1.3. Depression and Generalized Anxiety Disorder: PHQ-4 (Patient Health Questionnaire)\u003c/h2\u003e \u003cp\u003eTo assess depression and generalized anxiety symptoms, PHQ-4 (Patient Health Questionnaire) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], as an abbreviated form of the Patient Health Questionnaire (PHQ-D), was utilized. PHQ-4 can be subdivided into a module for depressive symptoms (PHQ-2) and a module for generalized anxiety symptoms (GAD-2).\u003c/p\u003e \u003cp\u003eThe PHQ-2 [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] questioned the frequency of depressed mood and anhedonia in the past two weeks. On a 4-point Likert scale from \u0026ldquo;not at all\u0026rdquo; (0) to \u0026ldquo;almost every day\u0026rdquo; (3) participants indicated the frequency of experiencing \u0026ldquo;little interest or pleasure in things\u0026rdquo; and felt \u0026ldquo;dejection, melancholy or hopelessness \u0026ldquo;. Clinically relevant depressive symptoms were defined as a sum score greater than or equal to 3.\u003c/p\u003e \u003cp\u003eThe Generalized Anxiety Disorder Scale 2 (GAD-2) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] as a screening instrument for clinically relevant symptoms of generalized anxiety disorder asks about the frequency of feelings of \u0026ldquo;nervousness, anxiety, or tension\u0026rdquo; and \u0026ldquo;not being able to stop or control one\u0026rsquo;s worry\u0026rdquo; during the past 2 weeks on a 4-point Likert scale ranging from \u0026ldquo;not at all\u0026rdquo; (0) to \u0026ldquo;present almost daily\u0026rdquo; (3) with a cut-off score greater than or equal to 3 of the sum score indicating clinically relevant symptom severity.\u003c/p\u003e \u003cp\u003eFor this sample, the Cronbach\u0026rsquo;s Alpha was 0.82 for PHQ-2 and 0.86 for GAD-2.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e2.1.4. Life satisfaction in Germany\u003c/h2\u003e \u003cp\u003eLife satisfaction with participants\u0026rsquo; lives in Germany was measured by a visual analogue scale consisting of following manifestations \u0026ldquo;not satisfied at all\u0026rdquo; (0) to \u0026ldquo;very satisfied\u0026rdquo; (10).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Statistical analysis\u003c/h2\u003e \u003cp\u003eIMB SPSS Statistic 29 (IBM Corporation, Armonk, NY, USA) was applied for the statistical analysis. Means, standard deviation, range and frequencies were calculated for the descriptive analyses. Participants who did not complete the relevant questionnaires were excluded from the sample. The sample of 899 participants was reduced to 528 due to missing answers for items relevant to the research question. In addition, three persons were excluded due to implausible answers. The investigated sample of 525 migrants in total was again divided into two subgroups, 137 refugees and 388 voluntary migrants.\u003c/p\u003e \u003cp\u003eBased on the available cut-off values, the prevalence rates for assessing clinically relevant symptoms of depression and generalized anxiety were calculated for each questionnaire.\u003c/p\u003e \u003cp\u003eFor the analysis of differences between refugees and voluntary migrants and between female and male migrants in terms of their mental health (PHQ-2 and GAD-2), experiences of VVI, experiences of discrimination (EDS) and life satisfaction, we conducted T-tests for independent samples after checking the normal distribution of the characteristic examined. The effect size was calculated using Cohen\u0026lsquo;s d (d\u0026thinsp;\u0026ge;\u0026thinsp;0.2\u0026thinsp;=\u0026thinsp;small, d\u0026thinsp;\u0026ge;\u0026thinsp;0.5\u0026thinsp;=\u0026thinsp;medium and d\u0026thinsp;\u0026ge;\u0026thinsp;0.8\u0026thinsp;=\u0026thinsp;large effect size).\u003c/p\u003e \u003cp\u003eMultiple linear regression analyses were calculated, in which the results point to a significant association of VVI experience and discrimination experiences with depressive and generalized anxiety disorder symptoms. Due to multicollinearity with a correlation coefficient of 0.75 between experiencing discrimination and VVI, we conducted two regression analyses for each outcome variable. The significance level was set at p\u0026thinsp;\u0026le;\u0026thinsp;0.05 in all analyses. For the regression analysis, we excluded three participants who had indicated \u0026ldquo;trans\u0026rdquo; as their gender as they could not be assigned to either the female or male gender group based on the information provided.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Sample characteristics (Socio-demographic and migration-specific variables)\u003c/h2\u003e \u003cp\u003eThe sample consisted of refugees (N\u0026thinsp;=\u0026thinsp;137) and voluntary migrants (N\u0026thinsp;=\u0026thinsp;388) from 60 different countries. Among the voluntary migrants, 372 were first-generation and 61 were second-generation migrants. There were more women among the sample of voluntary migrants (70%) than among the refugee sample (32%). The average age of the total sample was 38.22 years (SD\u0026thinsp;=\u0026thinsp;11.64; range 18\u0026ndash;78). One hundred and eight refugees (79%) and 353 (91%) voluntary migrants had completed secondary school with a degree. 75% of the sample had a high (at least level B2) German language proficiency. The three most frequently mentioned reasons for migration were family/partnership (30%), flight/forced migration (28%) and studying (24%). On average, refugees had lived in Germany for 9.35 years (SD\u0026thinsp;=\u0026thinsp;10.12) and voluntary migrants for 15.20 years (SD\u0026thinsp;=\u0026thinsp;13.27).\u003c/p\u003e \u003cp\u003eFurther sociodemographic and migrant-specific variables are listed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocio-demographic and migration-specific characteristics of the total sample.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal (N\u0026thinsp;=\u0026thinsp;525; 100%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003erefugees (N\u0026thinsp;=\u0026thinsp;137; 26%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eVolunteer Migrants (N\u0026thinsp;=\u0026thinsp;388; 74%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eWomen (N\u0026thinsp;=\u0026thinsp;316; 60%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMen (N\u0026thinsp;=\u0026thinsp;206; 39%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003cp\u003eMale\u003c/p\u003e \u003cp\u003eDiverse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e316 (60%)\u003c/p\u003e \u003cp\u003e206 (39%)\u003c/p\u003e \u003cp\u003e3 (1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44 (32%)\u003c/p\u003e \u003cp\u003e92 (67%\u003c/p\u003e \u003cp\u003e1 (1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e272 (70%)\u003c/p\u003e \u003cp\u003e114 (29%)\u003c/p\u003e \u003cp\u003e2 (1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e316 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e206 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge in years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRange 18\u0026ndash;78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;38.2\u003c/p\u003e \u003cp\u003e(SD 11.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;36.0\u003c/p\u003e \u003cp\u003e(SD 11.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;39.0\u003c/p\u003e \u003cp\u003e(SD 11.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;37.9\u003c/p\u003e \u003cp\u003e(SD 10.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;38.9\u003c/p\u003e \u003cp\u003e(SD 12.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003cp\u003ePermanent partnership\u003c/p\u003e \u003cp\u003eMarried\u003c/p\u003e \u003cp\u003eDivorced\u003c/p\u003e \u003cp\u003eWidowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e139 (27%)\u003c/p\u003e \u003cp\u003e74 (14%)\u003c/p\u003e \u003cp\u003e275 (52%)\u003c/p\u003e \u003cp\u003e34 (6%)\u003c/p\u003e \u003cp\u003e3 (1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53 (39%)\u003c/p\u003e \u003cp\u003e8 (6%)\u003c/p\u003e \u003cp\u003e70 (51%)\u003c/p\u003e \u003cp\u003e6 (4%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e86 (22%)\u003c/p\u003e \u003cp\u003e66 (17%)\u003c/p\u003e \u003cp\u003e205 (53%)\u003c/p\u003e \u003cp\u003e28 (7%)\u003c/p\u003e \u003cp\u003e3 (1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e77 (24.5%)\u003c/p\u003e \u003cp\u003e54 (17%)\u003c/p\u003e \u003cp\u003e157 (50%)\u003c/p\u003e \u003cp\u003e25 (8%)\u003c/p\u003e \u003cp\u003e3 (1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e62 (30%)\u003c/p\u003e \u003cp\u003e18 (9%)\u003c/p\u003e \u003cp\u003e117 (57%)\u003c/p\u003e \u003cp\u003e9 (4.5%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducational degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLeft school without graduation\u003c/p\u003e \u003cp\u003eCompulsory school finished with a diploma\u003c/p\u003e \u003cp\u003eFinished secondary school with a diploma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (2%)\u003c/p\u003e \u003cp\u003e52 (10%)\u003c/p\u003e \u003cp\u003e461 (88%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (6%)\u003c/p\u003e \u003cp\u003e21 (15%)\u003c/p\u003e \u003cp\u003e108 (79%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (1%)\u003c/p\u003e \u003cp\u003e31 (8%)\u003c/p\u003e \u003cp\u003e353 (91%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (1%)\u003c/p\u003e \u003cp\u003e24 (8%)\u003c/p\u003e \u003cp\u003e288 (91%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7 (3%)\u003c/p\u003e \u003cp\u003e28 (14%)\u003c/p\u003e \u003cp\u003e171 (83%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVocational training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCompleted\u003c/p\u003e \u003cp\u003eStarted, but not yet completed\u003c/p\u003e \u003cp\u003eStarted, but canceled\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e234 (45%)\u003c/p\u003e \u003cp\u003e21 (4%)\u003c/p\u003e \u003cp\u003e5 (1%)\u003c/p\u003e \u003cp\u003e265 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53 (39%)\u003c/p\u003e \u003cp\u003e9 (7%)\u003c/p\u003e \u003cp\u003e3 (2%)\u003c/p\u003e \u003cp\u003e72 (52%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e181 (46%)\u003c/p\u003e \u003cp\u003e12 (3%)\u003c/p\u003e \u003cp\u003e2 (1%)\u003c/p\u003e \u003cp\u003e193 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e133 (42%)\u003c/p\u003e \u003cp\u003e11 (3.5%)\u003c/p\u003e \u003cp\u003e2 (0.5%)\u003c/p\u003e \u003cp\u003e170 (54%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e100 (48.5%)\u003c/p\u003e \u003cp\u003e10 (5%)\u003c/p\u003e \u003cp\u003e2 (1%)\u003c/p\u003e \u003cp\u003e94 (46%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge at immigration in years\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;464;\u003c/p\u003e \u003cp\u003e136 R\u003csup\u003e1\u003c/sup\u003e, 328 VM\u003csup\u003e2\u003c/sup\u003e, 183 W\u003csup\u003e3\u003c/sup\u003e, 183 M\u003csup\u003e4\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;25.1\u003c/p\u003e \u003cp\u003e(SD 9.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;26.5\u003c/p\u003e \u003cp\u003e(SD 10.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;24.6\u003c/p\u003e \u003cp\u003e(SD 8.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;24.8\u003c/p\u003e \u003cp\u003e(SD 9.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;25.6\u003c/p\u003e \u003cp\u003e(SD 8.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of stay in years (N\u0026thinsp;=\u0026thinsp;463;\u003c/p\u003e \u003cp\u003e136 R\u003csup\u003e1\u003c/sup\u003e, 327 VM\u003csup\u003e2\u003c/sup\u003e, 183 W\u003csup\u003e3\u003c/sup\u003e, 182 M\u003csup\u003e4\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;13.4\u003c/p\u003e \u003cp\u003e(SD 12.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;9.4\u003c/p\u003e \u003cp\u003e(SD 10.