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The Coronavirus disease 2019 (COVID-19) pandemic, immigrant status and being a member of the LGBT+ community are all independent factors associated with increased stress levels. Few studies provide more complex analysis on this issue, and there has been no research on the cumulative burden of perceived stress that people belonging to both minorities experience in the current epidemiological situation. The aim of this study was to assess the ability to deal with an external situation during the third wave of the COVID-19 pandemic in Poland in the following groups with different stress levels (total sample n = 370): Polish heterosexual men (n = 202), heterosexual men from Ukraine (n = 131) and homo- and bisexual men (men who have sex with men—MSM) from Ukraine (n = 37). A Perceived Stress Scale (PSS-10) was used. The analysis of the survey did not show statistically significant differences between the three study groups in the general level of perceived stress (24.71, 24.77 and 26.49 points, respectively, p = 0.551), but it revealed numerous differences in coping with various aspects of everyday functioning between these groups. Negative assessment of one’s own health proved to be the main factor negatively affecting the level of perceived stress, however specific health risks, medical history or the participants’ previous experience have not been taken into account in the study. Our research shows differences in the needs, resources and methods of coping with stress between men who are Polish citizens and migrants from Ukraine, both heterosexual and belonging to the MSM group. Proper identification and addressing of these needs, taking into account different availability of health services, could be the responsibility of NGOs or insurance providers. This should result in the reduction of mental health burdens and the risk of developing serious mental disorders, and consequently in better functioning of persons belonging to minorities and in a reduced burden on the health care system.
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International Journal of
Environmental Research
and Public Health
Article
Perceived Stress Levels among Ukrainian Migrant and LGBT+
Minorities in Poland during the COVID-19 Pandemic
Tomasz Michalski 1, Maciej Brosz 2, Joanna Stepien 3, Karolina Biernacka 4, Michal Blaszczyk 4
and Jakub Grabowski 5, *


Citation: Michalski, T.; Brosz, M.;
Stepien, J.; Biernacka, K.; Blaszczyk,
M.; Grabowski, J. Perceived Stress
Levels among Ukrainian Migrant and
LGBT+ Minorities in Poland during
the COVID-19 Pandemic. Int. J.
Environ. Res. Public Health 2021,18,
12838. https://doi.org/10.3390/
ijerph182312838
Academic Editor: Paul B. Tchounwou
Received: 4 November 2021
Accepted: 3 December 2021
Published: 6 December 2021
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Copyright: © 2021 by the authors.
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This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
1Department of Regional Development, Faculty of Social Science, University of Gdansk,
80-309 Gdansk, Poland; tomasz.michalski@ug.edu.pl
2Institute of Sociology, Faculty of Social Sciences, University of Gdansk, 80-309 Gdansk, Poland;
maciej.brosz@ug.edu.pl
3Department of Socio-Economic Geography, Faculty of Social Science, University of Gdansk,
80-309 Gdansk, Poland; joanna.stepien@ug.edu.pl
4Adult Psychiatry Scientific Circle, Division of Developmental Psychiatry, Psychotic and Geriatric Disorders,
Department of Psychiatry, Faculty of Medicine, Medical University of Gdansk, 80-210 Gdansk, Poland;
kbiernacka@gumed.edu.pl (K.B.); michalb079@gumed.edu.pl (M.B.)
5Division of Developmental Psychiatry, Psychotic and Geriatric Disorders, Department of Psychiatry,
Faculty of Medicine, Medical University of Gdansk, 80-210 Gdansk, Poland
*Correspondence: jakub.grabowski@gumed.edu.pl; Tel.: +48-583446085
Abstract:
The Coronavirus disease 2019 (COVID-19) pandemic, immigrant status and being a
member of the LGBT+ community are all independent factors associated with increased stress levels.
Few studies provide more complex analysis on this issue, and there has been no research on the
cumulative burden of perceived stress that people belonging to both minorities experience in the
current epidemiological situation. The aim of this study was to assess the ability to deal with an
external situation during the third wave of the COVID-19 pandemic in Poland in the following groups
with different stress levels (total sample n= 370): Polish heterosexual men (n= 202), heterosexual
men from Ukraine (n= 131) and homo- and bisexual men (men who have sex with men—MSM) from
Ukraine (n= 37). A Perceived Stress Scale (PSS-10) was used. The analysis of the survey did not show
statistically significant differences between the three study groups in the general level of perceived
stress (24.71, 24.77 and 26.49 points, respectively, p= 0.551), but it revealed numerous differences in
coping with various aspects of everyday functioning between these groups. Negative assessment
of one’s own health proved to be the main factor negatively affecting the level of perceived stress,
however specific health risks, medical history or the participants’ previous experience have not
been taken into account in the study. Our research shows differences in the needs, resources and
methods of coping with stress between men who are Polish citizens and migrants from Ukraine, both
heterosexual and belonging to the MSM group. Proper identification and addressing of these needs,
taking into account different availability of health services, could be the responsibility of NGOs or
insurance providers. This should result in the reduction of mental health burdens and the risk of
developing serious mental disorders, and consequently in better functioning of persons belonging to
minorities and in a reduced burden on the health care system.
Keywords:
SARS-CoV-2; mental health; depression; stigma; sexual and gender minorities; men who
have sex with men; homosexuals; bisexuals; transients; migrant workers
1. Introduction
1.1. Coronavirus Disease 2019 (COVID-19) Pandemic and Mental Health Burden
The COVID-19 pandemic as a threat to global public health has an impact on the
mental health and stress levels of different populations. Numerous studies have shown a
general deterioration of mental well-being in the general population [
1
,
2
]. An increased
Int. J. Environ. Res. Public Health 2021,18, 12838. https://doi.org/10.3390/ijerph182312838 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2021,18, 12838 2 of 16
frequency of symptoms of anxiety, depression and stress disorders has been observed in
populations of countries affected by the pandemic, which, according to Stueck’s Pandemic
Management Theory [
3
], follows from the complex mechanism behind facing adversities
individually and collectively within a community.
