Refugees’ physical and mental health, after arriving in Sweden: An unfolding process: A Qualitative case study on the dilemmas with refugee facilities

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Refugees’ physical and mental health, after arriving in Sweden: An unfolding process

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- A Qualitative case study on the dilemmas with refugee facilities

Bachelor Thesis in Peace and Development Studies

Author: Helen Fawaz Tutor: Christopher High

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Abstract

This case study touches on the development of refugees’ mental and physical health from their stays in the refugee facilities during and after the limbo process for a temporary and permanent visa, which in turn affected their socioeconomic integration. Seven refugees and their families that came to Sweden during the refugee crisis in 2015-2016 and were moved to a facility where I worked, were interviewed on how those issues impacted them.

With the help of Egon Kunz’s [Refugee Theory] theory, the study showed that constant relocation to different facilities in Sweden, and experienced events and conflicts at the facilities have resulted in long-term health and socioeconomic problems. Such as PTSD, mental and physical recovery from occurred events at the facilities, in turn, negatively affecting socioeconomic integration. Additional research in those issues showed that other countries like Germany, which also had a large influx of refugees during that time, had better and faster success with integration when they helped the refugees with the language and societal information at the beginning of limbo. Because their interest in learning and integrating is higher, and the health and integration issues are much lower than when refugees are sometimes forced to wait at least two years, which is what some of the participants and other refugees in this study did before starting SFI, integration programs and have their own private place live in.

The temporary visa, especially with no help to integrate, caused the lack of interest in learning the language; socioeconomic integration, mainly when the person was alone with no family. Moreover, their developed health from their time at the facilities is still a recovering process.

Key words: Refugee facilities, 2015-2016, Physical and Mental health, Sweden, Socioeconomic Integration, Limbo, SFI, Refugee crisis, Integration

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Acknowledgements

I would like to acknowledge and express my deepest gratitude to the people who have supported and helped me throughout this case study.

To my family and friends, without your support and positive pushing words, I would have given up a long time ago.

To the interviewees, thank you for trusting me with the personal and challenging information that you shared with me. Without you, none of this would be possible. Your shared experiences have helped make this case study more personal and humane, and hopefully, it will make a difference to you and others.

And to my tutor, Christopher High, thank you so much for your guidance and quick response during the tutoring process. Your help, kind and pushing words throughout this process helped keep me from becoming grey-haired, calmed me down when I was panicking and hopefully stayed somewhat sane. There are not enough words to express my gratitude.

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List of Abbreviations and Definitions/Terminologies

AT-UND Arbetstillstånd-Undantag (Work Permit-Exception / WP-E) is for refugees and asylum seekers waiting for a decision on their application for residency in Sweden. It is a permit card (LMA) that allows them to work without the demand for an actual work visa. However, to get the LMA, the refugees and asylum seekers have to meet a set of different demands the Swedish Migration Agency have set up, such as having to turn in reliable identification of themselves and their case has to be conducted in Sweden.

Försäkringskassan It is the state agency that financially supports families, people who are unemployed, and people who are physically and/or mentally sick and/or disabled

Limbo It is the time of waiting for a decision on the asylum application for both temporary (TUT) and permanent residence permit (PUT) and the events and experiences that happen during that time.

LMA Lagen om Mottagande av Asylsökande (The law of admitting asylum seekers) is a card that proves the person is an asylum seeker, but they cannot use it to identify (id-card) themselves with it.

PRS Protracted Refugee Situations is when at least 25 000 refugees from the same country have been away or living in exile for five years or more. It is a phase of limbo when the refugees cannot return to their homeland but are still also waiting for a decision if they can stay in the country they are currently seeking refuge in, such as TUT and PUT.

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PTSD Post-Traumatic Stress Disorder is a set of mental reactions or disorders that occurs with people who have witnessed or experienced traumatic events, causing flashbacks, nightmares, panic attacks, etc.

PUT Permanent uppehållstillstånd is a permanent visa (acceptance) to stay in Sweden that immigrants can receive from the Swedish Migration Agency after they have legally lived and still live and are registered in Sweden at the minimum of two years. The person can travel in and out of the country as long as they carry a valid, not expired passport and their PUT card when returning to Sweden.

SFI Svenska för invandrare (Swedish for immigrants) are the Swedish language classes immigrants have to participate in when they receive TUT and/or PUT in Sweden.

Socioeconomic It is a term that describes a person’s social process of acquaintance with others and their personal financial situation and development

TUT Tillfälligt uppehållstillstånd is a temporary visa (acceptance) to stay in Sweden for three years that immigrants can receive from the Swedish Migration Agency. They have to apply for a new visa before the one they have expired. With TUT, they can live, work, and receive the same healthcare as PUT. They can travel in and out of the country if they carry a valid, not expired passport and TUT card when returning to Sweden.

Utlänningsnämnden It is the Board of Foreigners that investigates and decides on appeals from private citizens made against decisions taken by the Swedish Migration Agency.

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1 Introduction

“No one puts their children in a boat unless the water is safer than the land” (Shire, 2015).

This quote from a poem written by the Somalian-British poet, Warsan Shire, became more poignant (Wilson, 2015; Shire, 2015) when the picture of Aylan Kurdi’s lifeless body washed up on a beach in Turkey, which became an international image on September 3^rd 2015 (Hjertén, 2016) seen and shared by over 20 million people on social media. Aylan was a three-year-old Syrian boy who fled the Syrian war with his family in a small dinghy carrying several other refugees heading to Europe (Devichand, 2016). He immediately became an icon and a real image of a refugee crisis that could no longer be ignored. It restarted the discussion and debates in and between the nations of the refugee crisis that was and is still happening. After this event, the Swedish government decided to open its borders for the refugees, creating debates between the Swedish people and the different governmental parties who were for and against this decision (Roxvall, 2015; Darvishpour & Westin, 2016: 195).

