Main findings

In general, refugees had higher risk estimates of all measures of LMM compared with native Swedes. These higher risks remained also after adjustment for sociodemographic, work-related and medical factors, even if the differences generally were attenuated. Refugees from Africa and Asia had the highest risk estimates, while refugees from Europe and South America had relatively low risk estimates for the combined measure of LMM. Refugees from Africa and Asia, especially refugees from Somalia and Syria, had high risk estimates of unemployment. Refugees from Europe (mainly from former Yugoslavia) had rather high risk estimates of both long-term sickness absence and disability pension in relation to risk estimates in other refugee groups. Refugees from Chile had rather low risk estimates of all studied measures of LMM. Sociodemographic factors, mainly educational level, explained a large share of the differences between refugees and native Swedes for most outcome measures.

The risk of long-term unemployment was, compared with native Swedes, especially high among refugees from Africa and Asia. Sociodemographic and work-related factors played, however, an important role in explaining differences in long-term unemployment between refugees and the native Swedish population. Both Asian and African refugees had in the final model still an almost three times higher risk of unemployment compared with the native Swedish population and reasons for that may be, for example, mismatch on the labour market due to problems with approval of education from the birth country, language problems but also discrimination.10 16 Moreover, business cycles seem to be of importance for the likelihood to be established on the labour market in the host country. If migrants arrive in Sweden during economic prosperous times, their chances to be established permanently on the labour market will increase.16 This might apply to whole cohorts of refugees from one country or region. There was a large inflow of refugees from Africa during the late 2000s, which was coinciding with the global financial crisis. During the first years of the 1990s, many refugees came to Sweden from former Yugoslavia, which in turn coincided with a large financial crisis in Sweden. Therefore, refugees from different countries might have different initial problems to have gainful work, which might affect the subsequent position on the labour market. Also duration of residence might play a crucial role, as most refugees from Chile came during the 1970s; they have been here for nearly 40 years, while most of the African refugees came during the last years of the 2000s. We have seen that duration of residence was of importance mostly among refugees from Africa, Asia and Europe outside EU25. This has been reported also by previous studies.17

Refugees had, compared with native Swedes, a generally increased risk of all outcome measures of LMM, but there were large differences between regions/countries. Many factors other than illness, such as educational level, eligibility for social security benefits, health status, employability and so on, seem to predict the patterns of LMM.10 14 In order to have benefits from the sickness insurance, a certificate from a physician is required. A study from Norway reported that Somalian refugees often rely on family, friends and their ethnic/religious community, rather than seeking healthcare.12 This may apply also to refugees from other countries and might reduce their likelihood of receiving a certificate from a physician. Moreover, the high risk of unemployment among African refugees likely makes them less eligible for sickness absence, as those benefits require income from previous work.18 Moreover, the higher risk estimates of LMM among refugees might be a consequence of hardships before and during the migration process, which may lead to higher prevalence of mental disorders. The increased risk estimates of LMM might also be due to that family reunion migrants and labour migrants have an established network to a higher extent when arriving to the host country, giving them an advantage compared with refugees.19 There were, however, some exceptions and refugees from Africa had about the same risk estimates for both unemployment and disability pension as non-refugee migrants from the same continent. Reasons for this might, for example, be that family reunion migrants have been seen to have higher rates of sickness compared with labour migrants, and this may eradicate some of the differences between refugees and other migrants.17 Ethnical discrimination and other forms of obstacles on the labour market may have similar impact on both refugees and non-refugee migrants and may hence prevent that migrants in general get a permanent position on the labour market.20 The differences in risk estimates of LMM between refugees, non-refugee migrants and natives might also be due to the healthy migrant effect, that is, that only individuals with good physical and mental health, often in young age, have the strength to leave the home country and start over again in a new country.21 However, even if these migrants may be healthier compared with the general population in their home countries, they are typically less healthy compared with the host populations in most Western countries.21 Reasons for this discrepancy likely include premigration factors such as poor disease prevention in the birth country and higher prevalence of some unhealthy behaviour that might lead to poor health. As an example, smoking is more than doubled among some migrant groups compared with the native Swedish population and has been shown to increase the risk of both physical and mental ill health.15 22 These factors increase the risk of having sickness absence and disability pension. Postmigration factors such as low socioeconomic status in the host country as well as discrimination may be explanations to worse health among migrants compared with the host population.10 As reported by previous studies, medical factors seem, however, to be of rather low importance in explaining differences in unemployment between migrants/refugees and the host population.10

Educational level was one of the most important variables in explaining differences between refugees and native Swedes. Low educational level generally increases the likelihood of having benefits from sickness insurance, and a high educational level in general leads to a lower risk of such benefits.23 Educational level explained much of the difference between refugees/non-refugee migrants and native Swedes for all outcome measures except for sickness absence. There is a considerable heterogeneity among refugees with different origin, where some groups have higher educational level than others. Among migrants from, for example, Chile and Iran, a rather high share of them has completed upper secondary education.13 This might be one explanation to why Chilean refugees have a lower risk of LMM compared with other refugees. However, Iranian refugees display rather high levels of LMM despite a relatively high educational level. Educational level might, however, also be connected to the ability and capacity to gather information about, for example, social insurance regulations, at least during the first time in the country, and hence the possibility to have benefits. We can see that migrants from, for example, Africa, where a relatively high proportion of individuals has just elementary education, had a very low risk of long-term sickness absence.13 Both high and low educational level might therefore paradoxically increase the propensity to have long-term sickness absence and to some extent also disability pension.10 24

Strengths and limitations

Strengths include the use of high-quality data from Swedish nationwide registers providing large study populations with practically no loss to follow-up.25–27 The inclusion of health-related factors as time-dependent variables makes the analyses more accurate. We can thereby consider variation in health and social measures also during follow-up. We have also considered competing events, as individuals having disability pension no longer are at risk for the other outcome measures of LMM. This strengthens the results. Moreover, previous LMM has been taken into account, as joblessness in itself may have detrimental effects on later labour market participation.28 29 Migrants were divided into groups with regard to both reason for settlement as well as for region of birth country, which has not been done previously in this research field.

This study had also some limitations. Somatic and mental disorders were defined by inpatient or specialised outpatient care, which mostly reflect medically more serious cases since individuals treated in primary healthcare could not be included due to lack of register data in national Swedish registers. Although the analyses were adjusted for previous LMM and labour market attachment, there might still be remaining residual confounding.29 30 In this study, we did not stratify by sex, and therefore there might be masked differences between men and women. We did, however, adjust the analyses for sex. The study will mainly be generalisable to countries with similar welfare regimes. We have, however, tried to increase the generalisability to other countries by introducing a combined measure of LMM. Finally, the use of large data sets will increase the chance of finding statistically significant differences between groups. Small significant differences may not, however, be clinically relevant.