During the COVID-19 pandemic, also in the Polish population, a high level of stress
experienced by the studied individuals has been observed [
4
,
5
], with a tendency to correlate
with factors such as an unstable work situation, a lower level of education, and a younger
age. Among residents of Gda ´nsk (the largest city in the Pomeranian Voivodeship and one
of the largest cities in Poland), almost half of the 1500 respondents in non-representative,
convenience sampling assessed their mental well-being in June 2021 as worse than before
the pandemic [6].
1.2. Ukrainian Migrants in Northern Poland
Regardless of the ongoing pandemic, immigrants are known to have a higher level
of psychosomatic and mood problems [
7
]. There is a clear influence of both personality
traits and external factors resulting from cultural differences, including the often-different
work culture. For migrants, negative consequences include, among others, separation
from family and friends (sometimes resulting in family breakdown), living and working
in worse conditions in the destination country than in the country of origin or taking up
employment inconsistent with qualifications (the so-called brain waste) [8,9].
Almost all immigrants from Ukraine to Poland are labor migrants. Surveys conducted
in the Pomeranian Voivodeship in 2019 show that before the outbreak of the pandemic,
immigrants from Ukraine worked mainly in industry, trade, construction and repair ser-
vices (56.7%). Almost half of the respondents (47.0%) declared that they had been staying
in Poland for 1 to 3 years [
10
]. The large volume of emigration from Ukraine results from
a relatively unfavorable economic situation in that country [
11
]. On the other hand, the
fact that Poland, rather than richer countries in the European Union, is most often their
country of choice can be explained by cultural proximity and by the fact that only in Poland
can citizens of Ukraine work without a visa, provided they have a biometric passport
and a declaration of employment [
12
,
13
]. As of the beginning of September 2021, 508,800
foreigners had valid documents entitling them to stay in Poland, of which 59.4% were men.
Citizens of Ukraine prevailed in this group, accounting for more than half (55.9%) [
14
,
15
].
In the Pomeranian Voivodeship, which has a population of approx. 2.35 million people [
16
],
until September 2021 almost 9500 residence permits were issued to Ukrainian men [
15
].
One can presume that the real number of migrants is higher both due to the long waiting
time for a formal decision regarding the possibility of remaining legally (and, consequently,
inclusion in the statistics) and to illegal immigration. Figure 1shows the gradually in-
creasing migration from Ukraine to Poland since the Euromaidan revolution (2014) [
17
]
using the example of men settling in the Pomeranian Voivodeship. Similar correlations
are observed in most regions of the country. Additional information is provided by the
analysis of declarations of giving work to foreigners, which in January–June 2021 in the
Pomeranian Voivodeship alone concerned 40,000 men from Ukraine [18,19].
Studies in other countries have found greater levels of distress in migrant and refugee
populations during the COVID-19 pandemic. These populations reported subjectively
higher levels of discrimination and more daily stressors [
8
]. However, there is a lack of
research on the subjective perception of the levels of stress experienced by immigrants from
Ukraine to Poland during the pandemic. Before the outbreak of COVID-19 in 2019, the
high acceptance of the model of life in Poland was indicated in the study in which among
immigrants from Ukraine and Belarus as many as 55.5% of the respondents declared their
willingness to stay permanently in the Pomeranian Voivodeship [
10
]. In turn, a survey
conducted in 2020 (already during the pandemic) among immigrants from Ukraine staying
in Poland showed that 67% of them were satisfied with their life situation in Poland, despite
the fact that 53% declared that the pandemic worsened their satisfaction with this situation.
49% of them had already brought or were planning to bring their families to Poland [20].
Int. J. Environ. Res. Public Health 2021,18, 12838 3 of 16
Int.J.Environ.Res.PublicHealth2021,18,xFORPEERREVIEW3of16
Figure1.IncreaseinmaleUkrainianswithvaliddocumentsentitlingthemtostayinPoland(issuedbythePomeranian
voivode).Exponentialautoregression(R2=0.96).OwnelaborationofdatafromPolishOfficeforForeigners[15].
Studiesinothercountrieshavefoundgreaterlevelsofdistressinmigrantandrefugee
populationsduringtheCOVID19pandemic.Thesepopulationsreportedsubjectively
higherlevelsofdiscriminationandmoredailystressors[8].However,thereisalackof
researchonthesubjectiveperceptionofthelevelsofstressexperiencedbyimmigrants
fromUkrainetoPolandduringthepandemic.BeforetheoutbreakofCOVID19in2019,
thehighacceptanceofthemodeloflifeinPolandwasindicatedinthestudyinwhich
amongimmigrantsfromUkraineandBelarusasmanyas55.5%oftherespondentsde
claredtheirwillingnesstostaypermanentlyinthePomeranianVoivodeship[10].Inturn,
asurveyconductedin2020(alreadyduringthepandemic)amongimmigrantsfrom
UkrainestayinginPolandshowedthat67%ofthemweresatisfiedwiththeirlifesituation
inPoland,despitethefactthat53%declaredthatthepandemicworsenedtheirsatisfaction
withthissituation.49%ofthemhadalreadybroughtorwereplanningtobringtheirfam
iliestoPoland[20].
Amajorproblemthatmayaffectthelevelofperceivedstress,especiallyduringa
pandemicthatrepresentsasubstantialhealthhazard,isthelimitationofaccesstomedical
services.ImmigrantsfromUkrainehaveaverynegativeopinionofaccesstothe
healthcaresysteminPoland;only25%declaredthatitissufficientandmeetstheirneeds.