The time of waiting for a decision on the asylum application for both temporary (TUT) and permanent residence permit (PUT) can be perceived as the definition of the terminological concept of limbo. It is constant uncertainties and worrying, along with experiences from positive and negative events happening during the waiting period, hence the word ‘limbo’ (Brun

& Fábos, 2015).

After the event of Aylan, the influx of refugees to Sweden increased between 2015 and 2016, which contributed to many overcrowded refugee facilities and many movements to different facilities across the country. Some facilities were better than others, and some stays lasted longer than others. Because of the high refugee influx at the same time, the refugees were forced to stay or be moved to other facilities even after they received TUT or PUT. The constant movements and the occurring events at these facilities have contributed to different negative health changes (Roxvall, 2015; Andersson, 2015). The high influx and stays at the facilities also prolonged the limbo process, which increased the adverse health developments (Leiler et al., 2018). Research has shown (Tuck et al., 2019; Kunz, 1981) if the refugees are not surrounded by a stable support system, such as family; employment; permanent address; and language skills, physical and mental health deteriorates. This affects their integration process, creating more problems for the host country (Tuck et al., 2019; Kunz, 1981; Norström, 2004:

184-185).

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The thesis is based on the refugees’ interviews that I worked with during 2015-2016. They stayed at what was supposed to be a temporary facility for three to four days before they would be taken to a larger place in the country, such as a hotel (Migrationsverket, 2015; Andersson, 2015). Instead, the refugees stayed at the facility for between four to five months. The research centralizes how their physical and mental health has been affected by their time in the facilities during and after limbo, and in turn, if and how those issues affected their socioeconomic integration in a host country (Tuck et al., 2019; Kunz, 1981; Norström, 2004: 184-185).

1.1 Research Problem and Relevance

With everything that happens during the refugees’ wait for PUT/TUT, their physical and mental health are often heavily impacted, which in turn plays a part in their socioeconomic integration during and after limbo (Norström, 2004: 184-185). However, since the experiences are from different occasions and places, the focus is solely on how they were mentally and physically affected by their stays in the Swedish facilities.

There is much research about the health developments that occur with refugees in the host country, but not much of it is focused on the health effects that occur from their time at the different facilities they are moved around to in Sweden during and after limbo. The study could help the authorities improve their preparations if and when these issues happen again, especially when a lot of the data comes directly from the people who experienced it.

1.2 Objective

The objective is to provide personal holistic information and understanding on how refugees’

physical and mental health was affected by their time in the Swedish facilities during and after limbo and how it later affected their socioeconomic integration process. The findings were analysed through the lens of Egon Kunz’s [Refugee] theory (1981) with the support of Mehrdad Darvishpour and Charles Westin’s [Migration and ethnicity] literature (2016) to understand better the refugees’ perspectives on these issues, how and why they occur.

1.3 Research Questions

• What are the health effects on the refugees from their time at the facilities in Sweden?

• In what ways were the health effects managed by the refugees and the authorities in charge of the refugees and their wellbeing?

• What are the effects of the health changes on socioeconomic integration?

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1.4 Thesis structure

The thesis was structured into nine chapters, starting with the introduction in the first chapter explaining the case study and its motive, followed by four different sections: the research problem and relevance, objective, research questions, and this structure section.

Chapter two presents studies related to the research gap. Chapter three demonstrates the applied analytical framework, its segments and how it was used in the research. Chapter four outlines the methods used to conduct the research and the arguments as to why they were used. Chapter five starts with a background of the issues during limbo and continues presenting the findings from the participants’ interviews. In Chapter six, the findings are analysed with the help of the analytical framework and literature, then finished with a short discussion. Chapter seven presents the concluded answers for the research questions, along with a section of recommendations. Chapter eight and nine presents the used references and appendices.

2 Literature Review

The chosen literature was used to present the issues in the research topic to identify the research gap (Creswell, 2018: 27). The literature is related to this study and the gap is presented and highlighted in the last section [The research gap] for this chapter.

2.1 Mental health and quality of life among asylum seekers and refugees living in refugee housing facilities in Sweden

A quantitative case study was through a distribution of questionnaires answered by 510 refugees in Swedish facilities that came at the end of 2015 when Sweden received one of the highest amounts of refugees entering the country and one of the highest influxes than most other European countries (Leiler et al., 2018). The aim was to understand how their mental health and quality of life have developed was and impacted by their time at the facilities before and after the TUT/PUT decisions. It showed that 56-58,4% experienced different negative mental health developments. However, since it was a quantitative study, they did not conduct any interviews that would help elaborate more about how and why their health was impacted and what events contributed to these factors. This thesis is a qualitative study that will help fill the holes on the different issues from the facilities that effected the refugees´ overall health and how it eventually also affected their socioeconomic integration. The authors themselves (Leiler et al., 2018) argue on the little research done on the health development from the time at the facilities. However, since the refugees only answered the questions in the surveys, they could

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not elaborate and give more in-depth explanation and information like semi-structured interviews do. Although, the attained data (Ibid) will be used for both chapter five and six. This thesis is an in-depth study presenting more personal and holistic information about a few refugees and their experiences from some of the facilities they stayed at.

2.2 Pending asylum

Eva Norström wrote “Pending asylum” (I väntan på asyl) (2004), a Swedish literature analysis on how the asylum cases in Sweden are conducted in accordance to the Swedish laws, regulations and asylum politics through different steps and the process of appeal when the application is denied (Ibid: 20-25). Norström explains the asylum process that Ahmed, a Palestinian asylum-seeking man, had to endure that covered many case bases and the personal struggles that developed throughout the case. In chapter five, the literature was used in both the findings and background sections that present the health effects during limbo, like it did in Ahmed’s case. The asylum subject is a constant debate between the politicians and researchers (Ibid: 20-25). Norström cites the sociologist Roine Johansson (1992), who debates the state dilemma scholars focus on, instead of how the state officials work on individual errands, and the effects from their work environment.

“But where does the ‘state’ go in this research? It becomes a large box or possibly a stiff organisation structure without its own life within. The researchers focus on the input and output, not what happens inside the box” (Johnsson, 1992 cited in Norström, 2004: 22).

