Introduction
Migration is a process of displacement, stress, and loss in time and space (Bhugra and Becker, Reference Bhugra and Becker2005). Migration includes multiple stresses and factors that may affect the mental health of individuals. The areas that might be affected are, for example, the social support system, changes in identity, concept of self, and adjustment to a new culture. These factors play an important role in the increasing rates of mental illness among immigrants (Bhugra, Reference Bhugra2004).
The whole migration process affects different individuals in different ways and results in different individual responses (Bhugra and Arya, Reference Bhugra and Arya2005). The migration process may cause poor mental health before, during, and after migration. The health consequences of forced migration can be different from those of voluntary migration (Silove et al., Reference Silove, Sinnerbrink, Field, Manicavasagar and Steel1997; Araya et al., Reference Araya, Chotai, Komproe and De Jong2007). Reasons and preparedness for migration differ, and although the social contexts migrants face in a new country may be similar, each individual has unique experiences and adapts uniquely to the new social contexts. Furthermore, cultural and social adjustments that each person must make are also factors that have an important influence on the mental health of immigrants (Bhugra and Arya, Reference Bhugra and Arya2005). A study investigating the mental health of immigrants from Poland and Vietnam in Germany showed that both groups have a higher prevalence of anxiety and depression than the native German population. However, the nature of the problems reported by the two groups of immigrants differed (Wittig et al., Reference Wittig, Lindert, Merbach and Brahler2008). Other factors known to be associated with psychological distress and mental health problems in immigrants include under-employment or unemployment (Jafari et al., Reference Jafari, Baharlou and Mathias2010) and job dissatisfaction (de Castro et al., Reference De Castro, Gee and Takeuchi2008).
Trauma and torture before migration may have a significant influence on health, even after many years of resettlement in a new country (Mollica et al., Reference Mollica, Sarajlic, Chernoff, Lavelle, Vukovic and Massagli2001; Marshall et al., Reference Marshall, Schell, Elliott, Berthold and Chun2005). Kurdish immigrants to Western countries have almost always been exposed to persecution, forced assimilation, and forced resettlement in their home countries for many years (Gunter, Reference Gunter1990; McDowall, Reference McDowall1992; Bozarslan, Reference Bozarslan2000). Kurdish political refugees began arriving in Sweden in the early 1970s.
This qualitative study was an effort to further explore findings of earlier quantitative studies and ethnographic observation by members of this research group. In these quantitative studies, we found higher prevalence of anxiety and psychological distress in Kurds in Sweden than in Swedes (Taloyan et al., Reference Taloyan, Johansson, Johansson, Sundquist and Kocturk2006; Reference Taloyan, Sundquist and Al-Windi2008). Moreover, the first author's ethnographic observations suggested that Kurdish men felt misjudged on the basis of negative stereotypes, and Kurds who migrated to Sweden for political reasons were more often men than women. We also believed that the findings of this qualitative study on Kurdish men would be applicable to other immigrant groups from countries with wars and/or other conflicts, especially groups who might be stereotyped in their new country. We planned to start investigating the mental health issues of Kurdish immigrants by studying the experiences of Kurdish men and then to continue by studying the experiences of Kurdish women.
Methods
Participants
Identifying Kurds in Sweden
It is impossible to identify Kurds in Sweden using official records. In Sweden, immigrants are registered as citizens of the countries from which they come. Registration by ethnicity is absent from official Swedish statistics.
Snowball sampling
The first contact person was a member of a Kurdish cultural network who was asked to list others with similar characteristics, and these persons were approached for interviews. This procedure, called snowball sampling (Biernacki, Reference Biernacki1981), was repeated from one participant to the next and so on. Snowball sampling is particularly useful in research populations that can be difficult to find in other ways, such as via official records (Khavarpour and Rissel, Reference Khavarpour and Rissel1997). The interviews and analyses were conducted between 2005 and 2007. We used pseudonyms in the presentation of quotes in this study.
