Introduction
We are witnessing a time in which forced migration is surging and the need to ensure protection, health, and wellbeing of people on the move is ever so vital. This sentiment is echoed in the Sustainable Development Goals of
leaving no one behind [
1]. In every stage of the migration process (pre-migration, during migration and after resettlement) impact on health and wellbeing is inevitable [
2,
3]. Possible health risks and potential protective factors influence the health outcomes of the migrant, and there is an ongoing attempt to identify the relevance of each of these factors [
4].
Populations at risk of poor health and health care disparities are generally considered as being vulnerable [
5]. Migrants may encounter several barriers to health care because of their legal status and due to economic and social marginalization. Forced migrants differ from other types of migrants in that they are survivors of persecution, violence, and war - factors that might add to their health vulnerability. Hence, it remains unclear if the selection described in the ‘healthy migrant effect’ that postulates migrants’ health advantage compared to both citizens in the home country and in the host country holds true for refugees and other forced migrants [
4,
6]. The accumulation of stressors leading to deterioration in migrants’ health over time have been explained by the ‘exhausted migrant theory’ [
7]. Others have suggested that the migration experience in itself could be the cause of this deterioration [
8] addressing the very act of migration as a social determinant for migrants’ health [
9].
Despite forced migrants’ exposures to stressful events, there is also increasing evidence of positive mechanisms like post-stress growth, described as positive changes following adversity [
10], and resilience, which is characterized by the ability to exhibit a stable health trajectory in difficult times [
11]. Consequently, both adverse conditions rendering forced migrants susceptible for health disparities and the sources of resilience and growth must be considered in attempting to understand migrant health [
12]. Furthermore, these factors need to be understood in synergy with contextual factors as well as embedded in a life trajectory, highlighting the different migration stages [
13].
Although the body of evidence in terms of morbidity and mortality of migrants in host countries is growing, research on forced migrants throughout their often long journeys continues to be scarce [
4], and has largely been limited to cross-sectional designs [
14]. Also, previous research on forced migration has focused mainly on mental health [
2,
15], often centered on negative health outcomes, predominantly in torture and trauma victims. Knowledge of overall and general health in non-clinical refugee populations remains insufficient.
Self-rated health (SRH) has proven to be a valuable predictor of all-cause mortality and morbidity [
16,
17], including in minority populations [
2], and is widely used in health monitoring and to research health inequalities. Quality of life (QoL) is considered a fundamental construct in public health that reflects complete wellbeing, going beyond old paradigms viewing health as merely the absence of disease [
18].
Migration is a global, multifaceted, and dynamic phenomenon in which the migration experience in itself constitutes an important segment of the health trajectory [
8,
9,
13]. In line with recommendations to address multiple phases of the migratory process [
3] we aimed to assess general health among Syrian refugees following their health trajectory from a transit setting to after resettlement using a salutogenic approach. Specifically, our research questions are: 1) how does SRH and QoL of forced migrants change from the transit phase to the early resettlement phase? 2) Which factors (sociodemographic, social support, and migration related) can be identified as modifiers of change? As a second aim, we sought to compare our participants QoL-scores with international samples of QoL used as reference points against which we can interpret our findings. We hypothesized that our cohort of forced migrants would have a stable or decreasing health status after resettlement, as a consequence of post-migration stressors such as acculturation stress, poor access to healthcare, cultural discontinuity, loss of social support and perceived stigma and discrimination [
2,
3,
19].
Discussion
Our study used longitudinal data to examine changes in SRH and QoL among Syrian refugees at two stages of their migration path. Overall, we found that SRH remained stable while QoL increased significantly in the short follow-up period of one year. Furthermore, our results suggest that gender, age and factors connected to the situation in transit (social support and residence permit in transit country) are important effect modifiers of change in SRH and QoL. The generally positive outcomes from this study lend credence to the notion of refugees’ inherent health resources stimulating growth and resilience [
27]. A positive subjective health outcome is an essential means to successful integration, at the same time as successful integration enables good health [
28].
Over half of the refugees rated their health as good at baseline (58%). This finding corresponds to levels of SRH measured in Syrian adults residing in pre-war Syria (55.3%) [
29] and is also similar to previous findings on SRH among forced migrants resettled in high income countries, ranging from 58 to 64% [
30,
31]. In contrast, in the general Norwegian population, over 70% rated their health as good [
32]. Thus, we postulate that our cohort of forced migrants do not have an evident health advantage when compared with their final host population, which contradicts the healthy migrant effect/paradox [
4,
6]. Notably, the SRH level increased marginally but non-significantly after only one year in resettlement.
