Is legal status associated with mental illness among newly arrived refugees in Sweden: an epidemiological study

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Migrants are at heightened risk for mental illness compared to host country populations. While previous research highlights the need to adequately assess mental illness, few have taken the diversity among newly arrived migrants into account. This study aims to estimate the prevalence and associated risk factors of mental illness among asylum seekers, quota and other refugees in Stockholm, Sweden. Methods: Using a cross-sectional design, data was collected as part of a mental health screening initiative integrated into routine health examinations in two health care clinics in Stockholm. Screening was done with the Refugee Health Screener, RHS-13, a validated instrument for assessing mental health in refugee populations. Results: A total of 1163 individuals were eligible for screening, of whom 566 participated (response rate 48.6 %). Among the participants 47.9% indicated symptoms of mental illness. Compared with asylum seekers, the risk of mental illness was lower among quota and other refugees (adjusted odds ratio 0.60, 95% confidence interval 0.37-1.00). Female gender, higher age, coming from a middle-income country and low probability of being granted asylum were significant predictors of mental illness. Conclusion: Refugee legal status is associated with mental illness. Asylum seekers are at greater risk of mental illness compared to quota and other refugees. Our findings call for screening for mental illness among newly arrived migrants, especially among those with pending residence permits. refugees asylum seekers mental health screening primary care Background In recent years, wars, conflicts and violation of human rights have led to forced displacements, with millions of people seeking protection outside of their home countries [ 1 ]. The global population of forcibly displaced people grew substantially from 43.3 million in 2009 to 70.8 million in 2018 [ 1 ]. In 2017–2018 Sweden hosted the largest number of refugees in the European Union (EU) per capita [ 2 – 4 ] and today, in 2022, there are millions of Ukrainian people fleeing their homes seeking safety, protection and assistance. Migrants are a heterogenous population in their needs and rights, including differences in reasons for migrating [ 2 , 5 , 6 ]. According to the United Nations (UN) definition, migrants are adults who were born in one country and have moved to and settled in another. Refugees are a subgroup of migrants. From a legal perspective, an asylum seeker is a person who seeks sanctuary and files for refugee status in a country other than their own and awaits a decision while a refugee is someone who has been recognized under the 1951 Convention relating to the status of refugees to be a refugee [ 7 ]. In the later definition, quota refugees are included as those who have been selected by the UN´s refugee agency, United Nations High Commissioner for Refugees (UNHCR), to be resettled to a third country that offers them protection. Resettling in a third country is a solution for people who can neither remain in their first country of asylum nor return home. Unlike asylum seekers, quota refugees have a residence permit upon arrival. The same applies for other non-refugee migrants, such as those coming for family reunification [ 3 , 7 ]. Migration itself is not a risk factor for poor health as migrants are often comparatively healthy. However, vulnerability to mental, physical and social problems may result from the process and specific circumstances of migrating [ 8 , 9 ]. Studies have shown migrants at heightened risk for certain mental health conditions such as post-traumatic stress disorder (PTSD), anxiety and schizophrenia compared to host country population [ 5 , 6 , 10 – 13 ]. The social determinants of mental health are relevant for asylum seekers and refugees. If they are unevenly distributed, this may create social inequalities in mental health across migrant groups. A person’s move from one country or context to another means additional strain. However, migrant-specific social determinants of health are often separated into pre-, peri- and post-migration factors [ 14 , 15 ]. Pre-migration factors refer to factors before migration such as social disadvantage in the country of origin or conflict-related traumatic experiences. Post-migration factors include a poor social network in host country, acculturation and adaptation barriers, and overlap with general social determinants of health [ 14 , 15 ]. Estimates of the prevalence of mental illness in refugees varies. A recent review on refugee mental health found prevalence rates of 43% for PTSD, 40% for depression, and 26% for anxiety among 8.176 Syrian refuges resettled in 10 countries [ 2 , 16 ]. Furthermore, a review undertaken across 15 countries, found similar rates for PTSD (31.46%), depression (31.5%) and anxiety disorders (11%) [ 13 ]. In Germany, one of the countries hosting the largest number of refugees in Europe, a meta-analysis found differences depending on type of screening method, with significantly higher prevalence estimates for depressive symptoms reported using screening tools (39.8%) in comparison with diagnostic instruments (28.4%), whereas survey methods provided comparable prevalence estimates for symptoms of PTSD (28.1% v. 29.9%) [ 9 ]. The variation in presence of mental illness among refugees could be explained by differences in methods applied but also differences in the characteristics of the populations (e.g., country/area of origin, experiences before, during and after migration, years in the new country). Additional reasons for wide variability could be the lack of differentiation between different groups of newly arrived people such as asylum seekers and refugees, including both quota and another refugees. Another reason is that some of these studies include migrants from one country only. Additionally, groups such as asylum seekers and quota refugees are especially understudied. Therefore, the aim of this study is to estimate the differences in prevalence of mental illness between asylum seekers and refugees, including both quota and other refugees at a free-of-charge health examination in a primary health setting and to determine if gender, age, gross national income per capita in the country of origin, or country of origin could explain these differences. We hypothesize that the risk for mental illness could differ between groups, and that all the above-mentioned factors would impact the likelihood of mental illness. Method Setting The study was conducted in two primary health care clinics in Stockholm Region, Sweden. All asylum seekers and refugees are offered a free-of-charge health examination (HE) in primary health care clinics. The HE aims to identify health care needs, including mental and physical health problem that require immediate attention and to detect infectious diseases that require special control measures [ 17 , 18 ]. The HE is voluntary and in terms of content, the patient chooses what health related information he or she wants to share during the HE. Design and population Healthcare professionals use unstandardized methods to address mental health during the HE [ 17 ]. A first step towards overcoming the issue with unstandardized methods was to introduce a validated screening instrument, the Refugee Health Screener (RHS-13), discussed further under the sub-section “Outcome” [ 19 ]. The RHS-13 screening instrument was implemented and integrated within the HE. Screening was performed by the healthcare professional conducting the HE during a period of 6 months and registered in the electronic medical record system (October 2018- March 2019). Using a cross sectional design, data for this period was extracted during September 2019. The two clinics accounted together for more than half of all HE conducted in the region during this period. All migrants, age 14 or older were eligible for the screening. Not all completed screening with the RHS-13. Out of all individuals who came for a HE during the study period, 597 (51,4%) were not screened. Reasons for no screening were not recorded. Six individuals were excluded from the analysis due to not meeting the inclusion criteria of being 14 years of age or older and 9 were excluded due to missing data on RHS-13. Ethical issues Ethical clearance was obtained from the Swedish Ethical Review Authority (Dnr: 2019–01408) to retrieve HE data from medical records (MR). All data was recoded and pseudonymized, meaning data items were recorded to an artificial identifier (a pseudonym). This step was done on site at the health care clinic to ensure privacy. Data were coded into excel files. Outcome The outcome was prevalence of mental health illnesses which was measured with RHS-13. RHS-13 is a screening tool to identify individuals with symptoms of mental illness (i.e., not a diagnostic tool) [ 19 – 21 ]. RHS-13 consists of 13 questions and assesses symptoms of the most common mental health problems in refugees: PTSD, depression, and anxiety. The original version, consisting of 15 items, shows excellent internal consistency (Cronbach´s a = 0.91) (PTSD: sensitivity 0.81/specificity 0.87, anxiety 0.94/0.86, and depression 0.95/0.89 [ 19 ]. A 13-item version of the RHS-15 has been tested, which showed strengthened psychometric properties (Cronbach´s a = 0.96) without comprising the validity of the instrument [ 20 , 21 ]. RHS-13 has been validated and is available in 18 languages including Swedish [ 21 ]. The RHS-13 scale is answered with a five-point Likert scale, with scores from 0 to 4, corresponding to “Not at all” to “Extremely”. The total range of scores is thus 0–52 [ 19 , 20 ]. A cut-off of ≥ 11 has been suggested to identify positive screening for mental illness. The instrument has also been tested in Sweden for severity levels of symptoms of psychological distress where a score of 11–17 is interpreted as mild symptoms, 18–24 clinically significant problems (moderate), and 25 or above as acute and severe problems [ 19 , 21 ]. We present prevalence of mental illness based both on dichotomized scores (positive 11–52 vs. negative 0–10), as well as based on cut-offs for mild (11–17), moderate (18–24) and severe (25–52) problems. Exposure Our primary exposure was legal status, categorized as “Asylum seekers” or “Quota and Other refugees”. The group called “Others” accounts for individuals who have entered Sweden for family reunification knowing that they would qualify for a residence permit as they have one or more family members who have been granted permit as a refugee or a person in need of subsidiary protection (i.e., someone who do not qualify as refugee but would face a real risk of suffering serious harm in his or her home country). Individuals with family reunification were merged into the group “Quota and Others” as we expected them to share similar characteristics and legal benefits as quota refugees. Co-variates Sociodemographic Measures Gender was categorized into men and women. Age was categorized into the following groups 14–25 years, 26–35 years and 36 and older. Gross national income per capita (GNI) is the dollar value of a country’s income in a year, divided by its population. GNI presents a country’s economic strengths and is closely linked to indicators on individual level such as social, economic and environmental well-being. Countries with higher GNI, tends to have higher literacy rates and longer life expectancies. Country of origin by World Bank GNI Classification was defined as: low-income country ( $ 1.025 or less) lower-middle income country ( $ 1,026- $ 3.995) upper-middle and high ( $ 3.995 or more) income country Data on GNI classification was retrieved from the World Bank and reflects classifications made 2020 [ 22 ]. Country of origin by Probability rate of first-time recognition reflects the recognition rate, the share of positive decisions among the total number of decisions by citizenships of asylum applicant in the EU. Rates account for positive decisions from the 4th quartile 2017 to the 4th quartile 2018 for refugee