Mental health of immigrants in Sweden : A scoping review

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School of Health, Care and Social Welfare

MENTAL HEALTH OF IMMIGRANTS IN

SWEDEN

A scoping review

HAMDI SARDEYE

Public health sciences Advanced level 15 hp

Magister in public health Degree project in public health

FHA024

Supervisor: Robert Larsson Examiner: Thomas Ljung Seminar date: 2020-06-03 Grade date: 2020-06-16

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ABSTRACT

Sweden has a long history of migration since 1950s, and the number of immigrants has increased rapidly in recent years. Research studies have shown that mental health disorders among immigrants in Sweden have increased in the past years. While the problem is an emerging issue, little is known on what the literature says about the impact of immigration on the mental health of immigrants. Thus, this study aims to investigate the mental health and factors that influence immigrant’s mental health in Sweden. This was done by using a scoping review method. As such, a literature search in databases of Medline, Cinahl Plus and APA PsycINFO and manual search on the reference list of the included articles was

performed. The included studies were Swedish studies published from February 2014, peer-reviewed research published in English, reporting immigrants aged 16 and above years old suffering from mental health disorders. Fifteen articles were analysed, and the findings show that immigrants showed an increased risk of mental disorders and suicide in Sweden when compared with the native population. The main mental health problems faced immigrants are post-traumatic stress disorder, depression and anxiety, psychosis and suicide. It was also found that low socio-economic status was also common among immigrant groups compared to natives which identified as a risk factor for poor mental health. It can also be concluded that social determinants such as socio-economic status and social capital in the host country play important roles in the mental health of immigrants.

Keywords: Ecological model, immigrants, mental health/illness, social capital, social determinants of health, Sweden.

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1 INTRODUCTION

Sweden has historically had one of the most generous immigrants’ policies in the world. According to the Swedish agency of statistics, 19.1% of the total population of Sweden in 2020 was recorded as foreign-born (Statistiska Centralbyrån, 2020b). In the autumn of 2015, Sweden as well as other European Union countries, faced a migration crisis by receiving immigrants from conflict areas such as Syria, Afghanistan and Iraq. Sweden was particularly impacted by hosting almost 163,000 people. This resulted in many challenges for the

government, municipalities and the civil society. One of the problems affecting these conflict-generated immigrants in Sweden is mental health disorders.

Mental health is a comprehensive concept which includes good mental health, mental illness and psychiatric conditions, and it can be measured in different ways. Mental health is a fundamental of an individual's ability to think, cooperate and earn an enjoyable life. Since the individual’s mental health is the basis for good well-being, it is, therefore, essential to

promote health and prevent illness of the population. Mental health disorders among

immigrants in Sweden has increased in the past years. This problem is more severe amongst immigrant group than it is for the natives’ group as many previous studies noted. The seriousness of this problem was also observed by the National Board of Health and Welfare which reported that between 20 to 30 % of immigrants who come to Sweden were estimated to suffer from mental health problems and fewer of those people seeks primary care and mental health services (Socialstyrelsen, 2015).

While mental health problem for immigrants is both an emerging issue and area of research, yet little is known on what the literature says about the impact of immigration on the mental health of immigrant’s groups. Specifically, which scientific evidence are available regarding the prevalence of mental health among immigrants and the factors of its deterioration for the immigrant’s groups. Some studies are emerging on the mental health of immigrants in Sweden.

This topic is thus chosen to enhance a broader understanding of mental health among

immigrants since mental illness has become daily health problems that are increasing among immigrants in Sweden. Furthermore, the author of this study has an immigrant background and has knowledge of public health and mental health. For this reason, the interest in

studying this topic and group raised in order to reduce the mental health burden and increase knowledge that may be useful for this vulnerable population.

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2 BACKGROUND

In this background section, it presents the description of mental health and immigrants as well as the relevance of mental health to public health. This section also presents different determinants of mental health, the theoretical perspective and the problem formulation of the study.

2.1 Health

Health is a concept that can be defined in different ways. World Health Organisation (WHO) defined the concept of health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." (WHO, 1948, p. 100). Health has also been defined as “a resource for everyday life, not the objective of living. It is a positive concept emphasising social and personal resources as well as physical capabilities” (WHO, 1986, p.1). Based on this definition, health is considered as a resource for daily life that individual is capable of engaging in activities (sports and social encounters) and to pursue their personal goals (Pellmer, Wramner & Wramner, 2012).

Every human being has the right to enjoy the highest attainable standard of health without distinction of race religion, economic, political belief or social condition. In order to achieve health for all people in society, it needs a full co-operation of individual and States to attain peace and security. Furthermore, the promotion and protection of health are of value to all (WHO, 1948), and it is not only the responsibility of the health sector but goes beyond healthy lifestyles to well-being (WHO, 1986). Working with public health has a significant role in an individual’s health and seeks to improve the health and quality of life. This is done by promoting health and preventing disease among the population. People’s health depends on various determinants, and these have much to do with circumstances in which the person is born, grows, study and work (WHO, 2018).

2.2 Determinants of health

Different factors affect the health of individuals and their communities. According to the WHO (2020), various factors, circumstances and environment make people healthy or not. Such factors combined can be understood as health determinants (WHO, 2020). For

Whitehead & Dahlgren (2006), the health determinants can be put into different layers, from genetic factors to structural factors such as socio-economic, cultural and environmental conditions. These as such, Dahlgren and Whitehead developed a model which shows the determinants of health and factors that affect our health in a simple way (Dahlgren & Whitehead, 2007). Figure 1 shows the model of the main determinants of health.

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Figure 1: The main determinants of health obtained from Dahlgren and Whitehead, 1991.

Following the model of Dahlgren &Whitehead (2007), fundamental factors are, for example, economic security, adequate housing and food security. These factors contribute to the maintenance of health. Control over life outcomes, good relationship in the home and other social relationship are also essential positive health factors (Whitehead & Dahlgren, 2006). On the other hand, psychosocial factors, such as, social support and feeling of purpose and meaning of life are factors that are recognised to protect health. Physical activity and a healthy diet are also considered to be protective (Dahlgren & Whitehead, 2006).

2.3 Public health and Agenda 2030

The overall public health goal of good and equal health is reflected in the Swedish

government national public health policy for which the purpose is to create the conditions which ensure good health on equal terms for the whole population and close the health gaps within a generation (Prop. 2017/18:249). According to government policy, eight general objectives for public health are to be achieved. Each public health objective is based on different determinant of health and explains the important factors affecting people's health to promote good and equitable health for the whole population. This study will be based on five of these eight objectives. The objective two which focuses on developing people's skills and knowledge by learning and education to achieve good and equal health. Objective three which have a focus on work and working environment since people who work have better health than those who are unemployed, and it is important to improve this area to achieve equal health. Objective four focuses on income and opportunities to earn a living, and this is one of the important factors for social differences in health. The objective five focuses on

accommodation and neighborhood, which is considered as an important factor component of good and equal health. Objective six is about living habits which are a key area for achieving equal health. Many of the prerequisites for good health are affected by living habits and by the individual's own choices and lifestyle (Regeringskansliet, 2018).

