Our analyses suggest that negative experiences from forced migration reduce quality of life after resettlement, as proposed in our first hypothesis. As proposed in the “Ecological model of refugee distress”, post-migration stressors independently and fully mediated the relationship between PTEs and HRQoL, supporting its relevance and as a mediator also for HRQoL. This reflects earlier findings of post-migration stressors as a mediator to mental distress [7
] but is contrary to the results of a recent meta-analysis that found no mediating effect of post-migration stressors on wellbeing indicators [7
]. This could be due to only a handful of studies being relevant and the use of different measures in a variety of contexts, but is also an indication of the need to replicate our results in larger studies. Although numerous studies have found that mental distress predict quality of life [27
], few have investigated this as a mediator between trauma and quality of life as we proposed in our third hypothesis. One study of adult Ethiopians in refugee camps found that trauma from displacement had both a direct effect upon HRQoL and an indirect effect through mental distress [29
]. However, in our study mental distress did not act as an independent mediator, and hypothesis three was not supported. The different results could be due to differences in age, contexts and levels of distress. Conversely, we found that mental distress acted as a mediator in conjunction with post-migration stressors, supporting our fourth hypothesis, and reaffirming the importance of including both factors when assessing HRQoL in refugees.
Longitudinal studies on refugee youth suggest differential impact of pre- and post-migration factors throughout the resettlement process, as traumatic experiences before arrival predict short-term reactions and stressors in exile better predict psychological problems a decade after arrival [45
In the present study, the impact of pre- and post-factors also varied with type of mental distress, as post-migration stressors seemed to be more relevant for general mental distress and explained more variance in HRQoL, whilst PTEs seemed to have more relevance for PTSD and explained less of the variance. These differences have also been found in other studies [46
] and suggest that discussions on pre- and post-migration influence should not be an either/or debate, but relate to their differential impact throughout the settlement process. Type of mental distress is also pertinent to consider in addition to levels above thresholds, as there was no significant association between PTSD and HRQoL after controlling for earlier experiences (PTEs), despite almost half of the participants scoring above the thresholds.
A cumulative effect of post-migration stressors was supported by our analyses, but further exploration also revealed differences between types of stressors and dimensions of HRQoL. Global HRQoL and the dimension of psychological wellbeing were most affected by post-migration stressors and physical wellbeing the least, suggesting that other factors (e.g. somatic symptoms) could be relevant for the latter. Some stressors were relevant across several dimensions, notably economic concerns
and perceived discrimination
, which are repeatedly found as detrimental to health and wellbeing [3
]. In contrast, two of the most commonly reported experiences (missing family or previous life
) had low correlation, possibly indicating less severe emotional distress [17
]. These results reflect the “ecological model of refugee distress” where factors at multiple levels influence health and wellbeing. They also inspire hope as the most influential stressors are malleable factors. However, it also highlights the responsibility of host nations for protecting against or alleviating unnecessary pressure on an already vulnerable population as the most influential types of stressors seem to be embedded in social structures.
As mentioned earlier,
Miller and Rasmussen [12
] suggested that post-migration stressors could deplete coping mechanisms, affecting the capacity to recover from trauma. Other theories, such as the “
Stress sensitivity theory” propose that past trauma activates an overreaction to ongoing demands thus decreasing the tolerance for stressors perceived as manageable by others [48
]. These could be explanations as to why increasing numbers of PTEs were associated with higher frequencies of post-migration stressors in our study. Emotion dysregulation has been found to mediate mental distress in refugees [4
]. Also, psychological processes such as emotion regulation, memory and executive functions are susceptible to the influence of trauma or elevated stress during development with long-lasting effects, as this in turn affects the capacity to regulate future stress responses [50
]. The proposed model might also be reversed in a “Stress generation model” [51
], as tested in Fig. 4
. Mental distress would then make people behave and react in ways that create more stressful situations, for example, by avoiding social interaction or making impulsive financial choices. The general burden of mental distress could also act as a worry or stressor in itself and is in fact included in some post-migration stressor scales [52
]. The interaction between distress and stressors suggests a bidirectional relationship where both processes occur, also shown in other studies [53
], creating a more complex and transactional model [51
]. These proposed processes could inform current treatments for mental distress or general psychosocial interventions in schools. For example, the models could help explain why some experience reduced symptom burden after treatment for PTSD but not increased quality of life, and vice versa. Implications for a therapeutic approach would be the importance of addressing currents stressors, not only symptoms, as failure to do so may limit the effectiveness of treatment [10
] and also to include holistic treatment goals such as quality of life. Lastly, broader and structural interventions, including all refugee youth, may alleviate or prevent post-migration stressors and mental distress and should be implemented by host nations.
Although psychological problems are frequent in refugee children, the extents are reduced over time in settlement [13
] and wellbeing remains high [23
]. This could be a sign of natural recovery processes or resilience, where youth develop new resources such as cultural competence, language skills or networks. Resettlement can therefore be stressful, but also involve personal growth and resilience [55
], and as such it supports Antonovsky’s criticism of early stress theories for assuming that stressors were inherently negative and the importance of focussing on health resources [56
]. Social support and positive coping styles are suggested as protective factors buffering mental distress in refugee children and youth [3
] and are also associated with increased quality of life [18
]. Our models did not investigate any protective factors, and further studies should include such measures.