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Resilience, mental health, and exposure to violence among individuals with former or current experiences of being a refugee in Sweden: quantitative and qualitative studies
Linköping University, Department of Biomedical and Clinical Sciences, Barnafrid. Linköping University, Faculty of Medicine and Health Sciences.ORCID iD: 0000-0002-0796-3921
2024 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Studies indicate that individuals with current or former experiences of being a refugee are more likely to have experienced adverse events, like violence, and face mental health challenges in their host countries. After arrival in host countries, people with refugee experiences often confront various post-migration adversities like discrimination. However, research in this area has been hampered by limitations and a lack of child perspective. This thesis aims to examine both pre-, peri- and post-migration factors that impact the health, well-being, and experiences of children and adults who have migrated to Sweden as refugees.

Article I is a systematic review of Nordic studies on resilience, risk and protective factors for health in refugee children. We found that adversity was consistently identified as a risk factor for poorer health, but otherwise, findings were inconsistent. No study explicitly examined resilience. Article II examined the relationship between refugee experiences in childhood and health in adulthood in a nationally representative sample. The study found no clear link between childhood refugee experiences and worse health in adulthood. Article III investigated differences in health and health-related behaviours between sexual and gender minority refugees, migrants, and Swedish/Western-born individuals and their heterosexual peers. We found higher rates of mental and general ill-health and worse health-related behaviours in sexualand gender-minority individuals regardless of whether they were refugees, migrants, or Swedish and Western-born. Surprisingly, our study revealed no indications of inferior health outcomes among refugee or migrant sexual and gender minorities in comparison to Swedish/Western-born individuals. Article IV investigated mental health and functioning of refugee children and young adults in Sweden. We found lower rates of mental ill-health than previously reported in other studies on refugee children and young adults. Unaccompanied refugee children had worse outcomes than those accompanied. Article V explored the experiences of refugee children and their agency in constructing their own lives during migration. We found that child refugees express a longing for a good life and demonstrate active agency despite facing diverse challenges.

Overall, the prevalence rates for mental ill-health were lower than in many previously published studies even though the prevalence rates are higher than in many studies published on the general population of children in Sweden. Further, the results suggest that these effects are transient. The studies highlight the need to focus on the heterogeneity of the population, for example, by addressing factors that pose a risk to health and rights in refugee children and adults. Moreover, the research emphasizes the importance of adopting a perspective that simultaneously acknowledges both the strengths and vulnerabilities of refugee children. Additionally, this perspective should recognize individual differences, rights, and goals.

Abstract [sv]

Tidigare forskning har visat att personer med nuvarande eller tidigare erfarenheter av flykt löper större risk att erfara negativa händelser och att drabbas av psykisk ohälsa. Efter flykten kan även motgångarna fortsätta i det nya landet exempelvis i form av diskriminering. Forskningen inom detta område har dock begränsats av metodologiska brister och en avsaknad av barnperspektiv. Denna avhandling syftar till att belysa både pre- , peri- och postmigratoriska faktorer som påverkar hälsa, välbefinnande och upplevelser hos barn och vuxna som har flytt till Sverige.

Artikel I är en systematisk översikt av studier om resiliens och riskoch skyddsfaktorer för fysisk och psykisk hälsa hos barn på flykt i de nordiska länderna. Vi fann att olika typer av negativa livshändelser genomgående identifierades som en riskfaktor för försämrad hälsa, medan resultaten för andra faktorer var inkonsekventa. Ingen studie undersökte uttryckligen resiliens. I artikel II undersöktes sambandet mellan att ha flytt i barndomen och senare hälsoutfall som vuxen i ett nationellt representativt urval. Studien fann ingen tydlig koppling mellan erfarenhet av flykt i barndomen och negativa hälsoutfall i vuxen ålder när man kontrollerade för störvariabler. Artikel III undersökte hälsa och hälsorelaterade beteenden hos flyktingar och migranter i jämförelse med de som är födda i Sverige eller annat land i väst som identifierar sig som homosexuella, bisexuella, transpersoner, personer med queera uttryck och identiteter. Vi fann högre nivåer av ohälsa och hälsorelaterade beteenden för sexuella och könsminoriteter oavsett om man var flykting, migrant eller född i Sverige eller annat land i väst. Vi fann dock inga bevis för sämre hälsa hos flyktingar- eller migranter jämfört med de födda i Sverige eller annat land i väst. Artikel IV undersökte förekomst av psykisk ohälsa och funktionsförmåga hos barn på flykt och unga vuxna på flykt i Sverige. Vi fann lägre förekomst av psykisk ohälsa än vad som tidigare rapporterats i andra studier av barn och unga vuxna på flykt. Ensamkommande barn hade sämre hälsa än barn som anlänt i familj. Artikel V utforskade barns upplevelse och deras förmåga att forma sina egna liv under flykten. Vi fann att barn som befinner sig på flykt, trots att de står inför olika utmaningar, uttrycker en längtan efter ett gott liv och visar aktiv handlingskraft.