status, subsidiary protection and humanitarian reasons in the EU [ 23 ]. Low probability rate was defined as 0–39% Middle 40–79% High 80–100% Statistical analyses Sociodemographic variables were described by absolute and relative frequencies. Chi 2 -test were used for associations between categorical independent variables, as well as to compare between subjects who participated in screening and those who did not. Prevalence (%) of positive screenings for mental health symptoms by sociodemographic characteristics were estimated with 95% Confidence intervals (CI). Regression models were performed on the dichotomized outcome, defined as score RHS-13 ≥ 11, as it is more established and used than the ordinal outcome (with 3 severity levels). Logistic regression was used to control the association between the outcome and exposure for potential confounders. Stepwise modelling, using a bidirectional elimination method was completed [ 24 ]. Backward elimination and forward selection approaches were conducted. We tested all independent variables incrementally for significance. All significant variables were imputed in the final model and variables were removed to test for significance. We tested for interaction between all independent variables. One significant interaction was found, between gender and GNI classification. Stratified analysis by gender is presented for both crude and adjusted models. Two adjusted models are presented. Model 1 was adjusted for age, gender, and probability of getting asylum, leaving GNI classification out, considering it to be a priori confounder. Model 2 was adjusted for age, gender, probability of getting asylum, GNI classification as well as the interaction between gender and GNI classification. Interaction variables were not used in stratified models. Results are presented for crude and adjusted odds ratios (ORs) with 95% confidence intervals. A p-value of 0.05 was considered statistically significant. Statistical analyses were performed using IBM SPSS version 26 [ 25 ]. Results Out of the 1163 respondents who came and underwent a health examination, 566 completed screening with the RHS-13 (48.6%). The majority were men and the largest group by country of origin were Syrians followed by Eritreans, Iranians, and Uzbeks. In total, 78 countries were represented. Majority of the cohort came from a low-income country and with a low probability rate of first-time recognition (Table 1 ). Table 1 Sample Characteristics of respondents Sample Characteristics Total N = 566 n (%) Clinic Clinic 1 246 49.7 Clinic 2 320 47.9 Gender Men 354 62.5 Women 212 37.5 Legal status Asylum seekers 393 69.4 Quota and other refugees 171 30.2 Age 14–25 183 32.3 26–35 170 30.0 36> 213 37.6 Country of origin by World Bank GNI Classification Low 227 40.1 Lower-middle 152 26.9 Upper- middle and high 186 32.9 Probability rate of first-time recognition Low (0–39%) 319 56.4 Middle (40–79%) 118 20.8 High (80–100%) 129 22.8 Country of origin Syria 78 13.8 Eritrea 51 9.0 Iran 51 9.0 Uzbekistan 30 5.3 All Others 356 62.9 Table 1 in here In total, 47.9% scored positive for symptoms of mental illness (score ≥ 11) (Table 2 ). A score ≥ 11 was significantly more common among asylum seekers than quota and other refugees (Table 2 ). Women, older age groups and people from a middle- or high-income country had significantly higher prevalence of a score ≥ 11. The prevalence of score ≥ 11 was similar for individuals with a low and middle probability of getting a positive decision on their asylum application, but significantly lower for those with a high probability. Significant differences were found in the prevalence of severe mental illness (score ≥ 25) in the univariate comparisons regarding gender, age, country of origin by GNI classification and probability rate of first-time recognition (Table 2 ). The prevalence of severe symptoms was about twice as high for women compared to men, asylum seekers compared to quota and other refugees, older population compared to younger population, and those from middle-income compared to low-income countries. Those from countries with a low probability of first-time recognition had about three times higher prevalence of severe problems than those with high probability. Table 2 Prevalence (%) with 95% confidence intervals (CI) of mental illness measured with RHS-13 in total and by sociodemographic characters, country of origin by World Bank GNI classification and by probability rate of being granted protection status in EU Mental Illness measured with RHS-13 Mild mental illness (≥ 11–17) Moderate mental illness (≥ 18–25) Severe mental illness (≥ 25) Any mental illness (all ≥ 11) n = 74 n = 73 n = 124 n = 271 % (95% CI) % (95% CI) % (95% CI) % (95% CI) Total 13.1 (10.3–15.8) 12.9 (10.1–15.6) 21.9 (18.4–25.3) 47.9 (43.7–52.0) Gender Men 13.3(9.8–16.8) 11.9 (8.5–15.3) 16.7 (12.8–20.6) 41.8 (36.7–46.9) Women 12.7 (8.2–17.2) 14.6 (9.8–19.4) 30.7 (24.5–36.9) 58.0 (51.4–64.6) Legal Status Asylum seeker 13.7 (10.3–17.10) 13.2 (9.8–16.5) 26.0 (21.6–30.3) 52.9 (48.0-57.8) Quota and other refugees 11.7 (6.9–16.5) 11.7 (6.9–16.5) 12.3 (7.4–17.2) 35.7 (28.5–42.8) Age 14–25 13.1 (8.2–18.0) 11.5 (6.9–16.1) 15.3 (10.1–20.5) 9.9 (32.8–47.0) 26–35 15.3 (9.9–20.7) 17.1 (11.4–22.8) 17.1 (11.4–22.7) 49.4 (41.9–56.9) 36> 11.3 (7.0-15.6) 10.8 (6.6–15.0) 31.5 (25.3–37.7) 53.5 (46.8–60.2) Country of origin by World bank GNI Classification Low 13.0 (8.6–17.4) 12.2 (8.0-16.4) 13.9 (9.4–18.4) 39.1 (32.8–45.4) Lower-middle Upper-middle and high 12.7 (7.4–18.0) 13.4 (8.5–18.3) 15.3 (9.5–21.1) 11.8 (7.2–16.4) 26.7 (19.6–33.8) 28.0 (21.5–34.5) 54.7 (46.8–62.6) 53.2 (46.0-60.4) Probability rate of first-time recognition Low (0–39%) 13.8 (10.0-17.6) 14.1(10.3–17.9) 24.1 (19.4–28.8) 52.0 (46.5–57.4) Middle (40–79%) 11.0 (5.4–16.6) 11.0 (5.4–16.6) 30.5 (22.2–38.8) 52.5 (43.5–61.5) High (80–100%) 13.2 (7.4–19.0) 11.6 (6.1–17.1) 8.5 (3.7–13.3) 33.3 (25.2–41.4) Table 2 in here For the total population, the crude odds ratio for mental illness according to RHS-13, (score ≥ 11), was higher for women, asylum seekers and those of higher age (except age category 26–35) (see Table 3 ). A significantly higher likelihood of mental illness was found among those from a middle- or high-income country by GNI classification compared to those from a low-income country. Furthermore, having a low and middle probability of receiving a positive decision on the asylum application was significantly associated with mental illness. Although stratified analysis showed substantially higher odds for women, this was not apparent for men. Table 3 Crude odds ratios (OR) for the associations between mental illness (score ≥ 11) sociodemographic characters, country of origin by World Bank GNI classification and largest groups by probability rate of being granted protection status in EU with 95% confidence intervals (CI), for total sample and stratified by gender and legal status. Crude odds ratios (OR) for mental illness Total sample Stratified by Gender Stratified by Legal status All Men Women Asylum Seekers Quota and other refugees OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) Gender Women 1 1 1 Men 0.52 (0.36–0.73) 0.43(0.28–0.66) 0.65 (0.34–1.23) Legal status Asylum seekers 1 1 1 Quota and other refugees 0.49 (0.34–0.71) 0.55 (0.33–0.89) 0.36 (0.20–0.65) Age 14–25 1 1 1 1 1 26–35 1.47 (0.96–2.24) 1.68 (0.98–2.86) 0.99 (0.48–2.03) 1.25 (0.75–2.08) 1.65 (0.73–3.73) 36> 1.73 (1.16–2.58) 1.64 (0.99–2.72) 1.53 (0.77–3.05) 1.79 (1.09–2.94) 1.37 (0.66–2.82) Country of origin by World bank GNI Classification Low 1 1 1 1 1 Lower-middle 1.87 (1.23–2.84) 1.42 (0.84–2.37) 4.01 (1.83–8.77) 2.87 (1.26–6.64) 1.01 (0.43–2.35) Upper- middle and high 1.77 (1.19–2.61) 1.16 (0.70–1.94) 3.36 (1.76–6.40) 2.17 (1.03–4.53) 1.54 (0.74–3.22) Probability rate of first-time recognition High 1 1 1 1 1 Middle 2.21 (1.32–3.70) 1.82 (0.93–3.55) 2.82 (1.25–6.39) 1.09 (0.62–1.91) 4.0 (1.15–13.91) Low 2.17 (1.41–3.32) 1.67 (0.97–2.87) 3.59 (1.77–7.31) 1.13 (0.66–1.94) 1.0 (0.17–5.64) Stratified by gender, asylum seeking men and women still had double the likelihood of mental illness as compared with quota and other refugee men and women. Stratified by legal status, asylum seeking men still had about half the likelihood of mental illness compared to women. Furthermore, quota and other refugee men had a lower likelihood of mental illness compared to their counterpart, however this association was not statistically significant. Gender and legal status stratification showed that age was not associated with mental illness except for asylum seekers in the oldest age category, 36 and above. Gender analysis found the highest association for women from lower-middle and upper-middle- and high-income countries, OR = 4.01 (CI 1.83–8.77) and OR = 3.36 (CI 1.76–6.40) respectively but with large confidence intervals. Stratified analysis by legal status showed GNI classification (lower-middle and upper-middle-and high) to be significantly associated with mental illness among asylums seekers. Table 3 in here Full Model The full model (Table 4 ), when adjusting for age, gender and probability rate of first-time recognition showed that quota and other refugees had a significantly lower odds of mental illness than asylum seekers. In model 2, when adjusting for GNI classification and interactions, quota and other refugees were still less likely to report mental illness. Stratified analysis by gender observed higher odds for asylum seeking men. When adjusting for variables in model 2, this association was not observed for women. Only when adjusting for variables in model 1 were higher odds found for asylum seeking women compared to quota and others. Table 4 Adjusted odds ratios (OR) for mental illness (score ≥ 11) by legal status. Total sample and stratified by gender, presented with 95% confidence intervals (CI). Model 1 was adjusted for age, gender, and probability of getting asylum. Model 2 was adjusted for age, gender, probability of getting asylum, GNI classification as well as the interaction between gender and GNI classification Adjusted odds ratios (OR) for mental illness by legal status Model 1 Model 2 Model 1 Model 2 Model 1 Model 2 All All Men Men Women Women Legal Status Asylum seeker 1 1 1 1 1 1 Quota and other refugees 0.60 (0.38–0.93) 0.60 (0.37-1.00) 0.65 (0.36–1.18) 0.52 (0.27–0.99) 0.51(0.26–0.99) 0.74 (0.33–1.6) Table 4 in here Discussion The aim of this study was to estimate the differences in prevalence of mental illness between asylum seekers and refugees, including both quota and other refugees. We found quota and other refugees to be at 40% lower risk of mental health illness compared to asylum seekers, confirming our hypothesis. We also assessed whether gender, age, gross national income per capita in the country of origin, or by probability of being granted asylum could explain the differences in mental health among the groups. Our hypothesis was not fully confirmed. Although these variables partly influenced the prevalence of mental illness, they did not explain the prevalence in a consistent way. Our results depict that asylum seekers have a specifically high likelihood of mental illness compared to other refugees such as quota and those coming under other prerequisites. Previous studies have shown that asylum seekers are at increased risk of developing mental illnesses, but these studies have often compared with migrants who have been in the country for a longer period, and as a result, potentially made the comparison possibly biased [ 2 , 11 , 26 ]. The increased risk for asylum seekers found in our study could be partly explained by their uncertain residence status and uncertainty regarding their asylum application [ 27 – 30 ]. Asylum seekers are confronted with more unfavorable circumstances when it comes to, for instance, housing opportunities, health care education and working conditions, compared to those who have been granted residence permit. Legal status has shown to be a significant predictor of poor mental health, even when controlling for pre-and post-migration factors such as traumatic events, post migration resources and social desirability [ 11 , 30 ]. Remarkably, severe levels