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The 2030 sustainable development agenda seeks to ensure healthy lives and promote well-being for all at all ages (Regeringskansliet, 2018). Since this study seeks to better understand the impact of immigration on mental health of immigrants in Sweden, it will therefore be in line with the 2030 sustainable development agenda as well as the overall Swedish public health goal and its general objectives contained in the Swedish public health policy.

2.4 Mental health

The concept of mental health can be defined as a state of well-being in which an individual has the ability to cope with the normal stress of life, can contribute to the society around him or her and can work productively (WHO, 2018). Mental health is described as a

comprehensive concept which includes good mental health, mental illness and psychiatric conditions, and it can be measured in different ways. Mental health is a fundamental of an individual's ability to think, cooperate with each other and earn an enjoyable life (WHO, 2018). Public health, in general, has improved over the past few years and most people reported that they have good health. Nonetheless, this does not apply much to mental health and well-being among the population. Mental health problems, such as, anxiety, depression and insomnia has increased in the past 20 years and this occurred in all groups in the

population including in high-income countries (Folkhälsomyndigheten, 2019; WHO, 2018). The World Health Assembly approved a "Comprehensive Mental Health Action Plan for 2013-2020" in 2013. The plan aimed to take specific action to improve mental health, prevent mental disorders and reduce morbidity and mortality for persons with mental disorders. WHO has committed this plan and signed to support governments in the goal of

strengthening and promoting mental health (WHO, 2018). In Sweden, a large number of stakeholders contributing in many ways to improve mental health; researchers, government agencies, civil society and health care sectors (Regeringskansliet, 2018).

2.5 Determinants of mental health

Various social, psychological and biological factors determine the level of mental health of a person at any time. Factors such as low socio-economic and violence are recognised risk to mental health (WHO, 2018). Mental illness is also related to quick social change, physical ill-health, unhealthy lifestyle, discrimination, social exclusion and human rights violation (WHO, 2018). Moreover, creating an environment that supports mental health is essential since an environment that protects, and respects fundamental civil, socio-economic, cultural and political rights is a prerequisite for good and equal mental health. It is challenging to maintain a high level of mental health without security and freedom given by these rights (WHO, 2018).

Dahlgren and Whitehead (2006) note that high-income countries in the European region including Sweden, face a concern of socio-economic inequalities among different groups of their population which affect the mental health of less privileged groups negatively. Among

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these are immigrants whose background are not favourable to stable and quality mental health. They distinguish three explaining features as far as health inequalities in this region are concerned. The first is the systematic pattern according to which variations in health show a consistent pattern in different socio-economic groups of the population. For example, less advantaged group exhibit worse mental health. The second pattern is the social processes creating inequalities amongst different groups and which authorities can alter. The third pattern relates to unfairness in accessing health services (Whitehead & Dahlgren, 2006: 3). Moreover, another concern observed by Whitehead and Dahlgren (2006) in the high-income countries, including Sweden is the social gradient phenomenon. According to this

phenomenon, a linear decrease in health is seen with a linear decrease in the social position. Furthermore, they explain that health inequalities in these countries are generally due to difficulties in geographic access, economic access and cultural access. Geographically some groups inhabit far away from where quality health services are delivered. In Sweden, for example, most publicly financed medical specialists are clustered in the highly populated neighborhood in Stockholm and rarely available in the low-income places of the same city (Whitehead & Dahlgren, 2006: 9). Economically, some disadvantaged groups face difficulties in paying the health bills. In addition, culturally, there are cases of a language barrier, limited awareness or other cultural barriers preventing ethnic groups, especially immigrants' groups from accessing certain services.

2.5.1 Socio-economic status

There are many definitions of socio-economic status, and different authors imply different definitions of socio-economic status. In this study, the author uses the definition of Rostila and Toivanen (2012), who defines socio-economic status as the level of education, profession and income. Education measures the level of the person’s skills and understanding, and it is used as an indicator of socio-economic status (Galobardes, Shaw, Lawlor, Lynch & Smith, 2006). Education level is classified into three levels; upper secondary, secondary and post-secondary education (Folkhälsomyndigheten, 2016; Socialstyrelsen, 2013). The person’s level of education may affect the ability to obtain information about health and capacity to access the appropriate healthcare services (Galobardes et al., 2006). Furthermore, education affects a person’s employment and secure labour market positions as well as income because a high-level job and payment require a high high-level of education (Folkhälsomyndigheten, 2016; Socialstyrelsen, 2013). Individual’s employment elects a person's social status as well as a high level of income gives possibilities to access resources such as healthy food and activities, which in turn influences individual health. Moreover, a high level of income may improve individual self-esteem, which contributes to a person’s feeling of security to interact with society (Galobardes et al., 2006).

2.5.2 Neighborhood and social capital

There are differences in lifestyle habits and health among neighborhoods. Socio-economic factors affect the choice of neighborhood, depending on the level of education, employment and income (Gilliver et al., 2014; Rostila & Hjern, 2012). In fact, individuals living in a

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neighborhood with a high level of education have better living habits and mental well-being than those living in a neighborhood with a low level of education as they tend to have worse living habits and mental disorders. A neighborhood can, for instance, affect immigrant's health behaviour, socio-economic status, their experience of discrimination and their opportunities in the labour market (Rostila & Hjern, 2012).

Moreover, a neighborhood from the same ethnic background is a key determinant of people’s social capital. This neighborhood characterises a group of people sharing the same tradition and value, active citizens and trusting each other and their organisations (Putnam, 2000). As Putnam (2000) has pointed out, when such a group of people have a better education and economic productivity, they can exhibit a lower rate of criminality and better health. Furthermore, if there is social capital in the community, the country’s equality will work better. In fact, the lack of social capital can be associated with various health problems, including poor mental health (Giacco & Priebe, 2018). Several studies examined the

association between a neighborhood and mental health found that ethnic minorities who live in neighborhoods from their ethnic background will have a lower prevalence of mental disorder than those who live in other neighborhoods. A related study found that because of social support with their neighbors, shared cultural norms and language reduce exposure to discrimination and racism and thereby, good mental health (Bosqui & Shannon, 2014).