Focus group
Initial data were collected in a focus group interview that was conducted by the first author and an observer. Four potential focus group participants were found via snowball sampling. Each of them received a letter with information and a semi-structured interview guide that listed open questions that they would be asked to discuss freely during the interview. Topics included the men's experiences in Sweden, values and norms, and cultural identity, and started with the question ‘How do you feel?’. In response to the open questions, each participant described his own perceptions and opinions. Participants listened to each other and responded in a lively back-and-forth discussion. They agreed about some matters and disagreed about others. The interview, led by the first author (MT), was held in Swedish. The outside observer was present to gather information about the interviewer's objectivity and additional information about the interview, such as the mood and body language of the participants. The outside observer is a usual feature of focus group interview methodology (Barbour, Reference Barbour2001). Copies of the transcript were sent to all participants to check whether they thought the transcript was in agreement with the original conversation. All participants sent the copies back with their approval.
In-depth individual interviews
The focus group discussion showed that each participant wished to tell his own story about his experiences of the migration process. Furthermore, it was clear that not all of the participants were comfortable with talking about deeper explanations and definitions of events and feelings in the context of a focus group. After discussion within our research team and consultation with several researchers knowledgeable about qualitative methods, we decided to continue data gathering via in-depth interviews. Questions that arose from the focus group interview were used as a guide for the initial in-depth interviews. A semi-structured interview guide was designed by MT, NSS, and LMJ.
Ten individual in-depth interviews were conducted. They ranged from 60 to 120 min in length and were audiotaped. All participants were contacted by the first author by phone and were free to choose between Swedish and Kurdish as the interview language. Each participant was informed of the purpose of the research and interview, was assured confidentiality, and was asked to interrupt whenever he wanted to. A total of seven chose to be interviewed in Swedish and three to be interviewed in Kurdish. All interviews were conducted by the first author (MT) under the supervision of an expert in qualitative research methodology (NSS).
The three Kurdish-language interviews were translated to Swedish and back-translated to Kurdish by the first author and a person who was not involved in the research, who had Kurdish as his mother tongue, and who had a good command of Swedish. Translation of all interviews from Swedish to English was undertaken by the first author. Selected key quotations were checked by two native speakers of English, both of whom work as professional editors and have a good command of Swedish.
After the model was developed, the first author returned to informants from nine of the in-depth interviews (the 10th declined to participate) and asked whether the model and the categories in the model were in accord with their perceptions. At this point, three new participants were recruited to test the validity of the model and to check whether there was any need to modify the model (modifiability) (Lomborg and Kirkevold, Reference Lomborg and Kirkevold2003). They were chosen on the basis of the same criteria used to select the other participants. Validation was undertaken on an individual basis rather than in a focus group, as this was what the participants preferred.
Analysis
The method used for data analysis was the qualitative, inductive, constant comparative method known as Grounded Theory (GT) (Strauss, Reference Strauss and Corbin1990). In accordance with GT methodology, in-depth interviews and analyses of data from the in-depth interviews occurred concurrently.
Two members of the research team (MT and NSS) performed data analyses; NSS has a great deal of experience with the GT method (Saleh-Stattin, Reference Saleh-Stattin2001). The data analyses began with coding, which consists of line-by-line reading and extraction of important units of meaning from the transcribed interviews. Participants’ own words were used as much as possible in the coding process. Subcategories were then generated using the codes. Next, relationships between the subcategories were analyzed and the related subcategories were grouped into core categories (see
Box 1). Afterward, a model was developed that includes both subcategories and core categories. During analysis, we kept notes (memos) explaining each step in the analytical process. The memos also detailed what kind of individual should be interviewed next and what categories should be added to the interview questions.
Box 1
Throughout the entire analysis process, including the development of the model, we continuously went back to the transcriptions of the original interviews to check the accuracy of the categories, subcategories, and coding against the language and content of the original interviews. This continuous dialogue between researcher and data is in accordance with GT methodology (Charmaz, Reference Charmaz2006).
After the analysis of each new interview, the interview guide was adjusted to include questions about any newly generated themes. For example, after interview number 3, we added three new questions: ‘What do you think about education?’, ‘Do you feel free in Sweden?’, and ‘If yes, why?’. After interview number 4, we added the question ‘Do you accept yourself, your background, and the reason why you are in Sweden?’. And after interview number 5, we added further questions, including: ‘Do you feel lonely?’ and ‘How do you deal with your feelings?’.