of mental illness were more commonly reported than mild and moderate levels of mental illness, for both groups, 52,9% and 35,7% respectively, indicating higher intensity of symptoms. Our finding also corroborates previous literature on the differences in risk of mental illness by country or region of origin. Regional differences in both reported mental illness, experienced traumatic events and use of psychiatric care have been found [ 10 , 31 – 33 ]. A recent Finish study found asylum seekers from Africa (excluding North Africa) reported traumatic events more frequently than asylum seekers from other regions [ 31 ]. Moreover, refugees from Syria, Iraq, and Afghanistan were most likely to exhibit a positive screening for mental health symptoms compared to refugees from other countries such as Somalia, Myanmar and D.R. Congo [ 32 ]. Various hypotheses have been postulated to explain this, including socioeconomic factors, cultural differences, differences in social support and coping style, discrimination, and varying vulnerabilities among different subgroups [ 15 , 32 , 34 ]. Our study expands on prior research examining differences by gender and age, with women reporting higher odds for mental illness, compared to men. Both female gender and older age have been linked with poorer psychological health in refugees, though there are some studies that demonstrate no effect of gender on outcomes [ 8 , 32 , 34 – 36 ]. It has been suggested that the gender differences in mental health are linked to roles and social positions, where women are limited in their role and lack of choice. Literature has been devoted to explaining the gender gap as a result of exposure to trauma and lack of self-control. Indeed, the broader social determinants of health associated with restricted economic opportunities, insecure housing, location of residence and migration status can have a profound influence on one’s sense of control [ 34 , 36 , 37 ]. It could also be that women may be at higher risk due to increased sexual victimization and domestic violence. Considering age, our results are consistent with past work, inciting greater vulnerability in older people. This could be due to greater accommodation of traumas over time [ 15 , 32 ] for older people, or younger refugees being less affected by the enduring stresses of displacement. Determination of illness severity could have important clinical implications when it comes to, for example treatment strategies or prioritizing care when resources are scares. Considering this aspect may be useful in planning public health interventions targeting this vulnerable group. Furthermore, our findings could be applicable to individuals without legal document/status (former asylum seekers who have been rejected asylum/or others without legal status) as these individuals are often confronted with similar challenges and have same health care entitlements as asylum seekers. Limitations And Strengths The study has many strengths: first, data is generated through a validated screening instrument specifically developed for refugee populations. Although the study was conducted only in one region in Sweden, it was conducted in two primary healthcare centers that together executes a high number of HE in Stockholm, in addition to including both asylum seekers and other refugees, leading to increasing the generalizability of the findings. Both asylum seekers and other refugees are represented in our study, giving the study a good representation in terms of migrants. Data was collected with the help of health care professionals working in the centers and there was no need for outreach methods, which minimizes the risk of bias or misunderstanding of the data. While this study provides important information on differences in mental illness by legal status there are several limitations. We had no information on risk and resilience factors related to participants’ mental health such as trauma experiences, length of stay in Sweden, educational level and other known determinants of mental health. Another limitation is possible selection bias as the RHS-13 screening was part of a voluntary HE and those opting out of HE might have different mental health profiles. In addition, we do not have information about the few who took part in an HE but declined screening with the RHS-13. It could be that their mental health profiles too were different from those that accepted screening. Conclusion Legal status moderated mental health illness. Asylum seekers were at greater risk of mental illness compared to quota and other refugees. Legal status as well as female gender and region of origin were associated with migrant’s mental health. Our findings call for screening of mental illness in this vulnerable group. Additionally, consideration of legal status should be considered to better understand and plan interventions targeting asylum seekers and refugees’ mental health. Abbreviations European Union, EU Gross National Income, GNI Health examination, HE Medical record, MR Post-traumatic stress disorder, PTSD Refugee Health Screener, RHS-13 United Nations, UN United Nations High Commissioner for Refugees, UNHCR Declarations Ethics approval and consent to participate Ethical permission for the project was granted by the Regional Ethics Committee, Stockholm (Dnr: 2019–01408). All procedures performed in the studies were in accordance with the ethical standards of the institutional and/ or national research committee and with the 1964 Helsinki declaration and its later amendments. Informed consent to participate was not required since this study uses already existing administrative data, that is routinely collected within healthcare, and not personally identifiable. Consent for publication Not applicable Availability of data and materials The data that support the findings of this study are available from the two participating health care clinics in region Stockholm, but restrictions apply to the availability of these data, which were under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of the Swedish Ethical Review Authority Competing interests The authors declare that they have no competing interests Funding The study has been funded by Stockholm Region, (grant 2018–0034, project 1513). The funding did not influence the study design, data collection, analysis, interpretation of data or preparation of the manuscript. Open Access funding provided by Karolinska Institutet. Authors' contributions HH and KL designed the study. SD, JS and AH collected the data. SD conducted data analysis and drafted the manuscript. ACH contributed critically to the interpretation of results. All authors approved the final version of the manuscript to be published. Acknowledgements Not applicable References United Nations High Commissioner for Refugees. Global Trends. Forced displaced in 2018. https://www.unhcr.org/5d08d7ee7.pdf . Accessed 26 May 2020. Tinghög P, Malm A, Arwidson C, Sigvardsdotter E, Lundin A, Saboonchi F. Prevalence of mental ill health, traumas and postmigration stress among refugees from Syria resettled in Sweden after 2011: A population-based survey. BMJ Open. 2017;7(12). Swedish Migration Agency. 2018 EMN Annual Report on Migration and Asylum 2018 https://ec.europa.eu/home-affairs/sites/homeaffairs/files/00_eu_arm2019_synthesis_report_final_en_0.pdf . Accessed 25 January 2022. Eurostat. Asylum decisions in the EU. 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Prevalence of depressive symptoms and symptoms of post-traumatic stress disorder among newly arrived refugees and asylum seekers in Germany: systematic review and meta-analysis. BJPsych Open. 2021;7(3):1–12. Hollander A-C, Bruce D, Burström B, Ekblad S. The association between immigrant subgroup and poor mental health- A population-based register study. J Nerv Ment Dis. 2013;201(8):645–52. Posselt M, Mcintyre H, Ngcanga M, Lines T, Procter N. The mental health status of asylum seekers in middle- to high-income countries: a synthesis of current global evidence. Br Med Bull. 2020;1–17. Duggal AK, Kirkbride JB, Dalman C, Hollander A-C. Risk of non-affective psychotic disorder and post-traumatic stress disorder by refugee status in Sweden. J Epidemiol Community Health. 2019;276–82. Blackmore R, Boyle JA, Fazel M, Ranasinha S, Gray KM, Fitzgerald G, et al. The prevalence of mental illness in refugees and asylum seekers: A systematic review and meta-analysis. PLoS Med. 2020;17(9):1–24. Zimmerman C, Kiss L, Hossain M. Migration and Health: A Framework for 21st Century Policy-Making. PLoS Med. 2011;8(5). Porter M, Haslam N. Predisplacement and postdisplacement of refugees and internally displaced persons. J Am Med Assoc. 2005;294(5):610–2. Peconga E k, Høgh Thøgersen M. Post-traumatic stress disorder, depression, and anxiety in adult Syrian refugees: What do we know? Scand J Public Health. 2020;48(7):677–87. Delilovic S, Kulane A, Åsbring N, Marttila A, Lönnroth K. What value for whom? - Provider perspectives on health examinations for asylum seekers in Stockholm, Sweden. BMC Health Serv Res. 2018;18(1):1–9. Government Offices of Sweden. Lag (2008:344) om hälso- och sjukvård åt asylsökande m.fl. Svensk författningssamling 2008:344 (Health and medical care for asylum seekers and others act.).2008. Available from: https://www.riksdagen.se/sv/dokument-lagar/dokument/svensk-forfattningssamling/lag-2008344-om-halso--och-sjukvard-at_sfs-2008-344 Hollifield M, Verbillis-Kolp S, Farmer B, Toolson EC, Woldehaimanot T, Yamazaki J, et al. The Refugee Health Screener-15 (RHS-15): Development and validation of an instrument for anxiety, depression, and PTSD in refugees. Gen Hosp Psychiatry. 2013;35(2):202–9. Hollifield M, Toolson EC, Verbillis-Kolp S, Farmer B, Yamazaki J, Woldehaimanot T, et al. Effective screening for emotional distress in refugees: The Refugee Health Screener. J Nerv Ment Dis. 2016;204(4):247–53. Bjärtå A, Leiler A, Ekdahl J, Wasteson E. Assessing Severity of Psychological Distress among Refugees with the Refugee Health Screener, 13-Item Version. J Nerv Ment Dis. 2018;206(11):834–9. The world Bank. World Bank Country and Lending Groups, Country Classification. 2020. https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-group . Accessed November 2020. Eurostat. Asylum quarterly report 2020. Statistics Explained. 2018. https://ec.europa.eu/eurostat/statistics-explained/index.php/Asylum_quarterly_report#Where_do_asylum_applicants_go_to.3F%0Ahttp://ec.europa.eu/eurostat/statistics-explained/index.php/Asylum_quarterly_report . Accessed 26 May 2020. Hosmer D. W, Lemeshow S, Sturdivant RX. (2013). Applied logistic regression. 3rd ed edition. JOhn Wiley & Sons, Hoboken, NJ. IBM Corp. Released 2019. IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp. 2019. Leiler A, Bjärtå A, Ekdahl J, Wasteson E. Mental health and quality of life among asylum seekers and refugees living in refugee housing facilities in Sweden. Soc Psychiatry Psychiatr Epidemiol. 2019;54(5):543–51. Solberg Ø, Vaez M, Johnson-Singh CM, Saboonchi F. Asylum-seekers’ psychosocial situation: A diathesis for post-migratory stress and mental health disorders? J Psychosom Res. 2020;130(May 2019). Gerritsen AAM, Bramsen I, Devillé W, van Willigen LHM, Hovens JE, van der Ploeg HM. Physical and mental health of Afghan, Iranian and Somali asylum seekers and refugees living in the Netherlands. Soc Psychiatry Psychiatr Epidemiol. 2006;41(1):18–26. Heeren M, Mueller J, Ehlert U, Schnyder U, Copiery N, Maier T. Mental health of asylum seekers: a cross-sectional study of psychiatric disorders. BMC Psychiatry. 2012;12. Heeren M, Wittmann L, Ehlert U, Schnyder U, Maier T, Müller J.Psychopathology and resident status – comparing asylum seekers, refugees, illegal migrants, labor migrants ,and residents. Compr Psychiatry. 2014;55(4):818–25. Garoff F, Skogberg N, Klemettilä A, Lilja E, Ahmed Haji Omar A, Snellman O, et al. Mental health and traumatization of newly arrived asylum seeker adults in finland: A population-based study. Int J Environ Res Public Health. 2021;18(13). Schlaudt VA, Bosson R, Williams MT, German B, Hooper LM, Frazier V, et al. Traumatic experiences and mental health risk for refugees. Int J Environ Res Public Health. 