Crowded living and its association with mental ill-health among recently-arrived migrants in Sweden: a quantitative study

Migrants’ mental health issues frequently present a challenge to clinicians and policy makers in the recipient country [1]. The mental health of migrants may by influenced by the migration experience, and some scholars define this as ‘pre-migration trauma and post-migration living difficulties’ [2]. Some studies report a gradual improvement in symptoms over a period of a decade, to the point where the observed prevalence rates of mental disorder become lower than that of the general population of the host country [3, 4]. Other studies have found prevalence rates that were substantially higher than those of the general population [5–7]. The different outcome regarding mental health among migrants could according to Hansson et al. [8] depend on differences in social context as well as country of origin, age and socioeconomic status. These factors could affect mental health for everyone in the population but migrants could be more exposed to the negative effects of these determinants [8].

Housing and neighbourhood conditions are widely acknowledged to be important social determinants of health [9] and health inequalities persisting in developed countries despite general improvements in health outcomes across the population [10]. Evans et al. suggest that various characteristics of housing quality may influence psychosocial processes, which in turn can affect mental health [11]. According to Krieger & Higgins, crowded living has been associated with psychological stress among women aged 25–45 in London as well as living with temporary housing, has been shown to cause behavioural problems among children [12]. Another study by Gove et al. [13], suggest as well that crowded living could affect mental health negatively. In an American study, the authors noticed that mothers that experienced housing disarray and housing instability were more likely to screen positive for depression [14]. In another American study by Evans et al. [15], an association was seen between children living in crowded conditions and effects on their psychological health. This concerned children living in both urban and rural areas. Furthermore, women experiencing crowded living conditions were more likely to suffer from depression than men experiencing the same, with the latter likely to suffer from withdrawal or aggression [16]. Since previous research indicates that housing conditions could be associated with mental ill-health [11–14] as well as that recently-arrived migrants (RAM) suffer from mental ill-health [1, 2, 5–7], it is of great importance to investigate if crowded living could affect mental ill-health among RAM in Sweden. The aim of this study was, therefore, to investigate the association between crowded living conditions among RAM in Sweden and mental ill-health.

The study included 461 males, 204 females and 16 who did not specify their gender. There were 307 respondents between the ages of 18 and 34 and 155 between the ages of 35 and 44. A total of 301 respondents had a high educational level (218 males and 83 females), 141 had a medium educational level (94 males and 47 females) and 146 had a low educational level (102 males and 44 females). Of the 681 respondents, 166 rented an apartment without a creditor (111 males and 55 females) and 198 were living with friends or family (152 males and 46 females).

The results showed that being a RAM and living in crowded living conditions increased the odds for suffering from mental ill-health, if the whole population was analysed both before and after adjustment were made for age and educational level. However, after adjusting the results for stability of housing, the results turned non-significant. The results after adjustments for stability of housing was borderline-significant, which indicates that crowded living could have a small effect on mental-ill-health, but to a greater extent is stability of housing effecting mental ill-health OR 1.40 (0.99–1.99). This is in line with the results from the American study by Suglia et al. [14], which saw that insecurity in housing increased the odds for mothers suffering from depression. In Sweden, there is currently a lack of apartments with an affordable rent, which makes it difficult for RAM to find a stable housing condition [22]. Efforts are taken for finding improvement regarding this concern [22]. This is important since we know that RAM could be at a higher risk of depression, psychosis and suicidal thoughts [23], and since we know that participation in the establishment process for RAM requires active participation, it is of great importance to reduce the risk for increased suffering from mental ill-health, as well as reducing the risk for those unable to establish themselves successfully in a new country. When considering both the results from the current study, as well as those mentioned in the earlier studies concerning housing conditions [11–14], it is of great importance to work for a suitable and stable housing for the RAM in Sweden.

The strength of the current study is that it targets health issues as closed to the arrival of RAM to Sweden as possible. As compared to the latest regional public health survey in Scania, the current response rate is lower [20, 24]. However, when comparing the response rate of both studies—more precisely, respondents with a country of birth outside of Europe—the current response rate of 39.5% is moderately higher. Furthermore, the response rate is about the same or higher than that of other studies in the same field [20, 24]. The response rate resulted in 681 study participants, which probably is the reason why the gender specific analyses turned out to be non-significant after adjustments for age and educational level. When adjustments were made for stability of housing, the analysis could only be made with men and women together, due to too less power.

GHQ-12 was used as a tool for assessing mental health and this instrument is internationally well validated for assessing mental ill-health [18, 25]. This instrument is the shortest of the GHQ measuring instruments, but has shown itself to be a secure measure of psychological health [18] and its validity characteristics are not influenced by gender, age or educational level [18]. The GHQ-12 scale has shown good psychometric properties in other studies [26–28]. Crowded living was defined as crowded on basis of a definition from Statistics Sweden [19] and in Sweden, there are three ways to calculate crowded living [19] and we have selected the version already specified. It could be discussed how well this definition is well-suited for refugees that could have lived with other cultural practices regarding living conditions. However, this is a definition that is based on two people per room compared to the other two definitions with one or three persons per room [19] and we considered this version as a mean version between the two other mentioned.

The fact that all participants were anonymous made any dropout analyses impossible. However, an approximate dropout analysis was performed by comparing the characteristics of the study participants with statistics from Swedish Public Employment Service. The analysis suggested that people with higher levels of education were over-represented in the present study [29]. It would have been considered beneficial if a greater population of migrants could have been investigated. However, it was only possible to follow these migrants on a regional level, although a national level would be better.