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;15.1\u003c/p\u003e \u003cp\u003e(SD 13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;13.9\u003c/p\u003e \u003cp\u003e(SD 12.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;13.0\u003c/p\u003e \u003cp\u003e(SD 13.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFive most common countries of origin\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;523;\u003c/p\u003e \u003cp\u003e137 R\u003csup\u003e1\u003c/sup\u003e, 386 VM\u003csup\u003e2\u003c/sup\u003e, 312 W\u003csup\u003e3\u003c/sup\u003e, 205 M\u003csup\u003e4\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61 (12%) Germany\u003c/p\u003e \u003cp\u003e53 (10%) Afghanistan\u003c/p\u003e \u003cp\u003e53 (10%) Poland\u003c/p\u003e \u003cp\u003e48 (9%) Syria\u003c/p\u003e \u003cp\u003e41 (8%) Mexico\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45 (33%) Syria\u003c/p\u003e \u003cp\u003e44 (32%) Afghanistan\u003c/p\u003e \u003cp\u003e14 (10%) Iran\u003c/p\u003e \u003cp\u003e6 (4%) Poland\u003c/p\u003e \u003cp\u003e5 (4%) Turkey\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e61 (15%) Germany\u003c/p\u003e \u003cp\u003e47 (12%) Poland\u003c/p\u003e \u003cp\u003e41 (11%) Mexico\u003c/p\u003e \u003cp\u003e25 (6%) Ecuador\u003c/p\u003e \u003cp\u003e24 (6%) Turkey\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e39 (12.5%) Germany\u003c/p\u003e \u003cp\u003e36 (11.5%) Mexico\u003c/p\u003e \u003cp\u003e29 (9%) Poland\u003c/p\u003e \u003cp\u003e19 (6%) Iran\u003c/p\u003e \u003cp\u003e17 (5.5%) Ecuador\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e45 (22%) Afghanistan\u003c/p\u003e \u003cp\u003e32 (15.5%) Syria\u003c/p\u003e \u003cp\u003e24 (12%) Poland\u003c/p\u003e \u003cp\u003e22 (11%) Germany\u003c/p\u003e \u003cp\u003e14 (7%) Turkey\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGerman citizenship by birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46 (9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e42 (11%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e27 (8.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e19 (9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsylum application (N\u0026thinsp;=\u0026thinsp;382;\u003c/p\u003e \u003cp\u003e117 R\u003csup\u003e1\u003c/sup\u003e, 265 VM\u003csup\u003e2\u003c/sup\u003e, 225 W\u003csup\u003e3\u003c/sup\u003e, 155 M\u003csup\u003e4\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e109 (28%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e109 (93%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e31 (14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e77 (50%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResidence status (N\u0026thinsp;=\u0026thinsp;382;\u003c/p\u003e \u003cp\u003e117 R\u003csup\u003e1\u003c/sup\u003e, 265 VM\u003csup\u003e2\u003c/sup\u003e, 225 W\u003csup\u003e3\u003c/sup\u003e, 155 M\u003csup\u003e4\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePermanent\u003c/p\u003e \u003cp\u003eTemporary\u003c/p\u003e \u003cp\u003eNo title\u003c/p\u003e \u003cp\u003eOther\u003c/p\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e207 (54%)\u003c/p\u003e \u003cp\u003e126 (33%)\u003c/p\u003e \u003cp\u003e14 (4%)\u003c/p\u003e \u003cp\u003e10 (3%)\u003c/p\u003e \u003cp\u003e25 (6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33 (28%)\u003c/p\u003e \u003cp\u003e61 (52%)\u003c/p\u003e \u003cp\u003e13 (11%)\u003c/p\u003e \u003cp\u003e5 (4.5%)\u003c/p\u003e \u003cp\u003e5 (4.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e174 (65%)\u003c/p\u003e \u003cp\u003e65 (24.5%)\u003c/p\u003e \u003cp\u003e1 (0.5%)\u003c/p\u003e \u003cp\u003e5 (2%)\u003c/p\u003e \u003cp\u003e20 (8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e143 (64%)\u003c/p\u003e \u003cp\u003e62 (28%)\u003c/p\u003e \u003cp\u003e2 (1%)\u003c/p\u003e \u003cp\u003e2 (1%)\u003c/p\u003e \u003cp\u003e16 (7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e64 (41%)\u003c/p\u003e \u003cp\u003e63 (41%)\u003c/p\u003e \u003cp\u003e12 (8%)\u003c/p\u003e \u003cp\u003e8 (5%)\u003c/p\u003e \u003cp\u003e8 (5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReason to migrate (N\u0026thinsp;=\u0026thinsp;465;\u003c/p\u003e \u003cp\u003e137 R\u003csup\u003e1\u003c/sup\u003e, 328 VM\u003csup\u003e2\u003c/sup\u003e, 278 W\u003csup\u003e3\u003c/sup\u003e, 184 M\u003csup\u003e4\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFlight/Forced Migration\u003c/p\u003e \u003cp\u003eWork\u003c/p\u003e \u003cp\u003eEducation/Further education\u003c/p\u003e \u003cp\u003eStudy\u003c/p\u003e \u003cp\u003eFamily and partnership reasons\u003c/p\u003e \u003cp\u003eEconomic reasons\u003c/p\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e129 (28%)\u003c/p\u003e \u003cp\u003e72 (15%)\u003c/p\u003e \u003cp\u003e35 (7%)\u003c/p\u003e \u003cp\u003e111 (24%)\u003c/p\u003e \u003cp\u003e139 (30%)\u003c/p\u003e \u003cp\u003e48 (10%)\u003c/p\u003e \u003cp\u003e33 (7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e127 (93%)\u003c/p\u003e \u003cp\u003e4 (3%)\u003c/p\u003e \u003cp\u003e4 (3%)\u003c/p\u003e \u003cp\u003e7 (5%)\u003c/p\u003e \u003cp\u003e4 (3%)\u003c/p\u003e \u003cp\u003e7 (5%)\u003c/p\u003e \u003cp\u003e11 (8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e68 (21%)\u003c/p\u003e \u003cp\u003e31 (9%)\u003c/p\u003e \u003cp\u003e104 (32%)\u003c/p\u003e \u003cp\u003e135 (41%)\u003c/p\u003e \u003cp\u003e41 (12%)\u003c/p\u003e \u003cp\u003e22 (7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e43 (15.5%)\u003c/p\u003e \u003cp\u003e46 (16.5%)\u003c/p\u003e \u003cp\u003e23 (8%)\u003c/p\u003e \u003cp\u003e69 (25%)\u003c/p\u003e \u003cp\u003e113 (41%)\u003c/p\u003e \u003cp\u003e30 (11%)\u003c/p\u003e \u003cp\u003e12 (4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e86 (47%)\u003c/p\u003e \u003cp\u003e26 (14%)\u003c/p\u003e \u003cp\u003e11 (6%)\u003c/p\u003e \u003cp\u003e42 (23%)\u003c/p\u003e \u003cp\u003e25 (14%)\u003c/p\u003e \u003cp\u003e17 (9%)\u003c/p\u003e \u003cp\u003e15 (8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGerman language skills (N\u0026thinsp;=\u0026thinsp;461;\u003c/p\u003e \u003cp\u003e130 R\u003csup\u003e1\u003c/sup\u003e, 331 VM\u003csup\u003e2\u003c/sup\u003e, 274 W\u003csup\u003e3\u003c/sup\u003e, 184 M\u003csup\u003e4\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo knowledge\u003c/p\u003e \u003cp\u003eA1\u003c/p\u003e \u003cp\u003eA2\u003c/p\u003e \u003cp\u003eB1\u003c/p\u003e \u003cp\u003eB2\u003c/p\u003e \u003cp\u003eC1\u003c/p\u003e \u003cp\u003eC2\u003c/p\u003e \u003cp\u003eFirst language\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (1%)\u003c/p\u003e \u003cp\u003e24 (5%)\u003c/p\u003e \u003cp\u003e29 (6%)\u003c/p\u003e \u003cp\u003e59 (13%)\u003c/p\u003e \u003cp\u003e95 (21%)\u003c/p\u003e \u003cp\u003e119 (26%)\u003c/p\u003e \u003cp\u003e108 (23%)\u003c/p\u003e \u003cp\u003e23 (5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (1%)\u003c/p\u003e \u003cp\u003e11 (8%)\u003c/p\u003e \u003cp\u003e9 (7%)\u003c/p\u003e \u003cp\u003e22 (17%)\u003c/p\u003e \u003cp\u003e38 (29%)\u003c/p\u003e \u003cp\u003e32 (25%)\u003c/p\u003e \u003cp\u003e14 (11%)\u003c/p\u003e \u003cp\u003e3 (2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (1%)\u003c/p\u003e \u003cp\u003e13 (4%)\u003c/p\u003e \u003cp\u003e29 (6%)\u003c/p\u003e \u003cp\u003e37 (11%)\u003c/p\u003e \u003cp\u003e57 (17%)\u003c/p\u003e \u003cp\u003e87 (26.5%)\u003c/p\u003e \u003cp\u003e94 (28.5%)\u003c/p\u003e \u003cp\u003e20 (6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (1%)\u003c/p\u003e \u003cp\u003e14 (5%)\u003c/p\u003e \u003cp\u003e18 (6.5%)\u003c/p\u003e \u003cp\u003e33 (12%)\u003c/p\u003e \u003cp\u003e48 (17.5%)\u003c/p\u003e \u003cp\u003e75 (27.5%)\u003c/p\u003e \u003cp\u003e70 (25.5%)\u003c/p\u003e \u003cp\u003e14 (5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2 (1%)\u003c/p\u003e \u003cp\u003e9 (5%)\u003c/p\u003e \u003cp\u003e11 (6%)\u003c/p\u003e \u003cp\u003e25 (13.5%)\u003c/p\u003e \u003cp\u003e46 (25%)\u003c/p\u003e \u003cp\u003e44 (24%)\u003c/p\u003e \u003cp\u003e38 (21%)\u003c/p\u003e \u003cp\u003e9 (5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecognition of the degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComplete\u003c/p\u003e \u003cp\u003ePartial\u003c/p\u003e \u003cp\u003eNone\u003c/p\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e198 (38%)\u003c/p\u003e \u003cp\u003e96 (18%)\u003c/p\u003e \u003cp\u003e96 (18%)\u003c/p\u003e \u003cp\u003e135 (26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36 (26%)\u003c/p\u003e \u003cp\u003e32 (23%)\u003c/p\u003e \u003cp\u003e34 (25%)\u003c/p\u003e \u003cp\u003e35 (26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e162 (42%)\u003c/p\u003e \u003cp\u003e64 (16%)\u003c/p\u003e \u003cp\u003e62 (16%)\u003c/p\u003e \u003cp\u003e100 (26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e123 (39%)\u003c/p\u003e \u003cp\u003e61 (19%)\u003c/p\u003e \u003cp\u003e62 (20%)\u003c/p\u003e \u003cp\u003e70 (22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e74 (36%)\u003c/p\u003e \u003cp\u003e35 (17%)\u003c/p\u003e \u003cp\u003e33 (16%)\u003c/p\u003e \u003cp\u003e64 (31%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOccupation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGerman course\u003c/p\u003e \u003cp\u003eIntegration course\u003c/p\u003e \u003cp\u003eWork/occupation\u003c/p\u003e \u003cp\u003eSchool\u003c/p\u003e \u003cp\u003eStudy\u003c/p\u003e \u003cp\u003eVocational training/apprenticeship\u003c/p\u003e \u003cp\u003eInternship\u003c/p\u003e \u003cp\u003eHousewife/househusband\u003c/p\u003e \u003cp\u003e(Early) retirement\u003c/p\u003e \u003cp\u003eJob search\u003c/p\u003e \u003cp\u003eOther\u003c/p\u003e \u003cp\u003eNone of the above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (7%)\u003c/p\u003e \u003cp\u003e12 (2%)\u003c/p\u003e \u003cp\u003e339 (65%)\u003c/p\u003e \u003cp\u003e8 (1%)\u003c/p\u003e \u003cp\u003e88 (17%)\u003c/p\u003e \u003cp\u003e30 (6%)\u003c/p\u003e \u003cp\u003e15 (3%)\u003c/p\u003e \u003cp\u003e41 (8%)\u003c/p\u003e \u003cp\u003e13 (2%)\u003c/p\u003e \u003cp\u003e38 (7%)\u003c/p\u003e \u003cp\u003e11 (2%)\u003c/p\u003e \u003cp\u003e19 (4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22 (16%)\u003c/p\u003e \u003cp\u003e8 (6%)\u003c/p\u003e \u003cp\u003e58 (42%)\u003c/p\u003e \u003cp\u003e5 (3.5%)\u003c/p\u003e \u003cp\u003e24 (17.5%)\u003c/p\u003e \u003cp\u003e14 (10%)\u003c/p\u003e \u003cp\u003e9 (6.5%)\u003c/p\u003e \u003cp\u003e6 (4.5%)\u003c/p\u003e \u003cp\u003e5 (3.5%)\u003c/p\u003e \u003cp\u003e12 (9%)\u003c/p\u003e \u003cp\u003e5 (3.5%)\u003c/p\u003e \u003cp\u003e5 (3.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13 (3.5%)\u003c/p\u003e \u003cp\u003e4 (1%)\u003c/p\u003e \u003cp\u003e281 (66%)\u003c/p\u003e \u003cp\u003e3 (1%)\u003c/p\u003e \u003cp\u003e64 (16%)\u003c/p\u003e \u003cp\u003e16 (3%)\u003c/p\u003e \u003cp\u003e6 (1.5%)\u003c/p\u003e \u003cp\u003e35 (9%)\u003c/p\u003e \u003cp\u003e8 (2%)\u003c/p\u003e \u003cp\u003e26 (7%)\u003c/p\u003e \u003cp\u003e38 (10%)\u003c/p\u003e \u003cp\u003e14 (3.