2.6 The mental health of immigrants

The mental health of immigrants is an emerging issue. Immigrants show higher rates of mental health disorders (Giammusso et al., 2018). This trend is different in immigrant population since it is related to health inequalities between groups and cultural issue. Long-term adjustment difficulties in another country and poor living conditions and social exclusion are often cited as factors that might contribute to the prevalence of mental health disorder among immigrants (Giacco & Priebe, 2018). The higher risk for immigrants can be explained by the fact that they experience a wide range of traumatic events before and after the migration journey. Depression, post-traumatic stress disorder (PTSD), anxiety, trauma and suicidal ideation are common mental health disorders amongst immigrants (Bogic, Njoku & Priebe, 2015; Fazel, Wheeler & Danesh, 2005). This increased mental health problem has been related to both pre-migration circumstances as mentioned above,

particularly those experienced in war trauma as well as post-migration status and stressors, which often common among immigrants. For instance, factors such as separation from family, difficulty situations with asylum procedure, inadequate housing, unemployment and matters linked to acculturation may contribute to poor mental health (Porter & Haslam, 2005). Therefore, due to the high prevalence of mental health disorders over past few years, the needs of specific psychological of traumatised refugees and asylum-seekers are

recognised, and psychological services for this group is established in various high-income countries of resettlement (Giacco & Priebe, 2018; Jefee-Bahloul, Bajbouj, Alabdullah, Hassan, & Barkil-Oteo, 2016).

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2.7 Immigrants in Sweden and their mental health

There are currently 2,019,733 immigrants, i.e. foreign nationals in Sweden (Statistiska Centralbyrån, 2020a), and the number of immigrants is increasing annually. The term immigrant means a person who has come into a foreign country in order to live there permanently. An immigrant can also be defined as a person who either born in a country other than Sweden or had two foreign-born parents (Pellmer et al., 2012; Statistiska Centralbyrån, 2020b). Sometimes immigrants can be classified according to the reason behind their immigration. Labour immigrant means a person who moved from his or her country to work in another country. Moreover, the immigrant population includes refugees, asylum seekers, undocumented migrants, adopted children and first-and second-generation migrant groups (Pellmer et al., 2012; Rostile & Hjern, 2012).

At the end of the 1960s, a large group of immigrants from Finland, Italia, Greece, Yugoslavia and Turkey come to Sweden to work, immigrants from Iran were the most immigrants who came to Sweden at the end of the 1980s and Yugoslavia at the beginning of the 1990s. In the autumn of 2015, Sweden had a migration crisis, and the number of immigrants who came to Sweden was almost 163,000 people, which resulted into many challenges for the government, municipalities and the civil society. The number of immigrants has increased from 2000 and reached an all-time high in 2016 due to several reasons; asylum seekers, family reunification and immigration due to employment and studies. Most of them immigrated due to conflicts and political instability in their countries. In 2019, 116 000 immigrants came to Sweden, but it is estimated to decrease in the following years, and it will be difficult to predict when these peaks will occur (Statistiska Centralbyrån, 2020b).

Previous research, both in Sweden and other countries show that immigrants have higher mortality and worse health compared to Swedish-born (Giacco & Priebe, 2018). However, all immigrants have not worse health status, and this depends on socio-economic inequality between groups in a population such as education, employment and income level (Pellmer et al., 2012; Rostila & Hjern, 2012). In Sweden, both immigrants from OECD (Organisation for Economic Co-operation and Development) countries and those from outside OECD countries reported mental health problems to a much greater extent than indigenous populations (Rostila & Hjern, 2012). The National Board of Health and Welfare reported that between 20 to 30 % of immigrants who come to Sweden were estimated to suffer from mental health problems and fewer of those people seeks primary care and mental health services (Socialstyrelsen, 2015).

Moreover, the Public Health Agency in Sweden reports that mental health inequalities are based on socio-economic factors such as income and education. The report also highlights the relationship between income and mental health, clarifying that mental illness can lead to reduced income and reduced income can lead to mental illness (Folkhälsomyndigheten, 2019). Thus, migrating from one country to another can have effects on mental health for immigrant’s groups. Low socio-economic status is one of those factors which increase mental disorder rates. Several types of research show that socio-economic status differs between ethnic groups in western countries (Rostila & Hjern, 2012). In Sweden, immigrants often have a lower socio-economic status than Swedish citizen, and it depends on the country of

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origin (Gilliver, Sundquist, Li & Sundquist, 2014). Furthermore, a Swedish survey showed that employees originally born in Eastern Europe, Latin America and non-western countries who had insecure work had more mental health problems and poor health than Swedish born employees (Dunlavy & Rostila, 2013). In Sweden, due to social factors, including education, employment and income level may partly contribute and differentiate the prevalence of mental disorders between indigenous and immigrant populations and certain groups of immigrants may have a severe mental disorder which needs treatment (Gilliver et al., 2014).

2.8 Theoretical framework

2.8.1 Social-Ecological Model

The social-ecological model will be used in this study to discuss the results of this study on the mental health of immigrants and the external factors influencing mental health. This model was developed by Urie Bronfenbrenner who divided the model into four levels; microsystem, mesosystem, exosystem and macrosystem (Bronfenbrenner, 1996; see figure 2). The first level, microsystem, refers to the individual and places that the person spend time and participate in, such as home, school, work, family and society around the individual. This level has the main impact on an individual's health since it is the immediate environment which influences a person’s behaviour. The mesosystem is shaped by the connections in the microsystem, for instance, the linkage between home and school and between family and friends. These contacts and connections developed by an individual form social capital. According to Putnam (2000), the theory of social capital is conceptualised as having three different types, namely bonding, bridging and linking. Bonding social capital explains strong ties between individuals such as, family and friends and often explains the concept of social support. Bridging social capital is characterised trust in organisations or neighbours, whereas linking social capital explains the connection between individuals across authority gradients (Putnam, 2000). The exosystem refers to the indirect environment such as, places and people that include the parent's workplaces and the individual neighborhood. This is a social system which influences the person positive and negative even if the person does not participate in this context. The level of macrosystem include factors such as social and cultural value in the society as well as the political and economic system in the country. This system is far away from the individual comparing to the previous systems (Bronfenbrenner, 1996).

This model will help the study to enhance understanding of the impact of immigration on immigrant's mental health by examining the available research evidence. The

social-ecological model will thus contribute to explain the complexity of mental health amongst the immigrant's group under this study. Furthermore, the model explains the relationship between individual factors that can influence mental health as mentioned above, such as, employment and income as well as the social interaction within the community. The different levels of the system are factors that have impacts to individual's mental health and the

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individual's mental health in different ways. Figure 2 shows the different levels of the social-ecological model.

Figure 2. The social-ecological model obtained from Bronfenbrenner 1996.

