**1. Introduction**

The link between stressors pre-, peri- and post-migration and mental ill health in refugees resettled in high-income host countries is well documented [1–4], and a growing number of studies are exploring how these stressors are associated with the broader concept of quality of life (QoL). A review of refugee populations in high-income countries concluded that social networks and social integration was positively associated with QoL, whereas mental ill health (e.g., depression or PTSD) was negatively associated with QoL [5]. When comparing QoL in general and clinical populations of refugees in community settings, a recent review found that there was a wide heterogeneity in the scores, and domain-specific

**Citation:** Sengoelge, M.; Nissen, A.; Solberg, Ø. Post-Migration Stressors and Health-Related Quality of Life in Refugees from Syria Resettled in Sweden. *IJERPH* **2022**, *19*, 2509. https://

doi.org/10.3390/ijerph19052509

Academic Editors: V. K. Kumar and Jasmin Tahmaseb-McConatha

Received: 20 December 2021 Accepted: 18 February 2022 Published: 22 February 2022

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patterns of QoL varied across the two groups [6]. Both reviews acknowledge the complexity and diversity of the refugee experiences and the variety of elements that may affect QoL.

Indeed, QoL is a complex, multidimensional concept developed to encompass an individual's perception of one's physical and psychological state, level of independence, social relationships, personal beliefs and relationship to the environment [7,8]. Moreover, health is a major component of QoL, ye<sup>t</sup> the related term health-related quality of life (HRQoL) has been inconsistently defined and operationalized in the scientific literature of migrants [9]. For example, use of the term HRQoL when referring to a measure of self-perceived health status, or when stating that research is focusing on HRQoL when the instrument measures "overall" QoL [10]. The key to HRQoL research is an individual's *evaluation of* one's health state, as compared to solely reporting on it [11,12]. The term HRQoL should be utilized when either: (a) exploring how health affects QoL using separate measures of each and statistically exploring how they relate to one another, or (b) examining the utility associated with different health states using health status questionnaires with an attached value set [13].

Preference-based HRQoL studies both assess and apply preference weights for different health states. This valuation is summarized as a health index score anchored on a 0 (dead) to 1 (perfect health) scale [14]. Such measures have been increasingly used to determine whether there has been a change in HRQoL in the population [15]. Examples of such measures include the SF −6D [16] and the European Quality of Life Five Dimensions known as the EQ–5D [17]. Few studies in the published literature to date have explored HRQoL in refugee populations using such a preference-based approach. One study of 133 Syrian refugees in Germany found that the HRQoL of the refugees reported was lower compared to a representative German population sample [18]. A prior publication by our research group used the EQ–5D–5L index score to examine gender differences in HRQoL in Syrian adult refugees resettled in Sweden but based on the United Kingdom population data as no value set was available for the Swedish population at the time [19]. The study found that male sex, younger age, living with a partner and social support were positively associated with HRQoL [19].

Moreover, potential determinants of HRQoL in refugee populations might be related to the level of trauma experienced before and during flight [20], including exposure to torture [21]. Other determinants may involve stressors experienced in the resettlement phase [22]. These post-migration stressors can be family-related (e.g., family separation, conflicts with family), related to poor social integration and weak social networks (e.g., no or low number of friends from within or outside one's ethnic community, low participation in activities), or related to financial or housing difficulties, poor host language proficiency and/or unemployment [23]. All of these resettlement stressors have been shown to be associated with higher levels of negative mental health outcomes, particularly post-traumatic stress disorder, anxiety and depression [3,24]. HRQoL may also likely be linked to cultural values in the perception of one's own state of health [25].

In sum, there is a scarcity of studies that utilize the full potential of HRQoL measures in refugee populations examining preference-based HRQoL and in relation to flight-related trauma exposure and post-migration stressors. Host countries need to obtain an understanding of the HRQoL of its refugee population in order to allocate resources and monitor the effectiveness of broad community interventions. With this knowledge, host countries can more effectively identify and support positive resettlement interventions, services and policies that mitigate unmet needs. Thus, the aim of the present study was to establish a benchmark reporting of HRQoL among a sample of Syrian adult refugees resettled in Sweden using preference-weighted data, and to explore how post-migration factors influence HRQoL.

#### **2. Materials and Methods**

#### *2.1. Study Population*

Eligible participants for the study included all adult refugees from Syria who were given permanent residency in Sweden and resettled in the country between 2011 and 2013. A random sample of 4000 refugees was drawn from a sampling frame of *N* = 9662 identified through the Swedish Population Registry. All sampled refugees were invited to participate in a postal questionnaire survey in 2016 on self-reported health, pre- and peri-migration experiences and various aspects of their resettlement, drawn up in Swedish and back-translated into Arabic. Of the invited refugees, 1215 returned the questionnaire (response rate = 30%). More detailed information on design, sampling and recruitment strategies and potential study population bias has been previously published [26].