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12 (4%)\u003c/p\u003e \u003cp\u003e7 (2%)\u003c/p\u003e \u003cp\u003e214 (68%)\u003c/p\u003e \u003cp\u003e6 (2%)\u003c/p\u003e \u003cp\u003e56 (18%)\u003c/p\u003e \u003cp\u003e14 (4.5%)\u003c/p\u003e \u003cp\u003e8 (2.5%)\u003c/p\u003e \u003cp\u003e36 (11.5%)\u003c/p\u003e \u003cp\u003e2 (0.5%)\u003c/p\u003e \u003cp\u003e22 (7%)\u003c/p\u003e \u003cp\u003e6 (2%)\u003c/p\u003e \u003cp\u003e7 (2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e23 (11%)\u003c/p\u003e \u003cp\u003e5 (2.5%)\u003c/p\u003e \u003cp\u003e124 (60%)\u003c/p\u003e \u003cp\u003e2 (1%)\u003c/p\u003e \u003cp\u003e32 (15.5%)\u003c/p\u003e \u003cp\u003e16 (8%)\u003c/p\u003e \u003cp\u003e7 (3.5%)\u003c/p\u003e \u003cp\u003e5 (2.5%)\u003c/p\u003e \u003cp\u003e10 (5%)\u003c/p\u003e \u003cp\u003e15 (7%)\u003c/p\u003e \u003cp\u003e2 (1%)\u003c/p\u003e \u003cp\u003e11 (5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eForm of employment (N\u0026thinsp;=\u0026thinsp;310;\u003c/p\u003e \u003cp\u003e54 R\u003csup\u003e1\u003c/sup\u003e, 256 VM\u003csup\u003e2\u003c/sup\u003e, 195 W\u003csup\u003e3\u003c/sup\u003e, 115 M\u003csup\u003e4\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFull-time employment\u003c/p\u003e \u003cp\u003ePart-time employment\u003c/p\u003e \u003cp\u003eMarginal employment\u003c/p\u003e \u003cp\u003eOccasional or irregular employment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e217 (70%)\u003c/p\u003e \u003cp\u003e76 (24%)\u003c/p\u003e \u003cp\u003e12 (4%)\u003c/p\u003e \u003cp\u003e5 (2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42 (78%)\u003c/p\u003e \u003cp\u003e10 (18%)\u003c/p\u003e \u003cp\u003e2 (4%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e175 (68%)\u003c/p\u003e \u003cp\u003e66 (26%)\u003c/p\u003e \u003cp\u003e12 (5%)\u003c/p\u003e \u003cp\u003e3 (1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e116 (59.5%)\u003c/p\u003e \u003cp\u003e65 (33.5%)\u003c/p\u003e \u003cp\u003e11 (5.5%)\u003c/p\u003e \u003cp\u003e3 (1.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e101 (88%)\u003c/p\u003e \u003cp\u003e11 (10%)\u003c/p\u003e \u003cp\u003e1 (1%)\u003c/p\u003e \u003cp\u003e2 (2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSense of belonging to country of origin from 0\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;1.99 (SD .91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;1.86 (SD .96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;2.04 (SD .88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;2.07 (SD .86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;1.89 (SD .95)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSense of belonging to Germany from 0\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;1.74 (SD .85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;1.76 (SD .88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;1.73 (SD .85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;1.69 (SD .88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;1.83 (SD .81)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFuture in Germany\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003ePartly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e260 (49%)\u003c/p\u003e \u003cp\u003e67 (13%)\u003c/p\u003e \u003cp\u003e198 (38%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e90 (65.5%)\u003c/p\u003e \u003cp\u003e9 (6.5%)\u003c/p\u003e \u003cp\u003e38 (28%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e170 (44%)\u003c/p\u003e \u003cp\u003e58 (15%)\u003c/p\u003e \u003cp\u003e160 (41%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e139 (44%)\u003c/p\u003e \u003cp\u003e46 (14.5%)\u003c/p\u003e \u003cp\u003e131 (41.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e120 (58%)\u003c/p\u003e \u003cp\u003e21 (10%)\u003c/p\u003e \u003cp\u003e65 (31.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLife satisfaction from 0\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;7.1 (SD 1.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;6.7 (SD 2.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;7.2 (SD 1.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;7.18 (SD 1.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;7.91 (SD 2.01)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003csup\u003e\u003cem\u003e1\u003c/em\u003e\u003c/sup\u003e \u003cem\u003eR: refugees;\u003c/em\u003e \u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e \u003cem\u003eVM: voluntary migrants;\u003c/em\u003e \u003csup\u003e\u003cem\u003e3\u003c/em\u003e\u003c/sup\u003e \u003cem\u003eW: women;\u003c/em\u003e \u003csup\u003e\u003cem\u003e4\u003c/em\u003e\u003c/sup\u003e \u003cem\u003eM: men\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003e3.2.1. Verbal violence in German public institutions\u003c/h2\u003e \u003cp\u003eThe average sum score of the total sample for the 24 items was 25.15 (SD\u0026thinsp;=\u0026thinsp;18.09). There was no significant difference (t(524)\u0026thinsp;=\u0026thinsp;0.67; p\u0026thinsp;=\u0026thinsp;0.50; d\u0026thinsp;=\u0026thinsp;0.07) between refugees (M\u0026thinsp;=\u0026thinsp;26.04; SD\u0026thinsp;=\u0026thinsp;18.46) and voluntary migrants (M\u0026thinsp;=\u0026thinsp;24.84; SD\u0026thinsp;=\u0026thinsp;17.97). However, female voluntary migrants experienced significantly more VVI (M\u0026thinsp;=\u0026thinsp;26.42; SD\u0026thinsp;=\u0026thinsp;18.02) than male voluntary migrants (M\u0026thinsp;=\u0026thinsp;20.51; SD\u0026thinsp;=\u0026thinsp;16.56; t(385)\u0026thinsp;=\u0026thinsp;3.01; p\u0026thinsp;=\u0026thinsp;0.003; d\u0026thinsp;=\u0026thinsp;0.34). There were no significant differences in the frequency of VVI experienced by female (M\u0026thinsp;=\u0026thinsp;26.70; SD\u0026thinsp;=\u0026thinsp;16.16) and male (M\u0026thinsp;=\u0026thinsp;25.38; SD\u0026thinsp;=\u0026thinsp;19.34) refugees (t(135)\u0026thinsp;=\u0026thinsp;0.39; p\u0026thinsp;=\u0026thinsp;0.69; d\u0026thinsp;=\u0026thinsp;0.07).\u003c/p\u003e \u003cp\u003eVVI was most experienced in the following settings: public transport (53%), immigration offices (53%), doctors\u0026rsquo; offices (48%), hospitals (41%), and city council/district offices (38%). No significant differences were found in frequency, occurrence and location of VVI neither between voluntary migrants and refugees, nor between women and men.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e3.2.2. Discrimination\u003c/h2\u003e \u003cp\u003eThe participants reported perceiving discrimination (EDS) in Germany less than once a year (M\u0026thinsp;=\u0026thinsp;11.97; SD\u0026thinsp;=\u0026thinsp;9.63) without a significant difference (t(524)\u0026thinsp;=\u0026thinsp;0.97; p\u0026thinsp;=\u0026thinsp;0.33; d\u0026thinsp;=\u0026thinsp;0.10) between refugees (M\u0026thinsp;=\u0026thinsp;12.66; SD\u0026thinsp;=\u0026thinsp;10.27) and voluntary migrants (M\u0026thinsp;=\u0026thinsp;11.73; SD\u0026thinsp;=\u0026thinsp;9.40). Gender differences were not significant (t(135) = -0.48; p\u0026thinsp;=\u0026thinsp;0.63; d = -0.09) for female (M\u0026thinsp;=\u0026thinsp;11.95; SD\u0026thinsp;=\u0026thinsp;8.62) and male (M\u0026thinsp;=\u0026thinsp;12.86; SD\u0026thinsp;=\u0026thinsp;10.98) refugees. There were also no significant differences in the experience of everyday discrimination (t(385)\u0026thinsp;=\u0026thinsp;1.16, p\u0026thinsp;=\u0026thinsp;0.25; d\u0026thinsp;=\u0026thinsp;0.13) for female (M\u0026thinsp;=\u0026thinsp;12.03; SD\u0026thinsp;=\u0026thinsp;9.15) and male voluntary migrants (M\u0026thinsp;=\u0026thinsp;10.82; SD\u0026thinsp;=\u0026thinsp;9.90).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003e3.2.3 Depression\u003c/h2\u003e \u003cp\u003eOne hundred and sixty-five of the 525 participants (31%) showed clinically relevant depressive symptoms (PHQ-2\u0026thinsp;\u0026ge;\u0026thinsp;3), 42% of refugees and 28% of voluntary migrants. The average value for depressive symptoms was 2.09 (SD\u0026thinsp;=\u0026thinsp;1.70). Refugees (M\u0026thinsp;=\u0026thinsp;2.53; SD\u0026thinsp;=\u0026thinsp;1.72) presented significantly more depressive symptoms than voluntary migrants (M\u0026thinsp;=\u0026thinsp;1.94; SD 1.66; t(524)\u0026thinsp;=\u0026thinsp;3.51; p\u0026thinsp;\u003cb\u003e\u0026lt;\u003c/b\u003e\u0026thinsp;0.001; d\u0026thinsp;=\u0026thinsp;0.35). The results revealed no significant differences in the prevalence of depressive symptoms between female (M\u0026thinsp;=\u0026thinsp;2.36; SD\u0026thinsp;=\u0026thinsp;1.56) and male (M\u0026thinsp;=\u0026thinsp;2.60; SD\u0026thinsp;=\u0026thinsp;1.80; t(135) = -0.74; p\u0026thinsp;=\u0026thinsp;0.46; d = -0.14) refugees. There were no significant differences regarding depressive symptoms between female (M\u0026thinsp;=\u0026thinsp;1.96; SD\u0026thinsp;=\u0026thinsp;1.67) and male (M\u0026thinsp;=\u0026thinsp;1.87; SD\u0026thinsp;=\u0026thinsp;1.64; t(385)\u0026thinsp;=\u0026thinsp;0.47; p\u0026thinsp;=\u0026thinsp;0.64; d\u0026thinsp;=\u0026thinsp;0.05) voluntary migrants. Among the nine most common countries of origin, Syria (M\u0026thinsp;=\u0026thinsp;2.63; SD\u0026thinsp;=\u0026thinsp;1.79), followed by Iran (M\u0026thinsp;=\u0026thinsp;2.19; SD\u0026thinsp;=\u0026thinsp;1.90), revealed the highest mean for depressive symptoms. In an additional file [see Additional file 1] further mean values for the nine most common countries of origin in the study sample are provided.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003e3.2.4. Generalized anxiety symptoms\u003c/h2\u003e \u003cp\u003eOne hundred and fifty-four of 525 participants (29%) in the total sample had clinically relevant anxiety (GAD-2\u0026thinsp;\u0026ge;\u0026thinsp;3), constituting 34% of refugees and 28% of migrants. The mean score of the total sample was 2.05 (SD 1.76) on the GAD-2 scale. The T-test indicated no significant differences between refugees (M\u0026thinsp;=\u0026thinsp;2.28; SD\u0026thinsp;=\u0026thinsp;1.77) and voluntary migrants (M\u0026thinsp;=\u0026thinsp;1.97; SD\u0026thinsp;=\u0026thinsp;1.76; t(524)\u0026thinsp;=\u0026thinsp;1.75; p\u0026thinsp;=\u0026thinsp;0.08; d\u0026thinsp;=\u0026thinsp;0.17) or between female (M\u0026thinsp;=\u0026thinsp;2.11; SD\u0026thinsp;=\u0026thinsp;1.77) and male (M\u0026thinsp;=\u0026thinsp;2.38; SD\u0026thinsp;=\u0026thinsp;1.77; t(135) = -0.82; p\u0026thinsp;=\u0026thinsp;0.41; d = -0.15) refugees or female (M\u0026thinsp;=\u0026thinsp;2.04; SD\u0026thinsp;=\u0026thinsp;1.76) and male (M\u0026thinsp;=\u0026thinsp;1.78; SD\u0026thinsp;=\u0026thinsp;1.73; t(385)\u0026thinsp;=\u0026thinsp;1.31; p\u0026thinsp;=\u0026thinsp;0.19; d\u0026thinsp;=\u0026thinsp;0.15) voluntary migrants. However, when looking at the mean scores for the individual countries of origin, differences are detectable. Migrants from countries such as Syria (M\u0026thinsp;=\u0026thinsp;2.54; SD\u0026thinsp;=\u0026thinsp;1.92), Iran (M\u0026thinsp;=\u0026thinsp;2.19; SD\u0026thinsp;=\u0026thinsp;0.67) or Afghanistan (M\u0026thinsp;=\u0026thinsp;2.10; SD\u0026thinsp;=\u0026thinsp;1.76) demonstrated the highest levels of anxiety disorder symptoms in our sample. Mean scores for the nine most common countries of origin can be found in an additional file [see Additional file 1].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003e3.2.5. Life satisfaction\u003c/h2\u003e \u003cp\u003eOn a scale of 0 to 10, voluntary migrants (M\u0026thinsp;=\u0026thinsp;7.20; SD\u0026thinsp;=\u0026thinsp;1.89) showed significantly higher life satisfaction compared to refugees (M\u0026thinsp;=\u0026thinsp;6.70; SD\u0026thinsp;=\u0026thinsp;2.04; t(524) = -2.61; p\u0026thinsp;=\u0026thinsp;0.009; d\u0026thinsp;=\u0026thinsp;0.26). The results revealed significant differences in terms of life satisfaction between female (M\u0026thinsp;=\u0026thinsp;7.14; SD\u0026thinsp;=\u0026thinsp;1.62) and male (M\u0026thinsp;=\u0026thinsp;6.46; SD\u0026thinsp;=\u0026thinsp;2.18; t(135)\u0026thinsp;=\u0026thinsp;2.04; p\u0026thinsp;=\u0026thinsp;0.04; d\u0026thinsp;=\u0026thinsp;0.34) refugees. There were no significant differences between female (M\u0026thinsp;=\u0026thinsp;7.18; SD\u0026thinsp;=\u0026thinsp;1.92) and male (M\u0026thinsp;=\u0026thinsp;7.27; SD\u0026thinsp;=\u0026thinsp;1.80; t(385) = -0.42; p\u0026thinsp;=\u0026thinsp;0.68; d = -0.05) voluntary migrants.