**4. Discussion**

In the present study, refugees from Syria resettled in Sweden reported a lower HRQoL than an age-matched Swedish reference population [31] and lower than the general Swedish norm data from which the value set was derived [28]. A markedly higher proportion of refugees reported problems in the Anxiety/depression domain (62% vs. 37% in the Swedish norm data). In contrast, the proportion with reported problems in the domains Mobility, Self-care and Usual activities were comparable in both groups, whereas a somewhat lower proportion of refugees reported problems in the domain Pain/discomfort (55% vs. 68% in the Swedish norm data). Mental health is therefore the likely driver of the lower HRQoL reported by the refugee group. However, comparability of HRQoL index scores in the current study with those of the representative Swedish population samples is limited due to the younger age of the current sample. Approximately half of the refugees were under 40 years of age compared to 9% in the Swedish sample, and there exists a known and very strong negative association between age and HRQoL. The estimated mean index score is also somewhat higher than the 0.82 value found in a study of Syrian refugees resettled in Germany [18]. Possible explanations for this difference include the use of value sets obtained from different populations (Sweden versus Germany). Additionally, an inclusion criterion in the German study was the presence of mild to moderate symptoms of posttraumatic stress, whereas the present study used a general refugee population. Moreover, the German sample had a notably higher proportion of singles/divorced and civil status was strongly associated with HRQoL in our study.

To our knowledge, the present study is one of the first studies to estimate HRQoL using preference-weighted data in a large sample of refugees while exploring the association between HRQoL and post-migration stressors. Refugees who reported experiencing high levels of post-migration stressors had the lowest HRQoL scores. The stressors driving this association were firstly financial strain, followed by social strain.

The measure of financial strain used in the present study was related to material and economic hardship threatening integrity, independence, dignity and well-being. Refugees in Sweden receive financial assistance to cover basic needs for clothing and food, but the findings from this study sugges<sup>t</sup> that many refugees nonetheless experience financial strain that may adversely and significantly impact HRQoL. This is supported by a study on Iraqi asylum seekers in the Netherlands, which found that socioeconomic living conditions was a more important predictor of reduced overall QoL than psychopathology [32]. While relatively few studies have explored the association between financial strain and QoL in refugee populations, there is solid evidence for the adverse association between financial strain and mental distress (for an overview see [4,24]), including a recent, longitudinal study from Australia providing consistent evidence across all time-points that economic stressors were positively associated with mental illness [1]. Limited access to employment and economic opportunities is key to explaining the economic hardship often faced by refugees. Employment rates of refugees resettled in high-income countries are typically under 20% in the first two years after arrival and then increase depending on the host country. However, refugees have been shown to continue having lower employment rates than other immigrants and natives, even ten years after migration [33]. Moreover, adequacy of income and employment have been shown to be significant predictors of general mental health for resettled refugees [34,35] and to moderate the adverse mental health effects of pre- and peri-migratory stressors experienced by refugees [36]. Barriers to employment identified by refugees include adverse effects of PTSD, problems with professional recertification and economic barriers to pursuing education [37].

In the case of social strain related to feelings of isolation and loss of status in the host country, a fair number of studies have found positive associations between social integration/support and QoL both in selected [38,39] and more general refugee populations [40–42]. Studies have further shown that social connectedness and support are key enablers for integration, health and well-being, with some evidence suggesting patterns are gender specific [43,44]. A recent, large German survey of 4325 resettled refugees found

that contact with members of the host society, better host country language skills and being employed were related to reduced distress and higher levels of life satisfaction [45]. The negative relationship between social integration and mental distress has been documented in several studies [39,46,47], including in the abovementioned longitudinal study of refugees resettled in Australia [1]. The study found that loneliness during resettlement was positively associated with PTSD and severe mental illness over time, though the strength of the association fluctuated across timepoints, suggesting time-varying effects. A challenge when comparing findings from the present study to the existing literature is that the concept of social strain is defined and measured in different ways across studies. Whereas many studies focus primarily on loneliness and the lack of social networks, the present study also includes status loss and frustration at not being able to use skills and competence. In summary, the overall findings in the current study on financial and social strain are consistent with much of the available evidence to date linking both stressors to lower levels of positive mental health outcomes, such as QoL and well-being, and elevated levels of mental distress.

Contrasting this overall picture is a recent systematic review by Hou and colleagues [48].The review investigated both general distress and well-being/QoL in relation to postmigration everyday life stressors stratified into *subjective* (perceived emotional distress associated with different daily experiences), *interpersonal* (e.g., conflict, discrimination, isolation, lack of emotional support) and *material* (e.g., housing/neighborhood contexts, accommodation difficulties, employment-related issues, access to social or mental health services). Results showed consistent positive associations of daily stressors with general distress but, somewhat surprisingly, non-significant effect sizes between daily stressors and general well-being/QoL across seven studies. The authors concluded that more research focusing on domain-specific QoL in relation to stressors is needed. By using a single index value as the outcome measure for HRQoL, the present study took a somewhat opposite approach. The strong associations found between both financial and social strain and the single index HRQoL score sugges<sup>t</sup> this approach may be reasonable. A large sample size increasing power may partly explain why significant associations were found in the present study and not in the studies included in the review by Hou [48]. Another possible explanation is that the present study used a preference-based approach to HRQoL. Our findings demonstrate that worse HRQoL among Syrian adult refugees living in Sweden may not be limited to mental health problems, but also extend to other dimensions of general health that in turn influence quality of life. This is important from a health determinants viewpoint as interventions to address this are limited by the complexity of resettlement hardships faced by this group as they attempt to acculturate into the host society. Future studies are needed to analyze the HRQoL of refugees in Sweden longitudinally, as compared to the general Swedish population and in refugees of different countries of origin. More research is also required to identify mechanisms that strengthen HRQoL, such as support networks, employment and education opportunities.

## *Strengths and Limitations*

Strengths of the study include random sampling from population-based registries, a large sample size and the use of well-established measures of key variables. A particular strength is that HRQoL was estimated by combining refugees' HRQoL self-reported data with an experienced, preference-based value set obtained from the general Swedish population. The study thus follows expert advice that studies on HRQoL should move beyond looking solely at self-perceived health and/or general QoL, and instead focus on the *utility* associated with health, accomplished by using health status data in combination with an attached value set [13]. Our results represent a benchmark that can be used to evaluate changes in HRQoL in this sample over time or after participation in specific interventions or policies. Furthermore, information about the sociodemographic variables, except civil status, was retrieved from national, high-quality registers, reducing the risk of information bias.

A limitation is that self-reported health is likely linked to cultural values [25], thus, applying preference data from one culture to another, in this case adults in Sweden to adults with a refugee background from Syria living in Sweden, could lead to an index score with low validity. However, in the absence of available preference data from any refugee population, this may still be the best alternative. Another limitation is that the data were self-reported through a postal survey. Refugees with low HRQoL may have not been able to participate in the survey (non-responders), resulting in potential selection bias and a sample that is healthier than the target population.