2020;17(6). Dykxhoorn J, Hollander A-C, Lewis G, Magnusson C, Dalman C, Kirkbride JB. Risk of schizophrenia, schizoaffective, and bipolar disorders by migrant status, region of origin, and age-at-migration: a national cohort study of 1.8 million people. Psychol Med. 2019;49(14):2354–63. Steel Z, Chey T, Silove D, Marnane C, Bryant RA van OM. Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis. JAMA. 2009;302(5):537–49. Hollander A-C, Bruce D, Burström B ES. Gender related mental-health differences between refugees and non-refugee immigrants- A cross-sectional register-based study. BMC Public Health. 2011;11(1):180. Jarallah Y, Baxter J. Gender disparities and psychological distress among humanitarian migrants in Australia: A moderating role of migration pathway? Confl Health. 2019;13(1):1–11. Porter M. Global Evidence for a Biopsychosocial Understanding of Refugee Adaptation. Transcult Psychiatry. 2007;44(3):418–39. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 24 Mar, 2023 Read the published version in BMC Psychiatry → Version 1 posted Editorial decision: Major revision 12 Sep, 2022 Reviews received at journal 07 Sep, 2022 Reviews received at journal 30 Jun, 2022 Reviewers agreed at journal 20 Jun, 2022 Reviewers invited by journal 16 Jun, 2022 Editor assigned by journal 16 Jun, 2022 Editor invited by journal 23 May, 2022 Submission checks completed at journal 23 May, 2022 First submitted to journal 17 May, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1664429","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":108054324,"identity":"34992d02-acba-4973-a150-5f59d66074d0","order_by":0,"name":"Sara Delilovic","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2UlEQVRIiWNgGAWjYNACNgYZNnYgncBgY8BGrBYeNmawljQStDAwg1mHDQgqlm8/+/ADQ5kNDx8z8zGJBzXnjfkY2B8+wKfF4Ey6sQTDuTSgw9jSJBKO3TYD2miM1yoDhjQGCca2w0AtQJWJDbdtQP6SwOuw/mfMPxjb/sO0nANqYX/+A69nbqSxAW05ANJi+CCx4QDQYQxmeHUY3HjGZpFwLhnkl8QHCceSjUHWEXBYGvOND2V2cvLtzQcO/qixM5zf3g4MQ0IgAYXHTFD9KBgFo2AUjAJCAABK9jjA2bGhIQAAAABJRU5ErkJggg==","orcid":"","institution":"Karolinska Institute","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Sara","middleName":"","lastName":"Delilovic","suffix":""},{"id":108054325,"identity":"07d200ba-8af3-4cdf-8efd-99ec14f90e2d","order_by":1,"name":"Ana Hagström","email":"","orcid":"","institution":"Karolinska Institute","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ana","middleName":"","lastName":"Hagström","suffix":""},{"id":108054326,"identity":"9b07ca0a-36ab-4184-a5e8-f5aa5bd0e477","order_by":2,"name":"Jad Shedrawy","email":"","orcid":"","institution":"Karolinska Institute","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jad","middleName":"","lastName":"Shedrawy","suffix":""},{"id":108054327,"identity":"efc0db23-7e83-4a53-9ece-6cce8dfe0cf7","order_by":3,"name":"Anna Clara Hollander","email":"","orcid":"","institution":"Karolinska Institute","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Anna","middleName":"Clara","lastName":"Hollander","suffix":""},{"id":108054328,"identity":"43e9a37f-baca-48b1-9b7d-8403e8a094c7","order_by":4,"name":"Knut Lönnroth","email":"","orcid":"","institution":"Karolinska Institute","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Knut","middleName":"","lastName":"Lönnroth","suffix":""},{"id":108054329,"identity":"9ef33438-6e0e-4a21-a830-0437a110ef9b","order_by":5,"name":"Henna Hasson","email":"","orcid":"","institution":"Karolinska Institute","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Henna","middleName":"","lastName":"Hasson","suffix":""}],"badges":[],"createdAt":"2022-05-17 08:14:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1664429/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1664429/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12888-023-04679-y","type":"published","date":"2023-03-24T20:08:14+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":44723286,"identity":"524d46aa-fd9f-4520-95ee-a26b39fc06b7","added_by":"auto","created_at":"2023-10-16 20:15:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":470823,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1664429/v1/21e5533e-3274-4500-abd9-8615158029f8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Is legal status associated with mental illness among newly arrived refugees in Sweden: an epidemiological study","fulltext":[{"header":"Background","content":"\u003cp\u003eIn recent years, wars, conflicts and violation of human rights have led to forced displacements, with millions of people seeking protection outside of their home countries [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The global population of forcibly displaced people grew substantially from 43.3\u0026nbsp;million in 2009 to 70.8\u0026nbsp;million in 2018 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In 2017\u0026ndash;2018 Sweden hosted the largest number of refugees in the European Union (EU) per capita [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] and today, in 2022, there are millions of Ukrainian people fleeing their homes seeking safety, protection and assistance.\u003c/p\u003e \u003cp\u003eMigrants are a heterogenous population in their needs and rights, including differences in reasons for migrating [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. According to the United Nations (UN) definition, migrants are adults who were born in one country and have moved to and settled in another. Refugees are a subgroup of migrants. From a legal perspective, an asylum seeker is a person who seeks sanctuary and files for refugee status in a country other than their own and awaits a decision while a refugee is someone who has been recognized under the 1951 Convention relating to the status of refugees to be a refugee [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In the later definition, quota refugees are included as those who have been selected by the UN\u0026acute;s refugee agency, United Nations High Commissioner for Refugees (UNHCR), to be resettled to a third country that offers them protection. Resettling in a third country is a solution for people who can neither remain in their first country of asylum nor return home. Unlike asylum seekers, quota refugees have a residence permit upon arrival. The same applies for other non-refugee migrants, such as those coming for family reunification [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMigration itself is not a risk factor for poor health as migrants are often comparatively healthy. However, vulnerability to mental, physical and social problems may result from the process and specific circumstances of migrating [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Studies have shown migrants at heightened risk for certain mental health conditions such as post-traumatic stress disorder (PTSD), anxiety and schizophrenia compared to host country population [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe social determinants of mental health are relevant for asylum seekers and refugees. If they are unevenly distributed, this may create social inequalities in mental health across migrant groups. A person\u0026rsquo;s move from one country or context to another means additional strain. However, migrant-specific social determinants of health are often separated into pre-, peri- and post-migration factors [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Pre-migration factors refer to factors before migration such as social disadvantage in the country of origin or conflict-related traumatic experiences. Post-migration factors include a poor social network in host country, acculturation and adaptation barriers, and overlap with general social determinants of health [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEstimates of the prevalence of mental illness in refugees varies. A recent review on refugee mental health found prevalence rates of 43% for PTSD, 40% for depression, and 26% for anxiety among 8.176 Syrian refuges resettled in 10 countries [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Furthermore, a review undertaken across 15 countries, found similar rates for PTSD (31.46%), depression (31.5%) and anxiety disorders (11%) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In Germany, one of the countries hosting the largest number of refugees in Europe, a meta-analysis found differences depending on type of screening method, with significantly higher prevalence estimates for depressive symptoms reported using screening tools (39.8%) in comparison with diagnostic instruments (28.4%), whereas survey methods provided comparable prevalence estimates for symptoms of PTSD (28.1% v. 29.9%) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe variation in presence of mental illness among refugees could be explained by differences in methods applied but also differences in the characteristics of the populations (e.g., country/area of origin, experiences before, during and after migration, years in the new country). Additional reasons for wide variability could be the lack of differentiation between different groups of newly arrived people such as asylum seekers and refugees, including both quota and another refugees. Another reason is that some of these studies include migrants from one country only. Additionally, groups such as asylum seekers and quota refugees are especially understudied. Therefore, the aim of this study is to estimate the differences in prevalence of mental illness between asylum seekers and refugees, including both quota and other refugees at a free-of-charge health examination in a primary health setting and to determine if gender, age, gross national income per capita in the country of origin, or country of origin could explain these differences. We hypothesize that the risk for mental illness could differ between groups, and that all the above-mentioned factors would impact the likelihood of mental illness.\u003c/p\u003e"},{"header":"Method","content":"\u003cdiv class=\"Section2\" id=\"Sec3\"\u003e\n \u003ch2\u003eSetting\u003c/h2\u003e\n \u003cp\u003eThe study was conducted in two primary health care clinics in Stockholm Region, Sweden. All asylum seekers and refugees are offered a free-of-charge health examination (HE) in primary health care clinics. The HE aims to identify health care needs, including mental and physical health problem that require immediate attention and to detect infectious diseases that require special control measures [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e]. The HE is voluntary and in terms of content, the patient chooses what health related information he or she wants to share during the HE.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec4\"\u003e\n \u003ch2\u003eDesign and population\u003c/h2\u003e\n \u003cp\u003eHealthcare professionals use unstandardized methods to address mental health during the HE [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e]. A first step towards overcoming the issue with unstandardized methods was to introduce a validated screening instrument, the Refugee Health Screener (RHS-13), discussed further under the sub-section \u0026ldquo;Outcome\u0026rdquo; [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\n \u003cp\u003eThe RHS-13 screening instrument was implemented and integrated within the HE. Screening was performed by the healthcare professional conducting the HE during a period of 6 months and registered in the electronic medical record system (October 2018- March 2019). Using a cross sectional design, data for this period was extracted during September 2019. The two clinics accounted together for more than half of all HE conducted in the region during this period. All migrants, age 14 or older were eligible for the screening. Not all completed screening with the RHS-13. Out of all individuals who came for a HE during the study period, 597 (51,4%) were not screened. Reasons for no screening were not recorded.\u003c/p\u003e\n \u003cp\u003eSix individuals were excluded from the analysis due to not meeting the inclusion criteria of being 14 years of age or older and 9 were excluded due to missing data on RHS-13.