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e3.3. Predictors of depression and generalized anxiety symptoms\u003c/h2\u003e \u003cp\u003eWe conducted multiple regression analyses to examine the association between VVI and mental health. Sociodemographic and migration-specific variables such as migrant group (refugee or voluntary migrant), experience of VVI, gender, age, marital status, educational degree, occupation, knowledge of German, sense of belonging to the country of origin, sense of belonging to Germany, and life satisfaction were considered. The results are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eBecause of the high correlation between VVI and perceived discrimination, separate multiple regression analyses to examine the relationship between perceived discrimination and psychological well-being were conducted. These can be found in an additional file [see Additional file 2] as the results are similar to those of the regression analysis with VVI as a predictor variable.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultiple linear regression analyses including VVI and socio-demographic and migration-related characteristics as predictor variables.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePredictors of Depressive Symptoms\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSE\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eβ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95% CI\u003csup\u003e5\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMigrant group\u003csup\u003e6\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.442\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.184\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.116\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e.017\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.80 to \u0026minus;\u0026thinsp;.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVerbal violence in public institutions\u003csup\u003e7\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.152\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.01 to .02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLife satisfaction\u003csup\u003e8\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.228\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.046\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.263\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.32 to \u0026minus;\u0026thinsp;.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003csup\u003e9\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.162\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.032\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.493\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.21 to .43\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.032\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.514\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.02 to .01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital status\u003csup\u003e10\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.029\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.165\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.861\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.30 to .35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducational degree\u003csup\u003e11\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.714\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.509\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.061\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.162\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.29 to .95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOccupation\u003csup\u003e12\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.071\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.207\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.732\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.48 to .34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGerman language skills\u003csup\u003e13\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.051\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.994\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.10 to .10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSense of belonging to the country of origin\u003csup\u003e14\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.084\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.067\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.123\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.29 to \u0026minus;\u0026thinsp;.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSense of belonging to Germany\u003csup\u003e15\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.166\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.082\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.38 to .05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePredictors of GAD Symptoms\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVerbal violence in public institutions\u003csup\u003e7\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.238\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.01 to .03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSense of belonging to the country of origin\u003csup\u003e14\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.181\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.084\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.091\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e.032\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.35 to \u0026minus;\u0026thinsp;.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLife satisfaction\u003csup\u003e8\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.213\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.046\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.236\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.30 to \u0026minus;\u0026thinsp;.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMigrant group\u003csup\u003e6\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.181\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.185\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.046\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.330\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.55 to .18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003csup\u003e9\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.032\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.163\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.846\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.29 to .35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.043\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.365\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.02 to .01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital status\u003csup\u003e10\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.107\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.166\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.028\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.519\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.44 to .22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducational degree\u003csup\u003e11\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.359\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.513\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.030\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.484\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-1.37 to .65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOccupation\u003csup\u003e12\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.258\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.209\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.055\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.217\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.15 to .67\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGerman language skills\u003csup\u003e13\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.093\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.051\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.082\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.071\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.19 to .01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSense of belonging to Germany\u003csup\u003e15\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.182\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.087\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.097\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.40 to .03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003csup\u003e \u003cem\u003e1\u003c/em\u003e \u003c/sup\u003e \u003cem\u003ePHQ-2: Patient Health Questionnaire\u0026mdash;Depression Module, sum score, range: 0\u0026ndash;6 (higher values are linked to higher symptom severity);\u003c/em\u003e \u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e \u003cem\u003eGAD-2, Generalized Anxiety Disorder Scale, sum score, range: 0\u0026ndash;6 (higher values are linked to higher symptom severity);\u003c/em\u003e \u003csup\u003e\u003cem\u003e3\u003c/em\u003e\u003c/sup\u003e \u003cem\u003eB: regression coefficient;\u003c/em\u003e \u003csup\u003e\u003cem\u003e4\u003c/em\u003e\u003c/sup\u003e \u003cem\u003eSE: standard error;\u003c/em\u003e \u003csup\u003e\u003cem\u003e5\u003c/em\u003e\u003c/sup\u003e \u003cem\u003eCI: confidence interval;\u003c/em\u003e \u003csup\u003e\u003cem\u003e6\u003c/em\u003e\u003c/sup\u003e \u003cem\u003e0: refugee; 1: voluntary migrant;\u003c/em\u003e \u003csup\u003e\u003cem\u003e7\u003c/em\u003e\u003c/sup\u003e \u003cem\u003everbal violence in German institutions, average sum score, range: 0\u0026ndash;96 (higher values are linked to higher experience of verbal violence in institutions);\u003c/em\u003e \u003csup\u003e\u003cem\u003e8\u003c/em\u003e\u003c/sup\u003e \u003cem\u003elife satisfaction, sum score, range: 0\u0026ndash;10 (higher values indicate higher life satisfaction);\u003c/em\u003e \u003csup\u003e\u003cem\u003e9\u003c/em\u003e\u003c/sup\u003e \u003cem\u003e1: female; 2: male;\u003c/em\u003e \u003csup\u003e\u003cem\u003e10\u003c/em\u003e\u003c/sup\u003e \u003cem\u003e0: single; 1: relationship;\u003c/em\u003e \u003csup\u003e\u003cem\u003e11\u003c/em\u003e\u003c/sup\u003e \u003cem\u003e0: no; 1: yes;\u003c/em\u003e \u003csup\u003e\u003cem\u003e12\u003c/em\u003e\u003c/sup\u003e \u003cem\u003e0: no; 1: yes;\u003c/em\u003e \u003csup\u003e\u003cem\u003e13\u003c/em\u003e\u003c/sup\u003e \u003cem\u003eGerman language skills, sum score, range: 0\u0026ndash;8 (higher values are linked to higher German language skills)\u003c/em\u003e \u003csup\u003e\u003cem\u003e14\u003c/em\u003e\u003c/sup\u003e \u003cem\u003esense of belonging to the country of origin, sum score, range: 0\u0026ndash;3 (higher values are linked to higher sense of belonging);\u003c/em\u003e \u003csup\u003e\u003cem\u003e15\u003c/em\u003e\u003c/sup\u003e \u003cem\u003esense of belonging to Germany, sum score, range: 0\u0026ndash;3 (higher values are linked to higher sense of belonging).\u003c/em\u003e\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e \u003ch2\u003e3.3.1. Regression analysis PHQ-2\u003c/h2\u003e \u003cp\u003eIn the regression analysis with VVI as predictor variable and PHQ-2 as outcome variable, being a refugee (β = -0.11; p\u0026thinsp;=\u0026thinsp;0.03), low life satisfaction (β = -0.29; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and a higher amount of experiencing VVI (β\u0026thinsp;=\u0026thinsp;0.17; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were significantly associated with increased symptoms of depression. The explained variance was 23%.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003e3.3.2. Regression analysis GAD-2\u003c/h2\u003e \u003cp\u003eVariables significantly associated with increased symptoms of generalized anxiety were a lower sense of belonging to the country of origin (β = -0.10; p\u0026thinsp;=\u0026thinsp;0.03), lower life satisfaction (β = -0.25; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and more frequent experiences of VVI (β\u0026thinsp;=\u0026thinsp;0.26; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The explained variance was 26%.