Additionally, we found that the pre-arrival QoL scores for physical health, psychological health, and environment were rated significantly lower than the mean scores from the WHOQOL-BREF international field trials [
26]. The physical and psychological domain improve significantly after resettlement but remain lower than international reference scores. In the environmental domain, mean QoL-scores surpass the levels of international reference scores after resettlement. Only a few previous studies have explored the concept of QoL specifically in forced migrants. Some of them found low scores in the environmental domain [
33,
34] while others did not [
35], but comparison is impeded by heterogeneity in the samples, apparent differences in migrant legal status and differences in countries’ reception schemes upon arrival. In our study, the lowest ratings at baseline were seen in the environment domain, which contains facets on financial resources, safety and security, accessibility of healthcare services and physical environment. Low scores could be attributed to circumstances observed in refugee settlements where unstable living conditions and poor provision of health services are prevalent. Our finding that all three domain scores: physical, psychological, and environment, improved after one year’s stay in the host country supports this theory. In addition, supportive resources upon arrival and favorable integration policies might have contributed to outweigh the effect of post-migration stressors [
13].
The social relationship domain scores were lower than international reference scores at baseline but exceeded both international and Norwegian reference scores at follow-up [
26]. Even though migration is a main cause of family disruption, most participants in our sample were resettled together with other family members, which might partially explain the high scores in social relationships. Some studies have reported favorable social relationships scores among forced migrants [
35,
36] while others found results pointing in the opposite direction [
37]. A high social capital has been identified as an important protective factor for poor mental health outcomes [
38] and in sustaining refugee resilience and acculturation in the resettlement process [
39]
.
We found stronger improvement in SRH and two out of four QoL domains among men compared to women. These gender-related differences are comparable with evidence from previous research reporting worse health outcomes for female refugees [
2,
30]. A gender-gap in SRH-measures has for long been conceptualized by researchers and has been attributed to a combination of biological and socio-behavioral differences [
40]. In addition to known gender differences in SRH, the migration experience most likely affects men and women differently [
3]. In the psychological domain, there was a larger improvement among younger participants, aged less than 40. This supports the notion of greater resilience seen in younger refugees [
2,
41]. Moreover, we found that participants with low social support while in Lebanon had stronger improvement in SRH and QoL. Since there is a strong correlation between social support, SRH and QoL at baseline and their baseline measures were much lower than participants with high social support, this improvement indicates a larger “catch-up” for a group with an inferior starting point. It also means that within the right circumstances, an increase in SRH and QoL can be achieved regardless of your starting level of social support. The same catch-up phenomenon was seen for the ones who did not have a residence permit in Lebanon. Again, both these findings could point to internal resources in the refugee population enabling adjustment and growth after adversity. Contrary to our expectations, education - a social determinant of health, was not identified as a positive modifier of improvement. This could be attributed to the negative effect of losing your status prevailing over the protective effect of education [
2]. Only a few migrated without family (16%) and it is possible that this small number made us unable to detect significant interactions for this variable.
Strengths and limitations
The main strength of our study is the unique pre-arrival assessment that enabled us to trace refugee health outcomes before and after arrival to the host country using a longitudinal design. To our knowledge, this is a novel contribution to the research field allowing us to shed light on the sequential changes in health in a people moving from completely disparate settings. Secondly, we have a high response rate. In joint, the use of only validated instruments and a high response rate supports the internal validity of the study.
However, our findings should be interpreted in the context of the following limitations. Primarily, since there are no available registers on forced migrants during migration, we cannot state to which degree our sample is representative for the target population. This lack of an overall sample frame is a common limitation to observational studies on migrant health [
42]. To compensate for this, efforts were put in the design to increase representativeness by inviting all the persons from Syria that were to be resettled to Norway in a given time period, as well as having a long recruitment period and recording of non-participation. Another limitation could be the deliberate change in assessment method from mainly self-completed questionnaire at baseline to telephone interviews at follow-up that introduces the possibility of interviewer bias. We used a short follow-up time that gives us important insight into the first phase of resettlement. However, we lack a long-term perspective. Prior research has shown deterioration in health over time [
43] which warrants further longitudinal follow-up.
Our findings of an overall healthy cohort of refugees showing improvement in QoL in a short period of time provide important and novel information about a phase of the migration trajectory where little previous knowledge exists. From a clinical point of view, this information can encourage a shift in attention from pathogenesis to salutogenesis [
44]. Recognizing positive health outcomes and refugees’ inherent health resources is important in the developing of interventions to bolster growth, resilience, and adaptation for the general refugee. In a policy-making setting, our findings suggest that women and older refugees should be subjected to a special effort to improve health. Our findings are also important in informing political and public discourse, nuancing the perception of refugees as a group with an inferior health status. We recommend more in-depth research to understand the mechanisms behind this rapid increase in QoL so that it can be sustained.
Acknowledgments
We greatly acknowledge the International Organization for Migration (IOM) and The Norwegian Directorate of Integration and Diversity for aid in the data collection process. We would also like to thank the Research Council of Norway for funding this study. The funder had no role in study design, data collection, data analysis, data interpretation, or writing of the report.
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