Vol.3, No.1, 12-21 (2013) Open Journal of Preventive Medicine
http://dx.doi.org/10.4236/ojpm.2013.31002
Culture- and evidence-based health promotion
group education perceived by new-coming a dult
Arabic-speaking male and female refugees to
Sweden—Pre and two post assessments*
Solvig Ekblad#, Maria Asplund
Cultural Medicine Unit, Department of Learning Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden;
#Corresponding Author: [e-mail]
Received 20 August 2012; revised 23 September 2012; accepted 30 September 2012
ABSTRACT
Objective: According to a theoretical approach,
events that elicit stress after arrival in the re-
ception country, i.e., post-migration stress, have
a negativ e impact on health-relate d quali ty o f life
among newly-arrived refugees. With the aim of
paying attention to such symptoms, a revised
culturally-tailored clinical health promotion model
developed at Harvard Program in Refugee Trau-
ma was used for invited groups of new-coming
adult refugees in a town south of the Swedish
capital. Methods: A coordinator administered
the five-weekly sessions, 2 hours/week, with a
professional interpreter. It covered major topics
from Western and Arabic worldviews: 1) intro-
duction; 2) health care: organisation and access
to; 3) exercises; 4) stress management and
coping, 5) medical doctor-patient communica-
tion. Each topic was led by a nurse, a physio-
therapist, a psychologist and a physician with
experience of encounters with this target group
in health care. Data cover results from 70 par-
ticipants attending six groups; 39 participants
with pre-course findings and, post-course and
six-month follow-ups. There were no significant
differences in background factors between the
participants and the drop-outs. Results: Partici-
pants’ perceptions of their health, measured by
EQ-5D, changed positively over time, above all
immediately after the course, with no significant
differences between the two follow-ups. In the
follow-ups, female participants perceived their
health as significantly worse than males. Quali-
tative data at the six-month follow-up assessed
the course as useful but expressed a wish to
continue a similar course with a focus on post-
migration stress. Conclusion: The results sup-
port earlier findings. A course, administered to a
small group in a dialogue setting, has value for
the participants’ empowerment and perception
of health. It is recommended that reception be
more adapted to coping of pos t-migration stress
of new-coming refugees. Practical Implications:
The results have implications for education in
clinical health promotion, intercultural commu-
nication and inter-professional collaboration in
refugee reception.
Keywords: Health Promotion; Refugees;
Arabic-Speaking; Health-Related Qu ality of Life
1. INTRODUCTION
A systematic review shows that compared with age-
matched general populations in Western countries, refu-
gees could be around ten times more likely to have Post-
traumatic Stress Disorder (PTSD), which is the most
common form of mental illness among refugees [1]. The
second most common is mood disorders [2]. There is
co-morbidity between these two disorders [3] and a
dose-effect relationship, i.e., increasing levels of trauma
lead to higher rates of the symptoms. A study by Kinzie
et al. [4] shows that PTSD increases the risk of public
health diseases, e.g., hypertension, cardiovascular dis-
ease and diabetes, diseases that may be prevented or
ameliorated through education and advice. According to
a theoretical approach by Silove [5], events that elicit
stress after arrival in the reception country, i.e., post-
migration stress, have a negative impact on health-re-
lated quality of life (HRQoL) among newly-arrived re-
fugees [6]. To promote self-care and a proper use of the
health care system by new-coming refugees in the recep-
*Competing interests: the authors have no competing interests.

S. Ekblad, M. Asplund / Open Journal of Preventive Medicine 3 (2013) 12-21 13
tion country, culturally tailored evidence-based knowl-
edge of clinical health promotion and communication in
health care and other educational information on health
issues are of significance not only for the individual and
relatives but also for health care and society as a whole.
This project adapted the model which the Harvard
Program in Refugee Trauma (HPRT)
(www.hprt-cambridge.org) had used since 2000 for
Cambodian survivors of torture, in the form of a Health
Promotion Program with a 5-session group format [7].
The Swedish reception system and the Health Promotion
Intervention Course (HPIC), its contents and structure
have been described in detail elsewhere [8].