In this study, we used theoretical sampling, a method that involves choosing who will be interviewed next and choosing interview questions on the basis of gaps in data and holes in theories that are found during the analysis of the previous interviews. For instance, if analysis indicates that there is insufficient information on the impact of education in life, then the next informant would be chosen (via snowball sampling as described above) because of his experience with education.
The emerging categories were reviewed by the expert in psychiatry and psychotherapy (LMJ) and a general practitioner with extensive research experience in the field of family medicine (AAW). Furthermore, an expert in social anthropology was asked to assess the development of the subcategories and the relationships between subcategories on the basis of the original text. The purpose of the assessment was to help ensure the ‘fit, work, modifiability and relevance’ (Lomborg and Kirkevold, Reference Lomborg and Kirkevold2003) of the subcategories.
In GT, interviews continue until theoretical saturation is reached in the categories (Strauss, Reference Strauss and Corbin1998). Theoretical saturation occurs when nothing arises in the last interview that has not been covered in the previous interviews. In this study, theoretical saturation was reached after interview number 8. Nevertheless, we continued with two additional interviews to be sure that saturation had actually been achieved. Analysis of these interviews confirmed that saturation had been achieved.
To test the reliability of categories and subcategories, the first author and NSS collaborated to examine the data in order to assess whether or not the coding, interpretations, and conclusions were supported by the empirical data (Lincoln and Guba, Reference Lincoln and Guba1985). During the entire analysis process, the first author and co-authors were careful to maintain their awareness of reflexivity, that is, to keep in mind and to examine their own positions and roles as researchers. Ideally, a researcher is as an objective tool for data collection and analysis (Holloway and Freshwater, Reference Holloway and Freshwater2007). Awareness of one's own position and role as a researcher can help create relationships between the researcher and participants that are based on mutual trust and respect (Ø´vretveit, Reference Ø´vretveit1998), and we believe that this was the case in our study.
Ethical considerations
The Regional Ethical Committee of the Karolinska Institute, Stockholm, approved the study in October 2004 (reference number 04-617/5).
Findings
A total of 17 men participated in the study. We conducted one focus group interview with four men and individual in-depth interviews with a further 10 men. An additional three men who had participated neither in the focus group nor in the in-depth interviews were recruited to help validate the model (see the section ‘Analysis ’ above for details). All participants were Kurdish men between the ages of 24 and 60 years who were born in south-eastern Turkey. Ten of the participants were political refugees. Number of years of residence in Sweden ranged between 8 and 28. In our sample, 12 persons were married, four were divorced, and one was unmarried. Fourteen of the men had children. All of them were employed at the time of the interviews.
As shown in Model (see
Figure 1), the analysis identified two core categories: protective factors for good mental health and risk factors for poor mental health. Each core category contained multiple interlinked categories and subcategories. Protective factors for good mental health consisted of four categories: satisfaction with oneself, sense of belonging, creation and re-creation of Kurdish identity, and sense of freedom. Risk factors for poor mental health also included four categories: dissatisfaction with Swedish society, lack of sense of freedom, yearning, and worry over the current political situation in the home country. The two core categories were not mutually exclusive; neither were the categories or subcategories. For example, a single individual could express both an experience of satisfaction with oneself (a protective factor for good mental health) and dissatisfaction with Swedish society (a risk factor for poor mental health). Factors within the model were also interlinked in complex ways. This section will first describe the protective factors for good mental health, then the risk factors for poor mental health. Next, the complex links will be discussed in greater detail. A number of the subcategories within the model are also partly discussed in our recently published study on coping strategies in Kurdish men (Taloyan et al., Reference Taloyan, Johansson, Saleh-Stattin and Al-Windi2010).
Figure 1
One of the protective factors for good mental health was satisfaction with oneself. The following subcategories were included in the category satisfaction with oneself: acceptance of self, acceptance of past and present, finding a function, creating a family, reaching internal safety and confidence, and sense of being a Kurd.