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec5\"\u003e\n \u003ch2\u003eEthical issues\u003c/h2\u003e\n \u003cp\u003eEthical clearance was obtained from the Swedish Ethical Review Authority (Dnr: 2019\u0026ndash;01408) to retrieve HE data from medical records (MR). All data was recoded and pseudonymized, meaning data items were recorded to an artificial identifier (a pseudonym). This step was done on site at the health care clinic to ensure privacy. Data were coded into excel files.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec6\"\u003e\n \u003ch2\u003eOutcome\u003c/h2\u003e\n \u003cp\u003eThe outcome was prevalence of mental health illnesses which was measured with RHS-13. RHS-13 is a screening tool to identify individuals with symptoms of mental illness (i.e., not a diagnostic tool) [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]. RHS-13 consists of 13 questions and assesses symptoms of the most common mental health problems in refugees: PTSD, depression, and anxiety. The original version, consisting of 15 items, shows excellent internal consistency (Cronbach\u0026acute;s a\u0026thinsp;=\u0026thinsp;0.91) (PTSD: sensitivity 0.81/specificity 0.87, anxiety 0.94/0.86, and depression 0.95/0.89 [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e]. A 13-item version of the RHS-15 has been tested, which showed strengthened psychometric properties (Cronbach\u0026acute;s a\u0026thinsp;=\u0026thinsp;0.96) without comprising the validity of the instrument [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]. RHS-13 has been validated and is available in 18 languages including Swedish [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\n \u003cp\u003eThe RHS-13 scale is answered with a five-point Likert scale, with scores from 0 to 4, corresponding to \u0026ldquo;Not at all\u0026rdquo; to \u0026ldquo;Extremely\u0026rdquo;. The total range of scores is thus 0\u0026ndash;52 [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]. A cut-off of \u0026ge;\u0026thinsp;11 has been suggested to identify positive screening for mental illness. The instrument has also been tested in Sweden for severity levels of symptoms of psychological distress where a score of 11\u0026ndash;17 is interpreted as mild symptoms, 18\u0026ndash;24 clinically significant problems (moderate), and 25 or above as acute and severe problems [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]. We present prevalence of mental illness based both on dichotomized scores (positive 11\u0026ndash;52 vs. negative 0\u0026ndash;10), as well as based on cut-offs for mild (11\u0026ndash;17), moderate (18\u0026ndash;24) and severe (25\u0026ndash;52) problems.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec7\"\u003e\n \u003ch2\u003eExposure\u003c/h2\u003e\n \u003cp\u003eOur primary exposure was legal status, categorized as \u0026ldquo;Asylum seekers\u0026rdquo; or \u0026ldquo;Quota and Other refugees\u0026rdquo;.\u003c/p\u003e\n \u003cp\u003eThe group called \u0026ldquo;Others\u0026rdquo; accounts for individuals who have entered Sweden for family reunification knowing that they would qualify for a residence permit as they have one or more family members who have been granted permit as a refugee or a person in need of subsidiary protection (i.e., someone who do not qualify as refugee but would face a real risk of suffering serious harm in his or her home country). Individuals with family reunification were merged into the group \u0026ldquo;Quota and Others\u0026rdquo; as we expected them to share similar characteristics and legal benefits as quota refugees.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec8\"\u003e\n \u003ch2\u003eCo-variates\u003c/h2\u003e\n\u003c/div\u003e\n\u003ch2\u003eSociodemographic Measures\u003c/h2\u003e\n\u003cp\u003eGender was categorized into men and women.\u003c/p\u003e\n\u003cp\u003eAge was categorized into the following groups 14\u0026ndash;25 years, 26\u0026ndash;35 years and 36 and older.\u003c/p\u003e\n\u003cp\u003eGross national income per capita (GNI) is the dollar value of a country\u0026rsquo;s income in a year, divided by its population. GNI presents a country\u0026rsquo;s economic strengths and is closely linked to indicators on individual level such as social, economic and environmental well-being. Countries with higher GNI, tends to have higher literacy rates and longer life expectancies. Country of origin by World Bank GNI Classification was defined as:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003cp\u003elow-income country (\u003cspan\u003e$\u003c/span\u003e 1.025 or less)\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003elower-middle income country (\u003cspan\u003e$\u003c/span\u003e 1,026-\u003cspan\u003e$\u003c/span\u003e3.995)\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eupper-middle and high (\u003cspan\u003e$\u003c/span\u003e 3.995 or more) income country\u003c/p\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eData on GNI classification was retrieved from the World Bank and reflects classifications made 2020 [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eCountry of origin by Probability rate of first-time recognition reflects the recognition rate, the share of positive decisions among the total number of decisions by citizenships of asylum applicant in the EU. Rates account for positive decisions from the 4th quartile 2017 to the 4th quartile 2018 for refugee status, subsidiary protection and humanitarian reasons in the EU [\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003cp\u003eLow probability rate was defined as 0\u0026ndash;39%\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eMiddle 40\u0026ndash;79%\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eHigh 80\u0026ndash;100%\u003c/p\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv class=\"Section2\" id=\"Sec10\"\u003e\n \u003ch2\u003eStatistical analyses\u003c/h2\u003e\n \u003cp\u003eSociodemographic variables were described by absolute and relative frequencies. Chi\u003csup\u003e2\u003c/sup\u003e-test were used for associations between categorical independent variables, as well as to compare between subjects who participated in screening and those who did not. Prevalence (%) of positive screenings for mental health symptoms by sociodemographic characteristics were estimated with 95% Confidence intervals (CI). Regression models were performed on the dichotomized outcome, defined as score RHS-13\u0026thinsp;\u0026ge;\u0026thinsp;11, as it is more established and used than the ordinal outcome (with 3 severity levels). Logistic regression was used to control the association between the outcome and exposure for potential confounders. Stepwise modelling, using a bidirectional elimination method was completed [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e]. Backward elimination and forward selection approaches were conducted. We tested all independent variables incrementally for significance. All significant variables were imputed in the final model and variables were removed to test for significance. We tested for interaction between all independent variables. One significant interaction was found, between gender and GNI classification. Stratified analysis by gender is presented for both crude and adjusted models. Two adjusted models are presented. Model 1 was adjusted for age, gender, and probability of getting asylum, leaving GNI classification out, considering it to be a priori confounder. Model 2 was adjusted for age, gender, probability of getting asylum, GNI classification as well as the interaction between gender and GNI classification. Interaction variables were not used in stratified models.\u003c/p\u003e\n \u003cp\u003eResults are presented for crude and adjusted odds ratios (ORs) with 95% confidence intervals. A p-value of 0.05 was considered statistically significant. Statistical analyses were performed using IBM SPSS version 26 [\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOut of the 1163 respondents who came and underwent a health examination, 566 completed screening with the RHS-13 (48.6%). The majority were men and the largest group by country of origin were Syrians followed by Eritreans, Iranians, and Uzbeks. In total, 78 countries were represented. Majority of the cohort came from a low-income country and with a low probability rate of first-time recognition (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSample Characteristics of respondents\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"3\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eSample Characteristics\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u0026thinsp;=\u0026thinsp;566\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eClinic 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e246\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eClinic 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e320\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e354\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e62.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWomen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e212\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eLegal status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAsylum seekers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e393\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e69.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQuota and other refugees\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e171\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14\u0026ndash;25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e183\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26\u0026ndash;35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e170\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36\u0026gt;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e213\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eCountry of origin by World Bank GNI Classification\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e227\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLower-middle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e152\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUpper- middle and high\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e186\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eProbability rate of first-time recognition\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLow (0\u0026ndash;39%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e319\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMiddle (40\u0026ndash;79%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e118\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh (80\u0026ndash;100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e129\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eCountry of origin\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSyria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEritrea\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIran\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUzbekistan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAll Others\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e356\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e62.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e \u003cspan class=\"Underline\" name=\"Emphasis\" type=\"Underline\"\u003ein here\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eIn total, 47.9% scored positive for symptoms of mental illness (score\u0026thinsp;\u0026ge;\u0026thinsp;11) (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). A score\u0026thinsp;\u0026ge;\u0026thinsp;11 was significantly more common among asylum seekers than quota and other refugees (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Women, older age groups and people from a middle- or high-income country had significantly higher prevalence of a score\u0026thinsp;\u0026ge;\u0026thinsp;11. The prevalence of score\u0026thinsp;\u0026ge;\u0026thinsp;11 was similar for individuals with a low and middle probability of getting a positive decision on their asylum application, but significantly lower for those with a high probability. Significant differences were found in the prevalence of severe mental illness (score\u0026thinsp;\u0026ge;\u0026thinsp;25) in the univariate comparisons regarding gender, age, country of origin by GNI classification and probability rate of first-time recognition (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). The prevalence of severe symptoms was about twice as high for women compared to men, asylum seekers compared to quota and other refugees, older population compared to younger population, and those from middle-income compared to low-income countries. Those from countries with a low probability of first-time recognition had about three times higher prevalence of severe problems than those with high probability.