Bycontrast,14%statedthataccessispracticallyimpossible,29%thatitisdifficultand11%
thatonlypaidcareisavailabletothem[20].Inanotherstudy,ontheproblemswithliving
conditionsdeclaredbyUkrainianimmigrants,themajorityofresponsesindicateddiffi
cultiesinaccesstomedicalservices(26.6%).Housingproblemscamesecond(23.2%).In
spiteofthis,32.4%ofrespondentssaidtheyhadnoproblems.Simultaneously,aneedfor
supportinthefieldofmedicalcarewasdeclaredby26.5%,whichwasthe6thinorder
[10].
Anotherproblemisanincreaseinnegativeattitudestowardsimmigrants.Regarding
thePomeranianVoivodeshipin2017,4.1%ofthesurveyedimmigrantsfromBelarusand
Ukraineconfirmedthattheywerebadlytreatedordiscriminatedagainst,whilein2019it
wasasmanyas40.2%[10].ThispartlycorrespondstothesituationinPoland,whichisas
Figure 1.
Increase in male Ukrainians with valid documents entitling them to stay in Poland (issued by the Pomeranian
voivode). Exponential autoregression (R2= 0.96). Own elaboration of data from Polish Office for Foreigners [15].
A major problem that may affect the level of perceived stress, especially during a
pandemic that represents a substantial health hazard, is the limitation of access to medical
services. Immigrants from Ukraine have a very negative opinion of access to the healthcare
system in Poland; only 25% declared that it is sufficient and meets their needs. By contrast,
14% stated that access is practically impossible, 29% that it is difficult and 11% that only
paid care is available to them [
20
]. In another study, on the problems with living conditions
declared by Ukrainian immigrants, the majority of responses indicated difficulties in access
to medical services (26.6%). Housing problems came second (23.2%). In spite of this, 32.4%
of respondents said they had no problems. Simultaneously, a need for support in the field
of medical care was declared by 26.5%, which was the 6th in order [10].
Another problem is an increase in negative attitudes towards immigrants. Regarding
the Pomeranian Voivodeship in 2017, 4.1% of the surveyed immigrants from Belarus
and Ukraine confirmed that they were badly treated or discriminated against, while in
2019 it was as many as 40.2% [
10
]. This partly corresponds to the situation in Poland,
which is as follows: in 2020, 48% of Polish respondents described their attitude towards
Ukrainians as positive, 43% as neutral and 9% as negative [
13
]. This stems from many
factors. Certainly, the increase in the number of Ukrainians in Poland after 2014 is important,
which means intensification of contacts, and this may translate into a greater number of
negative events. Moreover, Tyma [
21
] draws attention to the lack of a proper response on
the part of the Polish state authorities to manifestations of hatred based on nationality, etc.
On the other hand, the actions of local governments in the study area are very favorable
to immigrants [
22
,
23
]. Some reports also point to possible disinformation activities, one
element of which is the construction of a negative image of immigration and refugees [
24
].
1.3. LGBT Community in Poland and Ukraine
Ukraine has been shown to possess a lower acceptance of the LGBT+ community than
Albania and Italy [
25
], which in previous studies seemed to be two of the most homophobic
countries [
26
]. It is worth noting that the decriminalization of homosexual relationships in
Ukraine has taken place relatively recently, and homophobic attitudes among the popula-
tion have remained high for a long time [
27
]. Moreover, even in 2012 Ukraine was planning
Int. J. Environ. Res. Public Health 2021,18, 12838 4 of 16
to introduce a law that would punish the promotion of homosexuality with imprisonment
of up to 5 years [
28
]. It was only in 2015 that the Verkhovna Rada of Ukraine amended the
Labor Code to grant equal rights to employees without regard to their sexual orientation
or gender identity [29].
More recent studies [
30
] place Poland and Ukraine among the least tolerant countries
in Europe, which is also confirmed in other publications, both as regards Poland [
31
,
32
] and
Ukraine [
33
,
34
]. From a national perspective, the situation of LGBT+ people is especially
bad in small towns and rural areas. Moreover, it can be noticed that the situation of LGBT+
people in Poland varies not only in terms of the juxtaposition of large and medium cities
as well as towns and villages, but also in geographical terms. For example, some Polish
local governments have adopted resolutions that indirectly affect the LGBT+ community
and are called “LGBT-free zones” [
35
], although advocates of these resolutions argue the
opposite [
36
]. The current list of local governments that have adopted such resolutions
is available in the so-called “Atlas Nienawi´sci” (Eng. “Atlas of Hate”) [
37
]. Its analysis
shows that such resolutions were adopted by a large number of local governments, mainly
in south-eastern Poland and partially in central Poland, and that, according to the authors
of the initiative, at the beginning of 2020 these local governments covered an area of nearly
1/3 of the country, covering 1/3 of its population. In the Pomeranian Voivodeship, which
is the subject of this study, no local government has adopted such a resolution, despite
lobbying being undertaken.
Evidence suggests that one of the more important causes of the migration of gay,
bisexual and other men who have sex with men (MSM) may be the seeking of rights and
freedoms unavailable to the LGBT+ community in their home countries [
38
,
39
]. Despite
the lack of legal recognition of same-sex partnerships in Poland as well as some indicators
placing Poland among the most conservative European countries [
30
] and the reservations
described above, 78% of Poles declare tolerance towards homosexual persons, with the
highest percentage declared by residents of the largest cities [
40
]. Despite social changes
taking place and the growing general tolerance and acceptance of LGBT+ persons, these
people are still at a higher risk of anxiety disorders, depression and substance abuse [
41
],
which is sometimes associated with internalized homophobia [
42
]. Additionally, people
who happen to also be migrants and belong to the LGBT+ community seem to face more
barriers in the mental health system, although there is little research on this topic [
43
]. They
are potentially affected by two types of stigma, both that against migrants and that against
sexual minorities. However, most studies show both of these phenomena separately, indi-
cating that anti-gay structural stigma (through discriminatory laws, institutional policies
and cultural norms) adversely affects the health of sexual minorities [
39
,
44
], clearly corre-
lating it with the occurrence of depression [
28
]. In turn, anti-immigrant stigma negatively
affects immigrants’ health [
45
]. However, some studies show that the phenomenon of
disapproval of one’s own homosexuality decreases among migrants as they move on to a
new country [46], and is largely dependent on the attitudes of the local population [47].
