A cross-sectional study of health and well-being among newly settled refugee migrants in Sweden–The role of health literacy, social support and self-efficacy

PLOS ONE RESEARCH ARTICLE A cross-sectional study of health and wellbeing among newly settled refugee migrants in Sweden–The role of health literacy, social support and self-efficacy Maissa Al-Adhami ID1,2*, Erik Berglund3,4, Josefin Wångdahl2,5, Raziye Salari2 a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 1 Research and Learning for Sustainable Development and Global Health (SWEDESD) Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden, 2 Child Health and Parenting (CHAP), Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden, 3 Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden, 4 Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden, 5 Aging Research Center, Karolinska Institutet & Stockholm University, Stockholm, Sweden * OPEN ACCESS Citation: Al-Adhami M, Berglund E, Wångdahl J, Salari R (2022) A cross-sectional study of health and well-being among newly settled refugee migrants in Sweden–The role of health literacy, social support and self-efficacy. PLoS ONE 17(12): e0279397. https://doi.org/10.1371/journal. pone.0279397 Editor: Ricarda Nater-Mewes, Universität Wien: Universitat Wien, AUSTRIA Received: February 15, 2022 Accepted: December 7, 2022 Published: December 19, 2022 Copyright: © 2022 Al-Adhami et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: The data contain sensitive information on immigrants and participants in this study have not consented to deposition of the data. Due to ethical restrictions related to protecting patient confidentiality imposed by the Swedish Ethical Review Authority, all relevant data are available upon request and approval from the Senior Registrar Clerk at Uppsala University (). Interested researchers may contact research group leader Professor Anna Sarkadi (anna.sarkadi@pubcare. Abstract Structural barriers such as inadequate housing, lack of employment opportunities, and discrimination are known to adversely affect the health of newly settled refugee migrants. However, these barriers remain largely unresolved and unaddressed. Thus, there is a need to better understand how other factors, such as individual-level health resources, may influence health and mitigate ill health in the early post-migration phase. In this study, we aimed to explore the relationship between health outcomes and individual health resources including health literacy, social support, and self-efficacy in newly settled refugee migrants. Survey data was collected from 787 refugee migrants in Sweden. Logistical regression analysis showed that limited health literacy, lack of emotional support, and low self-efficacy were consistently associated with poor health outcomes. Demographic variables such as gender, education, and type of residence permit were not as imperative. Individual-level health resources may play an important role in the general and psychological well-being of newly settled migrants. Promoting health literacy and facilitating the attainment of social support may buffer for structural challenges in the establishment phase and enhance the prospects of later health and social integration. Introduction Sweden is one of the largest recipient countries of refugee migrants in the European Union (EU). At the end of 2018, Sweden had 25 refugees per 1,000 inhabitants compared to the average of 2.7 per 1,000 in receiving high-income countries [1]. In recent years, both number of granted asylum applications and new arrivals have dropped markedly due to new immigration policies and the effect of the Covid-19 pandemic. Nevertheless, even with the implementation of restrictive immigration policies in Sweden and other EU countries, the WHO estimates that PLOS ONE | https://doi.org/10.1371/journal.pone.0279397 December 19, 2022 1 / 15 PLOS ONE uu.se) or Principal Investigator, Associate Professor Raziye Salari (. se) to request the data used for the analyses in this paper. Funding: The study was supported by the European Union Asylum, Migration and Integration fund, grant number I2120 (registration number: 2222-2016-27207). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist. A cross-sectional study of health and well-being among newly settled refugee migrants in Sweden one in 10 persons in the European Region is a migrant [2], making the issue of migrants and refugees health a major public health concern. The health of refugee migrant populations is often poorer than among native-born populations in the receiving high-income countries. This has been shown for both general self-rated health (SRH) [3] and mental health [4–6], in the early stages of the resettlement process as well as beyond [7, 8]. Health is affected by factors that occur throughout the migration process, i.e., pre-, peri- and post-migration [9]. Differences in pre-migration health and experiences in the migratory process are important to consider in the post-migration phase as they can explain differences in health outcomes within the migrant group, e.g., mental health outcomes [6, 10]. However, factors in the post-migration resettlement process are increasingly being recognized as important for migrants’ health [11–13] as they are, on one hand, often modifiable, and on the other hand, affect migrants as a group, irrespective of prior health. With regard to post-migration factors that negatively impact migrants’ health, numerous studies have reported the importance of socio-political factors such as uncertainty about asylum processes [14, 15], socio-economic factors such as housing and unemployment [4, 16], and contextual factors such as isolation and discrimination [11, 17]. Although these structural factors have a large impact on health [18] (arguably the largest) and as imperative as it is to address them, they remain largely unaddressed and unresolved in many receiving countries. This gap justifies investigations of factors that may increase resilience at the individual level, e.g., how different health resources may be related to the newly settled migrants’ health and well-being, as well as their potential to buffer against post-migration barriers. We define individual health resources as different forms of downstream and midstream social determinants of health, e.g., health-related knowledge, abilities, and social support [19, 20]. The concept is inspired by the Ottawa Charter for Health Promotion where health is defined as social and personal resources, as well as physical capacities [21]. Specifically, we examine (1) health literacy, i.e., people’s knowledge, motivation, (...truncated)