Analyzing the past and accepting the reason for forced migration was one way to achieve satisfaction with oneself. One of the participants explained it like this:
A sense of internal safety, security, and confidence is dependent on how each person works through his or her thoughts and feelings… . Do I know myself, where I come from, why I'm here? Analyzing yourself, going back to the roots, analyzing the country you were in and fought [for]. When you've analyzed that, then analyze why you ended up here, in this country… . More than anything else, acceptance of what happened, acceptance of yourself.
(Karwan)
Several informants expressed acceptance of self, despite the stressful situation in the new country. This stressful situation could include feeling labeled as a member of a group that had a negative reputation rather than being seen as an individual. Kurdish men's perceptions of being labeled negatively are discussed in more detail later in the text. One highly educated man who came to Sweden as a political refugee about 20 years before the interview stated:
… I don't feel any identities within myself that threaten me, the person I am… . Some identities can be a threat. It depends on the context you live in, which society you live in… . That's what a threatening identity is: how others see you! If they see you as an individual or one of a group that has actually failed, that has a certain kind of behaviour.
(Karwan)
The sense of being a Kurd plays an important part in further descriptions of satisfaction with life and oneself. And belonging to the Kurdish ethnic group was the next factor that appeared in many of the subcategories in the model. ‘Being a Kurd means everything to me,’ said a man who had been imprisoned for 10 years in Turkey for activities in the Kurdish political party. Keeping up political activities that were related to being a Kurd contributed to finding meaning in life and a sense of freedom:
From a political perspective … my work here for my people is more important than work in my homeland… . My life is meaningful. If I didn't feel like a Kurd, I wouldn't agree to an interview to shed light on the question about Kurds. I agreed to the interview because you are a Kurdish woman doing research about Kurds. This is very important to me.
(Saman)
For many of the men, being Kurdish was closely linked with the issue of language, namely, with the preservation and development of Kurdish language and literature in Sweden. In the final model, use of the Kurdish language was linked to a sense of freedom. One man summarized why he was satisfied with his life's work, which was writing in Kurdish, the language that was so important to him:
It has been said that the Kurdish language is nothing. I proved the opposite. I have written the best novels in Kurdish… . I proved that it is a literary language … I proved that you can conduct politics in Kurdish, you can write in Kurdish, be an important author.
(Mirza)
Moreover, use of Kurdish as a legal and officially recognized language gave energy and strength:
I'm very satisfied with my life. For instance, coming here and being interviewed by you gives me lots of energy. It gives me energy that you are speaking Kurdish with me officially; I feel powerful and strong.
(Amin)
Probably because the Kurdish language was and still is officially forbidden in Turkey, it is the first and most central factor in the process of creating and re-creating a Kurdish identity in Sweden. One 50-year-old man says:
…I am engaged in educational issues and the Kurdish language all the time. You commit your whole life to creating an identity, a Kurdish identity in a foreign country. You're passionate about it, you work for it!
(Nasdar)
In addition to the freedom to speak the Kurdish language, being able to present oneself as a Kurd in Sweden was linked to a sense of freedom. When he was asked if he felt free, one participant said:
Yes, I can express myself; I can actually think how I want without being punished. I can go out and say that I'm a Kurd, I want a free Kurdistan—without being punished for it. … I have freedom; I have a lot of freedom compared with in Kurdistan.
(Karwan)
Most participants in this study expressed a desire for Kurds in Sweden to organize as a group in order to maintain their Kurdish culture and identity, including the language. This is particularly tangible if an individual has never been integrated into Swedish society:
If I'm not integrated; I'm not a part of the Swedish society, [then] I look to my own community, and [if] my community is divided, then I'm affected; I get angry. I think that Kurdish society, groups in Sweden should be like a colony: [consisting of all] European Kurds. If we can keep our Kurdish identity for a hundred years, then we can also affect Kurds in our homeland… . But if they [Kurds in Sweden] are assimilated, how can they achieve that?! We don't have anything! We are a nation with a forbidden language!