1.4. Purpose of the Study
The aim of this study was to assess the ability to deal with an external situation during
the third wave of the COVID-19 pandemic in Poland [48,49] in the following groups with
different stress levels: Polish heterosexual men (exposure to the pandemic and restrictions
related to social isolation), heterosexual men from Ukraine (additional factors related to
migration) and MSM from Ukraine. Apart from the factors present in the other two groups,
MSM are also susceptible to factors related to functioning within the LGBT+ minority.
Furthermore, research showed that attitudes towards MSM tend to be more negative
than those towards women who have sex with women [
50
,
51
]. Estimating the level of
stress in the above communities could contribute to understanding the importance of
individual stressors in general well-being and to answering the question of whether the
pandemic itself with all its consequences [
3
,
52
] may be a strong enough stress factor that
Int. J. Environ. Res. Public Health 2021,18, 12838 5 of 16
the differences resulting from migration and/or the fact of belonging to a sexual minority
would become blurred.
Finding possible differences in the level of perceived stress could constitute an intro-
duction to further research aiming to identify the most important risk factors for increased
levels of stress in individual groups, along with the possible association of distress with
the incidence of mental disorders. This, in turn, could translate into targeted preventive
and therapeutic actions, taking into account the different needs and different availability of
health services for people from the studied groups. A special role could be played by some
of the more prolific national and local LGBT+ advocacy and support non-governmental
organizations, such as Stowarzyszenie Miło´c Nie Wyklucza [Eng.: Love Does Not Exclude
Association], Organizacja Po˙
zytku Publicznego Kampania Przeciw Homofobii [Eng.: the
Public Benefit Organization—Campaign Against Homophobia] or Tolerado Tricity. Despite
their extensive activities, to the best of our knowledge only one NGO in Poland runs a
Ukrainian section supporting migrants, which is Lambda Warsaw. On the other hand,
in Poland there are also organizations supporting immigrants, such as Fundacja Nasz
Wybór—Ukrai´nski Dom w Warszawie [Eng.: Our Choice Foundation—the Ukrainian
House in Warsaw]. Its goal is to work for the benefit of Ukrainian migrants in Poland, to
help them integrate into the Polish society and Polish culture and to familiarize Poles with
Ukrainian culture.
The phenomenon of “minorities within minorities” can be associated with multiple
exclusions (due to race, nationality, ethnicity, gender, sexual orientation, mental illness,
etc.) and stigmatization even within a seemingly homogeneous group. This, in turn, can
translate into increased stress and a predisposition towards the development of mental
disorders. This is particularly important during the current pandemic, with all its threats
and limitations. On the other hand, it is possible that the chronically increased stress to
which society is subjected may reach a level so high that the differences between groups
observed in pre-pandemic studies disappear. However, this may be due both to the fact that
personal problems of people belonging to minorities may be obscured by the traumatizing
effect of the pandemic and social isolation, and to the fact that the aforementioned social
isolation through social distancing also leads to less exposure to stigmatization. Such
observations could suggest a need to transfer most of the efforts and resources to eliminate
the current and expected prospective effects of the current epidemiological situation.
Although this study is limited to one region of Poland, it tries to draw attention to problems
that go far beyond its local character.
2. Materials and Methods
2.1. Participants and Procedure
The study sample consisted of Polish and Ukrainian men of working age (18–64 years)
living and working in Tri-City in Poland (an agglomeration in the Pomeranian Voivodeship
comprising the cities of Gda ´nsk, Sopot and Gdynia, with a population of about one million
people). Additionally, people living in the Tri-City suburban zone, including smaller towns
located in the immediate vicinity of the agglomeration, were allowed to participate in the
study. The field phase of the study (1 March–11 April 2021) was conducted at the peak
of the third wave of the COVID-19 epidemic in Poland and the related restrictions on
movement, social gatherings and running of a business. The exclusively male sample was
selected for this study due to more stigma around homosexuality in MSM than in women
who have sex with women [50,51].
The selection of respondents was deliberate; therefore, it was of a non-probabilistic
selection type and was mainly based on the snowball method. In order to diversify the
sample in terms of professional status and level of education, the study started by selecting
different work environments dominated by people with a specific level of education. The
informants who distributed the questionnaires in their environment came from professional
circles related to large corporations employing highly qualified specialists, as well as from
unskilled workers performing simple construction work. Some of the questionnaires
Int. J. Environ. Res. Public Health 2021,18, 12838 6 of 16
were also distributed in semi-legal workers’ hostels operating in Tri-City. Some of the
respondents from Ukraine were reached by establishing direct contact in a grocery store,
where they did shopping before work. People who did not want to fill in the questionnaire
in the presence of the researcher could do it online via a Google form, which was done by
six persons.
In total, the research sample amounted to n= 370. Among the respondents, there
were 168 people with Ukrainian citizenship and 202 with Polish citizenship. As regards
the respondents’ sexual orientation, the sample included 333 heterosexual persons and
37 homosexual or bisexual persons. Combining the variables of citizenship and sexual
orientation, the sample included 202 men from Poland of heterosexual orientation, 131 men
of Ukrainian origin and heterosexual orientation and 37 Ukrainian men of homosexual or
bisexual orientation.
2.2. Measures
The study was conducted using a self-reported community survey. In view of the con-
ditions of the study, a short questionnaire consisting of 19 closed questions was used. Due
to considerable distrust among the respondents and their reluctance to provide personal
information, the questionnaire was shortened to 13 questions, and only these answers were
included in the analysis. Questions regarding sensitive demographic data and the region
(district) of origin were excluded due to a poor response rate from the first respondents
during the pilot phase of the study.