Another issue is the question of credibility. While working with the refugees, they felt that no one would trust their word over the migration worker or the facility personnel because they were refugees. Norström and other literature (Darvishpour & Westin, 2016) mention these types of issues. It is a type of power dynamic and control often misused in ways that widen the gaps to the refugees’ disadvantages (Ibid: 66; Norström, 2004: 183). It creates mistrust in society and the system that is supposed to protect the individual; instead, they fear that their complaints might affect their asylum application. Research (Nilsson, 2016) has shown that a person in power has often used the refugees’ lack of knowledge in the system in ways such as threatening with deportation (Darvishpour & Westin, 2016: 16). During the interviews, this issue was discussed to understand if actions were taken, and if so, what kind to ensure these types of abuse of power were not repeated. Norström (2004) illustrates how Ahmed, thanks to the help of

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Swedish private citizens, wrote a letter of his experiences before and after he arrived in Sweden, he also asked for a new public counsel and sent it to the Board of Foreigners (Ibid: 185-186).

2.3 Migration and ethnicity: perspective on a multicultural Sweden

“Migration and ethnicity: perspectives on a multicultural Sweden” (Migration och etnicitet:

perspektiv på ett mångkulturellt Sverige) (Darvishpour & Westin, 2016) is an analytical literature on ethnicity and migration in Sweden. It discusses different subjects about migration, adaption, refugee politics, and multiculturalism. Some of these subjects were used to explain the behaviour of the refugees, which affected their health negatively. The literature is also used to highlight and expand the different arguments in Egon Kunz´s [Refugee] theory (1981) to analyse the findings.

The authors emphasised that many studies have shown that the number of “foreign-born”

individuals with mental and physical health issues is two and half times higher than those born in Sweden (Regeringskansliet, 2011: 98-102 cited in Darvishpour & Westin, 2016: 26). The leading causes are the limbo- and integration process and lack of knowledge of the healthcare system, which is also affected by the low Swedish language skills to understand and communicate (Ibid: 26-27). They noted that some scholars argued that the reasons behind the marginalisation of the deteriorating integration and health issues amongst the foreign-born community are “kulturella särdrag” (Ibid: 29), the cultural characteristics. Their theory is that when the individual comes from a non-individualistic to an individualistic society, such as Sweden, who does not share the same norms and culture as their mother country, it creates problems that affect their health and integration (Ibid).

As refugees still in limbo, they are worried to speak to higher authorities if they feel unfairly treated by staff members, such as the caseworkers from the Swedish Migration Agency or personnel at the refugee facilities. They fear that since they lack the knowledge of regulations and the Swedish language, the chances of being believed over the one they are accusing are very slim unless they could provide tangible proof. The authors argued that it should be

“distinguished as a question of abuse of power and status, rather than as identities” (Ibid: 16).

Unless you have social connections, language, etcetera, your credibility is questionable (Ibid:

16-17). Further, depending on their ethnicity and sometimes religious beliefs, some staff members at the refugee facilities tend to give special treatment to those they share with (Ibid:

15). The authors believe the experiences of discrimination should be described by the individuals subjected to it, not by the discriminators. Because if it is the other way around, the

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focus will be if it was intentional or not. Instead, if the individuals who experience discrimination are highlighted, the focus will be on the consequences of the discriminations (de los Reyes, 2008 cited in Darvishpour & Westin, 2016: 33).

2.4 Making Homes in Limbo? A Conceptual Framework

“Making Homes in Limbo? A Conceptual Framework” (Brun & Fábos, 2015) is a study about forced migration emphasising the issues of leaving their home and “making” a new long-term home in the new host country that embodies their values and believes while living with the uncertainties of limbo. Forced migrants are refugees who had no other choice but to leave for reasons such as war and oppression. The refugees in this case study all had reasons that identified them as ‘forced migrants’. The study presents some examples of forced migrants:

displaced Europeans from WW2 and Palestinians who lost their homes after WW2 with the UN Partition Plan in 1948, which started a war between Israel and the Arabic countries, and till this day, conflicts between Israel and Palestine.

The study touched on the different areas that could cause negative health developments and integration pace. For the refugees in this study, the occurred events and experiences at the facilities and continues moving while feeling as a guest and not at home eventually impact physical and mental health (Darvishpour & Westin, 2016: 66-67; Kunz, 1981). Brun and Fábos referred these types of issues to the term “protracted refugee situations” (PRS), which talked about the struggles forced migrants, such as the refugees, have to endure during limbo. This study, along with the other literature and Kunz’s theory (1981), were combined and implemented to highlight the refugees’ mental and physical health developed from their facility experiences, such as depression and weight loss. Those points affect the standards and process of their socioeconomic integration in the host country (Darvishpour & Westin, 2016; Kunz, 1981).

2.5 The research gap

The literature presented above discusses the negative health developments that occur in the host country during and after limbo. However, there is little detail in this work or others (eg. Chuang

& Moreno, 2011; Walther et al., 2020), that discusses the health effects from the refugees´ times at the facilities and the many movements, nor how health issues that arose during this time affected their socioeconomic integration. An exception is Leiler et al.’s (2018) quantitative research questionnaire on the mental health developments from the time at the facilities in

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Sweden, but they did not cover physical health effects nor how the mental health effects impacted socioeconomic integration. Hainmueller et al. (2016) examine the socioeconomic effects from the time during limbo due to different issues such as the waiting time, receiving TUT instead of PUT, and housing arrangements that come with different rules to be upheld.

But these issues are not directly linked to the events that occur and affect the overall health, especially physical health. Furthermore, many studies on health developments are primarily focused on mental health, along with being quantitative studies (Sheath et al., 2020; Tuck et al., 2019) and mostly done on facilities in other European and non-European countries whose system and policies differ from Sweden’s (eg. Ziersch et al., 2017; Mellou et al., 2016). The research gap is therefore that there is not enough research that links together the complexities of the post-arrival situation of refugees, their overall physical and mental health and how these factors affect socioeconomic integration. Further, Sweden and Germany had the highest influx of refugees in Europe (Leiler et al.,2018; Dalqvist, 2018), but Germany handled the refugee process differently than Sweden (Dalqvist, 2018).