2.9 Problem formulation

Mental health disorders among immigrants is a topical issue in Sweden. According to Gilliver et al. (2014), mental health disorders are more common among immigrants than native Swedes. Immigrants coming from conflict areas are especially exposed to poor health due to events in their country. What is more, in the host country, they find themselves in a socially and culturally different society and face the new cultural and social environment. This may have long-term adverse effects on the mental health of immigrants and their offsprings (Gilliver et al., 2014). While mental health disorders for immigrants is an emerging research area, the landscape of the available literature regarding the impact of immigration on mental health is not well known. Following Gilliver et al. (2014), this scoping study is an updated review which intends to fill this knowledge gap by mapping especially the available scientific evidence of prevalence on immigrant’s mental health and factors that have an impact on the individual’s mental health. There are systematic reviews that have investigated the

prevalence and factors that influence mental health which were conducted countries outside of Sweden. However, such studies focusing on immigrant’s mental health has not yet been done in Sweden. Therefore, this study will fill the scientific gap as far as the mental health of immigrants in Sweden is concerned. By using the scoping review method, the obtained results of this study will contribute to mapping the available research evidence on the matter while laying down the groundwork for further systematic reviews in the case of Sweden.

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3 AIM

The overall aim of this study is to conduct a scoping review of the existing literature on mental health as well as factors that influence mental health amongst adult immigrants in Sweden. To achieve this aim, the study map and categorise the available evidence in accordance with the following research questions:

3.1 Research questions

1. What evidence exists about the prevalence of mental ill-health among adult immigrants in Sweden?

2. What evidence exists about factors that influence mental health among adult immigrants in Sweden?

4 METHOD

This section presents the study design used in this study, how the literature search strategy was developed and identified articles, the study selection process, the data extraction chart and the data analysis stage.

4.1 Study design- Scoping review

To attain the research aim and answer the relevant research questions of the study and to get a broad understanding of immigrant’s mental health in Sweden, a scoping review was

conducted. According to Arksey & O'Malley's (2005), the scoping review means to review relevant literature on the topic, summarise empirical research and identify terms and gaps in knowledge for future research. Moreover, a scoping literature review was also the most ideal one as the aim 0f; this study fits the scientific field that is not often reviewed. Therefore, this method was appropriate for gathering existing evidence which is relevant for the aim and research questions of this study. In fact, the scoping review, which is suitable for an emerging research area allows a researcher to explore and demonstrate the "landscape" of the literature based on a particular question of interest. Besides, the scoping review is aimed to gather a large amount of studies and does not evaluate the study quality of the included articles of the study (Arskey & O'Malley, 2005).

The Arksey & O'Malley's five-step model of scoping review was selected and used in this research study. The first step was to identify the research question for the study. The second step was to identify relevant studies which answer the research question for the study. The third step was to select studies through the inclusion and exclusion criteria. The fourth step

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was charting the data, and the fifth step was organising, summarising and by using different themes describing the data which has been emerged (Arksey & O’Malley, 2005).

As a first step, the author of this study formulated the aim and research questions about mapping and categorising relevant research on the mental health of immigrants in Sweden. As soon as the aim and the research questions were established, the next step was to search relevant articles for the study. Thus, this is an updating study of the research by Gilliver et al. (2014), and therefore, the included studies should be published between February 2014 and April 2020. The third step was to sort studies and select studies meeting precise inclusion criteria. Only peer-reviewed studies were added to the inclusion criteria for this study, while the open character of the study would allow using grey literature as well. The fourth step was to establish a protocol in order to chart the data, and the last step was collating and

summarising the findings of the included articles into different themes and reporting the results (Arskey & O'Malley, 2005).

4.2 Developing a search strategy and identifying relevant studies

The search strategy consisted of identifying published studies that are relevant to the impact of immigration on the mental health of immigrants. The author received recommendation and guidance from the librarian to use the electronic databases Cinahl Plus and Medline as well as APA PsycInfo since these databases make the scoping review process more

manageable and broader as possible. The librarian also gave useful instructions on search strategies. Once the aim and research questions were established, the next step was to

develop an inclusion and exclusion criteria which were appropriate for this study and thereby identify relevant studies.

A literature search on electronic databases was performed on 09 April 2020, in the databases Medline, Cinahl Plus and APA PsycInfo and accessed through Mälardalen university's

electronic library, Primo, in order to derive relevant literature for this study. These databases were relevant for the aim of this study since they provide literature related to the health and social sciences. Another literature search performed on 24 April 2020, on Google scholar to gather and include more relevant articles into the study. The same search terms were used in the three databases and Google scholar. Thus, the literature search on Google Scholar did not generate any result as it resulted in the same articles which were already identified through the other databases.

The following search terms were used in Medline Cinahl Plus and APA PsycInfo databases; (Swed* AND “immigra* OR asylum*OR refuge*” AND "mental health" OR "mental illness" OR "mental disorder" OR "psychiatric illness" OR anxiety OR depression OR PTSD OR Psychosis), (Swed* AND “immigra* OR asylum*OR refuge*” AND factor* OR risk OR “psychosocial factors”*). These different combinations of search terms derived a plethora of relevant articles, and the most relevant ones were included in this study.

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4.3 Study selection process

After the deadline for the search of articles which was 2020-04-24, the screening for the relevance of identified articles was implemented. This was done by setting the inclusion criteria, screening at the title and abstract levels and full-text level. The number of articles which were identified through Medline, Cinahl Plus and APA PsycInfo was 299. These articles were imported into the reference management tool, EndnoteX9 online, which

organise references and remove duplicate studies, and due to duplication, 98 of these articles were automatically detected and excluded.

4.3.1 Inclusion and exclusion criteria of articles

Once a scoping review was selected, inclusion and exclusion criteria were developed in order to decrease articles related to the research questions and exclude irrelevant studies. The primary inclusion criteria for this study was that the articles would bepublished between February 2014 and April 2020 to retrieve as up-to-date evidence as possible because there was a previous study that reviewed the similar topic, sample and country in 2014 (Gilliver et al., 2014). The language of publication was another inclusion criterion because all included articles were written in the English language, since articles written in Swedish do not exist in the used databases. Due to the fact that articles written in other languages could not be translated into English given the limited time frame of the study Moreover, since the study emphasises on understanding adult immigrants’ mental health, the selected studies included all adults from 16 years and above. As such, the studies that included younger adolescents and children were excluded. Also, studies, where the whole population was examined, were excluded as well. Furthermore, only empirical studies were included in this study, as literature reviews, books, conference and discussion papers were excluded. Finally, the studies which were conducted in Sweden and investigated the prevalence of mental health and factors that influence the mental health, specifically in the immigrant population were included. Table 1 presents all inclusion and exclusion criteria in the study.