In this article we use HPRT’s definition of health,
which perceives health as an active, dynamic process
where the members of the target group are the key agents
in encouraging self-healing [9, cited in 7]:
“Health is a personal and social state of balance and
well-being in which people feel strong, active, wise and
worthwhile; where their diverse capacities and rhythms
are valued; where they may decide and choose, express
themselves, and move about freely” (p. 5).
With this theoretical approach, it is natural to use a
curriculum during the first session of the course to pene-
trate the participants’ potential personalized power to
themselves, prevent illness and promote health in the
short and longer run. Further, the health promotion ap-
proach is an active approach, in which the participants
can have a dialogue with the multidisciplinary team, i.e.,
ask questions about healthy living and their own deci-
sions concerning their individual targets for a healthy
lifestyle. In addition, the group dynamic generates peer
recommendations, which may be more influential than
individual sharing.
During the health promotion course, the multidiscipli-
nary team is sensitive and adapts the curriculum’s peda-
gogical technique to the Arabic-speaking participants.
Each of the five sessions with 10 - 14 male and female
participants was coordinated by a Swedish registered
nurse (second author) and health practitioners (a physio-
therapist and a psychologist, both ethnic Swedes, and a
medical doctor born in an Arabic country who speaks
Swedish during the course), with the same interpreter.
The team aimed to integrate the participants’ health con-
cepts and knowledge about a healthy life style with evi-
dence-based health data and encouraged them to absorb
the information and the active approach to their personal
health and well-being.
According to the health promotion groups, the plans
for the lesson were developed and designed to be few
and simple; the two hours were divided into one for in-
formation, followed by a short coffee-break and fruits,
free of charge, and one for dialogue about whether the
content was personally relevant and culturally meaning-
ful for the participants. In addition, a copy of the power-
point presentations with illustrations and other material
was given to each participant as a hand-out. It was im-
portant to have not just text but also illustrations as some
participants may have a low educational background and
a history of trauma that makes it difficult to concentrate.
The material was in Swedish, which provided an oppor-
tunity to learn practical Swedish about health issues.
During the session, humour and the ability to laugh were
an advantage; clinical experience has shown that healing
is promoted by stimulating positive physiological and
immune responses.
1.1. Aim and Research Questions
This study aimed to assess self-perceived health-re-
lated quality of life among newly-arrived adult Arabic-
speaking refugees, before and after they participated in a
HPIC [7,8]. As in the earlier studies, we were interested
in how participants perceived their health before and
after participating in HPIC.
The research questions were: How do HPIC partici-
pants assess their health before and after HPIC and at a
6-month follow-up? How do the participants describe
their experiences of participating in HPIC?
1.2. Curriculum
The approach focused on the following key health
promoting behaviours, which according to the literature
[1,8] prevent post-migration stress symptoms among
new-coming refugees: nutrition, physical activity, stress
and coping, and doctor-patient communication.
Session 1: the coordinator (second author) introduced
the five-session course by taking up the concepts of
health promotion and disease prevention by informing
about risk and protective factors for specific illnesses.
The coordinator encouraged the participants to have dia-
logue from their own healing perspectives and Arabic
cultural and spiritual history and informed and explained
the structure of the course, its expected benefits and what
the interdisciplinary team expected of the participants. It
was important to create a neutral atmosphere in which
participants could feel comfortable about asking ques-
tions and sharing old and new experiences right from the
first session.
Session 2: The nurse (second author) introduced ac-
cess to and the organisation of health care, as well as
basic principles of nutrition and their connection to dis-
ease prevention. These guidelines were explained in the
context of Arabic cuisine. For example, when teaching
about sodium reduction for blood pressure control and
sugar reduction for weight loss, the team recommended
limiting the consumption of traditional Arabic and West-

S. Ekblad, M. Asplund / Open Journal of Preventive Medicine 3 (2013) 12-21
14
ern foods that are high in sodium and sugar and informed
about wholesome alternative foods. The nurse distributed
the nutritional guide (kostcirkeln) with pictures of whole-
some and unwholesome foods.
