Physical activity, post-traumatic stress disorder, and exposure to torture among asylum seekers in Sweden: a cross-sectional study

As a result of war, conflict, persecution and human rights violations, the numbers of forcibly displaced people have escalated in recent years. Almost 80 million people are currently being forced to flee their homes, whereof 26 million are refugees and 4.2 million are asylum seekers, i.e., seeking international protection but whose claim for refugee status has not yet been determined [1]. Sweden is one of the largest European recipients of refugees and asylum seekers, and has received more than 500,000 applications for asylum over the past decade [2].

Forced migrant populations are subjected to extreme stress related to both ongoing living difficulties [3‐7] and high rates of pre-migratory exposure to trauma [7‐9], e.g., war at close quarters, witnessing the death of others, generalized violence, and torture. Experiences of interpersonal trauma, and especially torture, are powerful predictors of mental ill health in general and symptoms of post-traumatic stress disorder (PTSD) in particular [9‐11]. Torture is by definition a grave violation of human rights. It is prohibited in international human rights law, but still practiced in over 140 countries, including Syria, Afghanistan, Somalia, and other countries where many refugees originate [12]. Furthermore, exposure to trauma and extreme stress often continue both during and after the migration. Experiences such as separation from family, dangerous travel methods, continued conflicts in home country, prolonged and uncertain asylum processes, socioeconomic difficulties, and perceived racism may add to previous traumatic experiences and contribute to the development or maintenance of both mental and physical health problems, including symptoms of PTSD [3‐6, 10, 13, 14]. Consequently, refugees and asylum seekers are at high risk for complex health conditions. Previous research has demonstrated high rates of both PTSD and associated comorbidity such as depression and anxiety [4, 7, 9, 13], sleep disturbances, chronic pain, fatigue, and functional impairments [14‐18]. In all, these complex health issues constitute substantial health care challenges [10, 19, 20] and a significant public health problem in receiving countries [19, 21].

PTSD and other stress-related disorders are also associated with poor health behaviors, including low levels of physical activity (PA) [22‐25], which may additionally complicate the already burdened health situation among forced migrant populations. The health benefits of PA are well established [26] and regular PA is known as an effective stress reliever and associated with improved psychological wellbeing [27]. Both international [28] and national PA guidelines [29] suggest that at least 150 min of moderate-intensity PA per week is needed to obtain important health benefits. Conversely, insufficient PA (i.e. < 150 min per week) is strongly connected to adverse effects on both mental and physical health, including increased risks of chronic medical conditions such as diabetes, hypertension, and cardiovascular disease [30], which forced migrant populations are already at heightened risk for [18, 31]. Previous research on PA and PTSD has shown a potentially complex interrelationship, including different suggestions of directionality, and indications that low levels of PA may act as a reciprocal maintaining factor of both PTSD and comorbidity [23‐25, 32, 33]. For example, insufficient PA is generally proposed to be bi-directionally associated with depression, sleeping problems, and chronic pain, while these symptoms or conditions are also associated with symptoms of PTSD [14, 16, 34, 35]. Interventions including PA and exercise have been shown to alleviate the severity of PTSD symptoms and to have beneficial effects on prevalent psychological comorbidity such as depression and anxiety [36‐38]. Further, regular PA is also associated with a range of favorable health aspects that may be of particular importance concerning forced migrants’ health, including increased energy and daily life functioning, resilience and self-management of stress, sleep quality, physical health status, self-esteem and self-confidence, cognitive performance, and improved social relations [26, 27, 39, 40]. However, the potential impact of PA has received scarce research attention in the field of PTSD and forced migrants’ health, and particularly among the vulnerable group of asylum seekers. Despite the complex mental health needs related to stress and trauma exposure; neither the prevalence of PA, nor its association to PTSD and exposure to grave trauma, especially torture, has to our knowledge previously been examined.

Thereby, the aim of this study was to (i) assess the prevalence of PA among a cohort of asylum seekers in Sweden, in total and stratified by sex and age group, (ii) examine the differences in PTSD symptom severity between asylum seekers with different levels of PA, and (iii) examine the associations between PA and PTSD, controlled for exposure to torture.

Despite the well-known impact of PA on mental health and wellbeing [26‐28], little is currently known about PA among asylum seekers, a population which is known to display high prevalence of trauma exposure and mental ill health including PTSD [3, 4, 8, 9]. The results of this study revealed several noteworthy findings. First, almost 50% of the study population did not meet the international recommendations for a sufficient level of health-promoting PA, and were classified as either inactive or insufficiently engaged in PA. Second, both inactive and insufficient PA were found to be significantly associated with more PTSD symptom severity compared to those who met the recommendations for a sufficient level of PA. Finally, this association persisted and additionally accounted for a marked proportion of the variance in PTSD symptom severity even when analyses were controlled for sex, age, and exposure to torture.