The first two questions concerned citizenship (Ukrainian or Polish) and sexual orien-
tation (heterosexual or homo-/bisexual). The third question related to the current state of
health of the subject with no distinction between general and mental health (“How would
you rate your current health condition?”). The possible answers were as follows: “very
good”, “good”, “average”, “bad” and “very bad”. The last 10 questions were questions
included in the PSS-10—Perceived Stress Scale [
53
] in its standard timespan version, with
the scoring of items 4, 5, 7, and 8 reversed. The total score ranged from 0 to 40, with
higher scores indicating higher levels of perceived stress. According to the instruction,
scores ranging from 0–13 would be considered low stress, scores ranging from 14–26 would
be considered moderate stress and scores ranging from 27–40 would be considered high
perceived stress [
54
]. The following indicators were also distinguished in accordance with
the suggestions of the two-factor structure by Roberti et al. [
55
]: F1 (perceived helplessness)
and F2 (perceived self-efficacy).
In order to maintain the comparability of the results with other surveys, the calcu-
lations and analyses were also performed for the individual items of the PSS-10 scale.
However, although the problem of using single-item scales and single elements of multi-
item scales is known [
56
], the value of comparability is worth recognizing. During the
COVID-19 pandemic, a similar study was conducted on the perceived level of stress among
Polish and Italian residents [5].
Both the questionnaire and the PSS-10 form were in Polish. Only minor linguistic
difficulties were encountered among Ukrainian citizens. In these cases, the interviewer
assisted the respondent in his native language (Ukrainian, Russian) or in Surzhyk [57].
2.3. Ethical Consideration
Participation was voluntary and data processing was anonymous and confidential
in accordance with current regulations. The research followed the rules on bioethics
established in the Declaration of Helsinki and its latest update. This project was approved
by the Clinical Research Ethics Committee of Medical University of Gdansk (reference
number: NKBBN/144/2021).
2.4. Statistical Analysis
Quantitative variables were tested for compliance with the normal distribution by the
Shapiro-Wilk test. Depending on the obtained result of the compliance test, appropriate
Int. J. Environ. Res. Public Health 2021,18, 12838 7 of 16
statistical tests were used for intergroup comparisons. In the case of comparisons of two
groups, the t-test for parametric analyses and the Mann-Whitney Utest for nonparametric
analyses were used, while in the case of multi-group comparisons, one-way analysis of
variance (ANOVA) and the Kruskal-Wallis test were used in the case of failure to meet the
parametric assumption. The Mann-Whitney Utest was used to compare groups of unequal
sizes [
58
]. In the case of a statistically significant result of intergroup comparisons in the
ANOVA scheme, post hoc tests were performed in order to minimize the error resulting
from unequal sample sizes (Tamhane’s T2 and Games-Howell).
To determine which groups were significantly different from one another in individual
PSS items in the case of the Kruskal-Wallis test, post-hoc Dunn’s [
59
] tests with Holm’s [
60
]
adjustment method were also performed.
The reliability coefficient Cronbach-alpha for the PSS-10 test in the entire sample was
0.926, and was above 0.92 in individual subgroups included in the analyses. The level of
statistical significance in the analyses was adopted at p< 0.05.
At the initial stage of the conducted research, the statistical power analysis was not per-
formed. As the power parameters were not calculated prospectively, retrospective analysis
was not implemented due to the “after” approach being considered as a mistake [61,62].
Statistical analyses were performed using the R (4.0.3, Vienna, Austria) and RStudio
(1.4.1103, Boston, MA, USA) software.
3. Results
All respondents (n= 370) were Caucasian men aged 18–64, living in a large urban
center (the Tri-City agglomeration has over one million inhabitants) [63].
An overview of the study results, taking into account intergroup comparisons, is
presented in Table 1. The level of stress measured with the PSS-10 questionnaire yielded a
score of 24.91 (SD
±
9.11) for the entire sample. A low level of stress (a score of less than
13 points) was experienced by 15.4% (n= 57) of the respondents, a medium level of stress
(a score from 14 to 26 points) by 33.0% (n= 122) and a high level of stress (a score over
27 points) by more than half of the study participants (51.6%, n= 191).
Table 1. PSS test results crossed by independent variables.
n(%) PSS Score
Mean ±SD p-Value
total 370 (100%) 24.91 ±9.11 -
citizenship
Polish 202 (54.6%) 24.71 ±9.01 0.545
Ukrainian 168 (45.4%) 25.15 ±9.23
orientation
heterosexual 333 (90.0%) 24.74 ±9.16 0.286
homo- or bisexual 37 (10.0%) 26.49 ±8.62
citizenship and orientation
heterosexual citizens of Poland 202 (54.6%) 24.71 ±9.01
0.551
heterosexual citizens of Ukraine 131 (35.4%) 24.77 ±9.41
homosexual or bisexual citizens of Ukraine 37 (10.0%) 26.49 ±8.62
health condition self-assessed by
the respondents
very bad and bad 63 (17.0%) 30.54 ±7.56
<0.001
average 94 (25.4%) 26.98 ±8.40
good and very good 213 (57.6%) 22.33 ±8.88
Int. J. Environ. Res. Public Health 2021,18, 12838 8 of 16
The general level of perceived stress as well as the F1 (perceived helplessness) and F2
(perceived self-efficacy) indices calculated from the PSS-10 questionnaire were not related
to the respondents’ citizenship or their sexual orientation. Differences were revealed only
when analyzing individual PSS-10 questions (Table 2). The level of perceived stress was
also negatively correlated (rS = 0.447, p< 0.001) with self-assessment of the health condition.
In the group of respondents assessing their health condition as very bad or bad, the mean
PSS-10 test score indicated a high level of perceived stress. Respondents who rated their
health as average usually obtained a PSS score revealing an experience of stress of moderate
and strong intensity, and the respondents who assessed their health as good and very good
obtained results indicating stress at a moderate level. No value indicating a low level
of perceived stress was recorded in any of the groups distinguished on the basis of their
health condition.