Session 3: The physiotherapist gave guidelines on
physical activity, explained its benefits for physical and
mental health, led an exercise and gave it as homework.
The coordinator gave this exercise at the end of each
session (the participants decided that, that was when they
wanted to have the exercise, before they went home).
The exercise was important because chronic pain is
common among refugees who have experienced trau-
matic life events, e.g. torture [10].
Session 4: The psychologist (first author) informed,
taught and discussed the concept of stress (trauma and
post-migration stress management) and its connection
with chronic diseases such as depression, problems with
concentration and disturbed sleep. Together with the
participants, the psychologist discussed stress-reduction
techniques in their traditional culture as well as in the
reception country. A normalisation approach to stress
was introduced as a universal experience after traumatic
life events and that depression, concentration problems
and poor sleep are common among torture survivors.
Mental health in Arabic and Western concepts was dis-
cussed. Some basic guidelines for sleep hygiene were
included in this session. For all stress symptoms, the
psychologist recommended self-management and, when
this was not enough, applying for professional help. The
coordinator (second author) ended with the relaxation
response exercise.
Session 5: The physician first informed about the
Swedish health care organisation, pharmacy and the roles
of physicians and other health care professionals and
compared with the situation in Iraq. The physician then
looked at the authority of doctors in Arabic culture and
encouraged a more collaborative approach, also the con-
cept of emergency care in both countries as well as
common diseases, confidentiality and the right to have an
interpreter in health care. The coordinator (second author)
ended with the relaxation response exercise and con-
cluded the course by congratulating the participants and
giving them certificates of completion.
1.3. Setting
To avoid stigma, the sessions and follow-ups took
place in Södertälje, 30 kilometres south of Stockholm,
the capital of Sweden, at the office of the Swedish Public
Employment Service, the official reception agency for
refugees following a new law from December 1, 2010
[11]. Participants were invited to an appealing, non-
threatening environment. They sat round a large circular
table in a conference room. Refugees and their relatives
from Iraq were the most common target group. In the
light of experiences which the principal investigator (first
author) had, each course was reserved for a single lan-
guage group. The course lasted for five weeks, with a
two-hour meeting on the same day and time each week.
The last session was extended to 2.5 hours for a diploma
ceremony for participants who had attended at least four
of the five sessions.
2. MATERIALS AND METHOD
2.1. Study Design
The study was prospective, with data collection before
and immediately after the HPIC and at a six-month fol-
low-up. Data consisted of a questionnaire and, at the six-
month follow-up, semi-structured interviews with open-
ended questions; the mixed method was used to get a
better understanding of the participants’ perceptions of
health before, after and at the six-month follow-up. We
chose to include a qualitative design in the last follow-up
due to reason that the participants would feel free to an-
swer from their narratives. The data would be fruitful for
objective questions in a future follow-up. Answering the
questionnaire before and after HPIC took about 15 min-
utes. The follow-up of a group interview in respective
group at six month took up to one hour.
2.2. Participants
Eligibility criteria included being a new-coming refu-
gee of any gender with permission to stay in Sweden,
being over 18 and a willingness to participate in the pro-
gram. The HPIC recruited participants from a waiting list,
a convenient sample of Arabic-speaking new-comers,
mainly refugees and their relatives living in Södertälje, in
accordance with the law [11] on introduction activities
for certain newly-arrived immigrants at the Swedish
Public Employment Service. One or two assistants from
the Employment Service were invited to participate in
the HPIC as observers. After each group’s final session,
a meeting was held with the team to reflect narrative
experience but without talking about individual partici-
pants. The data in the project, which began in 2008, re-
ferred to 243 participants but the main study with a
six-month follow-up had to wait until the new reception
law came into force on December 1, 2010 [11]. The data
before 2011 were pilot data. The data on six groups with
five weekly sessions (n = 70) were collected from Feb-
ruary to November 2011 and the last six-month fol-
low-up was in April 2012. The course members did not
receive any monetary compensation for their participa-
tion but were included in health promotion activities in
the Swedish Public Employment Service program.