Table 1 Inclusion and exclusion criteria

Inclusion criteria

Exclusion criteria

• Published from 2014 (Feb) • Population "adult immigrants." • Swedish studies

• Studies that investigate the mental health of immigrant communities • Empirical study design (qualitative,

quantitative, mixed method) • Peer reviewed

• Published in English • Available full text

• Published before 2014

• Total population having other illness than mental disorders or aged under 16 years old

• Studies conducted outside of Sweden • Studies that investigate mental health

and not focusing on immigrants • Literature reviews, books, conference

and discussion papers • Not peer reviewed

• Published in other languages than English.

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4.3.2 Step one: Title and Abstract level

After the duplicates were removed, there were 201 articles remained, and by screening on title and abstract, 150 of these articles were excluded. At this stage, articles were excluded if the study addressed another topic, i.e., studies that are not conducted in Sweden, studies that investigate mental health that is not conducted with immigrants and studies that focused on general health among immigrants.

4.3.3 Step two: Full-text level

After the screening on titles and abstracts, there were 51 remaining articles, and these articles were reviewed in full text. At this stage, all inclusion criteria mentioned above were taken into consideration and some of the articles which did not relate to the aim of this study or studies where participants were adolescents under 16 years or children were excluded. Other articles which were not available in the full text were also excluded (total exclusion= 36). At this step, a manual check of reference lists of included articles was also conducted, but there were no articles selected for use in this exercise due to published year of articles which were before 2014. Finally, 15 articles were included which fit the aim and research questions of this scoping review (Figure 3).

Identified articles through databases N= 299

Figure 3: Flow chart of the searching procedure

Studies excluded due to duplicates N=98

Studies excluded due to title and abstract N=150 Assessed studies on title

and abstract N= 201

Assessed studies in full-text N= 51

Excluded articles by assessing full-text N= 36

Final included articles in the study N= 15

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4.4 Data extraction

After the inclusion and exclusion exercise, 15 articles were selected, and the author started to read them carefully. The data of these articles were charted and extracted by an established protocol. The protocol suggested by Arksey & O’Malley (2005) and general information about the article were included, i.e. authors name, publication year, country and other information related to the purpose of the study, the population, study design, the result and conclusion.

4.5 Data analysis

As soon as the information from the included articles were charted in the extraction protocol, the author started to investigate the data from articles by taking notes and summarising the findings. First, an overview of the 15 articles were established; this included general

information about the articles (see appendix 1) and formerly similar information from each article were grouped into categories. This was done by grouping similar information about different aspects of mental ill-health as well as factors that influenced the mental health of immigrants and thus developed themes in order to answer the research questions. Four themes were obtained which were applicable to answer the first research question, and these themes were emerged by grouping recurrent information about mental ill-health from different articles together. These themes were; post-traumatic stress disorder (PTSD), depression and anxiety, psychosis and suicide. In addition, further two themes were identified which were suitable to answer the second research question. These themes were emerged by grouping repeated information about factors that influenced mental health of immigrants from different articles as well. These two themes were; socio-economic status and social capital.

5 RESULTS

5.1 Overview of results

After the search from the databases was performed, a total of 299 articles were identified. Articles which met the inclusion criteria were 15, and the findings of these articles were summarised and organised to answer the research questions in this study. Descriptive details about included articles are presented in Appendix 1.

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5.1.1 Study population

The immigrant population in this study is composed of immigrant groups from different conflict-affected countries which, as a result, have come to live in Sweden. Thus, this study comprises of one study on undocumented migrants in Sweden (Andersson, Hjern & Ascher, 2018). Two studies where the studied population were immigrants from Iraq who resettled in Sweden (Lecerof, Stafström, Westerling & Östergren, 2016; Siddiqui, Lindblad & Bennet, 2014). There are also two studies in which the study population were immigrants from Syria resettled in Sweden 2011-2013 (Gottvall, Vaez & Saboonchi, 2019; Tinghög, Malm, Arwidson, Sigvardsdotter, Lundin & Saboonchi, 2017). There is also a study for which the studied population were people from the Middle East and North Africa, sub-Saharan Africa, Asia, Eastern Europe and Russia whom all were compared to Swedish-born people (Hollander, Dal, Lewis, Magnusson, Kirkbride & Dalman, 2016). The results of this study also comprise of a study whereby the studied population were immigrants from sub-Saharan Africa (Steel, Dunlavy, Harding & Theorell, 2017). Another study population from Kurdish immigrants in Sweden was also included (Nabi, 2014). A study of Sundvall, Tidemalm, Titelman, Runeson & Bäärnhielm (2015) regarding asylum seekers compared to non-asylum seekers in Sweden was also used. The remaining six studies population were all immigrants in Sweden compared to native Swedes. These are works by Brydsten, Rostila & Dunlay(2019); Di Thiene, Alexanderson, Tinghög, Torre & Rutz (2015); Helgesson, Tinghög,

Niederkrotenthaler, Saboonchi & Mittendorfer-Rutz (2017); Johnson, Rostila, Svensson & Engström (2017); Johnson-Singh, Rostila, Ponce de Leon, Forsell & Engström (2018); Niederkrotenthaler, Wang, Helgesson, Wilcox, Goud & Mittendorfer-Rutz (2017).

5.2 Prevalence of mental ill-health among immigrants in Sweden

As mentioned above, this scoping review seeks to lay down literature evidence about the prevalence of mental health issues among adult immigrants as well as the factors that have an impact on mental health for immigrants. In the following section, findings from the studied literature relevant to the first research question, which is about the prevalence of mental health problems among immigrants will be briefly presented. This is done by describing four relevant themes. These are post-traumatic stress disorder, depression and anxiety, psychosis and suicide.

5.2.1 Post-traumatic stress disorder (PTSD)

Post-traumatic stress disorder (PTSD) is a mental health status related to a traumatic event that the person experienced or witnessed. PTSD symptoms are more common among immigrants than native Swedes. This is explained by the fact that immigrants experience traumatic events in their country of origin. These experiences may take a long time after immigrants have settled in the new country. Accordingly, immigrants may continue to suffer from PTSD after they have settled in the new country. In fact, this can be illustrated by a cross-sectional study by Tinghög et al. (2017) which investigated Syrian refugee’s mental ill-health aged 18-64 years. About 30 per cent of the participants reported that they had been

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exposed to torture, and as expected, participants who had been exposed to torture had the nearly three times higher the risks to have PTSD symptoms. The study indicates that PTSD reactions may persist and even increase over time after war trauma and resettlement period. Another study by Gottvall et al. (2019) assessed the association between social support and exposure to torture and PTSD among Syrian refugees resettled in Sweden (n= 1215). This study reveals a higher average of PTSD. Moreover, this study notes that those who were exposed to torture were more than two and a half times more likely to suffer from PTSD than the non-exposed participants. Furthermore, those with lower social support were also more likely to suffer from PTSD. Older participants were also, to some extent, more likely to be among those who have PTSD (Gottvall et al., 2019).