Table 2. Descriptive statistics of PSS-10, F1 and F2.
PSS-10 Item Heterosexual
Citizens of Poland
Heterosexual
Citizens of Ukraine
Homosexual or
Bisexual Citizens of
Ukraine
Kruskal–Wallis p-Value
mean ±SD H
1. Been upset 2.65 ±1.15 3.11 ±0.97 3.05 ±0.91 15.284 <0.001
2. Unable to control 2.6 ±1.07 2.67 ±1.14 3.27 ±0.87 14.710 <0.005
3. Nervous-stressed 2.6 ±1.05 2.25 ±1.29 3.27 ±0.77 23.157 <0.001
4. Felt confident (R) 2.63 ±1.16 1.6 ±1.29 1.68 ±1.36 60.317 <0.001
5. Things-your way (R) 2.54 ±1.14 2.35 ±1.34 2.59 ±1.3 1.692 0.429
6. Could not cope 2.63 ±1.11 2.53 ±1.24 2.43 ±1.07 1.384 0.501
7. Control irritations (R) 1.98 ±1.13 2.67 ±1.08 2.46 ±1.43 29.430 <0.001
8. On top of things (R) 1.93 ±1.15 2.59 ±1.15 2.89 ±0.99 40.697 <0.001
9. Been angered 2.83 ±0.96 2.25 ±1.17 2.3 ±1.39 18.175 <0.001
10. Could not overcome 2.3 ±1.16 2.73 ±1.26 2.54 ±0.99 14.579 <0.005
PSS-10 total score 24.71 ±9.01 24.77 ±9.41 26.49 ±8.62 1.190 0.551
F1 15.63 ±5.55 15.56 ±5.77 16.86 ±9.62 1.291 0.524
F2 9.08 ±3.88 9.21 ±3.97 9.62 ±4.35 0.636 0.728
R = item is reverse scored; F1 = perceived helplessness; F2 = perceived self-efficacy; SD = standard deviation; PSS-10 = 10-item perceived
stress scale.
Reliability analysis of the PSS-10 and its two-factor structure is presented in Table 3.
Table 3. Reliability analysis of PSS-10, F1 and F2.
Heterosexual Citizens of Poland Heterosexual Citizens of Ukraine Homosexual or Bisexual Citizens of Ukraine
F1 0.925 0.898 0.874
F2 0.868 0.833 0.871
PSS-10 0.942 0.932 0.920
4. Discussion
To our knowledge, this is the first study to focus on migrant LGBT+ communities
during the COVID-19 pandemic, not only in the context of mental health burdens but also
in general. It is also one of the few studies concentrating on perceived stress in MSM or
(im)migrant populations in the course of the current COVID-19 pandemic.
Although the results obtained indicate a similar mean level of perceived stress in
heterosexual citizens of Poland and Ukraine (PSS-10 scores of 24.71 and 24.77, respectively)
and a higher one in MSM from Ukraine (26.49), these observations did not reach the level
Int. J. Environ. Res. Public Health 2021,18, 12838 9 of 16
of statistical significance (p= 0.551). Similar relationships were revealed in the analysis
of the two-factor model of perceived helplessness and perceived self-efficacy in all three
groups. Significant differences appeared only when analyzing specific items of PSS-10. The
respondents’ health condition proved to be the main factor influencing perceived stress.
Worse self-assessment of health status was associated with greater perceived stress,
which is probably related to greater concerns about falling ill and the risk of a severe course
of the disease during the third wave of the COVID-19 pandemic, which was ongoing
during the study [
49
]. It may also be partially due to the differences in awareness and the
previous experience of health issues and risks, but these were not explored between the
groups. It is worth noting that in comparison to the period before the pandemic, there was
a noticeable deterioration in the assessment of one’s own health. In 2019, 71.6% of men
from the Pomeranian Voivodeship (without distinguishing by nationality) assessed their
health as good or very good (vs. 57.6% in the present study), and only 8.7% as bad or very
bad (vs. 17% in the present study) [
64
]. It should be noted especially that the data from
2019 also took into account men aged over 64 years old who assessed their health the worst.
Among migrants, a negative assessment of their health condition may be an additional
stress factor (not only during a pandemic) due to the significantly more difficult access to
health services in their host country [65,66].
Lack of significant differences in the level of perceived stress between the three groups
may be explained by the significant impact of the COVID-19 pandemic. Hypothetically,
general mental health burdens caused by various factors associated with current epidemio-
logical situation may have reached a level so high that it prevents differentiation between
various risk factors. However, the informative value of this null result is questionable
given that one group contained only 37 participants, meaning there was a likely quite low
statistical power to have been able to detect a significant difference, even if there was one.
Admittedly, there is a lack of data on the level of stress in the studied samples in the period
before the pandemic or at its earlier stages. Consequently, it is difficult to assess the extent
to which the values obtained reflect a gradually deteriorating functioning in or, on the
contrary, an increasing adaptation to the epidemic situation. Previously conducted large
studies [
5
] indicate, however, that the level of stress among Polish male citizens (without
distinguishing between sexual orientation) was at a much lower level during the first wave
of the pandemic (the average PSS-10 score at that time was 19.66 vs. 24.71 in the present
study during the third wave). In addition, research on quality of life in Gda ´nsk (part of the
studied Tri-City agglomeration) conducted in June 2021, already after the end of the third
wave, on a group of 1500 people [
6
] indicated that nearly half of the respondents (48.1%)
assessed their mental well-being as worse than before the pandemic. Another point of
reference may be the recently published [
64
] statistical report for 2019, i.e., immediately
preceding the outbreak of the pandemic, according to which depressive symptoms, as
measured by the Patient Health Questionnaire (PHQ-8) [
67
], were manifested by 12% of
men, regardless of age.