3 Analytical Framework

To reach an understanding, a theory was used to build a hypothesis that would analyse the findings, answer the research questions, and contribute to developing solutions to the different dilemmas.

3.1 Choice of Analytical Framework

The choice of using a theory that goes in line with the study is essential to present and demonstrate the findings to clear complications and questions on the different issues of the thesis (Creswell, 2018: 49). According to Creswell (2018), whether or not researchers describe analytical frameworks as theories, they contribute to the analysis of the “culture-sharing behaviour and attitudes of people” (Ibid: 62). Egon F. Kunz (1981) developed a theory explaining what type of refugees exists. Depending on their reasons to why they left, they face different challenges. This theory was chosen to explain what happens with the refugees when they are in limbo in an unfamiliar country and what issues occur for both them and the society they live in if not handled correctly, ethically, and quickly. To elaborate different parts of the theory, Mehrdad Darvishpour and Charles Westin´s [Migration and ethnicity] literature (2016) will be used.

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3.2 Refugee Theory

To understand ongoing events and easier predict the following outcomes, Kunz developed the refugee theory. Kunz (1981: 42-43) argued: even though many refugees have different stories as to why they left, their situations are still relatable to one another in different ways.

To demonstrate what type of refugees they are, he sectioned them into three categories:

Majority-identified refugees distinguish themselves for being proud of their ethnicity and nationality but have strong critical opinions of resistance against the political parties and other issues in society. Events-alienated refugees have mostly left their homes because of ongoing or past discrimination against racial and/or religious minorities. They leave without looking back, rarely think of and identify themselves with their previous country or desire to move back. The self-alienated are refugees with different personal, individual reasons, and philosophies and have no desire to attach or identify with their country. They might hold on to a few things from their nation. However, their overall ideological opinions and reasons for leaving the country may be because of philosophical differences that are not shared with society, making them feel like outsiders (Ibid).

The categories identifies into two attitude groups of reasons for leaving their homeland: Active and Reactive. Reactive refugees are usually linked to fate-groups. Fate-groups are what Kunz calls “refugees of wars, sudden revolutionary changes and expulsions” (Ibid: 44). They could be both majority-identified and events-alienated refugees who reacted to situations, such as wars and/or oppression and saw no other choice but to flee, like the forced migrants Brun and Fábos’s (2015) talk about. Like Aylan Kurdi’s family, ready to risk their lives on dinghies’

across the ocean than to stay in their home countries and risk getting forced into the army, political or fate groups, prison, tortured or/and killed (Roxvall, 2015).

Self-alienated refugees are usually the Active group who are considered as Self-fulfilling purpose groups. They often remove themselves from the equation where they feel like outsiders and head to societies where they think they might fit in, making it unclear if they are refugees or voluntary migrants (Kunz, 1981: 43-45).

Kunz explains how refugees manage being in a new country, depending on their situation to why they left. Their first thoughts are about their homeland and what they went through, then gradually begin observing the new society they are in. Some decide to hold on to their culture entirely and isolate themselves; some will let go of their past and assimilate to the new culture

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and society, and some will combine the old with the new. For example, try new types of food outside and cook their traditional food at home; learn the new language but still watch tv-shows and the news from their homeland; learn to celebrate ‘new’ and ‘old’ holidays, etcetera. Then, depending on the host country, some welcome refugees if the country is underpopulated, but tend to take advantage of the refugees in work-related issues. Some overpopulated nations usually protest against having refugees because they do not want to assimilate or integrate the refugees into society, which sometimes leads to “us and them” situations (Ibid: 45-49).

Based on the alliances proposed and research on refugee movements, Kunz made a list of fifteen points and tools with “predictive hypotheses” that can be done, used, and thought about when attempting to improve and facilitate the situation for the refugees and the host countries (Ibid:

49-51).

“9) The distance of the native land from the country of asylum and the number of countries the refugee has to cross in his flight to get there, act as selective

factor: the distance overcome and the quality of refugee are positively related” (Ibid: 51).

Kunz argues: if the refugee managed to survive the trip to the country they are in right now and are in good health considering the circumstances, their health and integration chances in the host country are good.

“14) The absence of marginality experience among the majority identified reactive fate-groups makes them a primary target for shock, authoritarian attitudes, schizophrenia and alcoholism particularly if they find

themselves in a monistic society of alien tradition” (Ibid).

This point should be considered to find solutions quickly, such as developing and rehabilitation programs that gradually introduce them to the new and different society. It could be mandatory state-provided programs giving them societal information on behaviour, rights and obligations towards themselves and others. There could be classes to teach them the host country’s primary language, facilitating their socialisation in society, healthcare, etcetera. (Migrationsverket, 2020). It would help prevent them from ending up in a fragile physical and psychological state, possibly putting them and others at risk. So far, only non-profit organisations provide these lessons for those who know of them and are interested (Andersson, 2015; Migrationsverket, 2020). Darvishpour and Westin (2016) argued that if too much focus is put on the cultural

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differences in relations to the ethnic minorities’ cultural characteristics, it will be perceived as conclusive obstruction of integration in the new society. It contemplates as if ‘they’ are the problem, and ‘they’ should with the support of the ethnic majority, adapt and integrate to the norms and values in the new society. They suggested that if the ethnic relations are instead analysed from the viewpoint of power, issues such as discrimination, marginalisation and exclusion will become central subjects highlighting that ‘we’ are part of the problem. Minorities will be excluded and forced into segregation, preventing them from participating and integrating in the host country (Ibid: 16).