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eCurrently, 24.9\u0026nbsp;million people with migration background live in Germany (as of December 31, 2023) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. They make up 29.7% of the German population, and their number is increasing [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. To our knowledge VIOLIN is the first study investigating migrants\u0026rsquo; experiences of VVI in Germany and its association with their mental health states. We were able to reveal that migrants experienced VVI most frequently in public transport, immigration offices, doctors\u0026rsquo; offices, hospitals, and city council/district offices. Among voluntary migrants, females experienced VVI significantly more often than their male counterparts. There were no significant gender differences between female and male refugees in their experiences of VVI. Refugees showed significantly more depressive symptoms than voluntary migrants. In multiple regression analyses, being a refugee, low life satisfaction and frequent experiences of VVI were significantly associated with increased depressive symptoms. Regarding generalized anxiety disorder, life satisfaction, experiences of VVI as well as a low sense of belonging to the country of origin were significant predictors for elevated symptom severity.\u003c/p\u003e \u003cp\u003eIn terms of sociodemographic factors, migrants form a heterogeneous group. This makes comparisons within our sample difficult. With an average age of 38.2 years, our sample is older than the average age of migrants in Germany in 2019, which was 35.6 years [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. We suppose that the exclusion of children and adolescents in our survey contributes to this. Thirty-two percent of asylum applications in Germany in 2022 were submitted by women [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]; in our sample, 32% of refugees are female. Yet, the proportion of women in the group of voluntary migrants is above average at 70% in our sample. In 2022, 49% of people with migration background in Germany were women [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. In addition, our sample has an above-average level of education, with 71% holding a university degree, whereas in Germany in 2022, 38.5% of people with migration background aged 15 or older held a qualifying academic school degree [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. These aspects must be considered in the following.\u003c/p\u003e \u003cp\u003eOn average, migrants from our sample experience VVI rarely and discrimination less frequently than once a year, which can be regarded as positive. In the institutional context, studies about the situation in Germany mostly examined migrants\u0026rsquo; experiences of discrimination [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. As VV is a linguistic construct the studies did not focus on VVI. Since the 2014s, surveys have reported low levels of discrimination against migrants and refugees in Germany [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. However, people with a migration background experience discrimination significantly more often than people without [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Furthermore, migrants\u0026rsquo; experiences of discrimination in Germany seem to have increased in recent years [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. In a 2022 study 35% of migrants reported having been discriminated sometimes or often in the past year [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The German Centre for Integration and Migration Research examined in 2022 the experiences of discrimination of more than 21.000 people in Germany [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Using the EDS, around 90% of the visually recognizable people in the sample reported having experienced at least one of the forms of discrimination recorded in the scale in their everyday lives [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In general, awareness of the various forms of discrimination has also increased [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe could demonstrate that there are no significant differences in the experience of VVI and discrimination between refugees and voluntary migrants. Whereas female migrants, especially voluntary migrants, experience significantly more VVI compared to male migrants. This gender-specific difference was not found in the experiences of discrimination. This means that a larger group is detected as affected by hostile interactions when verbal violence is used as a measure. In contrast, the report of the National Discrimination and Racism Monitor 2023 by the German Center for Integration and Migration Research even reports that women experience less subtle discrimination on average than men [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. But the level of actual discrimination differs from the level of perceived discrimination [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe results on institutions where VVI is experienced, confirm the results of earlier studies, the areas where discrimination is perceived are agencies, authorities and the healthcare sector [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Compared to discrimination, including physical or sexual violence, VVI is more difficult to detect and establish retrospectively, as it does not leave any physical damage and is more difficult to objectify [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Moreover, in the context of migration, it can be masked by aspects such as language barriers and cultural differences [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The victim may assume that the manner of address corresponds to the customs of the country. As a result, the perpetrator has fewer inhibitions about practicing this form of discrimination. Fortunately, our findings indicate that migrants experience VVI not on a daily base. However, mental distress may be caused by VVI in the reported institutions such as public transport, immigration authorities and health care.\u003c/p\u003e \u003cp\u003eThe country of origin also plays a decisive role. In our study migrants from Iran, Mexico and Syria experienced the most VVI. When differentiating migrants by country of origin, various sociodemographic and migration-specific aspects must also be considered [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. In Germany, especially people with a Turkish migration background feel discriminated [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. The latter is often explained by the fact that certain nationalities are more often identified as migrants due to visible characteristics, accent or religious affiliation [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This visibility provides more targets for perpetrators. However, it should be noted here that in the case of VVI, i.e. the immigration departments, every migrant is identified as such by his or her counterpart. Prejudices and visual differences seem to play an additional role in the social interactions of migrants and refugees.\u003c/p\u003e \u003cp\u003eWe could demonstrate by our regression analyses that the experience of VVI is related to reduced mental health of migrants. This finding is also consistent with previous studies that have reported discrimination to be negatively associated with mental health [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In multiple regression analyses [see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Additional file 2], the effect of discrimination is slightly higher compared to the effect of the experience of VVI. One consideration would be that the EDS investigates everyday life [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], while the VVI questionnaire includes questions about specific situations in German institutions. By surveying a broader spectrum (not only institutions, not only verbal violence) it may be possible to capture stronger effects on mental health.\u003c/p\u003e \u003cp\u003eManifestations of mental distress, depression and anxiety are significantly higher in our study population than in the German general population [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. In line with our results, in the 2016 and 2017 IAB-BAMF SOEP survey of refugees in Germany, refugees had more depressive symptoms in PHQ-4 compared to the German population average [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. As has been shown in numerous studies ,prevalence scores for depression and anxiety among migrants vary by host country [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], country of origin [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], migrant subgroup [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], and generation [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Displaced persons are more likely to exhibit psychological distress [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e], which was also the case in our survey. In our sample, the prevalence scores for refugees of 42% for depression and 34% for anxiety disorders are slightly higher than the prevalence scores for refugees in similar studies [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Selection effects of the online study may have played a role here, so that those migrants and refugees affected with a high symptom burden were more likely to participate in the anonymous study. Refugees are more likely to experience depression compared to voluntary migrants [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. In our sample they exhibited significantly more depressive symptoms than voluntary migrants in our sample. Studies show, that compared to voluntary migrants, refugees are exposed to more pre-migratory stressors such as war and persecution, the flight itself, and post-migratory stressors such as procedures of residence permission which put a strain on their mental health. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The meta-analysis by Blackmore et al. [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] showed prevalence scores for refugees of 31.5% for depression and 11% for anxiety. For refugees exposed to an armed conflict, Mesa-Vieira et al. [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e] reported in a meta-analysis prevalence rates of 25% for major depression and 14% for general anxiety disorders. The meta-analysis by Lindert et al. found prevalences for anxiety disorder between 6% and 44% for migrant workers and between 5% and 90% for refugees [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Regarding anxiety disorders the comparison between refugees and voluntary migrants in our sample was not significant, but a tendency was evident. With a mean of 2.09 in the PHQ-2 and of 2.05 in the GAD-2, our total sample revealed significantly more symptoms of depression and anxiety than the German general population with a mean of 0.97 in the PHQ-2 and of 0.83 in the GAD-2 [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. In scientific literature unfortunately only few studies can be found that differentiate between refugees and voluntary migrants [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. However, prevalence values are known to vary widely across studies, as migrants represent a very heterogeneous group [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Yet, some studies didn\u0026acute;t find a difference between the mixed migrants population (voluntary migrants and refugees) and the general German population [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e], especially not for voluntary migrants considering prevalences for depression and anxiety [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Certain factors such as cultural adjustment stress, discrimination in the host country, pre-migration trauma and displacement or uncertain immigration status [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] may contribute to an increased level of distress symptoms among migrants in our sample and could also explain the increased prevalence of depressive symptoms among refugees compared to voluntary migrants.