(Amin)
Hence, achievement of a meaningful life in Sweden was connected to a sense of belonging – self-confidence as a Kurd, a sense of freedom, and satisfaction with oneself.
A number of factors in Swedish society contributed to what the men described as poor mental health. Factors such as feelings of being stereotyped in the mass media and in society and a constant sense of being stranger living in Sweden were subcategories of dissatisfaction with Swedish society. The mass media picture of Kurdish men came up to some extent, typically in connection with a specific chain of events:
…a few years ago there were those murders, so-called honour killings. Then all Kurdish men were assumed to be potential murderers or honour-murderers. Then [my] identity was threatened, in a group or with others who see that I'm a Kurd, because others look at that … yes, it felt pretty damn bad! … The identity that you are, a Kurd, can actually be a threat to yourself, just like I said – how society looks at you… . You were angry at the mass media, at society, that everyone was assumed to be a potential murderer.
(Karwan)
In addition, the interviewer (MT) observed that participants generally reacted defensively at first to the question about the picture of Kurdish men in Swedish society. As the conversations progressed, it became clear that the men felt affected by a widespread negative image of Kurdish men as honor killers. A taxi driver who typically meets a lot of Swedish-born customers every day explained:
…if a person wants to describe Kurds, they start with honour killing like the weather (How's the weather today?) that older Swedish women usually start talking about as soon as they sit down in the taxi. If some Swede talks with a Kurd, the conversation starts with honour killing.
(Mamo)
Despite having lived in Sweden for a long time, the feeling of not being regarded as Swedish was constantly present in the lives of most of the men:
I have lived in this country more than half of my life, I work here, my children were born here. But I still don't feel like this is my country. You don't feel secure as a person… . Most of all, I miss fellowship with Swedes. I mean in society, when you see that there is discrimination against a group of people, then you see that you are one of them no matter what [else] you are. You are also in that group.
(Darwish)
At the same time, the quotations above also describe feelings of discrimination, another subcategory of dissatisfaction with the host society. The experience of discrimination, especially on the labor market, is a frequent theme in some of the participants’ stories. A high level of education does not always guarantee employment, as one of participants experienced when he looked for a job in an urban area just outside the city of Stockholm:
It doesn't matter that I'm educated… . When they looked at my education, they said that I'm overqualified… . I don't get the job I want; the job that is outside your profession, there you're overqualified… . It feels really awful. That's what hurts.
(Darwish)
The same participant said that his attempts to integrate into Swedish society through housing also failed because of discrimination.
Only immigrants live in the area where I got an apartment. So I'm forced to separate myself from the masses, Swedish society, because they push me out all the time.
(Darwish)
Furthermore, the men explained that they might also feel like strangers in their home country if they returned:
Sixteen years is a long time… . Even if I go, I'll be a stranger there, too. This is a heavy burden. When you move and stay away for a long time, you're neither here nor there. Neither church nor mosque.
(Daran)
The majority of the participants expressed a desire to return home despite changes in the home country and the fact that for some, return is currently not possible. When asked if he planned to return when he first migrated, one political refugee said:
Yes, all the way to my sixth year in Sweden, I didn't go to school to learn Swedish either. I planned that when my children could take care of themselves here, I would return to my homeland. Now, you see [that] after 22 years, we have still not returned.
(Saman)
Not all participants experienced a sense of freedom in Sweden. This lack of a sense of freedom was expressed by one of the respondents as ‘psychological torture’:
I was tortured [in Turkey], but it didn't hurt as much as what people did in Sweden. I was prepared for the Turks, for the system, for the torture. But here it was different: it's not … you're tortured psychologically. And that's the worst! And everyone's been through it!
(Xelef)
Participants indicated that feelings of guilt and duty were still alive, especially as the political, economic, and social situation in the home country was still unstable. To be active and to make a contribution for Kurdish people in the home country was described as a way of dealing with these feelings:
The range of support that I got … I couldn't give back to friends, relatives, the village, the environment… . I have found a balance; I can do the best here just now, not there. My goal was that by the age of 50, I would persuade, give active support to 50 [Kurdish] young people [in Sweden] to study at the university… . I have succeeded.