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab2\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003ePrevalence (%) with 95% confidence intervals (CI) of mental illness measured with RHS-13 in total and by sociodemographic characters, country of origin by World Bank GNI classification and by probability rate of being granted protection status in EU\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"5\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003eMental Illness measured with RHS-13\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMild mental illness\u003c/p\u003e\n \u003cp\u003e(\u0026ge;\u0026thinsp;11\u0026ndash;17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eModerate mental illness (\u0026ge;\u0026thinsp;18\u0026ndash;25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSevere mental illness (\u0026ge;\u0026thinsp;25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAny mental illness\u003c/p\u003e\n \u003cp\u003e(all \u0026ge;\u0026thinsp;11)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u0026thinsp;=\u0026thinsp;74\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u0026thinsp;=\u0026thinsp;73\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u0026thinsp;=\u0026thinsp;124\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u0026thinsp;=\u0026thinsp;271\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003e% (95% CI) % (95% CI) % (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e% (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.1 (10.3\u0026ndash;15.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.9 (10.1\u0026ndash;15.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.9 (18.4\u0026ndash;25.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47.9 (43.7\u0026ndash;52.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.3(9.8\u0026ndash;16.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.9 (8.5\u0026ndash;15.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.7 (12.8\u0026ndash;20.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41.8 (36.7\u0026ndash;46.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWomen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.7 (8.2\u0026ndash;17.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.6 (9.8\u0026ndash;19.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30.7 (24.5\u0026ndash;36.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e58.0 (51.4\u0026ndash;64.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eLegal Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAsylum seeker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.7 (10.3\u0026ndash;17.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.2 (9.8\u0026ndash;16.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26.0 (21.6\u0026ndash;30.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e52.9 (48.0-57.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQuota and other refugees\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.7 (6.9\u0026ndash;16.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.7 (6.9\u0026ndash;16.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.3 (7.4\u0026ndash;17.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35.7 (28.5\u0026ndash;42.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14\u0026ndash;25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.1 (8.2\u0026ndash;18.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.5 (6.9\u0026ndash;16.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.3 (10.1\u0026ndash;20.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.9 (32.8\u0026ndash;47.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26\u0026ndash;35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.3 (9.9\u0026ndash;20.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.1 (11.4\u0026ndash;22.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.1 (11.4\u0026ndash;22.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49.4 (41.9\u0026ndash;56.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36\u0026gt;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.3 (7.0-15.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.8 (6.6\u0026ndash;15.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31.5 (25.3\u0026ndash;37.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53.5 (46.8\u0026ndash;60.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eCountry of origin by World bank GNI Classification\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.0 (8.6\u0026ndash;17.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.2 (8.0-16.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.9 (9.4\u0026ndash;18.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39.1 (32.8\u0026ndash;45.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eLower-middle\u003c/p\u003e\n \u003cp\u003eUpper-middle and high\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e12.7 (7.4\u0026ndash;18.0)\u003c/p\u003e\n \u003cp\u003e13.4 (8.5\u0026ndash;18.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e15.3 (9.5\u0026ndash;21.1)\u003c/p\u003e\n \u003cp\u003e11.8 (7.2\u0026ndash;16.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e26.7 (19.6\u0026ndash;33.8)\u003c/p\u003e\n \u003cp\u003e28.0 (21.5\u0026ndash;34.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e54.7 (46.8\u0026ndash;62.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53.2 (46.0-60.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eProbability rate of first-time recognition\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLow (0\u0026ndash;39%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.8 (10.0-17.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.1(10.3\u0026ndash;17.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.1 (19.4\u0026ndash;28.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e52.0 (46.5\u0026ndash;57.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMiddle (40\u0026ndash;79%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.0 (5.4\u0026ndash;16.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.0 (5.4\u0026ndash;16.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30.5 (22.2\u0026ndash;38.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e52.5 (43.5\u0026ndash;61.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh (80\u0026ndash;100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.2 (7.4\u0026ndash;19.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.6 (6.1\u0026ndash;17.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.5 (3.7\u0026ndash;13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33.3 (25.2\u0026ndash;41.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e \u003cspan class=\"Underline\" name=\"Emphasis\" type=\"Underline\"\u003ein here\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eFor the total population, the crude odds ratio for mental illness according to RHS-13, (score\u0026thinsp;\u0026ge;\u0026thinsp;11), was higher for women, asylum seekers and those of higher age (except age category 26\u0026ndash;35) (see Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). A significantly higher likelihood of mental illness was found among those from a middle- or high-income country by GNI classification compared to those from a low-income country. Furthermore, having a low and middle probability of receiving a positive decision on the asylum application was significantly associated with mental illness. Although stratified analysis showed substantially higher odds for women, this was not apparent for men.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab3\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCrude odds ratios (OR) for the associations between mental illness (score\u0026thinsp;\u0026ge;\u0026thinsp;11) sociodemographic characters, country of origin by World Bank GNI classification and largest groups by probability rate of being granted protection status in EU with 95% confidence intervals (CI), for total sample and stratified by gender and legal status.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"6\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"6\"\u003e\n \u003cp\u003eCrude odds ratios (OR) for mental illness\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal sample\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eStratified by Gender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eStratified by Legal status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAll\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWomen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAsylum Seekers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQuota and other refugees\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWomen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.52 (0.36\u0026ndash;0.73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.43(0.28\u0026ndash;0.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.65 (0.34\u0026ndash;1.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eLegal status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAsylum seekers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQuota and other refugees\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.49 (0.34\u0026ndash;0.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.55 (0.33\u0026ndash;0.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.36 (0.20\u0026ndash;0.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14\u0026ndash;25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26\u0026ndash;35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.47 (0.96\u0026ndash;2.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.68 (0.98\u0026ndash;2.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.99 (0.48\u0026ndash;2.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.25 (0.75\u0026ndash;2.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.65 (0.73\u0026ndash;3.73)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36\u0026gt;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.73 (1.16\u0026ndash;2.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.64 (0.99\u0026ndash;2.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.53 (0.77\u0026ndash;3.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.79 (1.09\u0026ndash;2.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.37 (0.66\u0026ndash;2.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eCountry of origin by World bank GNI Classification\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLower-middle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.87 (1.23\u0026ndash;2.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.42 (0.84\u0026ndash;2.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.01 (1.83\u0026ndash;8.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.87 (1.26\u0026ndash;6.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.01 (0.43\u0026ndash;2.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUpper- middle and high\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.77 (1.19\u0026ndash;2.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.16 (0.70\u0026ndash;1.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.36 (1.76\u0026ndash;6.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.17 (1.03\u0026ndash;4.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.54 (0.74\u0026ndash;3.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eProbability rate of first-time recognition\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMiddle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.21 (1.32\u0026ndash;3.