\u003c/p\u003e \u003cp\u003eLow overall life satisfaction is also statistically predictive of a prevalence of depression and anxiety disorders. With a mean of 6.7 among refugees and 7.2 among voluntary migrants, our results are comparable to those of the IAB-BAMF-SOEP survey, with mean values of 6.86 among refugees and 7.55 among migrants in Germany collected in 2015 [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe life satisfaction of refugees in Germany is related to their family situation, their residence status, their work and housing situation, their health situation, their feeling of being welcome in Germany, and the extent of their social contacts with Germans [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. Higher levels of feeling to be welcome in Germany and social support were also significantly associated with lower levels of depression and generalized anxiety in a study with 136 Syrian students in Germany [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGender was surprisingly not a significant predictor in our analysis. In literature female migrants showed significantly higher depression [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e] and anxiety symptoms [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e] compared to males. The gender differences for depression [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e] and generalized anxiety symptoms [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e] are also evident in the general German population. It is also possible that gender is no longer significantly associated with poorer mental health in our study population when other socio-demographic characteristics such as education level are considered.\u003c/p\u003e \u003cp\u003eAccording to a meta-analysis by Brance et al. [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e] social identification, both with the host country and with the home country community, protects ethnic minorities and migrants from depression and anxiety. The feeling of migrants of belonging to their country of origin, as a form of group affiliation, is also a negative significant predictor of anxiety disorders in our analysis (in the regression analysis with VVI as a predictor variable). One could assume that this feeling is a form of social identification, which acts as a protective factor against anxiety symptoms [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. Social identification also correlates with other factors such as trauma and persecution [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e], which in turn have a negative impact on mental health.\u003c/p\u003e \u003cp\u003eStrengths and Limitations\u003c/p\u003e \u003cp\u003eFirst of all, due to the cross-sectional design of the study, no causal conclusions can be drawn.\u003c/p\u003e \u003cp\u003eThe strength of the study is the size of the sample and the recruitment through different channels such as social media (Facebook, Instagram), churches and public institutions, e.g. integration councils and anti-discrimination bodies. In addition, the questionnaire could be answered in nine different languages and an equal access was ascertained for most ethnic groups.\u003c/p\u003e \u003cp\u003eThe questionnaire on VVI included 24 questions. This increases the likelihood that different aspects of experiences with VVI were made measurable.\u003c/p\u003e \u003cp\u003eOne weakness was the long time needed for completion of the questionnaire. Thus, some participants did not complete the survey. In addition, the questionnaire on VVI is not validated yet and we have used the sumscores. Therefore, comparison with other groups was not possible.\u003c/p\u003e \u003cp\u003eThe high proportion of participants with a high level of education and the high proportion of women in the group of voluntary migrants limit the representativeness of our sample. Recruitment also took place through university networks, which could be one reason why mainly young, well-educated migrants were reached. In an average composition of the cohort, different values of perceived VVI are to be assumed.\u003c/p\u003e \u003cp\u003eFuture research on the experience of VVI and its impact on mental health is needed to confirm recent findings and collect new results. For this, prospective studies need to be conducted so that the impact of VVI can be examined. In addition to the association with depression and generalized anxiety disorder, other disorders such as PTSD should also be considered. Gender differences must be looked at as well. In this context, it is also important to distinguish gender differences in the experience of VVI between female and male migrants as well as between women and men in the general population.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eVVI is highly associated with the state of migrants\u0026rsquo; mental health. This is of high importance as migrants, especially refugees, in Germany have a significantly higher risk of depressive and anxiety symptoms compared to the general population.\u003c/p\u003e \u003cp\u003eTo gain further insight specifically on VVI, further studies should be conducted in individual institutions, focusing on gender differences. Special attention should be paid to immigration offices, health care institutions and city councils/district offices.\u003c/p\u003e \u003cp\u003eTo reduce VVI in the future and to raise awareness and sensitize on the issue, courses could be set up for employees in these institutions.\u003c/p\u003e \u003cp\u003eTo minimize VVI in public places, for example in public transport, citizens could be reached directly, i.e. through advertising campaigns. Society benefits from such measures, but perhaps there is not yet sufficient awareness for this.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVVI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eVerbal violence in institutions\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eVerbal violence\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVIOLIN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eVerbal Violence against Migrants in Institutions\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethics Committee of the Medical Faculty of the Friedrich-Alexander University Erlangen-Nürnberg (FAU) (project identification code: 451_19B).\u003c/p\u003e\n\u003cp\u003eConsent for publication \u0026ndash; Not applicable\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe dataset analyzed during the current study is available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eNo potential conflict of interest was reported by the authors.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThe presented study was supported by the STAEDTLER Foundation and the Emerging Fields Initiative (EFI) of the Friedrich-Alexander-Universit\u0026auml;t Erlangen-N\u0026uuml;rnberg. The funders did not have any further role in the design of the study and collection, analysis, interpretation of data, or writing the manuscript.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions\u003c/p\u003e\n\u003cp\u003eMJ, AB, EM, FH, LRG, MA, NR, SJ, PB and YE designed the study concept. AB, FH, LRG and MA conducted the study. AB and MJ analyzed the data. MJ drafted the manuscript with corrections and commentaries from AB, EM and YE. All authors reviewed and approved the final draft of the manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgment\u003c/p\u003e\n\u003cp\u003eWe thank all migrant organizations, associations and institutions for their support in the recruitment process.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; information\u003c/p\u003e\n\u003cp\u003eMJ performed the present work in fulfilment of the requirements for obtaining the degree \u0026bdquo;Dr. med.\u0026rdquo;.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFederal Agency for Civic Education. [Discrimination/anti-discrimination - terms and basics]. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.bpb.de/shop/zeitschriften/apuz/221573/diskriminierung-antidiskriminierung-begriffe-und-grundlagen/\u003c/span\u003e\u003cspan address=\"https://www.bpb.de/shop/zeitschriften/apuz/221573/diskriminierung-antidiskriminierung-begriffe-und-grundlagen/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 1 March 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eErim Y, Schellong J. Special issue flight and migration. J Psychosom Res. 2020. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jpsychores.2020.110260\u003c/span\u003e\u003cspan address=\"10.1016/j.jpsychores.2020.110260\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerger M, Sarnyai Z. More than skin deep: stress neurobiology and mental health consequences of racial discrimination. Stress. 2015. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3109/10253890.2014.989204\u003c/span\u003e\u003cspan address=\"10.3109/10253890.2014.989204\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParadies Y, Ben J, Denson N, Elias A, Priest N, Pieterse A, et al. Racism as a Determinant of Health: A Systematic Review and Meta-Analysis. PLoS ONE. 2015. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pone.0138511\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0138511\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHajak VL, Sardana S, Verdeli H, Grimm S. A Systematic Review of Factors Affecting Mental Health and Well-Being of Asylum Seekers and Refugees in Germany. Front Psychiatry. 2021. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fpsyt.2021.643704\u003c/span\u003e\u003cspan address=\"10.3389/fpsyt.2021.643704\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchmitt MT, Branscombe NR, Postmes T, Garcia A. The consequences of perceived discrimination for psychological well-being: a meta-analytic review. Psychol Bull. 2014. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1037/a0035754\u003c/span\u003e\u003cspan address=\"10.1037/a0035754\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBorho A, Viazminsky A, Morawa E, Schmitt GM, Georgiadou E, Erim Y. The prevalence and risk factors for mental distress among Syrian refugees in Germany: a register-based follow-up study. BMC Psychiatry. 2020. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12888-020-02746-2\u003c/span\u003e\u003cspan address=\"10.1186/s12888-020-02746-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVoglino G, Gualano MR, Lo Moro G, Forghieri P, Caprioli M, Elhadidy HSMA, et al. Mental health and discrimination among migrants from Africa: An Italian cross-sectional study. J Community Psychol. 2022. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/jcop.22685\u003c/span\u003e\u003cspan address=\"10.1002/jcop.22685\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGerman Centre for Integration and Migration Research. [Racism and its symptoms: Report of the National Monitoring of Discrimination and Racism with a focus on health]. 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.rassismusmonitor.de/publikationen/rassismus-und-seine-symptome/\u003c/span\u003e\u003cspan address=\"https://www.rassismusmonitor.de/publikationen/rassismus-und-seine-symptome/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 10 November 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGerman Federal Statistical Office. [Migration background]. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.destatis.de/DE/Themen/Gesellschaft-Umwelt/Bevoelkerung/Migration-Integration/Glossar/migrationshintergrund.html?view=getColorboxEntry\u003c/span\u003e\u003cspan address=\"https://www.destatis.de/DE/Themen/Gesellschaft-Umwelt/Bevoelkerung/Migration-Integration/Glossar/migrationshintergrund.html?view=getColorboxEntry\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 20 October 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFederal Ministry for Economic Cooperation and Development. [Flight and Migration: Basics and Terms]. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.bmz.de/de/themen/flucht/fachbegriffe#lexicon=21872\u003c/span\u003e\u003cspan address=\"https://www.bmz.de/de/themen/flucht/fachbegriffe#lexicon=21872\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 20 October 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFederal Anti-Discrimination Agency. [Risks of discrimination for refugees in Germany]. 2016. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.antidiskriminierungsstelle.de/SharedDocs/forschungsprojekte/EN/Studie_DiskrRisiken_fuer_Gefluechtete_en.html\u003c/span\u003e\u003cspan address=\"https://www.antidiskriminierungsstelle.de/SharedDocs/forschungsprojekte/EN/Studie_DiskrRisiken_fuer_Gefluechtete_en.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 1 January 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInstitute for Employment Research. [The IAB-SOEP Migration Sample: Living, learning, working - how migrants are doing in Germany]. 2014. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doku.iab.de/kurzber/2014/kb2114.pdf\u003c/span\u003e\u003cspan address=\"https://doku.iab.de/kurzber/2014/kb2114.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 13 November 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInstitute for Employment Research, Federal Office for Migration and Refugees, Panel S-E. IAB-BAMF-SOEP Refugee Survey: overview and first results. 2016. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.bamf.de/SharedDocs/Anlagen/EN/Forschung/Forschungsberichte/fb29-iab-bamf-soep-befragung-gefluechtete.html?nn=283560\u003c/span\u003e\u003cspan address=\"https://www.bamf.de/SharedDocs/Anlagen/EN/Forschung/Forschungsberichte/fb29-iab-bamf-soep-befragung-gefluechtete.html?nn=283560\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 1 January 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMatheson K, Foster MD, Bombay A, McQuaid RJ, Anisman H. Traumatic Experiences, Perceived Discrimination, and Psychological Distress Among Members of Various Socially Marginalized Groups. Front Psychol. 2019. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fpsyg.2019.00416\u003c/span\u003e\u003cspan address=\"10.3389/fpsyg.2019.00416\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThe Expert Council on Integration and Migration. So, where are you originally from? Experiences of discrimination and phenotypic differences in Germany. 2018. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.svr-migration.de/en/publication/experiences_of_discrimination/\u003c/span\u003e\u003cspan address=\"https://www.svr-migration.de/en/publication/experiences_of_discrimination/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 1 January 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWieland U, Kober U. [Discrimination in the immigration society: perceptions and attitudes in the population]. 2023; \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.11586/2023020\u003c/span\u003e\u003cspan address=\"10.11586/2023020\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e[Experiences of discrimination in Germany: Results of a representative survey and a survey of the people affected]. 2017. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.antidiskriminierungsstelle.de/SharedDocs/downloads/DE/publikationen/Expertisen/expertise_diskriminierungserfahrungen_in_deutschland.html\u003c/span\u003e\u003cspan address=\"https://www.antidiskriminierungsstelle.de/SharedDocs/downloads/DE/publikationen/Expertisen/expertise_diskriminierungserfahrungen_in_deutschland.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 1 January 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJansen S, Romero L. Verbal violence \u0026ndash; a first approximation based on Latin American migrants\u0026rsquo; experiences in German institutions. The Mouth. Crit J Lang Cult Soc. 2021;ISSN:2513\u0026ndash;X101.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eErim Y, Morawa E. [Psychotherapy with Immigrants and Traumatized Refugees] PPmP - Psychotherapie \u0026middot;. Psychosom \u0026middot; Medizinische Psychologie. 2016. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1055/s-0042-115412\u003c/span\u003e\u003cspan address=\"10.1055/s-0042-115412\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBorho A, Morawa E, Schug C, Erim Y. Perceived post-migration discrimination: the perspective of adolescents with migration background. Eur Child Adolesc Psychiatry. 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00787-022-02084-6\u003c/span\u003e\u003cspan address=\"10.1007/s00787-022-02084-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilliams DR, Yu Y, Jackson JS, Anderson NB. Racial Differences in Physical and Mental Health:Socio-economic Status, Stress and Discrimination. J Health Psychol. 1997. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/135910539700200305\u003c/span\u003e\u003cspan address=\"10.1177/135910539700200305\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eL\u0026ouml;we B, Wahl I, Rose M, Spitzer C, Glaesmer H, Wingenfeld K, et al. A 4-item measure of depression and anxiety: Validation and standardization of the Patient Health Questionnaire-4 (PHQ-4) in the general population. J Affect Disord. 2010. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jad.2009.06.019\u003c/span\u003e\u003cspan address=\"10.1016/j.jad.2009.06.019\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care. 2003. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/01.Mlr.0000093487.78664.3c\u003c/span\u003e\u003cspan address=\"10.1097/01.Mlr.0000093487.78664.3c\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKroenke K, Spitzer RL, Williams JB, Monahan PO, L\u0026ouml;we B. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7326/0003-4819-146-5-200703060-00004\u003c/span\u003e\u003cspan address=\"10.7326/0003-4819-146-5-200703060-00004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFederal Agency for Civic Education. [Population with a migration background]. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.bpb.de/kurz-knapp/zahlen-und-fakten/soziale-situation-in-deutschland/61646/bevoelkerung-mit-migrationshintergrund/\u003c/span\u003e\u003cspan address=\"https://www.bpb.de/kurz-knapp/zahlen-und-fakten/soziale-situation-in-deutschland/61646/bevoelkerung-mit-migrationshintergrund/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 10 June 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGerman Federal Statistical Office, WZB Berlin Social Science Center, Federal Institute for Population Research. [Data Report 2021 - Social Report for Germany, complete edition]. 2021. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.destatis.de/DE/Service/Statistik-Campus/Datenreport/Downloads/datenreport-2021.html\u003c/span\u003e\u003cspan address=\"https://www.destatis.de/DE/Service/Statistik-Campus/Datenreport/Downloads/datenreport-2021.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 9 November 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFederal Agency for Civic Education. [Demographics of asylum seekers in Germany]. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.bpb.de/themen/migration-integration/zahlen-zu-asyl/265710/demografie-von-asylsuchenden-in-deutschland/\u003c/span\u003e\u003cspan address=\"https://www.bpb.de/themen/migration-integration/zahlen-zu-asyl/265710/demografie-von-asylsuchenden-in-deutschland/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 20 April 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStatista Research Department. Number of persons with migration background in Germany in 2022, by gender \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.statista.com/statistics/891857/number-persons-migrant-background-by-gender-germany/\u003c/span\u003e\u003cspan address=\"https://www.statista.com/statistics/891857/number-persons-migrant-background-by-gender-germany/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 1 January 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDistribution of the. population with and without a migrant background in Germany as of 2022, by school education. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.statista.com/statistics/921215/national-and-migrant-population-by-school-education-germany/\u003c/span\u003e\u003cspan address=\"https://www.statista.com/statistics/921215/national-and-migrant-population-by-school-education-germany/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 1 January 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eExpert Council on Integration and Migration. Germany's Transformation to a Modern Immigration Country: Annual Report 2014 with Integration Barometer. 2014. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.svr-migration.de/en/publication/annual-report-2014/\u003c/span\u003e\u003cspan address=\"https://www.svr-migration.de/en/publication/annual-report-2014/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 1 January 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAntidiskriminierungsstelle des Bundes. [Annual report 2022]. 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.antidiskriminierungsstelle.de/SharedDocs/downloads/DE/publikationen/Jahresberichte/2022.html\u003c/span\u003e\u003cspan address=\"https://www.antidiskriminierungsstelle.de/SharedDocs/downloads/DE/publikationen/Jahresberichte/2022.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 24 October 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDiehl C, Liebau E, M\u0026uuml;hlau P. How Often Have You Felt Disadvantaged? Explaining Perceived Discrimination. Cologne J Sociol Social Psychol. 2021. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11577-021-00738-y\u003c/span\u003e\u003cspan address=\"10.1007/s11577-021-00738-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorawa E, Erim Y. [The interrelation between perceived discrimination, depressiveness, and health related quality of life in immigrants of Turkish and Polish origin]. Psychiatr Prax. 2014. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1055/s-0033-1343221\u003c/span\u003e\u003cspan address=\"10.1055/s-0033-1343221\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWicke FS, Krakau L, L\u0026ouml;we B, Beutel ME, Br\u0026auml;hler E. Update of the standardization of the Patient Health Questionnaire-4 (PHQ-4) in the general population. J Affect Disord. 2022. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jad.2022.06.054\u003c/span\u003e\u003cspan address=\"10.1016/j.jad.2022.06.054\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInstitute for Employment Research. Second wave of the IAB-BAMF-SOEP Survey: Language skills and employment rate of refugees improving with time. 2019. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://nbn-resolving.org/urn:nbn:de:0168-ssoar-77905-9\u003c/span\u003e\u003cspan address=\"https://nbn-resolving.org/urn:nbn:de:0168-ssoar-77905-9\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 1 January 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBedaso A, Duko B. Epidemiology of depression among displaced people: A systematic review and meta-analysis. Psychiatry Res. 2022. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.psychres.2022.114493\u003c/span\u003e\u003cspan address=\"10.1016/j.psychres.2022.114493\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGkiouleka A, Avrami L, Kostaki A, Huijts T, Eikemo TA, Stathopoulou T. Depressive symptoms among migrants and non-migrants in Europe: documenting and explaining inequalities in times of socio-economic instability. Eur J Public Health. 