(Nasdar)
Multiple kinds of connections were observed within the model. For instance, analyses showed connections between the categories within each core category. The quotation below shows the relationship between three protective factors for good mental health: satisfaction with oneself, sense of freedom, and sense of belonging:
I am proud to be part of Swedish society and of reaching my goal—my education. But I think that the most important thing, the most glorious feeling I have is when I am included… . Sure, I am proud of my success. I think that the ultimate purpose for me is peace in the world for all people, for Kurdish people with the right to their own language, to their own culture, to their own country, and the right to be who they want to be!
(Bahat)
Subcategories could also be interlinked with other factors in complex ways. For instance, ‘discrimination,’ a subcategory of ‘dissatisfaction with Swedish society,’ could lead to other risk factors for poor mental health, such as ‘lack of sense of freedom,’ which in turn could lead to ‘yearning.’
The factors that had an impact on experiences of mental health were generated by the authors from the men's individual life journeys. For the individual men, the process of describing one's personal life journey was in itself a journey, that is, part of the process of creating one's social and ethnic identity. A number of the men indicated that this was the first time they had told their story, and that this opportunity gave them feelings of relief and confirmation on the individual level. Analysis of the men's stories shows that two important self-help skills were the ability to make sense of daily life and to find a meaningful function in life. Furthermore, the men indicated that it was of great importance feel that they were seen as individuals, were full participants in society, and could contribute to their own culture and development in their home country. If men found ways to feel satisfied with themselves and to maintain strong self-esteem and self-confidence, they could feel well even if they did not feel integrated in Swedish society.
Discussion
This study is the first to describe how Kurdish men from Turkey perceive the events of their lives and their experiences of mental health issues in Sweden during the whole migration process. The Kurds come from a collectivist rather than individualistic culture and society with a history of failed political, economic, and social struggles for freedom, autonomy, and independent states in Iran, Iraq, and Turkey. Kurds in these countries have a history of suffering and persecution (McDowall, Reference McDowall1992; Bozarslan, Reference Bozarslan2000).
After the military coups in Turkey in 1981, many of the participants in the study joined one of the several Kurdish political groups, which had the general aim of achieving an independent Kurdish state. The majority of the people in these groups, including the participants in this study, emigrated at relatively young ages (most in their 20s). Many of them experienced trauma from severe mental and emotional stress and physical torture in their home country as a result of the military coup and leaving behind their home country, family, and friends (Taloyan et al., Reference Taloyan, Johansson, Saleh-Stattin and Al-Windi2010).
The principal finding in this study was the identification of factors protective for mental health and risk factors for poor mental health in Kurdish men. Our results indicate that the participants in our study have a strong sense of ethnic identity. Participants expressed a sense of satisfaction with themselves when they were involved in activities related to the creation and re-creation of their Kurdish ethnic identity, when they interacted with Swedish society, and when they experienced a sense of belonging. On the other hand, several factors contributed to poor mental health, including worry about the political situation in the home country, yearning for the home country, and a negative image of Kurds in Swedish society and the mass media.
In Sweden, the Kurdish immigrant group is well known. Sweden has been referred to as the mother of Kurdish culture in a number of Swedish newspaper articles. This is probably because Kurdish culture blossomed during the early years of Kurdish migration to Sweden, in large part because of the publication of a great deal of literature in Kurdish in Sweden. The political situation and socio-economic conditions faced by Kurds in their countries of origin were and still are often mentioned in mass media sources in Sweden.
On the other hand, many of the participants said that lively debate in Sweden about Kurdish culture and values had resulted in a negative stereotype of Kurdish men. As a result of this stereotype, they often felt viewed as members of a negative group rather than as individuals. Furthermore, a history of political persecution, trauma, and multiple kinds of discrimination in their home countries may affect the mental health of Kurdish immigrants, particularly men, even after resettlement in a new country (Marshall et al., Reference Marshall, Schell, Elliott, Berthold and Chun2005).
Another source of poor mental health common to Kurdish men in Sweden was a lack of sense of belonging. Many Kurdish men decided to flee – to leave their home country for a few years but to return later. They came to Sweden and began a journey of waiting.