3.2.1 Applying Kunz’s theory

Parts from Kunz’s theory was used to analyse the findings: the categories that identifies with the refugees; the two attitude groups; the interest in refugees from over- and underpopulated countries, in this case Swedish cities; and some of the points of predictive hypothesis explaining the behaviours and different events that would lead to health changes and socioeconomic integration pattern as a result of RFS and the events at the facilities, creating more long-term side-effects (Kunz, 1981; Brun & Fábos, 2015). One predictive hypothesis is the 14^th point of Kunz´s theory (Kunz, 1981: 51). The majority identified reactive fate-groups struggle more with adapting to the new society, especially if they suffer from mental and/or physical health (Ibid). Westin (2016) mentions how the purpose of “Integrations politics” (Darvishpour &

Westin, 2016: 66) was supposed to incorporate immigrants into the leading society but let them hold on to their cultures, languages, and the support of the community they live in instead of generalizing the ‘us and them’ issue (Ibid). This is one of the parts and issues outlined with one of Kunz’s points (Kunz, 1981: 51). However, the missing part that might have improved their integration process was Kunz’s points on different mandatory programs for the refugees during their time at the facilities, like they do in Germany (Dalqvist, 2018). Through the analysis, the findings would present what happens if Kunz’s 9^th point was not followed early on.

4 Methodological Framework

This chapter outlines the used methods, reasons to use them and how they were used, along with the limitations and delimitations, collected data, sources, and ethical considerations.

4.1 Qualitative Case Study

The qualitative method emphasises its research on the findings contained from used sources, along with using abduction reasoning (Creswell, 2018: 180-183). Darvishpour and Westin

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(2016) present two studies that showed how structural discrimination within organisations and other societal structures systematically distinguishes specific collectives of people (Ibid: 33).

According to Danermark et al.’s (2002), the qualitative methodology focuses on one or several specific subjects, about one individual or more. The authors also mentioned that the study could be “an event or a process” (Ibid: 158). This particular thesis focused on highlighting several individuals and their physical and mental health processes from experienced events in the Swedish refugee facilities.

Semi-structured interviews facilitated the required information and gave the interviewees a chance to elaborate on their views and experiences. They were asked the needed and prepared questions while provided the chance to tell their stories more thoroughly and freely, creating follow-up questions and developing to more relaxed conversations (Corbin & Strauss, 2015:

39).

Creswell (2014) provides different steps and strategies of validity and reliability to ensure that they are implemented (Ibid). Validity refers to the different methods used to examine the accuracy of obtained research. Such as analysing apprehended studies through different channels; giving a thorough presentation of how the apprehended research is used; present both negative and positive information on found research (Ibid: 200-201). Creswell (2014) presented Yin’s (2009) argument that reliability emphasises thoroughness, ensuring the research is reliable through documentation on made decisions and used methods. By citing Gibbs (2007), Creswell arranged a system so others can observe the study’s conduction with total transparency (Ibid).

4.2 Abduction Reasoning

With abduction reasoning, assumptions could be made based on found and given information for the research. Abduction is a part of a framework with four different methods, which Danemark referred to as the “four modes of inference”, all with a function on how a more logical conclusion could be reached in a study (Bryman, 2016: 394; Danermark et al., 2002: 79-81).On that account, previous research has shown (Darvishpour & Westin, 2016) that the refugees’

overall health many times gets affected because of different reasons, such as poor language skills and housing changes (Ibid: 27). With the interviews, this research presented an in-depth analysis of experienced health issues, why they occurred, and how they affected their integration (Danermark et al., 2002: 94-95). Abductive reasoning was used to clarify the

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researched questions by the interpretations made from refugees’ stories. Hence, the findings do not give a final conclusion if they are unequivocally true or false (Ibid: 91-92).

4.3

Sources

The sources helped provide needed information for the research questions and the analysis. The interviewees are the primary sources since they provided first-hand information for the research gap from their personal experiences. Secondary sources are the literature in chapter two and additional online sources, which helped analyse, explain, and incorporate the given information from the primary sources (Streefkerk, 2019).

4.4 Methods of the interviewing process

With help from one of the female refugees that I have been in contact with since she and her family were moved to another facility, we contacted seven other refugees that I worked with in 2015-2016.

The process started with creating a zoom account where the interviews would be conducted, and with their permission, recorded for personal use. The objective and relevance of the study were presented, along with the ethical steps before and after the recording started. After covering the essential basic steps using Bryman (2016) as a guideline, the interviews started with prepared adjustable questions steered by the types of answers they would give (Bryman, 2016: 468-469; Corbin & Strauss, 2015: 39). For example, one of the prepared questions was if they were badly treated at any of the refugee facilities. If the answer was yes, they were asked to clarify how, by whom and if it had any long-lasting effects. If the answer was no, the questions would be if they could explain how they were treated.

Although not all have to be followed, Bryman referred to Kvale’s (1996) nine questioning steps for qualitative interviews (Bryman, 2016: 472-473). With the help of the tutor, Christopher High and guidelines from Bryman (2016) on how to conduct the interviews, the line of open- ended questioning was set up in three parts: easy and regular questions, more in-depth questions, and follow-up questions. The interviews started with easy and regular questions, such as nationality and current occupation. In-depth started with short explanations to why they left their countries, and then more in-depth answers to questions on their time in Sweden from when they first arrived until now. It was questions that would be answered on how the time at the facilities affected their everyday lives and overall health. Almost every question received an answer in a conversational story. Follow-up questions gave the interviewees possibilities to

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clarify statements and possibly provide further and more in-depth explanations. Conclusively, they were asked if they had something to add, how it felt to be interviewed, and if they had any feedback to offer, such as improvements and clarifications in the questioning or the ethical information (Ibid: 475, 483). During the interviews, useful information and impactful quotes were written down to highlight the objective and relevance of this study (Ibid: 482).

4.5 Thematic Analysis

Thematic analysis is one of the traditional approaches for qualitative research. In this case, it was used to find the common thread in the interviews, which was the health development in the refugee facilities and its effects on socioeconomic integration during and after their time at the facilities. The answers and information given and contained from the primary and secondary sources led to the choice of the thematic approach. Because it helped code the interviews and categorize them in relations to the research questions (Bryman, 2016: 584). For example, what kind of mental and physical health effects occurred, and the most common ones. The categories are presented and analysed in chapter six with the support of Kunz´s theory, along with the included literature. The first one will analyse the effects of moving during limbo;

discriminations by both personnel, other refugees and civilians; late language and integration programs; the impact with family nearby; and effects from insufficient knowledge and understanding by the healthcare system of the health problems that people with foreign origin have.

