Mental health and employment amongst persons who resettled in Sweden in 1993 1994 due to the war in Bosnia Herzegovina

Abstract: General aim: To explore employment and mental health among people from Bosnia-Herzegovina who came to Sweden in 1993-1994 due to the war. Hypotheses: 1) poor mental health is a barrier to employment; 2) exclusion from the labour market can lead to psychosocial stress. Methods: All data were collected from Oct 2001 to March 2002. Quantitative studies: Cross-sectional survey questionnaire and longitudinal register study, including variables largely from the LOUISE database (years 1993 1999). Six hundred and fifty people were randomly selected from 10 strata that included region (one urban (Malmö) and one rural (four municipalities in Småland) and levels of employment (study population, N = 4,185). Response rate: 63.5 %; n = 413. Qualitative study: Snowball sampled in-depth interviews (n = 26), tape-recorded and transcribed. Interviewees were from Bosnia-Herzegovina, in employment, unemployed or in rehabilitation, and living in the urban/rural regions (above). Results: Paper I explores associations between survey and register variables. Main mental health outcome: a high and a low symptom group were identified by using the symptom list from the Göteborg Quality of Life instrument (n =360). Binary logistic regression showed that unemployed men, men with long working experience in Bosnia-Herzegovina, and women with much (but not most) employment activity, as well as women living in the urban region, were overrepresented in the high symptom group. Paper II presents study population estimates of survey variables; prevalence of the use of sedatives was 26.5%, sleeping tablets 26.2%, and antidepressants 22.3%. Consumption of alcohol and cigarettes was 5.1% and 41.0%, respectively. Paper III presents longitudinal findings of registered labour market access, sickness and social benefit (1994-99) and their relation to the Göteborg Quality of Life high symptom group. In 1999, 62.4 % (of 412) had labour market access and 8.6 % of those eligible (n = 335) received sickness benefit. Survival analysis showed quicker access to employment for men compared with women. For women the delay was associated with belonging to the high symptom group. Older age was also associated with delay in access and binary logistic regression showed that older age increased the odds of belonging to the high symptom group. Paper IV explores the labour market process (from the outbreak of war to the labour market situation at the time of the interview) and perceptions of mental health in 22 interview transcripts. Qualitative content analysis highlighted the issue of war-time job loss and the importance of post-migration employment for mental health and well-being, as well as that the ability to work may be restricted by poor health (physical or mental) and that there may be a risk of exhaustion. Conclusions: While a level of mental health problems was expressed in the study, the problems did not seem to be mirrored by sickness benefit. However, access to the labour market was slow and although sickness benefit in the last follow-up year was high compared with the Swedish population that was not the case in the previous years, perhaps in part because many people had not yet had access to the labour market. Though data also suggests that a balance between employment and sickness benefit may be a better alternative for some in terms of health, overall it appears that faster access to employment is beneficial for perceived mental health. Implications: Policies and strategies concerning refugee reception should aim for humanity and pay attention to health and human rights. Keeping people in unemployment or social benefit may risk prolonging and/or worsening prospects of healing after war-related stressful experiences, and increase the risk of marginalisation. Thus structural interventions should support early access to employment so that the provision for the family can be secured as soon as possible with no further undermining of dignity. Nevertheless, it is important to maintain flexibility; as this study indicates, some people are incapable of working (at least full time) due to physical illness, severe concentration difficulties (PTSD) and/or depression. Thus, the labour market needs to be sufficiently flexible to find ways to provide access to stable jobs for persons with different functional levels while staying within the parameters of decent work, without decreasing job security or exploiting eager workers who may run a risk of exhaustion.