1. Global Migrations and Persons with Refugee Experiences

The 1951 Convention relating to the Status of Refugees, along with its 1967 Protocol, serve as the foundation of international refugee protection. These documents establish a comprehensive framework for the rights and obligations of refugees, as well as the responsibilities of host states (UNHCR 2011; UNHCR 2023). The Convention defines a refugee as an individual who, due to a legitimate fear of persecution based on factors such as race, religion, nationality, social group membership, or political opinion, is outside their country of origin and unable or unwilling to seek protection from that country (UNHCR 2011; UNHCR 2023). This definition has had a significant impact on shaping both national and international policies related to refugee protection and asylum procedures (Goodwin-Gill & McAdam 2007).

The process of international migration is influenced by various macro, meso, and micro-level factors. In this chapter, we focus on the combination of “push” and “pull” factors to simplify the complex motivations behind migration.

Migrants generally exhibit better health than both the population they depart from and the population of the destination country (Wickramage et al. 2018). This phenomenon, often referred to as the Healthy Immigrant Effect (HIE), suggests that migrants, particularly those who migrate voluntarily, tend to have better health outcomes upon arrival than native populations. This is attributed to self-selection biases, where healthier individuals are more likely to undertake migration (Abraído-Lanza et al. 1999; Kennedy et al. 2006). However, for refugees and forcibly displaced populations, the Healthy Immigrant Effect (HIE) is often less pronounced or absent due to the extreme hardship they experience before, during, and after migration (Norredam et al. 2010).

Regardless of the nature of the migration process, fleeing is a significant burden, and settling in a new country constitutes a profound transition. The migration process can be categorized into three stages: pre-migration, migration, and post-migration. Each of these stages features important factors that can have either a positive or negative impact on health. The different phases and critical factors that can influence health in both the short and long term are depicted in Figure 2.4. Additionally, a potential return phase has been incorporated in this representation.

I was very stressed both before and during the journey itself. It was the worst journey I have ever taken. We did not know how we would be treated, or what to expect. We heard stories that we would be stripped naked and body-searched, that we would be put in isolation, and that we would be treated very poorly.

During the escape, there was no time to think about our own health; we had two children to take care of. The only focus was on finding practical solutions so that the children were as safe as possible.

These quotes are taken from interviews with refugees conducted through the Physiotherapy and Refugees Educational Project (HVL 2018-2021). The first quote is from an interview with a man who came on a planned flight to Norway. He came as a quota refugee and had all his papers in order. Nevertheless, he experienced enormous fear and uncertainty about what awaited him in Norway. The second quote is from a man who was fleeing with his family for several years. They lived in several refugee camps before they came to Norway and were granted asylum here.

The Healthy Immigrant Effect (HIE), which suggests that migrants initially exhibit better health outcomes upon arrival, is often diminished or absent among refugees due to pre-migration trauma and migration hardships (Norredam et al. 2010). Even individuals who arrive in relatively good health frequently experience a gradual deterioration of physical and mental well-being as they navigate systemic barriers to healthcare, economic instability, restrictive asylum policies, and acculturative stress (Domnich et al. 2012; Hynie 2018). Studies indicate that prolonged asylum processes, social isolation, and precarious living conditions significantly elevate the risk of PTSD, depression, and anxiety (Silove et al. 2017; Priebe et al. 2016).

Yana is 15 years old and came with her family to Norway in 2015. She and her family have been back to their home country, but for Yana, it is here in Norway that she feels most at home. She speaks fluent Norwegian, has good friends, does well in school, and has leisure activities she enjoys. She sees that there are differences between the rules she has at home and some of what her friends have, which has recently led to some conflicts at home. In a conversation with her mother, the mother expresses the difficult situation where she feels she stands with one foot in Norway and one foot in her home country. Some of the things they do in Norway would have been completely unthinkable in their home country, such as being out with boys, going to a youth club, and the like. On one hand, she actually thinks it is okay, but on the other hand, she feels guilty and feels that she is not a good enough mother for Yana when she lets her do the same as her friends do.

Post-migration, refugees face the challenging task of integrating into new societies, learning new languages, and navigating unfamiliar cultural landscapes. This phase is often marked by a combination of relief and ongoing psychological distress as refugees reconcile their traumatic pasts with the challenges of building new lives. The mismatch between expectations and reality can lead to frustration and homesickness, further complicating the integration process (Sluzki 1979).

Abraído-Lanza, A. F., Dohrenwend, B. P., Ng-Mak, D. S., & Turner, J. B. 1999. ‘The Latino mortality paradox: A test of the “salmon bias” and healthy migrant hypotheses’, American Journal of Public Health, 89.10: 1543–1548.

Juárez, S. P., & Hjern, A. 2017. ‘The weight of inequalities: Duration of residence and offspring’s birthweight among migrant mothers in Sweden’, Social Science & Medicine, 175: 81–90.

Kennedy, S., McDonald, J. T., & Biddle, N. 2006. ‘The healthy immigrant effect and immigrant selection: Evidence from four countries’, Social and Economic Dimensions of an Aging Population Research Papers, 164.

Lindencrona, F., Ekblad, S., & Hauff, E. 2008. ‘Mental health of recently resettled refugees from the Middle East in Sweden: The impact of pre-resettlement trauma, resettlement stress and capacity to handle stress’, Social Psychiatry and Psychiatric Epidemiology, 43: 121–131.

Mandić, D. 2022. ‘What is the force of forced migration? Diagnosis and critique of a conceptual relativization’, Theory and Society, 51.1: 61–90.