Acknowledging the limitations of probing single-elements of multi-item scales [Hoepp-
ner], we decided to perform a more detailed analysis of the individual PSS-10 questions,
looking for possible differences between the study groups. Several distinctions were ob-
served. MSM from Ukraine, more often than respondents from other groups, indicated the
feeling of being unable to control important aspects of their lives and to deal with current
affairs (‘being on top of things’), as well as the feeling of being anxious or stressed. The
screening nature of PSS-10 and the lack of data from before the pandemic prevent a clear
conclusion as to what extent the observed dysfunctions are acute or chronic/permanent (re-
sulting from, e.g., chronic stress caused by the intolerance experienced during the lifetime
of the respondents or from constitutive personality traits) [
68
,
69
]. These men also reported
a more frequent feeling of anxiety caused by sudden events and a sense of inability to
control irritations in their lives, as well as a more frequent feeling of an inability to cope
with the accumulated difficulties than with the group of Polish heterosexual men. Yet
in these cases, even higher results, indicating greater problems concerning these aspects,
Int. J. Environ. Res. Public Health 2021,18, 12838 10 of 16
were noted in heterosexual men from Ukraine. This suggests that the observed differences
are more related to migration itself and to the ensuing lower stability of life and employ-
ment [
70
]. Especially during a pandemic, seasonal workers may be more prone to sudden
job-cuts or transfers to different positions (due to shortages resulting from absenteeism
connected to illnesses) [71]. In addition, people staying in night shelters, workers’ hostels
etc. may also be subject to more severe pandemic restrictions in their place of residence
in their free time, which is not experienced by local residents staying at that time in their
family homes. Another explanation may be that sudden events causing anxiety are not
directly related to the pandemic, but rather to unpleasant experiences resulting from anti-
immigrant stigma also known as the ‘COVID-stigma’. Already at the beginning of 2020,
the World Health Organization noted that, in view of the COVID-19 pandemic, minority
groups experienced increased discrimination and stigmatization by mainstream society.
Accused of posing an epidemic threat, members of national and ethnic minorities are par-
ticularly vulnerable to such negative consequences of the pandemic as stress, anxiety and
depression. Research results indicate that the pandemic exacerbates discrimination and
stigmatization behaviors, and reinforces economic, social and health inequalities, which
leads to a deterioration in the psychological well-being of minority groups. Members
of minority groups and migrants are blamed for creating epidemic threats for majority
groups. Increasing discriminatory behavior, including manifestations of aggression, as
well as the deteriorating situation of the labor market and the loss of sources of income,
have negative psychological effects [
72
,
73
]. On the other hand, Polish heterosexual men
felt less confident that they would be able to cope with their personal problems and, which
may be related, they were more often angry at events beyond their control. One possible
interpretation is that there is a greater sense of agency among migrants [
74
], who, making
serious life decisions, decided to leave their homeland. It is possible that this migration,
being primarily economic in nature [
11
], provided Ukrainian men (regardless of their
sexual orientation) with the means to solve their personal (financial) problems. Another
point might be that the people who possess the mental strength to migrate have a greater
sense of coherence, resourcefulness and are more resilient [
75
,
76
], so that their responses
are more positive. Paradoxically, increasing stigmatization may also enhance bonds within
a group of migrants, especially those speaking the same language, and thus reduce the
level of stress associated with acculturation [
77
]. For the LGBT+ group, being in a more
tolerant place than their homeland could also be a relief from some personal burdens,
for example by making it easier to form new relationships without a fear of exposure
to harassment, as could be the case in their country of origin [
28
]. The above should be
considered in the context of three distinct dimensions of social identification: centrality
(the importance of the group to the self), ingroup affect (the value ascribed to being a
member of the group) and ingroup ties (attachment to other members of the group) [
77
,
78
].
Physical and mental health outcomes are significantly associated with social identification
as a positive predictor of group-derived efficacy and individual self-efficacy [79].
Moderately, respondents often reported a feeling that things were not going as planned
and that they were experiencing difficulties in coping with all their responsibilities. In these
aspects, no significant differences were noted between the studied groups, which may indicate
that the pandemic itself, with the associated risks, nuisance and, possibly, new obligations [
3
],
is the main reason why things do not go as the subjects would have liked.
The study comprised a high percentage of MSM from Ukraine (37 out of 168 people,
i.e., 22%), compared to the expected 3–6% [
80
]. This may be related to the fact that, with a
general reluctance to participate in the study, people whom it directly concerned, i.e., men
from the LGBT+ community, were more interested in participating. It is also possible that
such overrepresentation results from the fact that metropolitan areas of Poland, including
the Pomeranian Voivodeship, are generally more tolerant of sexual minorities and are
therefore more often migration destinations for people from LGBT+ communities [15,81].
Int. J. Environ. Res. Public Health 2021,18, 12838 11 of 16
4.1. Limitations
We recognize several limitations to our study, such as its cross-sectional character and
a relatively small MSM sample. Despite the researchers’ efforts, the method of recruiting
participants may have resulted in the fact that the study groups do not reflect the actual
structure of migrants from Ukraine and of Polish citizens.
The respondents’ distrust, perhaps caused by the chosen method of recruitment and
by waiting for them to complete the survey, prevented collecting important demographic
data, such as education, exact age, marital status, income, current housing conditions
or the place of origin. Furthermore, completing the questionnaire in the presence of the
interviewer and, at times, the need for their assistance in translation may have significantly
limited honesty of the responses in some cases. In the context of the third wave of the
pandemic, housing conditions may have played a special role. Ukrainian seasonal and
lower-skilled workers often stayed in workers’ hostels or dormitories, which exposed them
to more contact and was associated with a greater risk of contracting COVID-19. This
infection, in view of the difficulty of access to medical services [
66
], could be associated
with greater health complications for migrants than for Polish citizens. Therefore, this
group would be more exposed to stress. There is also a lack of information on medical
history, which, in the case of some chronic diseases, could be associated with a worse
course of COVID-19, and therefore generate greater anxiety in at-risk participants of the
study. The participants’ knowledge of specific health risks and their previous experience in
the different groups were not determined, nor were inclusion and exclusion criteria based
on medical history used in the study, so that there remains a potential for confounding
factors associated with such knowledge.