A proportion corresponding to almost half of the cohort of this study not meeting the recommendations of sufficient PA appears as noticeably high compared to both international and national estimates of insufficient PA (also including those being completely inactive). According to the WHO Global Health Observatory data of 2016 [50], the worldwide estimates of insufficient PA were in average 27.5% (31.7% among women and 23.4% among men), whereas the same estimate for the general population in Sweden was 23.1% (24.7% among women and 21.5% among men). Our findings of possible differences between women and men are in line with these data as well as previous research reporting female gender to be associated with higher levels of insufficient PA across most countries and populations [51, 52]. However, the disparities between sexes varies considerably within and between countries. Differences in both level and types of PA has been suggested to be highly influenced by social and cultural norms and practices [52, 53], whereby some cultural norms have been recognized as particularly discouraging of women’s participation in PA, such as conservative dress codes, lack of social and community support, and lack of gender segregated facilities [54]. There is also a wide variation of overall country specific estimates of insufficient PA across both cultural and geographical regions [51], which is believed to be explained by numerous factors at multiple levels, including demographical, psychosocial, sociocultural, and environmental variables [52]. However, potential differences on basis of country by origin could not be reliable provided in this study, and neither could our overall estimates be further examined against relevant national estimates since such data are not available for either Afghanistan, Syria, or Somalia (i.e., representing almost 80% of our study population).

In general, the estimates of insufficient PA are higher in high-income countries than in low-income countries, with in average 36.8% of the populations in high-income countries being insufficiently active compared to 16.2% in low-income countries [51]. Most asylum seekers originate from low- or middle-income countries [1], indicating that the high prevalence of insufficient PA in our study may possibly be viewed as attributed to overall conditions associated with the process of forced migration, trauma exposure, and being an asylum seeker. More specifically, previous research has established that people with severe mental ill health are less likely to engage in PA and are more sedentary in comparison to the general population [55‐57], and, the process of cultural change and acculturation has been suggested to additionally influence almost all other correlates of PA, including key variables such as social inequalities, social support, and motivation [53, 58]. Given the high rates of trauma-related ill health [3, 4], disrupted daily life and work routines from home country [4, 6], as well as other barriers to engage in PA that are likely to be faced by forced migrant populations, such as economic strain, access to facilities, language difficulties, unfamiliarity with the environment, loss of social network, and lack of motivation when living under extreme stress and uncertainty about the future [53, 57‐59], it may be concluded that asylum seekers are more readily susceptible to insufficient PA. An increased focus on assessment and promotion of PA is thereby justified. This may be seen as particularly pertinent considering the currently much extended time of the asylum-seeking processes in many host countries [1]. In order for such actions to be efficient, particular attention to contextual and cultural factors may be necessary.

The issue of further assessment and promotion of PA among asylum seekers may also be seen in light of the WHO Global Action Plan on Physical Activity 2018–2030 [60], including an accentuated need to identify high risk groups of insufficient PA, to increase the knowledge and delivery of context and culturally sensitive actions to promote PA, and subsequently, to facilitate both mental and physical health. According to the few recent reports on PA and sport among forced migrant populations, such actions may not only be attributed to physical and psychological outcomes but also as a facilitator of social health, such as greater acculturation, integration, social inclusion, and feelings of belonging [38, 58, 61‐63]. In regard to promotion of PA, and partially related to our findings of more than one in eight asylum seekers being completely inactive, it may also be noted that recent research has demonstrated important health benefits even at much lower doses than advocated by generic PA guidelines, and especially when moving from completely inactive to some activity [64, 65]. Further, as it has been recognized that the current threshold of 150 min per week may seem unattainable or even discoursing for some people, it has also been argued that the promotion of any engagement in PA may, in some cases, be advisable and which has been particularly pronounced as a potentially important message among people currently inactive and/or suffering from severe mental ill health [65, 66].