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.82 (0.93\u0026ndash;3.55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.82 (1.25\u0026ndash;6.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.09 (0.62\u0026ndash;1.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.0 (1.15\u0026ndash;13.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.17 (1.41\u0026ndash;3.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.67 (0.97\u0026ndash;2.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.59 (1.77\u0026ndash;7.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.13 (0.66\u0026ndash;1.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0 (0.17\u0026ndash;5.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eStratified by gender, asylum seeking men and women still had double the likelihood of mental illness as compared with quota and other refugee men and women. Stratified by legal status, asylum seeking men still had about half the likelihood of mental illness compared to women. Furthermore, quota and other refugee men had a lower likelihood of mental illness compared to their counterpart, however this association was not statistically significant. Gender and legal status stratification showed that age was not associated with mental illness except for asylum seekers in the oldest age category, 36 and above. Gender analysis found the highest association for women from lower-middle and upper-middle- and high-income countries, OR\u0026thinsp;=\u0026thinsp;4.01 (CI 1.83\u0026ndash;8.77) and OR\u0026thinsp;=\u0026thinsp;3.36 (CI 1.76\u0026ndash;6.40) respectively but with large confidence intervals. Stratified analysis by legal status showed GNI classification (lower-middle and upper-middle-and high) to be significantly associated with mental illness among asylums seekers.\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e \u003cspan class=\"Underline\" name=\"Emphasis\" type=\"Underline\"\u003ein here\u003c/span\u003e\u003c/p\u003e\n\u003ch2\u003eFull Model\u003c/h2\u003e\n\u003cp\u003eThe full model (Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e), when adjusting for age, gender and probability rate of first-time recognition showed that quota and other refugees had a significantly lower odds of mental illness than asylum seekers. In model 2, when adjusting for GNI classification and interactions, quota and other refugees were still less likely to report mental illness. Stratified analysis by gender observed higher odds for asylum seeking men. When adjusting for variables in model 2, this association was not observed for women. Only when adjusting for variables in model 1 were higher odds found for asylum seeking women compared to quota and others.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab4\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eAdjusted odds ratios (OR) for mental illness (score\u0026thinsp;\u0026ge;\u0026thinsp;11) by legal status. Total sample and stratified by gender, presented with 95% confidence intervals (CI). Model 1 was adjusted for age, gender, and probability of getting asylum. Model 2 was adjusted for age, gender, probability of getting asylum, GNI classification as well as the interaction between gender and GNI classification\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"7\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"7\"\u003e\n \u003cp\u003eAdjusted odds ratios (OR) for mental illness by legal status\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eModel 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eModel 2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eModel 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eModel 2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eModel 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eModel 2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAll\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAll\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWomen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWomen\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eLegal Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAsylum seeker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQuota and other refugees\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.60 (0.38\u0026ndash;0.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.60 (0.37-1.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.65 (0.36\u0026ndash;1.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.52 (0.27\u0026ndash;0.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.51(0.26\u0026ndash;0.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.74 (0.33\u0026ndash;1.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e \u003cspan class=\"Underline\" name=\"Emphasis\" type=\"Underline\"\u003ein here\u003c/span\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe aim of this study was to estimate the differences in prevalence of mental illness between asylum seekers and refugees, including both quota and other refugees. We found quota and other refugees to be at 40% lower risk of mental health illness compared to asylum seekers, confirming our hypothesis. We also assessed whether gender, age, gross national income per capita in the country of origin, or by probability of being granted asylum could explain the differences in mental health among the groups. Our hypothesis was not fully confirmed. Although these variables partly influenced the prevalence of mental illness, they did not explain the prevalence in a consistent way.\u003c/p\u003e \u003cp\u003eOur results depict that asylum seekers have a specifically high likelihood of mental illness compared to other refugees such as quota and those coming under other prerequisites. Previous studies have shown that asylum seekers are at increased risk of developing mental illnesses, but these studies have often compared with migrants who have been in the country for a longer period, and as a result, potentially made the comparison possibly biased [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The increased risk for asylum seekers found in our study could be partly explained by their uncertain residence status and uncertainty regarding their asylum application [\u003cspan additionalcitationids=\"CR28 CR29\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Asylum seekers are confronted with more unfavorable circumstances when it comes to, for instance, housing opportunities, health care education and working conditions, compared to those who have been granted residence permit. Legal status has shown to be a significant predictor of poor mental health, even when controlling for pre-and post-migration factors such as traumatic events, post migration resources and social desirability [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Remarkably, severe levels of mental illness were more commonly reported than mild and moderate levels of mental illness, for both groups, 52,9% and 35,7% respectively, indicating higher intensity of symptoms.\u003c/p\u003e \u003cp\u003eOur finding also corroborates previous literature on the differences in risk of mental illness by country or region of origin. Regional differences in both reported mental illness, experienced traumatic events and use of psychiatric care have been found [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR32\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. A recent Finish study found asylum seekers from Africa (excluding North Africa) reported traumatic events more frequently than asylum seekers from other regions [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Moreover, refugees from Syria, Iraq, and Afghanistan were most likely to exhibit a positive screening for mental health symptoms compared to refugees from other countries such as Somalia, Myanmar and D.R. Congo [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Various hypotheses have been postulated to explain this, including socioeconomic factors, cultural differences, differences in social support and coping style, discrimination, and varying vulnerabilities among different subgroups [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur study expands on prior research examining differences by gender and age, with women reporting higher odds for mental illness, compared to men. Both female gender and older age have been linked with poorer psychological health in refugees, though there are some studies that demonstrate no effect of gender on outcomes [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan additionalcitationids=\"CR35\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. It has been suggested that the gender differences in mental health are linked to roles and social positions, where women are limited in their role and lack of choice. Literature has been devoted to explaining the gender gap as a result of exposure to trauma and lack of self-control. Indeed, the broader social determinants of health associated with restricted economic opportunities, insecure housing, location of residence and migration status can have a profound influence on one\u0026rsquo;s sense of control [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. It could also be that women may be at higher risk due to increased sexual victimization and domestic violence. Considering age, our results are consistent with past work, inciting greater vulnerability in older people. This could be due to greater accommodation of traumas over time [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] for older people, or younger refugees being less affected by the enduring stresses of displacement.\u003c/p\u003e \u003cp\u003eDetermination of illness severity could have important clinical implications when it comes to, for example treatment strategies or prioritizing care when resources are scares. Considering this aspect may be useful in planning public health interventions targeting this vulnerable group. Furthermore, our findings could be applicable to individuals without legal document/status (former asylum seekers who have been rejected asylum/or others without legal status) as these individuals are often confronted with similar challenges and have same health care entitlements as asylum seekers.\u003c/p\u003e\n\u003ch2\u003eLimitations And Strengths\u003c/h2\u003e\n\u003cp\u003eThe study has many strengths: first, data is generated through a validated screening instrument specifically developed for refugee populations. Although the study was conducted only in one region in Sweden, it was conducted in two primary healthcare centers that together executes a high number of HE in Stockholm, in addition to including both asylum seekers and other refugees, leading to increasing the generalizability of the findings. Both asylum seekers and other refugees are represented in our study, giving the study a good representation in terms of migrants. Data was collected with the help of health care professionals working in the centers and there was no need for outreach methods, which minimizes the risk of bias or misunderstanding of the data.\u003c/p\u003e \u003cp\u003eWhile this study provides important information on differences in mental illness by legal status there are several limitations. We had no information on risk and resilience factors related to participants\u0026rsquo; mental health such as trauma experiences, length of stay in Sweden, educational level and other known determinants of mental health. Another limitation is possible selection bias as the RHS-13 screening was part of a voluntary HE and those opting out of HE might have different mental health profiles. In addition, we do not have information about the few who took part in an HE but declined screening with the RHS-13. It could be that their mental health profiles too were different from those that accepted screening.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eLegal status moderated mental health illness. Asylum seekers were at greater risk of mental illness compared to quota and other refugees. Legal status as well as female gender and region of origin were associated with migrant\u0026rsquo;s mental health. Our findings call for screening of mental illness in this vulnerable group. Additionally, consideration of legal status should be considered to better understand and plan interventions targeting asylum seekers and refugees\u0026rsquo; mental health.