As soon as they moved to Sweden, the Kurdish men were free to openly identity themselves as Kurdish, and they began a process of creation and re-creating their identity. They began to develop connections with their own Kurdish political and/or cultural group and with Swedish society. This new freedom was along with plans to return to their home country, produced a strong sense of ethnic identity and belonging. As soon as they arrived in Sweden, they were free to present themselves officially as Kurds to the authorities, mass media, and society in general. This helped strengthen Kurdish identity. This new freedom, along with plans to return to their home country, produced a strong sense of ethnic belonging, of ethnic identity.
One way of fighting back against the system in the home country was to continue activities related to both communication and Kurdish ethnic identity, such as writing books in Kurdish and establishing Kurdish political and cultural organizations. Such activities were made possible by financial support from the Swedish government. As previously noted, even though the Kurdish men in the study came from a collective society with a collective identity (big families and big clans), they still considered themselves as a part of their home country – Kurdistan. ‘My home country is a part of me; I am a part of my home country’ was an expression that was repeated by most of the participants in this study. Several factors strengthened the men's emotional ties with their home country [Kurdistan] and made the men feel that it was more meaningful to contribute to their home country from Sweden than to return to Turkey and contribute there. These factors included an unchanged political, economic, and social situation in the home country; a feeling of not being able to relate to Swedish society; and discrimination in the labor market and in housing in Sweden.
Previous research
Our findings are in accord with the findings of previous studies on the impact of migration on mental health. A qualitative study on Iranian immigrants in Canada showed that the many challenges faced when coming to a new community can cause mental problems. Immigration-related risk factors such as inadequate English, under-employment or unemployment, cultural differences, and a lack of social support caused unsuccessful acculturation (Jafari et al., Reference Jafari, Baharlou and Mathias2010).
In an overview of migration and mental health, Bhugra and Jones divided factors that may be associated with vulnerability to psychiatric illness in migrants into two levels: macro-factors and micro-factors. As macro-factors, the authors cited preparation for migration, the migration process, and the acceptance of migrants by the new society. Factors such as ‘personality traits,’ ‘cultural identity,’ ‘social support,’ and ‘acceptance of others in their own ethnic groups’ were considered to be micro-factors (Bhugra and Jones, Reference Bhugra and Jones2001: p. 216).
According to Bhugra and Jones, social support from a society with strong ethnic communication in which people do not express their emotions to a great degree may protect mental health in the beginning and during the relapse period. In this study, our results indicated that an ethnically dense society is a protective factor even after many years in the host country. Separation from family, and thus patterns of insecure attachment and lower self-satisfaction and achievement, may also impact mental health. Sondergaard et al. (Reference Sondergaard, Ekblad and Theorell2001) showed that negative experiences that migrants had before moving to Sweden was associated with poor self-reported health in refugees from Iraq (Sondergaard et al., Reference Sondergaard, Ekblad and Theorell2001). According to the participants in the current study, the unstable political situation in their home country contributes significantly to their poor mental health even after many years of resettlement.
On the other hand, not all migrants in the world face similar experiences before or after migration. The type of migration (forced or voluntary) must be taken into consideration in the investigation of the influence of migration on health (Silove et al., Reference Silove, Sinnerbrink, Field, Manicavasagar and Steel1997; Bhugra and Arya, Reference Bhugra and Arya2005; Araya et al., Reference Araya, Chotai, Komproe and De Jong2007). The perceptions and experiences of immigrants are not static but rather change during their life cycles (Bhugra and Becker, Reference Bhugra and Becker2005). Not everyone experiences poor health as a result of immigration, and the impact of the length of stay in the host country on immigrant health differs. The role of acculturation in the understanding of immigrant health is complex and may differ for various ethnic groups (Kirmayer, Reference Kirmayer2001). Similar conclusions were drawn on the basis of the results of other studies that reported that some migrants attain resilience (positive adaptation) in their current lives in the new country (Schweitzer et al., Reference Schweitzer, Greenslade and Kagee2007).