There are also no data on the length of migrants’ stay in Poland (and the migrants’
generation), the reason for migration, the level of bonds with the country of origin and
religion, i.e., factors that could have a significant impact on the level of perceived stress
(integration, acculturation, language skills) [
46
]. However, it should be remembered that
many Ukrainian migrants probably work in Poland illegally, and that they came from a
country where, formally, a war is still being waged [
82
]. Moreover, MSM from Ukraine
could experience various kinds of violence in their country of origin. Considering the
above, it seems that the obtained sample is still satisfactory considering such a short period
of study (the third wave of the COVID-19 pandemic), and the number of MSM coming
from Ukraine is quite substantial.
Another limitation is the lack of a control group for Polish MSM, which would proba-
bly allow distinguishing factors more related to sexual orientation than those correlated
with migration. Moreover, the entire survey was conducted only in Polish, partly due to
the fact that in Ukraine two languages and Surzhyk are used in close relation to the region
of origin, and their use is often a source of conflict [
83
]. With the expected high level of
distrust, we wanted to avoid presenting the participant with the form in a language that
they did not acknowledge and which might have raised their additional reluctance.
Finally, one should take into account the lack of previous similar studies that could
serve as a reference point for the interpretation of the obtained data.
4.2. Future Outlook
The next study prepared by the present authors, which is to be conducted during the
fourth wave of the pandemic, will attempt to address most of the above-mentioned limitations.
Due to the lack of any similar research, it would seem reasonable to assess the level of stress
among LGBT+ migrants in other parts of the world, especially with additional consideration
of ethnic minorities, which seem to be even more exposed to stress [
84
] than the ethnically
homogeneous group of Ukrainian migrants described in this study.
5. Conclusions
In this study, we assessed the level of perceived stress among men during the third
wave of the COVID-19 pandemic. The groups of Polish citizens living in the Tricity
Int. J. Environ. Res. Public Health 2021,18, 12838 12 of 16
agglomeration as well as migrants from Ukraine, were compared, with the latter being
broken down into heterosexual and homosexual and bisexual men, the hypothesis being
that migrants, especially migrants belonging to a sexual minority, will be exposed to
higher stress due to numerous factors that may adversely affect their daily functioning.
The analysis of the survey among 370 respondents did not show statistically significant
differences between the three studied groups in their general level of perceived stress
measured by PSS-10, but it did reveal numerous differences in coping with various aspects
of everyday functioning between these groups. Negative assessment of one’s own health
proved to be the main factor negatively affecting the level of perceived stress. To our
knowledge, this is the first study to assess migrants belonging to a sexual minority during
the COVID-19 pandemic.
Further research should focus on recruiting a larger group of respondents and ob-
serving them during the subsequent stages of the pandemic, both in the periods of its
exacerbation and decline (and the accompanying reduction in the number of restrictions),
as well as on identifying factors negatively affecting the level of stress among the groups of
respondents. In this research, it would also be advisable to consider other regions of the
world as well as ethnic minorities among migrants and LGBT+ communities. Regardless of
this, our research shows differences in the needs, resources and ways of coping with stress
between men who are Polish citizens and migrants from Ukraine, both heterosexual and
belonging to the MSM group.
These varying needs could be addressed by psychological and social interventions
from various NGOs. Such interventions, apart from direct support, may focus on limiting
the gap in the accessibility of health services (including mental health care services). Fur-
thermore, when considering migrant workers, one should acknowledge varying insurance
statuses. Legal workers pay contributions to the National Health Fund, and theoretically
have the same access to health benefits as Polish citizens. Some employees rely only on
private insurance, and some are not insured at all because they work outside the system.
In the first two cases, it would be in the interest of the payer/insurance company to take
preventive measures to reduce high levels of stress and thus reduce the risk of developing
more serious psychiatric disorders that would require specialized, cost-intensive clinics or
hospital psychiatric treatment. Uninsured persons cannot count on free help and are left
to use private health care, which may result in their delaying looking for help in order to
avoid incurring costs. Such a phenomenon of neglecting one’s mental health may result in
serious consequences, including suicide due to untreated depressive disorders.
Undoubtedly, a comprehensive approach to the problem of mental disorders among
various minorities is necessary, both in research work and in preventive and therapeutic
activities. In addition to the human factor, more thorough studies should take into ac-count
cost-benefit economic analyses that could convince the authorities to devote more attention
to this issue.
Author Contributions:
Conceptualization, T.M.; methodology, T.M., M.B. (Maciej Brosz), J.G.; soft-
ware, M.B. (Maciej Brosz); validation, M.B. (Maciej Brosz); formal analysis, T.M., M.B. (Maciej Brosz),
J.G.; investigation, T.M.; resources, T.M.; data curation, T.M.; writing—original draft preparation,
T.M., M.B. (Maciej Brosz), M.B. (Michal Blaszczyk), K.B., J.G.; writing—review and editing, T.M.,
M.B. (Maciej Brosz), J.S., M.B. (Michal Blaszczyk), K.B., J.G.; visualization, T.M., M.B. (Maciej Brosz);
supervision, T.M., J.G.; project administration, T.M. All authors have read and agreed to the published
version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement:
The study was conducted according to the guidelines of
the Declaration of Helsinki, and approved by the Clinical Research Ethics Committee of Medical
University of Gdansk (reference number: NKBBN/144/2021, 5 March 2021).
Informed Consent Statement:
Informed consent was obtained from all subjects involved in
the study.
Int. J. Environ. Res. Public Health 2021,18, 12838 13 of 16
Data Availability Statement:
The raw data supporting the conclusions of this article will be made
available by the authors, without undue reservation.
Conflicts of Interest: The authors declare no conflict of interest.
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