Our findings of a clear pattern of differences in PTSD symptom severity relating to level of PA, support that there is an association between mental ill health and insufficient PA. Previous research has found substantial reductions in PA and active leisure time habits after the onset of PTSD [25], which may indicate a direction of mental illness as a contributing factor or an antecedent to insufficient PA. However, research has also shown that low levels of PA can act as a major risk factor for the development and maintenance of mental ill health, including PTSD and comorbidity [33, 35, 56, 67]. It is thus possible that a similar pattern is reflected in the findings of the present study. In that case, low levels of PA may adversely influence mental health and PTSD symptom severity among asylum seekers who have been exposed to severe traumatic experiences. Taken together, the associations indicated by the differences in regard to insufficient PA and PTSD symptom severity may as well be bi-directional in the same line as delineated by the Mutual Maintenance Model [68]. This model proposes that PTSD symptoms and chronic pain are mutually maintaining conditions, and that there may be several pathways by which both conditions can lead to an escalation of symptoms and distress following trauma. Concerning PA, presuming an equivalent analogy, this would imply that PTSD symptom severity may partially influence level of PA while also simultaneously be adversely influenced by insufficient PA. Promotion of PA may, in this case, be seen as both a preventative measure (i.e., to reduce the risks of maintenance or escalation of PTSD symptoms and PA-related comorbidity) and an attempt to alleviate current symptom severity. Based on this hypothetical analogy with the Mutual Maintenance Model, it should, however, also be noted that the mediating mechanisms between PTSD and chronic pain may be very different, and that chronic pain may in itself have an essential role in the links between PA and PTSD. For example, there are several proposed symptom overlaps between pain and PTSD, such as anxiety, avoidance behavior, and elevated somatic focus, which may also influence level of PA. Further, our findings of differences in PTSD symptom severity also between those being completely inactive compared to those with insufficient PA, might yield some support to previous suggestions that even a low dose of PA may be associated with important aspects of health [64, 65]. However, on basis of our results, the direction between respective associations remains unclear.

The possibility that levels of PA may, to some extent, influence PTSD symptom severity, was furthermore supported by the results of the analyses in which exposure to torture, as an established main predictor of PTSD [9, 10], was controlled for. While exposure to torture displayed an expected high explanatory function for PTSD symptom severity, insufficient PA provided additional high explanation for the variation in PTSD symptom severity beyond exposure to torture. Although those not exposed to torture may still have experienced other severe trauma, the overall pattern indicates that insufficient PA may act as a risk factor, mediator, or aggravator of PTSD symptom severity for those inflicted by severe trauma. On the other hand, and in line with the analogy with the Mutual Maintenance Model, higher symptom severity may also act as a risk factor for or mediator of lower PA. Nevertheless, as the cross-sectional nature of our data precludes causal inferences, the results need to be replicated by means of longitudinal studies in order to clarify causality and to assess each factor’s contribution to symptom severity. In addition, there may be other symptoms or conditions that may influence both PTSD symptoms and level of PA, such as poor social support [69], low self-efficacy [70], and as previously highlighted, chronic pain and sleeping problems [15‐17], which are common in the context of displacement and exposure to severe trauma, and thus, warranted further investigation in future studies.

Our results regarding different clusters of PTSD symptoms, i.e., arousal/intrusion and avoidance/numbing, showed similar patterns of differences and associations with insufficient PA as that of the overall PTSD symptom severity. These results deviate to some extent from the inferences of a systematic review by Vancampfort et al. [32], suggesting that the only correlate consistently associated with low PA in people with PTSD is symptoms of hyperarousal. Our findings, however, could also be viewed in light of other studies that have suggested that physical and social inactivity may also comprise a part of avoidance symptoms and negative cognitions and mood, e.g., avoidance of trauma-related stimuli, feeling isolated, and decreased interest in activities [25, 35, 37, 71]. Moreover, these symptom clusters may as well be closely interrelated in regard to their influence on PA, such as avoiding activities or exercise due to lack of energy or motivation, fear of bodily arousal (e.g., muscle tension, increased heart rate, shortness of breath), or fear of intrusive memories that may be triggered by physical strain. In addition, despite a recently increased attention [38, 40], the role of social, cultural, environmental, and policy factors on PA participation among people with PTSD in general [32], and forced migrant populations in particular [53, 58, 59], is still understudied and need to be further addressed by future research.

Insufficient PA appeared to be more prevalent among the cohort of asylum seekers in this study compared to the reported prevalence in general populations and our findings suggest that more PA is highly associated with lower PTSD symptom severity. An increased focus on assessment and promotion of PA among the trauma-prone populations of asylum seekers is thereby justified, and further discussed as particularly pertinent considering the currently much extended time of asylum-seeking processes. The results of this study support previous evidence of PA as a potentially important factor in the context of PTSD and forced migrants’ health, however, further research is warranted to clarify causality and to examine the potential efficacy of PA promotion in this regard.