According to Bhugra and Becker (Reference Bhugra and Becker2005), factors that help immigrants cope with stress and that help prevent mental disorders include a strong concept of self, cultural identity, a high degree of positive feelings about the new culture, religious rituals, meeting places for discussing private problems, and culture itself (Bhugra and Becker, Reference Bhugra and Becker2005). In the current study, we found that finding a meaningful function in Sweden and feeling connected to an ethnic and political identity contributed to a sense of well being.
Finally, migration from a socio-centric to an egocentric society produces stress, specifically for those without social support. Even ethnic density in the host country is linked to changes in concepts of self, as suggested by Bhugra (Reference Bhugra2005). Massive migration for political reasons may increase psychological vulnerability. Loss of status, social support, and relationships with significant others may lead to depression and grief. A sense of alienation and cultural distance can affect the individual's self-esteem and can lead to feelings of insecurity and greater vulnerability.
Strengths and limitations
The main limitation of this study was the selection criteria; only men were included. This step was undertaken because of the findings of a number of previous studies and observations by the first author (MT) and others. Several studies discussed below indicate that reasons for migration (eg, forced migration) can negatively affect mental health. Three previous studies by the first author show that Kurds who migrated to Sweden for political reasons were more often men than women, and that Kurds had a higher prevalence of anxiety and psychological distress than Swedes (Taloyan et al., Reference Taloyan, Sundquist and Al-Windi2008). In addition, in an unpublished master's degree research, the first author learned about the negative image of Kurdish men in Swedish society, which she hypothesized might also lead to poor health. In the future, we plan to conduct a follow-up study in which Kurdish women will be interviewed about their experiences of the migration process.
This study has several strengths. One was the inclusion of participants on the basis of self-reported Kurdish ethnicity. As previously noted, Kurds are impossible to identify from official Swedish records, which do not include information on ethnicity, only citizenship, and Kurds came from various countries. This is the only qualitative study conducted in Sweden among men who identified themselves as Kurdish and highlights the depth and usability of information that can be gathered via careful, in-depth focus on a well-defined group whose members have similar reasons for migration. The description of the whole migration process (pre-migration, initial migration, and post-migration) over a period of 20–25 years among persons with varying backgrounds and personalities is an important strength of this study. Furthermore, all of the authors have experience as immigrants to Sweden and have multiple years of experience of research on immigrants. Two of the authors (MT and NSS) have experience with qualitative methodology. All of these kinds of experience are useful when analyzing data according to the GT method and are important criteria for realistic and truthful validation (Lomborg and Kirkevold, Reference Lomborg and Kirkevold2003). An important strength of this study is that the model was developed using questions that were validated during the analysis process (Berlin et al., Reference Berlin, Hylander and Tornkvist2008) and was then validated by nine of the original interviewees plus three additional Kurdish men. The authors believe that it is feasible to use the thoroughly validated model in primary health care services as described in the implications section. An additional strength of the study is that the majority of participants told their stories and experiences for the first time in their lives, which they indicated contributed to feelings of relief and confirmation at the individual level.
Implications
The findings of this study highlight the common themes of the Kurdish men's experiences and suggest ways to ameliorate mental health issues, including feeling like one is seen as an individual, is a full participant in society, and can contribute to one's own culture. Telling one's own story for the first time, as majority of participants in this study did, may contribute to feelings of relief.
The main implication of our findings for primary health care professionals is that it is important for primary health care providers to be aware of the impact that similar migration-related and life experiences have on the health status of immigrants, and also to be aware that groups are comprised of unique individuals with differing experiences and reactions to those experiences. The themes developed as a result of this study may also be useful in developing strategies to assist other political refugees in Sweden, but only after additional studies confirm their applicability in other groups with similar migration backgrounds.
Acknowledgments
The authors would like to thank all participants in this study for sharing their life experiences and perceptions with us. We would also like to thank social anthropologist Salma Siddique of Edinburgh Napier University for helping with the development and assessment of subcategories, Isaac Austin for language revision, and Scientific Editor Kimberly L. Kane of the Center for Family and Community Medicine for language revision and valuable comments.