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eEuropean Union, \u003cstrong\u003eEU\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGross National Income, \u003cstrong\u003eGNI\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHealth examination, \u003cstrong\u003eHE\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMedical record, \u003cstrong\u003eMR\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePost-traumatic stress disorder, \u003cstrong\u003ePTSD\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRefugee Health Screener, \u003cstrong\u003eRHS-13\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUnited Nations, \u003cstrong\u003eUN\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUnited Nations High Commissioner for Refugees, \u003cstrong\u003eUNHCR\u003c/strong\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical permission for the project was granted by the Regional Ethics Committee, Stockholm (Dnr:\u0026nbsp;2019\u0026ndash;01408).\u0026nbsp;All procedures performed in the studies were in accordance with the ethical standards of the institutional and/ or national research committee and with the 1964 Helsinki declaration and its later amendments. Informed consent to participate was not required since this study uses already existing administrative data, that is routinely collected within healthcare, and not personally identifiable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the two participating health care clinics in region Stockholm, but restrictions apply to the availability of these data, which were under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of the\u0026nbsp;Swedish Ethical Review Authority\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study has been funded by Stockholm Region, (grant 2018\u0026ndash;0034, project 1513). The funding did not influence the study design, data collection, analysis, interpretation of data or preparation of the manuscript.\u0026nbsp;Open Access funding provided by Karolinska Institutet.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHH and KL designed the study. SD, JS and AH collected the data. SD conducted data analysis and drafted the manuscript. ACH contributed critically to the interpretation of results. All authors approved the final version of the manuscript to be published.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eUnited Nations High Commissioner for Refugees. Global Trends. Forced displaced in 2018. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.unhcr.org/5d08d7ee7.pdf\u003c/span\u003e\u003c/span\u003e. Accessed 26 May 2020.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eTingh\u0026ouml;g P, Malm A, Arwidson C, Sigvardsdotter E, Lundin A, Saboonchi F. Prevalence of mental ill health, traumas and postmigration stress among refugees from Syria resettled in Sweden after 2011: A population-based survey. BMJ Open. 2017;7(12).\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSwedish Migration Agency. 2018 EMN Annual Report on Migration and Asylum 2018 \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://ec.europa.eu/home-affairs/sites/homeaffairs/files/00_eu_arm2019_synthesis_report_final_en_0.pdf\u003c/span\u003e\u003c/span\u003e. Accessed 25 January 2022.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eEurostat. Asylum decisions in the EU. EU Member States granted protection to more than 330 000 asylum seekers in 2018.Eurostat press release. 2019 \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://ec.europa.eu/eurostat/documents/2995521/7233417/3-20042016-AP-EN.pdf/\u003c/span\u003e\u003c/span\u003e. Accessed 26 May 2020.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eBogic M, Njoku A, Priebe S. Long-term mental health of war-refugees: a systematic literature review. 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Prevalence of depressive symptoms and symptoms of post-traumatic stress disorder among newly arrived refugees and asylum seekers in Germany: systematic review and meta-analysis. BJPsych Open. 2021;7(3):1\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHollander A-C, Bruce D, Burstr\u0026ouml;m B, Ekblad S. The association between immigrant subgroup and poor mental health- A population-based register study. J Nerv Ment Dis. 2013;201(8):645\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003ePosselt M, Mcintyre H, Ngcanga M, Lines T, Procter N. The mental health status of asylum seekers in middle- to high-income countries: a synthesis of current global evidence. Br Med Bull. 2020;1\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDuggal AK, Kirkbride JB, Dalman C, Hollander A-C. Risk of non-affective psychotic disorder and post-traumatic stress disorder by refugee status in Sweden. 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Scand J Public Health. 2020;48(7):677\u0026ndash;87.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDelilovic S, Kulane A, \u0026Aring;sbring N, Marttila A, L\u0026ouml;nnroth K. What value for whom? - Provider perspectives on health examinations for asylum seekers in Stockholm, Sweden. BMC Health Serv Res. 2018;18(1):1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eGovernment Offices of Sweden. Lag (2008:344) om h\u0026auml;lso- och sjukv\u0026aring;rd \u0026aring;t asyls\u0026ouml;kande m.fl. Svensk f\u0026ouml;rfattningssamling 2008:344 (Health and medical care for asylum seekers and others act.).2008. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.riksdagen.se/sv/dokument-lagar/dokument/svensk-forfattningssamling/lag-2008344-om-halso--och-sjukvard-at_sfs-2008-344\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHollifield M, Verbillis-Kolp S, Farmer B, Toolson EC, Woldehaimanot T, Yamazaki J, et al. The Refugee Health Screener-15 (RHS-15): Development and validation of an instrument for anxiety, depression, and PTSD in refugees. Gen Hosp Psychiatry. 2013;35(2):202\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHollifield M, Toolson EC, Verbillis-Kolp S, Farmer B, Yamazaki J, Woldehaimanot T, et al. Effective screening for emotional distress in refugees: The Refugee Health Screener. 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BMC Psychiatry. 2012;12.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHeeren M, Wittmann L, Ehlert U, Schnyder U, Maier T, M\u0026uuml;ller J.Psychopathology and resident status \u0026ndash; comparing asylum seekers, refugees, illegal migrants, labor migrants ,and residents. Compr Psychiatry. 2014;55(4):818\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eGaroff F, Skogberg N, Klemettil\u0026auml; A, Lilja E, Ahmed Haji Omar A, Snellman O, et al. Mental health and traumatization of newly arrived asylum seeker adults in finland: A population-based study. Int J Environ Res Public Health. 2021;18(13).\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSchlaudt VA, Bosson R, Williams MT, German B, Hooper LM, Frazier V, et al. Traumatic experiences and mental health risk for refugees. Int J Environ Res Public Health. 2020;17(6).\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDykxhoorn J, Hollander A-C, Lewis G, Magnusson C, Dalman C, Kirkbride JB. Risk of schizophrenia, schizoaffective, and bipolar disorders by migrant status, region of origin, and age-at-migration: a national cohort study of 1.8 million people. Psychol Med. 2019;49(14):2354\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSteel Z, Chey T, Silove D, Marnane C, Bryant RA van OM. Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis. JAMA. 2009;302(5):537\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHollander A-C, Bruce D, Burstr\u0026ouml;m B ES. Gender related mental-health differences between refugees and non-refugee immigrants- A cross-sectional register-based study. BMC Public Health. 2011;11(1):180.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eJarallah Y, Baxter J. Gender disparities and psychological distress among humanitarian migrants in Australia: A moderating role of migration pathway? Confl Health. 2019;13(1):1\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003ePorter M. Global Evidence for a Biopsychosocial Understanding of Refugee Adaptation. Transcult Psychiatry. 2007;44(3):418\u0026ndash;39.\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"refugees, asylum seekers, mental health, screening, primary care","lastPublishedDoi":"10.21203/rs.3.rs-1664429/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1664429/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e There are about 80\u0026nbsp;million forcibly displaced people globally. Migrants are at heightened risk for mental illness compared to host country populations. While previous research highlights the need to adequately assess mental illness, few have taken the diversity among newly arrived migrants into account. This study aims to estimate the prevalence and associated risk factors of mental illness among asylum seekers, quota and other refugees in Stockholm, Sweden.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e Using a cross-sectional design, data was collected as part of a mental health screening initiative integrated into routine health examinations in two health care clinics in Stockholm. Screening was done with the Refugee Health Screener, RHS-13, a validated instrument for assessing mental health in refugee populations. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e A total of 1163 individuals were eligible for screening, of whom 566 participated (response rate 48.6 %). Among the participants 47.9% indicated symptoms of mental illness. Compared with asylum seekers, the risk of mental illness was lower among quota and other refugees (adjusted odds ratio 0.60, 95% confidence interval 0.37-1.00). Female gender, higher age, coming from a middle-income country and low probability of being granted asylum were significant predictors of mental illness.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Refugee legal status is associated with mental illness. Asylum seekers are at greater risk of mental illness compared to quota and other refugees. Our findings call for screening for mental illness among newly arrived migrants, especially among those with pending residence permits.\u003c/p\u003e","manuscriptTitle":"Is legal status associated with mental illness among newly arrived refugees in Sweden: an epidemiological study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-05-25 16:49:43","doi":"10.21203/rs.3.rs-1664429/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-09-12T14:48:35+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-09-07T10:20:43+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-06-30T15:32:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"62d0f131-c389-4c58-9b9e-cc6de3f50abd","date":"2022-06-20T14:10:22+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-06-16T15:49:41+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-06-16T15:42:17+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2022-05-23T10:29:26+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-05-23T10:23:04+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychiatry","date":"2022-05-17T08:07:06+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"224c03f4-41dd-4c0a-8f5a-1f87bb2b974c","owner":[],"postedDate":"May 25th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-10-16T20:12:02+00:00","versionOfRecord":{"articleIdentity":"rs-1664429","link":"https://doi.org/10.1186/s12888-023-04679-y","journal":{"identity":"bmc-psychiatry","isVorOnly":false,"title":"BMC Psychiatry"},"publishedOn":"2023-03-24 20:08:14","publishedOnDateReadable":"March 24th, 2023"},"versionCreatedAt":"2022-05-25 16:49:43","video":"","vorDoi":"10.1186/s12888-023-04679-y","vorDoiUrl":"https://doi.org/10.1186/s12888-023-04679-y","workflowStages":[]},"version":"v1","identity":"rs-1664429","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1664429","identity":"rs-1664429","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}