4.6 Ethical Considerations

The ethical considerations drew on guidelines and principles from ethical codes discussed in Erik Blennberger’s book, “Etik för samhällsvetare” (2011), designed for social science. It is different types of standards to be followed in both public and private sectors involving human interactions. This is believed to have more successful professionalism in areas that personally affect the private citizen (SSR, 2011). It also draws on Creswell’s (2014) & Bryman’s (2016) material on ethical research, specifically to ensure the interviewees understood their role in the case study (Bryman, 2016: 132; Creswell, 2014: 89, 92).

4.6.1 Procedure

Before starting the interviews, the choice of anonymity was presented to the adults and children:

should they want to, their names could be changed along with everything else that might identify them, and they will be presented with aliases. After oral permission and assurance, the

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interviews were recorded for the researcher to only use for the conduction of the thesis and not shared with other people, including the examiners and tutor. Since the interviews were conducted via zoom, they also gave oral consent after the recording started (Bryman, 2016:

128, 131; Creswell, 2014: 90, 92).

4.6.2 Risks

The research was not about issues and certain people who might jeopardise anyone’s safety.

However, if specific information would have been apprehended that was sensitive or perceived as such, and if it is about someone particular, an agreement would be made with the person in question on how to disclose it safely (Creswell, 2014: 92-96, 200-201).

4.6.3 Solutions

They were informed when or if they ever wanted to stop the interview, change their minds in participating and have the recording deleted, they could. If there were questions that would make them feel uncomfortable or bring back bad memories, they should not feel forced to answer the questions or continue the interviews. The children were asked only 3-4 simple and different questions with their parents present. Such as how old they are now, if they remember their time in Växjö, and if they are happy now where they live. Although, most of the presented findings regarding the children is information provided by their parents. Such as how many schools they had to change because the family was moved to a new facility, how the effects of the limbo process affected their health, etcetera. (Bryman, 2016: 136-137).

The interviewees were offered to read the final work of the thesis or have it explained to ensure their shared information aligned with the interpretations in the findings chapter (Creswell, 2014:

92-96, 200-201).

4.7 Limitations and Delimitations

Limitations with this study were the lack of actual face-to-face contact. A researcher can only get so much from online interviews. The interviewees live in different regions in Sweden, and because of the current COVID-19 pandemic, the idea of commuting was not recommended.

Furthermore, many participants kept rescheduling or not show up on the scheduled interviews, which delayed the key chapters in the study. That, and some personal issues in the family that were more important and time-consuming, took away from the needed time to work on the thesis.

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The delimitations are that the interviews were only with the refugees that I worked with.

Because the trust and acquaintance were already developed, which saved time from building a comfortable setting for the refugees to open up in the interviews. Further, the main focus was to as much as possible get information on the research questions. So additional information was useful but not the priority unless it was linked to the research gap.

5 Findings: Case study of 7 new arrivers and their families

With featured interviews, this chapter aims to give an overview of the health developments that occur in the refugee facilities and how socioeconomic integration has progressed from it. The chapter starts with a background on refugee life in refugee housings, and it will move on to connect with the interviewees. They will be introduced with first names only, followed by their stories individually. The interviewees answered the needed questions and provided new information that may have impacted their negative health development and their socioeconomic integration in Sweden.

5.1 Background

Most refugees face many struggles on the road towards their destination of safe place (Johansson’s chapter in Darvishpour & Westin, 2016: 195). Like Aylan Kurdi, some even die before arriving (Devichand, 2016). When they do arrive, new uncertainties, struggles and differences occur. It is issues that impact the refugees’ physical and mental health beyond what they already have been affected from before. One of them is the time spent at refugee housings and constant relocations from one facility to another before and after receiving TUT/PUT. This chapter emphasises the refugees’ time at the facilities while dealing with legal and social situations and its effects on the integration process, which is affected by their overall health (Norström, 2004: 184-185). Eva Norstöm (2004) talks about an asylum applicant’s process, Ahmed. He received a negative decision, appealed it, and was denied again, which gradually broke down Ahmed’s physical and mental health (Ibid: 98-99). Ahmed’s situation is similar to the interviewees’ legal and limbo process. Suicide thoughts and attempts are common amongst the refugees, and the right support system that impacts mental and physical health (Kunz, 1981:

51; Darvishpour & Westin, 2016:15-16).

Research showed (Leiler et al., 2018) that refugees’ health were and are negatively affected the longer they stay at facilities, and even more so when they are moved to different facilities until they get a permanent address to stay at privately and not with several others under the same

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roof. Because there was an unusually high influx of refugees in 2015 and 2016, the refugees stayed longer at the facilities than they would typically do because of the significant shortage of individual housing. Many were at the facilities even after they received decisions on their asylum application, which also increased the health changes. Furthermore, the refugees who received TUT or were still waiting showed even more negative health developments, specifically mental health (Ibid). Different events that happen in the facilities impacts significantly on both physical and mental health. Such as a misuse of power towards the refugees, unhealthy environment because of the large number of people in the same place, facility relocations, discriminations and racism.

5.2 Introducing the refugees

This section introduces the participants and their interviews. All participants arrived at the Växjö facility at the same time, and everyone but one family was moved at the same time to a much larger facility in Stockholm. Some interviews can be perceived to be more extended than the others’ because the information given about their facility experiences and opinions on their first encounters upon their arrival in Sweden was similar to each other. Which was described as humane treatment by the personnel and volunteers who worked day and night processing incoming refugees in the system, help them with their needs, and gave them unlimited access to supplies, such as food and hygiene products.