PTSD symptoms among immigrants who had experienced war events were also assessed. For example, the study conducted in 2017 by Steel et al., estimated pre-emigration trauma, post-migration stress, and psychological sequelae of immigrants from predominantly Sub-Saharan Africa who immigrated to Sweden. The study used the Harvard Trauma Questionnaire, and 89% of participants reported at least one traumatic experience before emigration, 47% of participants reported clinically significant PTSD symptoms. Male participants reported a significantly higher number of traumatic events and post-migration stress than females. Most participants who were exposed to traumatic life events were related to, e.g., loss of loved ones, combat and torture (Steel et al., 2017).

5.2.2 Depression and anxiety

Depression and anxiety disorders in refugee populations are known to vary extensively between studies and populations. Many studies have shown that the outcome of depression and anxiety are commonly related to both pre and post-migration phases. During the pre-migration phase, depression and anxiety are often associated with PTSD and severe traumatic events. During the post-migration phase, different types of difficulties and

stressors may develop mental ill-health, including depression and anxiety. A cross-sectional study by Tinghög et al. (2017) conducted on the immigrant population in Sweden, specifically on Syrian immigrants, measured the outcome of anxiety and depression. This study included 1215 individuals aged 18-64 years that were granted residency in Sweden on the grounds of the asylum. Depression was the most common type of mental ill-health among this group with 40.2% (95% CI 36.9% to 43.3%) and anxiety with 31.8% (95% CI 29.2% to 34.7%). Refugee related potentially traumatic events (PTEs), particularly being exposed to personal violence, and post-migration stress was linked to increased risks for anxiety and depression (Tinghög et al., 2017).

A further cross-sectional study with undocumented immigrants (n = 104) was performed in the three largest cities in Sweden from 2014-2016. This study aimed at analysing the mental health of the undocumented immigrants and found a higher rate of severe anxiety 68% as well as a severe depression 71% of participants. These outcomes were related to fear of returning to their country of origin for political reasons, or the fact that they belonged to a minority group thus worrying for harassment or due to war in progress in their home countries (Andersson et al., 2018).

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A related study by Steel et al. (2017) included 420 immigrants in the same location and using the same method found a higher rate of depression and anxiety. Twenty per cent of

participants reported clinically significant depressive symptoms, and females reported a higher prevalence of depressive symptoms when compared to males. This study notices problems associated with anxiety and depression in the post-migration phase when using regression analysis (Steel et al., 2017).

A further cross-sectional study of residents of the city of Malmö, aged 30-75 years analysed anxiety and depression and compared immigrants from Iraq to native Swedes (n = 634). The study showed that depression was five times as prevalent (16.3 vs 3.1%, p < 0.001) and anxiety three times as prevalent (52.6 vs 16.3%, p < 0.001) among Iraq immigrants than natives. Immigrants from Iraq were three times more likely to be depressed and anxious compared to Swedes (odds ratio (OR) 3.02, 95% confidence interval (CI) 2.06-4.41) (Siddiqui et al., 2014). Another study analysed the relation and how pre-migration, migration and post-migration factors influence the mental well-being of Kurdish refugees in Sweden. The result showed that psychological well-being was associated with factors in pre-migration,

migration, including post-migration phases. Fear and anxiety about the future as well as powerlessness were common factors that participants reported (Nabi, 2014).

5.2.3 Psychosis

After depression and anxiety, the most possibly mental disorder that immigrants to Sweden can receive are psychotic disorders. The prevalence of psychosis among immigrants in Sweden was noted, for example, one study by Hollander et al. (2016) based on a cohort study of 1.3 million people in Sweden examined whether refugees are at elevated risk of

schizophrenia and other psychotic disorders compared to Swedish born population. These refugees were from four major generating regions: The Middle East and North Africa, sub-Saharan Africa, Asia, Eastern Europe and Russia. The study found 3704 cases of

non-affective psychotic disorder; refugees were at increased risk of psychosis compared with both the Swedish-born population (adjusted hazard ratio (HR) 2.9, 95% confidence interval 2.3-3.6) and non-refugee immigrants (HR 1.7, 95% CI 1.3-2.1) (Hollander et al., 2016).

More evidence of a higher rate of psychosis among immigrants comes from a cohort study in Stockholm county, where the data were collected from participants aged 18-64 to 2002, 2006, and 2010. The study investigated the relationship between ethnic background and psychological distress which increases the risk for psychosis. The analysis showed that a 10% increase in ethnic density or diversity was associated with the prevalence of psychological distress (Johnson-Singh et al., 2018). A further cohort study related to the rate of psychosis analysed by Johnson et al. (2017) regarding immigrant's status on psychological distress compared to Swedish-born. This study included 50 498 individuals from Stockholm county in 2002, 2006 and 2010. Psychological distress which increases the risk of psychosis was measured, and the result showed that immigrants had higher odds of psychological distress than Swedish-born counterparts. The immigrant male had significantly higher odds of psychological distress than Swedish-born male (OR 2.01, 95% CI 1.60-2.52) (Johnson et al., 2017).

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5.2.4 Suicide

Suicide is a public health concern. In fact, several studies note that 95% of people who

commit suicide have a mental health disorder, i.e., depressive disorders, schizophrenia, PTSD and so on (Tinghög et al., 2017). People suffering from mental health disorder are often those who experienced isolation which easily correlates with suicide. It has also been observed that the suicide rate is higher among foreign-born than Swedish-born individuals. One such study investigated suicide risk in the first-generation and second-generation with foreign-born background compared with natives (Di Thiene et al., 2015). This cohort study included 4 034 728 individuals who were followed between 2005 to 2010. The result showed that suicide was significantly lower in first-generation immigrants (HR 0.83, CI 0.76 to 0.91), and higher in second-generation (HR 1.32, CI 1.15 to 1.52) and intermediate-generation immigrants (HR 1.20, CI 1.08 to 1.33) in comparison to natives (Di Thiene et al., 2015). A further study has assessed and compared 88 asylum seekers with 88 non-asylum seekers who have attempted suicide in Sweden. This study has found out that the seriousness of the suicide attempt and that its purpose was death were higher for the asylum seekers than the control group(93.0 vs. 73.8 %, p <0.05) and considered the act as a serious attempt to end life (97.8 vs. 65.0 %,

p <0.001). The suicide attempt for the asylum seekers was related to the previous exposed to

torture and diagnosed as having PTSD which were due to the asylum seeking process and the asylum decision that the asylum seekers go through (Sundvall et al., 2015).