Sammantaget var prevalensen av psykisk ohälsa lägre än vad som observerats i många tidigare publicerade studier, även om den fortfarande var högre än många studier om barn födda i Sverige. Vidare tyder resultaten på att dessa effekter kanske inte är permanenta. Studierna belyser behovet av att uppmärksamma gruppens heterogenitet avseende psykisk ohälsa, exempelvis genom att hantera faktorer som utgör risker för ohälsa och rättigheter hos både barn och vuxna på flykt. Slutligen betonar forskningen vikten av ett nyanserat perspektiv som erkänner både sårbarhet och motståndskraft, och som också respekterar dessa barns rättigheter, kompetenser, mål och styrkor.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2024. , p. 77
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1893
Keywords [en]
Refugee, Migrant, Mental health, Adversity, Resilience
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:liu:diva-201262DOI: 10.3384/9789180755078ISBN: 9789180755061 (print)ISBN: 9789180755078 (electronic)OAI: oai:DiVA.org:liu-201262DiVA, id: diva2:1841834
Public defence
2024-04-12, Belladonna, Building 511, Campus US, Linköping, 13:00
Opponent
Supervisors
Available from: 2024-03-01 Created: 2024-03-01 Last updated: 2024-03-01Bibliographically approved
List of papers
1. A systematic review of studies on resilience and risk and protective factors for health among refugee children in Nordic countries
Open this publication in new window or tab >>A systematic review of studies on resilience and risk and protective factors for health among refugee children in Nordic countries
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2024 (English)In: European Child and Adolescent Psychiatry, ISSN 1018-8827, E-ISSN 1435-165X, p. 667-700Article, review/survey (Refereed) Published
Abstract [en]

The Nordic welfare model is often used as an example for the promotion of health and wellbeing, even in vulnerable groups of children, such as refugees. Nonetheless, there are no published reviews on resilience and/or risk and protective factors for physical and mental health among refugee children living in Nordic countries. In this systematic review, we identified 5181 studies on the topic, screened titles, and abstracts, viewed 632, and finally included 26 studies. These studies described 18 samples with a total of 34,080 individuals ranging in ages 0–18 years. Overall, the studies were of good quality. Nearly all studies assessed adversity. Six studies reported physical health outcomes and all studies mental health outcomes, most often post-traumatic stress disorder and anxiety. None explicitly studied resilience. While we found that age and sex are the most frequently studied  risk- and protective factors, findings are inconclusive, since the direction of the associations was different in the different studies. This systematic review indicates that there is still a need for well-designed and -powered studies using clear definitions of key study concepts to examine health outcomes and resilience among refugee children in Nordic countries.

Place, publisher, year, edition, pages
Berlin, Germany: Springer, 2024
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:liu:diva-184444 (URN)10.1007/s00787-022-01975-y (DOI)000784912400001 ()2-s2.0-85128482498 (Scopus ID)
Note

Funding: Open access funding provided by Linköping University. FORTE (Dnr 2019–12-01).

Available from: 2022-04-21 Created: 2022-04-21 Last updated: 2024-03-15Bibliographically approved
2. Is refugee experience in childhood a risk for poorer health in adulthood?—A Swedish national survey study
Open this publication in new window or tab >>Is refugee experience in childhood a risk for poorer health in adulthood?—A Swedish national survey study
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2023 (English)In: PLOS Global Public Health, E-ISSN 2767-3375, Vol. 3, no 11, p. e0002433-e0002433Article in journal (Refereed) Published
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-199835 (URN)10.1371/journal.pgph.0002433 (DOI)
Available from: 2023-12-23 Created: 2023-12-23 Last updated: 2024-03-01
3. Health and health-related behaviours in refugees and migrants who self-identify as sexual or gender minority – A National population-based study in Sweden
Open this publication in new window or tab >>Health and health-related behaviours in refugees and migrants who self-identify as sexual or gender minority – A National population-based study in Sweden
2022 (English)In: eClinicalMedicine, E-ISSN 2589-5370, Vol. 52Article in journal (Refereed) Published
Abstract [en]