5.2.1 Mahmoud – 37-year-old single Palestinian male from Iraq

Mahmoud, who now lives in an apartment was moved seven times to different cities in two years by the migration agency. When asked if he could describe when he first arrived in Sweden, “There are no words”, he answered. It was crowded and cramped with refugees, but unlike most others (Sundin, 2018; Pedersen, 2015), Mahmoud did not have to wait long to be processed in the system because another family from Iraq found a shortcut at the compound in Malmö where they were.

He described his time at the facilities as a tiresome process, turning his’ nights to days, and days to nights’ with nothing to do or attend during the days, so he would sleep in and then stay up all night, mostly playing cards with other refugees. The two years not only contributed to the adverse health effects because of the uncertain feelings about the asylum application and the facility time, but it also affected the self-learning interest of the language, which made it

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harder for him to integrate in the new society socioeconomically, which is well-supported by research (Brun & Fábos, 2015; Norström, 2004; Kunz, 1981; Darvishpour & Westin, 2016).

Mahmoud felt well treated most of the times, but there were moments when he did feel discriminated against, unfairly treated and even worthless. Two moments stood out to him and contributed to his mental health. One of the personnel in the Växjö-facility allegedly treated the refugees differently depending on their ethnicity and religious beliefs. Mahmoud is Sunni- Muslim, the staffer was Shia, he noticed how she was cold and ignored him and others there.

She ensured that the refugees who had a common language and faith would choose the better clothes and other supplies first, which were donated by people and organisations in the city. He lied about his religious beliefs, making her believe he was Shia-Muslim. Her treatment towards him improved with small conversations and made sure he would experience the same perks as the others and even brought him brand new donated shoes. According to him, the second event was derogatory, “it made me feel less than nothing”. In the facility he was taken to after Växjö, the hygiene and cleanliness were terrible, which eventually evolved to different temporary physical illnesses, such as diarrhoea and headaches. Mahmoud felt many times that the food was not fresh, and one time he even found a worm in the salad, which he expressed to the chef in Arabic. The chef’s response:

“So, what is the problem? It is not like you haven’t eaten worse in your country. If it was so much better there, why did you leave and come to Sweden?”.

Mahmoud said that the chef’s response made him feel worthless. The two events were never mentioned to anyone with authority because he did not think he would be believed over a Swedish citizen, even though they had other ethnicities.

“They are hired employees, and I was only a stateless refugee at the time. They are more credible, and I was worried it could impact my asylum application”.

When Mahmoud was still in Växjö, he planned to visit his sister and her family in another city.

Instead, on the day of the planned visit, he and all the refugees were moved to the larger facility in Stockholm. This took a toll on him because he knew it would be harder to visit her the further away he was moved. What kicked-started his depression was when he was moved to a facility

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in a small village outside Söderhamn. It felt lonely and prison-like because they were too far from the city and the big stores. He experienced weight loss that had started from previous facilities because of depression and unusual food. He was hospitalised a few times and advised to talk to a professional about his mental health, but never did because his friends told him that the best help he could get was from himself.

Now that he has his own apartment, a state-paid job and exercising more, his overall health is better. In the beginning, he was sad that he could not celebrate the cultural and religious holidays he used to celebrate with his loved ones, but it does not bother him anymore. The issue affecting him now is his TUT visa, creating a feeling of uncertainty, which research covers fairly well (Darvishpour & Westin, 2016: 26-27; Brun & Fábos, 2015; Leiler et al., 2018).

5.2.2 Yasmin and her family – 29-year-old married female from Syria

Yasmin, a mother of four, came to Sweden with her husband Sameh and their three children at the time, one of whom were only two months old. She is the one who helped contact all but one couple for this case study.

Yasmine and her family did not get any rest or food until they were processed in the system when they arrived in Sweden. They were taken to a hotel three days after and shared a room with another family for a week. They and the others later spent two weeks at what seemed like an old airport before moving and spent four months in Växjö. The time at the airport was mentally exhausting, there was no bathroom nearby where they could shower, and they did not have extra sets of clothes they could change in to. A worker later gave her and her family some new clothes and took them to a place where they could get a quick shower. Of all the facilities, Yasmine’s family was most comfortable in Växjö. Their personal space was not invaded. The food was not what they were used to, but they found ways to make new meals out of them.

They, along with Mahmoud and the other participants, were moved from Växjö to the large facility in Stockholm that was unsanitary since it was almost 600 refugees in the same building, which resulted in many fleas, ants, and different diseases. What made matters worse, the staff would knock on the door and almost immediately after enter their rooms. The refugees were not allowed to cook in their rooms; Yasmine had plastic plates, utensils, cups, and an electric pot she used to cook in when she was in Växjö and sometimes in the Stockholm room. When she and her family were out, the staff entered her room and confiscated them for violating their rules. They also accused her of stealing items she bought with the money from the migration agency. As ‘punishment’, they were moved to another city up north.

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“I did not think it could get worse than the time in Stockholm, but they proved me wrong”.

The facility was an old school and was smaller, dirtier, and more unsanitary. The Arabic translator knowingly translated wrong, which created problems, especially with the migration agency. Yasmine realised that from the migration worker’s facial and body expression. She was complementing and expressing gratitude for their help and work done for her family, but the translator translated the opposite. So Yasmine asked the translator what he said, he confirmed her suspicions and said that Yasmine was complaining of their lack of interest making her feel neglected by the migration agency. Her mental and physical health deteriorated rapidly; she was sleep-deprived, did not eat well, and vomited blood and the food she managed to eat. That is when she started contemplating suicide. She was taken by ambulance and admitted to the psych ward for an evaluation and almost sedated because she did not sleep the first night. She was taken the next day to what looked like an interrogation room, to meet the doctor.

“I broke down in tears and told him about my suicide attempt and

how hearing my daughters’ voices stopped me from going through with it”.

Yasmine told the doctor that the reasons for her health development was the lack of privacy, unsanitary facility, and fights between the refugees at there. She was even more worried about their asylum application because of the translator’s wrong translations to the migration agency.