5.3 Factors that influence mental health among immigrants

This section deals with the second research question about factors that have an impact on immigrant's mental health. Two themes resulted from the analysis of relevant studied literature. The first revolves around factors that can be classified as socio-economic whereas the second theme has a social capital aspect.

5.3.1 Socio-economic factors

As mentioned in the background, socio-economic status is defined as the level of education, employment and income. Sweden faces a concern of socio-economic inequalities among different groups of the population which affect negatively the mental health of less privileged groups and immigrants are included in these groups (Helgesson et al., 2017). Low socio-economic status is linked to poor mental health which is common among immigrants. For example, one study illustrating this association investigated the association between financial difficulties, housing problem and poor mental health among Iraqi migrants in Sweden. The results revealed that poor mental health was associated with housing problems (OR 2.79, 95% CI 1.84–4.22), and financial difficulties (OR 2.14, 95% CI 1.44–3.19). Moreover, it was found that social determinants in the new country played an essential role in the mental health of immigrants (Lecerof et al., 2016).

Another study that illustrates how social and economic factors influence mental health of immigrants investigated the association between mental disorders and labour-market

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marginalisation. This cohort study comprised of 1, 7 million individuals, aged 20-35 years, both immigrants and native Swedes. The results of this study showed that immigrants had a higher risk of unemployment than natives (Helgesson et al., 2017).

Also, a qualitative study analysed the mental well-being of immigrants in Sweden based on data from Kurdish immigrants (n = 17); (aged 38-59 years). The results showed that immigrants who had succeeded to obtain a similar occupation or of higher level to their previous occupation in the original country were satisfied with their status. They also had higher self-esteem and mental well-being. The researcher concludes that social and professional regression were linked to worse self-esteem and well-being (Nabi, 2014). A further study examined whether some socio-economic indicators, such as employment conditions and economic disparities, explained mental health inequalities between native and immigrants in the Västra Götaland region in Sweden (n = 71, 643). The study found labour market disadvantages, such as being outside the labour market, unemployment, and experiencing financial strain among social, economic problems facing immigrants. Thus, the study suggested improving immigrants' financial strain to minimise mental health gaps between natives and immigrants in Sweden (Brydsten, Rostila & Dunlay, 2019).

Furthermore, a cross-sectional study of adult undocumented migrants (UM) in Sweden investigated living conditions, access to human rights and mental health. This study found a higher rate of anxiety (68%), depression (71%) and of PTSD (58%) among respondents. According to the same study, these mental health disorders were linked to socio-economic factors, for example, almost all respondents had an unstable housing situation and uncertain moving, 57 per cent experienced unguaranteed basic needs such as food insecurity which was stressful among UM (Andersson et al., 2018).

A cohort study analysed the association between suicide attempt and unemployment (Niederkrotenthaler et al., 2017). The study included European immigrants and

non-European immigrants and compared them to native Swedes. The study found that all migrant groups had higher risk estimates than natives for subsequent unemployment. Non-European immigrants with suicide attempt had a higher risk of subsequent unemployment than other immigrants and natives (2.8 (2.5–3.1) (Niederkrotenthaler et al., 2017). Another illustrative study assessed the association between economic insecurity and the prevalence of depression and anxiety among Iraqi immigrants compared to Swedes. The study indicated that economic insecurity had a significant impact on poor mental health for both groups (OR 2.16, 95% CI 1.56-3.01) (Siddiqui et al., 2014).

5.3.2 Social capital

While all psychological disorders mentioned above are common among immigrants in

Sweden, social capital is a more explanatory factor concerning mental health. Social capital is conceptualised as being of three different types; bonding, bridging, and linking social capital. Previous studies found strong evidence that low social capital is linked to socio-economic inequalities in health and social capital plays a specific role on mediating the effects of socio-economic position (Brydsten et al., 2019; Lecerof et al., 2016). Studies have also revealed that social capital may be particularly important regarding health inequalities between population

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groups, particularly among immigrants. One of the included studies investigated if social capital mediates the effect of immigrant status on psychological distress for different

immigrant groups as compared to Swedish-born. The participants in the study were 50, 498 randomly selected individuals from Stockholm county and their social capital were measured by using indicators of bonding, bridging and linking social capital. It was found that

indicators of social capital showed the most significant mediatory role for all immigrant men and refugee women in Sweden. All three social capital types had a strong explanatory effect (Johnson et al., 2017).

Another study that shows the way social capital influences mental health was done by investigating the association between social capital and poor mental health among recently settled Iraq immigrants in Sweden (n = 617) (Lecerof et al., 2016). In this study, social capital was defined as social participation and trust in others. The study showed that trust in others seemed to have a protective effect on mental ill-health when exposed to housing problems and financial difficulties. Social participation also had a protective effect when exposed to an experience of discrimination. The study concluded that social determinants and social capital in the host country play important roles regarding immigrant's mental health. Moreover, social capital alters the effect of risk factors and might be a useful way to minimise harmful factors to mental health among immigrants as it is important to combine with policy interventions reducing social inequalities (Lecerof et al., 2016).

Several previous studies have analysed the importance of social integration for good mental health ((Brydsten et al., 2019; Lecerof et al., 2016). A study survey from 2011/2015 in Västra Götaland, Sweden (n = 71,643) examined which indicators of social integration explained mental health inequalities between the native- and foreign-born (Brydsten et al., 2019). Included indicators were social activity, trust in others and social support and showed low levels of social activity (20%), trust in others (17%) and social support (16%) among immigrants. Low trust in others contributed to the mental health gap between the native-born and European-native-born (9% and 17%, respectively), and the native-native-born and non-European-born (10% and 19%, respectively). The study concluded that social integration factors play an important role in explaining the mental health gap and inequality between immigrants and natives in Sweden (Brydsten et al., 2019).

Another related study examined the link between people from a different ethnic background, social capital and psychological distress in Sweden. Data were collected from respondents aged 18-64 to 2002, 2006, 2010 baseline questionnaires of the Stockholm Public Health Cohort. The study found no difference in this association based on the measures of the ethnic background used. However, the research group concluded that some elements of social capital such as social inactivity and low trust in others are important explanatory factors of the excess risk of psychological distress with regards to the ethnic background (Johnson-Singh et al., 2018).