Background To examine health and health-related behaviors in migrant and refugee individuals who identify as sexual or gender minority, and in comparison to their heterosexual peers. Methods The study included 168,952 individuals (aged 16-84 years, males: 45.9%, sexual or gender minorities: 3.1%) who answered the Swedish National Public Health Survey in 2018 and 2020. Participants were grouped into Swedish-and Western-born (White) heterosexual, White sexual- or gender minority, migrant heterosexual, migrant sexual- or gender minority, refugee heterosexual, and refugee sexual- or gender minority. Outcomes included mental health (for example suicidal ideation, wellbeing), general health, risky behaviors (risk alcohol use, risk gambling, and substance use), and experiences of violence. Associations between 1) sexual- or gender -ethnic identities and 2) gender-ethnic identities and all outcomes were analyzed using logistic and linear regression adjusting for sex, age, and educational level. Findings Being a sexual- or gender minority, regardless of ethnic minority status, was associated with worse general health and mental ill-health compared to heterosexual peers including suicidal ideation in refugee sexual- or gender minority individuals (OR 2.42, 95 % CI 1.44-4.08). Ethnic minorities (heterosexual and sexual- or gender minority migrants and refugees) had lower odds of drug and risk alcohol use compared to White heterosexual peers but higher odds of risk gambling (1.88, 1.49-2.37 for refugee heterosexuals). Transgender refugees had high odds for risk gambling (8.62, 1.94-38.40) and exposure to physical violence (7.46, 2.97-18.70). Interpretation In this national population-based study, sexual and gender minority individuals have worse mental and general health regardless of ethnic minority status. We did not find evidence for worse health in sexual- or gender minority refugees in comparison to migrant, and White sexual- or gender minorities and their heterosexual peers. Transgender individuals (White and ethnic minority) experienced significantly higher levels of physical violence. Public health policy should emphasize preventive measures to reduce exposure to violence and discrimination in sexual- and gender minority individuals, increase access and use of mental healthcare services and sensitise healthcare professionals about higher rates of health and related issues faced by sexual- and gender minority individuals including those with multiple minority identities.

Place, publisher, year, edition, pages
Elsevier, 2022
Keywords
Ethnicity; Migrant; Refugee; Sexual minority; Gender minority; LGBTQ; Transgender health; Mental health; Inequalities; Sweden
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:liu:diva-188028 (URN)10.1016/j.eclinm.2022.101641 (DOI)000880311500001 ()36313143 (PubMedID)
Note

Funding: Linkoping University; Save the Children Sweden

Available from: 2022-09-02 Created: 2022-09-02 Last updated: 2024-03-01Bibliographically approved
4. “You cannot just stop life for just that”: a qualitative study on children’s experiences on refugee journey to Sweden
Open this publication in new window or tab >>“You cannot just stop life for just that”: a qualitative study on children’s experiences on refugee journey to Sweden
2024 (English)In: European Child and Adolescent Psychiatry, ISSN 1018-8827, E-ISSN 1435-165XArticle in journal (Refereed) Epub ahead of print
Abstract [en]

Children with refugee backgrounds are often exposed to violence and other adverse experiences with well-known detrimental consequences on mental health. However, the current group of approximately 40 million child refugees is heterogeneous, stressing the importance of first-person perspectives in understanding children's unique experiences and needs related to the migration process. Identifying contextual factors promoting health and resilience is also essential. For instance, the roles children play as active agents in constructing their own lives and adapting to different environments are poorly described in contemporary research on child refugees and their mental health. To address these knowledge gaps, we conducted qualitative interviews with a reflexive thematic analysis with eighteen children with refugee backgrounds in Sweden. This resulted in two main themes: Longing for a good life that cannot be taken for granted and Challenged agency and changing rights. The narratives indicate that children, although exposed to different challenges in different migration phases and based on gender and asylum status, have experiences of ordinary childhood with a desire for a good life with prospects. The results also show that children execute active and adaptable agency that is impacted by various factors. Reaching the full age appears to be a confusing and ambivalent transition due to changes in rights. The results pinpoint several possibilities to address factors that pose a risk to health and restrictions of rights among child refugees.

Place, publisher, year, edition, pages
SPRINGER, 2024
Keywords
Refugee; Adversity; Resilience; Agency; Human rights; Thematic analysis
National Category
Social Work
Identifiers
urn:nbn:se:liu:diva-200906 (URN)10.1007/s00787-024-02387-w (DOI)001162118900001 ()38360923 (PubMedID)
Funder
Linköpings universitet
Note

Funding: Linkoping University; Swedish Research Council for Health, Working Life and Welfare (FORTE) [Dnr 2019-12-01, Dnr 2022-01059]; Cocozza Foundation [Dnr LIU-2022-02135]

Available from: 2024-02-17 Created: 2024-02-17 Last updated: 2024-03-01

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