By that time, she had gone from weighing fifty kilos to forty kilos and started wearing children’s clothes. Because of the facility issues, the desire to learn the language on their own and integrate was slim. Shortly after her talk with the doctor, Yasmine and her family were given an apartment, which improved her health even though they were still waiting on the decision on their asylum application. Now, three moves later, the family’s health is “like day and night”

because they are more independent and have found routines that fit them. They are still in SFI but they know enough Swedish to not rely on translators anymore. The different culture affected a little, being apart from the relatives and less time were spent with the children.

“In Syria, I was a full-time housewife; here, there are so many choices of what I can do. Because I am alone here, I learned to be dependent, and more self-confident.”

Nevertheless, there are still some mental health effects from their time at the facilities. She avoided socialising and hanging out with friends; depressed for about a year and had an attitude

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problem, which she still has a little. She got to know and became friends with a Swedish woman who helped strengthen her language and socialising skills, along with her patients. They received PUT after two years, and now, her husband and their kids are Swedish citizens, she is still waiting.

Sameh – Palestinian 36-year-old married male from Syria

Sameh is Yamines’s husband. He was hospitalised twice for temporary vomiting and diarrhoea because of the unsanitary environment in the Stockholm facility. He never personally experienced racism, but he did, without wanting to elaborate, witness racism from the refugees towards the Swedish personnel. His mental health was ok, though he got a little depressed because:

“I saw my children and wife unhappy, and their health was getting worse, and there was nothing I could do about it”.

His mental health is better because his family are physically and mentally happier now. Sameh’s time in limbo did not encourage him to learn the language because of the uncertainty, which also complicated the integration process. When they received PUT, Sameh became eager to learn the language when he started SFI-classes, which he attended six months before finding a full-time job. Now he is on his second job as a full-time-janitor and has worked there for more than a year.

“I was relieved when we became Swedish citizens. All the pain, worrying and patients were all worth it because now my family is safe, and my children’s future is secured”.

11-year-old Baraa & 10-year-old Abrar – Sameh and Yasmine’s daughters Baraa and Abrar are the oldest of four siblings. The sisters quietly got affected by the constant moving and the food difference, which contributed to weight loss. During limbo, Baraa changed schools five times, making it hard for her to make friends. Often, she and Abrar felt alone, became closed off and barely spoke to anyone, including their parents. Just recently did their parents and teachers notice improvements in the girls. They are opening up and socialising more both at home and in school and making friends in school and where they live.

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5.2.3 Ramia – 35-year-old married female from Syria

Ramia arrived in Malmö with her husband and three children; today, they have four children.

“They helped us with our bags and even let us borrow phones to call and inform our families in Syria that we arrived”.

She and her family only stayed in Växjö for a month and twelve days. Then the migration agency moved them to an apartment in Åseda, where they were given everything they needed, such as furniture, kitchen tools, bed clothing, etcetera. However, the apartment was dirty and not healthy to live in; there were cockroaches and ants, so the exterminators were called in. So the family was happy when they were informed to be moved to Täby until they found out about the racism there (Clemens, 2020) and did not want to subject their children to that. The migration agency said: either move to Täby or find another place to live in, without financial support from the migration agency. By that time, the family’s mental health was affected because they had to borrow money from friends and relatives. They later got financial help through the Swedish Social Insurance Agency (Försäkringskassan). The next contributing factor developed when they moved to an apartment in Hagfors, where the children were subjected to racism in school. Ramia criticised the school for dividing the Swedish students into one class and immigrants in another.

“How will the kids learn the language and customs if they are separated from the Swedish children?”.

They did not receive school grades before and a long time after getting their four last digits of their social security (personal number), forcing them to repeat the same basic ‘integration classes several times. This delayed the older kids from moving forward in school; it made Ramia’s son unable to complete ninth grade, which stood in the way to apply to

‘Gymnasium’/High School. The children made friends in Åseda and Hagfors with kids who spoke the same language. The lacking language skills and the uncertainty with the asylum application affected the family’s interest to socialise with others. The children became closed off, and still to this day blame their parents for their school delay because they feel that they should have moved immediately to the city they live in now. Ramia also criticised SFI in the private sectors and overall:

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“They did not teach us communicative Swedish, they started with the grammar”.

The family moved four times during their limbo-time. They now live in the city they moved to after Hagfors and are happier because their language skills have improved along with socioeconomic integration, relatives and friends live nearby, the children have improved in school and received their citizenship, the parents have received PUT. Ramia studies SFI and plans to open a clothing shop after Covid-19, and her husband has been employed for six months at his first job since arriving in Sweden. The family does not plan to visit their relatives in Syria because of the ongoing war and conflicts. They also fear being forced to join political or military groups or captured and accused of treason and other political reasons because they fled the country.

5.2.4 Mohammed – Palestinian 35-year-old single male from Syria

Mohammed did not sleep for two days or receive a room to rest in because of the significant number of refugees that arrived simultaneously in Malmö. When it came to his time at the facilities during limbo, he and Mahmoud have the same opinion: Days turned into nights.

Mohammed is the only participant who did not have any family members or relatives in Sweden during his first limbo-years, which contributed to his health development and integration difficulties. He started SFI two years after arriving in Sweden; he was not encouraged to integrate or learn the language independently because he was unaware of the non-profit organisations that can help with that.

“Also, what’s the point with learning the language, when my asylum application might be denied?”.

Mohammed received TUT a year after arriving in Sweden, and then it got renewed another three years. The decision was made with the support of the Swedish law (2016:752), which is the same but an updated version from (2005:716) for “temporary limitations of possibilities for residency in Sweden”, in accordance with 16 a § (Riksdagen, 2020). Mohammed preferred a shorter renewal time because he feels that his life is on pause because of his refugee status, which has partially affected his desire to learn the language and socially integrate. It has also been difficult to learn the language because people show no interest in socialising. He is currently engaged to a Syrian woman in Germany who tells him about the German system

Refugees’ physical and mental health, after arriving in Sweden: An unfolding process: A Qualitative case study on the dilemmas with refugee facilities