2018. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/eurpub/cky202\u003c/span\u003e\u003cspan address=\"10.1093/eurpub/cky202\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJurado D, Alarc\u0026oacute;n RD, Mart\u0026iacute;nez-Ortega JM, Mendieta-Marichal Y, Guti\u0026eacute;rrez-Rojas L, Gurpegui M. Factors associated with psychological distress or common mental disorders in migrant populations across the world. Revista de Psiquiatr\u0026iacute;a y Salud Mental (English Edition). 2017. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.rpsmen.2017.02.004\u003c/span\u003e\u003cspan address=\"10.1016/j.rpsmen.2017.02.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeutel ME, J\u0026uuml;nger C, Klein EM, Wild P, Lackner KJ, Blettner M, et al. Depression, anxiety and suicidal ideation among 1st and 2nd generation migrants - results from the Gutenberg health study. BMC Psychiatry. 2016. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12888-016-0995-2\u003c/span\u003e\u003cspan address=\"10.1186/s12888-016-0995-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLevecque K, Van Rossem R. Depression in Europe: does migrant integration have mental health payoffs? A cross-national comparison of 20 European countries. Ethn Health. 2015. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/13557858.2014.883369\u003c/span\u003e\u003cspan address=\"10.1080/13557858.2014.883369\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTurrini G, Purgato M, Ballette F, Nos\u0026egrave; M, Ostuzzi G, Barbui C. Common mental disorders in asylum seekers and refugees: umbrella review of prevalence and intervention studies. Int J Mental Health Syst. 2017. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s13033-017-0156-0\u003c/span\u003e\u003cspan address=\"10.1186/s13033-017-0156-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlackmore R, Boyle JA, Fazel M, Ranasinha S, Gray KM, Fitzgerald G, et al. The prevalence of mental illness in refugees and asylum seekers: A systematic review and meta-analysis. PLoS Med. 2020. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pmed.1003337\u003c/span\u003e\u003cspan address=\"10.1371/journal.pmed.1003337\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMesa-Vieira C, Haas AD, Buitrago-Garcia D, Roa-Diaz ZM, Minder B, Gamba M, et al. Mental health of migrants with pre-migration exposure to armed conflict: a systematic review and meta-analysis. Lancet Public Health. 2022. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S2468-2667(22)00061-5\u003c/span\u003e\u003cspan address=\"10.1016/S2468-2667(22)00061-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClose C, Kouvonen A, Bosqui T, Patel K, O'Reilly D, Donnelly M. The mental health and wellbeing of first generation migrants: a systematic-narrative review of reviews. Global Health. 2016. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12992-016-0187-3\u003c/span\u003e\u003cspan address=\"10.1186/s12992-016-0187-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLindert J, Br\u0026auml;hler E, Wittig U, Mielck A, Priebe S. [Depression, anxiety and posttraumatic stress disorders in labor migrants, asylum seekers and refugees. A systematic overview]. Psychother Psychosom Medizinische Psychologie - PSYCHOTHER PSYCHOSOM MED PSYC. 2008. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1055/s-2008-1067358\u003c/span\u003e\u003cspan address=\"10.1055/s-2008-1067358\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarroll HA, Kvietok A, Pauschardt J, Freier LF, Bird M. Prevalence of common mental health disorders in forcibly displaced populations versus labor migrants by migration phase: A meta-analysis. J Affect Disord. 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jad.2022.10.010\u003c/span\u003e\u003cspan address=\"10.1016/j.jad.2022.10.010\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLindert J, von Ehrenstein OS, Wehrwein A, Br\u0026auml;hler E, Sch\u0026auml;fer I. [Anxiety, Depression and Posttraumatic Stress Disorder in Refugees - A Systematic Review]. Psychother Psychosom Med Psychol. 2018. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1055/s-0043-103344\u003c/span\u003e\u003cspan address=\"10.1055/s-0043-103344\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGlaesmer H, Wittig U, Br\u0026auml;hler E, Martin A, Mewes R, Rief W. [Are migrants more susceptible to mental disorders?]. Psychiatr Prax. 2009. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1055/s-2008-1067566\u003c/span\u003e\u003cspan address=\"10.1055/s-2008-1067566\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLindert J, Ehrenstein OSv, Priebe S, Mielck A, Br\u0026auml;hler E. Depression and anxiety in labor migrants and refugees \u0026ndash; A systematic review and meta-analysis. Soc Sci Med. 2009. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.socscimed.2009.04.032\u003c/span\u003e\u003cspan address=\"10.1016/j.socscimed.2009.04.032\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRefugees are improving their German language skills and continue to feel welcome in Germany: The third wave of the IAB-BAMF-SOEP Survey of Refugees. 2020. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.bamf.de/SharedDocs/Anlagen/EN/Forschung/Kurzanalysen/kurzanalyse1-2020_iab-bamf-soep-befragung-sprache.html?nn=404000\u003c/span\u003e\u003cspan address=\"https://www.bamf.de/SharedDocs/Anlagen/EN/Forschung/Kurzanalysen/kurzanalyse1-2020_iab-bamf-soep-befragung-sprache.html?nn=404000\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 1 January 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHosari RR, Borho A, Morawa E, Erim Y. Which Protective Factors Are Associated with the Mental Health of Syrian Students in Germany? A Register-Based Cross-Sectional Study. Int J Environ Res Public Health. 2022. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/ijerph192316200\u003c/span\u003e\u003cspan address=\"10.3390/ijerph192316200\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorawa E, Brand T, Dragano N, J\u0026ouml;ckel KH, Moebus S, Erim Y. Associations Between Acculturation, Depressive Symptoms, and Life Satisfaction Among Migrants of Turkish Origin in Germany: Gender- and Generation-Related Aspects. Front Psychiatry. 2020. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fpsyt.2020.00715\u003c/span\u003e\u003cspan address=\"10.3389/fpsyt.2020.00715\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGeorgiadou E, Zbidat A, Schmitt GM, Erim Y. Prevalence of Mental Distress Among Syrian Refugees With Residence Permission in Germany: A Registry-Based Study. Front Psychiatry. 2018. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fpsyt.2018.00393\u003c/span\u003e\u003cspan address=\"10.3389/fpsyt.2018.00393\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBusch MA, Maske UE, Ryl L, Schlack R, Hapke U. [Prevalence of depressive symptoms and diagnosed depression among adults in Germany: results of the German Health Interview and Examination Survey for Adults]. Fed Health Bull - Health Res - Health Prot. 2013. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00103-013-1688-3\u003c/span\u003e\u003cspan address=\"10.1007/s00103-013-1688-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHinz A, Klein AM, Br\u0026auml;hler E, Glaesmer H, Luck T, Riedel-Heller SG, et al. Psychometric evaluation of the Generalized Anxiety Disorder Screener GAD-7, based on a large German general population sample. J Affect Disord. 2017. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jad.2016.12.012\u003c/span\u003e\u003cspan address=\"10.1016/j.jad.2016.12.012\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrance K, Chatzimpyros V, Bentall RP. Increased social identification is linked with lower depressive and anxiety symptoms among ethnic minorities and migrants: A systematic review and meta-analysis. Clin Psychol Rev. 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.cpr.2022.102216\u003c/span\u003e\u003cspan address=\"10.1016/j.cpr.2022.102216\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Verbal Violence, Migrants, Refugees, Germany, Discrimination, Mental Health, Institution","lastPublishedDoi":"10.21203/rs.3.rs-4790467/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4790467/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eTheoretical background: Discrimination is a psychological stressor for migrants and increases the likelihood of mental illnesses. This cross-sectional online survey examined the frequency of experiences of verbal violence in institutions (VVI) and discrimination among voluntary migrants and refugees (N = 525) in Germany, as well as their association with mental health.\u003c/p\u003e\n\u003cp\u003eMethods: The measurement instruments included the Everyday Discrimination Scale (EDS), the Patient Health Questionnaire 2 (PHQ-2), the Generalized Anxiety Disorder Scale 2 (GAD-2), and the self-developed 24-item VVI questionnaire. Voluntary migrants were compared to refugees.\u003c/p\u003e\n\u003cp\u003eResults: The data of 137 refugees and 388 migrants in Germany were evaluated. Since living in Germany, migrants experienced VVI most frequently in public transport (53%), immigration offices (53%), doctors' offices (48%), hospitals (41%), and city council/district offices (38%). A comparison of the sum score of the questionnaire on VVI among voluntary migrants shows that females experienced VVI significantly more often than males (p = 0.018). There were no significant differences between refugees and voluntary migrants (p = 0.50), nor gender differences among refugees (p = 0.69) in their experiences of VVI. Experiences of discrimination were reported on a frequency of less than a yearly basis. Refugees showed significantly more depressive symptoms than voluntary migrants (p \u0026lt; 0.001), but the generalized anxiety symptoms were comparable in both groups (p = 0.08). In multiple regression analyses, being a refugee, low life satisfaction, frequent experiences of VVI and discrimination were significantly associated with increased symptoms of depression. Significant predictors for elevated symptoms of generalized anxiety were low life satisfaction, experiences of VVI and discrimination, as well as a low sense of belonging to the country of origin.\u003c/p\u003e\n\u003cp\u003eConclusion: The results show the need for additional action to reduce VVI against migrants, especially in the identified public institutions.\u003c/p\u003e","manuscriptTitle":"Results from the VIOLIN Study: Verbal violence against migrants in German public institutions, discrimination and their association with mental health – an online cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-22 15:55:41","doi":"10.21203/rs.3.rs-4790467/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-29T08:51:21+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-29T08:38:47+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-26T08:45:04+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2024-07-23T17:08:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1504fc43-c4c8-4a7f-876f-6c461e4938f5","owner":[],"postedDate":"August 22nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-09-01T16:02:52+00:00","versionOfRecord":{"articleIdentity":"rs-4790467","link":"https://doi.org/10.1186/s12889-025-24363-y","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2025-08-27 15:57:12","publishedOnDateReadable":"August 27th, 2025"},"versionCreatedAt":"2024-08-22 15:55:41","video":"","vorDoi":"10.1186/s12889-025-24363-y","vorDoiUrl":"https://doi.org/10.1186/s12889-025-24363-y","workflowStages":[]},"version":"v1","identity":"rs-4790467","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4790467","identity":"rs-4790467","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}