A related cohort study assessed the relationship between social support, exposure to torture and PTSD among Syrian refugees (n = 1215) resettled in Sweden 2011-2013. The study found that exposure to torture was related to lower social support and with higher odds for PTSD (OR 2.52, 95% CI) 1.83˗3.40). Moreover, higher social support was related to less possibility

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for PTSD. The study concluded that social support mediated the effect of torture exposure on PTSD (OR 1.13, 95% CI 1.06˗1.26) and may work as a protective factor for PTSD among torture exposed refugees (Gottvall et al., 2019).

6 DISCUSSION

In this discussion part, the author discusses firstly the method used and secondarily the result of this study.

6.1 Method discussion

To achieve the research aim and answer the research questions of the study and to get a broad understanding of immigrant’s mental health in Sweden, a scoping review was conducted. In this review, Arksey and O’Malley’s framework was applied to summarise the existing evidence on the topic and identify gaps in knowledge to highlight the needs of further research. Scoping reviews are a simplified approach to review health research evidence (Levac, Colquhoun & O’Brien, 2010).

The scoping review was suitable for this study since the topic is an emerging research area, and as such, there is a need to compile knowledge on this topic. Accordingly, the study needed to gather an accessible and relevant amount of studies on the topic to see what the literature says without in detail analysing the method used in the included studies (Arksey & O'Malley, 2005). This way of mapping knowledge without a thorough analysis of the method used does not apply to systematic reviews. Thus, the author of the thesis included articles that have methodologically mixed designs due to two reasons. First, assessing the

methodological design is not necessary for a scoping review. Second, the aspect of immigrants and mental health is an emerging research area, and the existing scientific evidence on the matter is not extensive. This, therefore, helped the author to include available studies which were deemed relevant. In fact, selecting studies regardless of their types of methodology design has been one of the inclusion criteria and facilitated the author of this thesis to generate a reasonable number of articles relevant to the aim of the study. Moreover, the scoping review is narrative and descriptive in nature which gives possibilities to gather a large amount of studies without assessing the quality of the study. This is one of the characteristics differentiating a scoping review from a systematic review. In fact, in scoping reviews, researchers do not formally need to assess the quality of included articles (Levac et al., 2010). A limitation occurs, however, because of the absence of assessing the quality of included studies which is important for evidence-based research. As a

consequence, as far as a scoping review is concerned, this may lead to a false conclusion about the nature and extent of those gaps if the quality of articles is not assessed.

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Furthermore, whereas a systematic review seeks to go deep in the analysis to answer a specific, targeted research question, a scoping review focuses on mapping and categorising the available research evidence on a topic. Thus, due to the shortage of time for this study, a scoping review was the most ideal and relevant approach in order to explore and demonstrate the "landscape" of the literature based on a particular question of interest.

Another limitation related to the scoping review for this study was that only one person was involved in search of articles, selection, analysing and interpretation of the findings which can lead to unavoidable bias when creating the inclusion criteria. For instance, one of the inclusion criteria was that the included studies should be published in English. This limits the possibilities that relevant studies could have been excluded if they were published in other languages than English. Moreover, the population age for included studies should also be over 16 years which led to the fact that relevant studies might be excluded due to the age barrier. For this study, only three databases were chosen for searching material; Medline, Cinahl Plus and APA PsycInfo. These were the most relevant databases recommended by the librarian of Mälardalen University. The databases were thus considered as the sources that might provide relevant results in regard to the aim and the research questions of this study. However, this can be a limitation for the study since there may be other existing databases which might give other relevant articles for this study.

On the other hand, there is a strength that the search strategy was performed with the support and recommendation of the librarian, especially on determining the relevant databases. This helped to gain time and work systematically in the method design of this scoping review. Moreover, the aim of this study was established by the support and guidance of the supervisor, which is also a strength. Another strength of this study was that all the included studies were conducted in Sweden, which means that the result of this study will be comparable with the immigrant population in Sweden. Nonetheless, this study has the

strength that almost all included studies are based on a large random sample which increases the accuracy of the results.

In this scoping review, the most previous studies about immigration focused on a

non-psychiatric condition, for example, general health or chronic diseases and the country of birth was one of the considered variables. In addition, there was a lack of qualitative studies on the mental health and factors that influence immigrant’s mental health in Sweden. This might reduce the quality of this study since only one of the fifteen included studies used a

qualitative study design. As such, the limitation occurs because of the absence of participants experiences on mental health in the study. Moreover, even though the focus was individuals aged from 16 and above, some of the included studies were referring to the total population when comparing immigrants to native Swedes. These studies did not mention included age population, and there could be possible that under 16 years old people were included, which might possibly affect the result of this study due to the included age criteria.

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6.2 Result summary and discussion

In the following section presents the summary of the result before a section on the result discussion.

6.2.1 Result summary

The overarching aim of this study was to map and summarise research on immigrant's

mental health in Sweden. This is done based on research conducted in the past six years. This study may thus help to identify the knowledge gap, which might be of interest for further research. To achieve the aim, this study set two research questions. The first one sought literature evidence on the prevalence of mental health among adult immigrants, whereas the second sought the same evidence about factors that have an impact on mental health among immigrants.

In accordance with these questions, the results of this study show that there is an increased risk of mental health problems, i.e. PTSD, depression and anxiety, psychosis and suicide amongst immigrants in Sweden when compared with the native population. Furthermore, the results show that factors that had an impact on the immigrants' mental health include socio-economic and social capital related factors. These are, for example, employment level, income level and social support. Such elements were found as factors that had an impact on immigrant's mental health in Sweden.

6.2.2 Result discussion

The discussions in the following section are done by taking into account the theoretical framework of this study which explains the social-ecological model. As seen above this model comprises of different levels which are discussed in accordance with the obtained results, i.e. the microsystem, the mesosystem, the exosystem as well as the macrosystem levels

(Bronfenbrenner, 1996).

As shown in the results of this study, the analysed articles show an increased risk of mental disorders as well as suicide in immigrants in Sweden. The prevalence of PTSD was more common among immigrants than native Swedes. This has also been in line with the previous research by Gilliver et al. (2014), that the increased risk of PTSD was more common among immigrants compared to the natives. The result of this study shows that the prevalence was related to previous traumatic or war events that some immigrants have experienced or witnessed. This can, therefore, match with the microsystem level of the social-ecological model according to which the places where the individual spends time and participate in, such as family, home, work, and society around the individual can influence person’s mental health (Bronfenbrenner, 1996). In fact, the traumatic places and environments in which immigrants spent their time in the past can affect their mental health conditions.

An illustrating example is about refugees from Syria, who later settled in Sweden, showing a higher prevalence of PTSD problems than other immigrant groups. This can be explained by the fact that the Syrian immigrant groups had been exposed to torture and as expected

Mental health of immigrants in Sweden : A scoping review