The participants were informed in advance, orally and

S. Ekblad, M. Asplund / Open Journal of Preventive Medicine 3 (2013) 12-21 15
by information sheet, about the purpose of the study and
the follow-up. They gave their oral consent to participate
and were free at any time to terminate without prejudice
to participation in the HPIC or other introduction activi-
ties.
2.3. Quantitative Data
With the aim of evaluating the HPIC from the partici-
pants’ point of view—a user-friendly approach—the co-
ordinator (second author) administered a questionnaire
individually to each participant during the first and last
lessons of the HPIC and by meeting each of the six
groups six months after the HPIC. Each participant was
given an identity number and they decided themselves
the code and used the same code for all measures (for
instance, □ or #).
As in the prospective study in Malmö by Eriksson-
Sjöö et al. [8], health-related quality of life was assessed
by EQ-5D self-assessment [12], which has been trans-
lated/back translated into Arabic (Lebanese version) and
copyrighted. The project’s PI (first author) was author-
ized to use the form already translated into the Arabic
version. In EQ-5D, the participant describes his or her
health in the following five dimensions: mobility, hy-
giene/self-care, main activities, pain/discomfort, anxi-
ety/depression, with three response options as to severity
(no, moderate or severe problems), as well as self-rated
health EQ VAS values on a visual analogue scale form 0
to 100, where 100 represents the “best imaginable health
state” and 0 the “worst imaginable health state”.
Socio-demographic background variables included age,
gender, marital status, education, work experience, length
of stay in Sweden and reason for migration.
2.4. Qualitative Data at the Six-Month
Follow-Up
The three main open narrative questions were: 1) Do
you want to tell how your health was before you started
in the HPIC? 2) How has the HPIC influenced you re-
garding your health? 3) What do you do to maintain your
health (self-healing)? The coordinator (second author)
made notes from narratives during the group discussion.
Unidentified citations will illustrate the quantitative data.
2.5. Translation/Back Translation
The socio-demographic questions were translated into
the Arabic language by an authorized translator and
back-translated orally by an authorized medical inter-
preter. These two versions were compared and minor
changes of no significance were performed. These ques-
tions have been used in earlier studies by the first au-
thor’s team. The coordinator (second author) and the
same professional interpreter in the course were present
each time the participants filled in the questionnaires.
2.6. Statistical Analysis
Data were coded and analysed using SPSS for Win-
dows, version 19.0. Changes between pre and post (after
the course and at the six-month follow-up) were com-
pared by using paired t-tests and binomial distribution
for exact significance test. All reported p-values are
two-tailed. Only p-values under 0.05 are reported in the
results.
2.7. Analysing Qualitative Data at the
Six-Month Follow-Up
An inductive approach was used for the qualitative
data, as is advisable when previous knowledge is lacking
[13], which was the case in this study. The data were
analysed with a revised version of a method for qualita-
tive content analysis [14]. Only manifest contents were
analysed as we relied on an interpreter for the translation
of communications and analysing the latent content is
questionable [8]. The answers to each of the three ques-
tions and the narratives from the group interview at the
six-month follow-up were summarized as notes by the
coordinator (second author) and marked independently
by each of the two authors, who then discussed the coded
material and arrived at content categories and themes.
The next step was to discuss sub-categories for each
category.
2.8. Ethical Considerations
This study was approved by the Stockholm Regional
Ethical Review Board (2011/1166-31/5).
3. RESULTS
3.1. Participants and Dropouts
This study comprised a total of 70 participants in the
HPIC. Men (n = 36) as well as women (n = 34), Arabic-
speaking, and aged between 18 and 64 years. Each group
consisted of between 7 and 14 (Md = 11) participants.
Of the 70 participants, 39 took part in the intervention
and were followed up immediately after the HPIC and at
six months; of these, 20 (51%) were men and 19 (49%)
were women. Three-quarters were married (29.7%), al-
most one-fifth were single (7.2%) and a few were wi-
dow/widower (3.8%). Significantly more male partici-
pants reported they were married and significantly more
women were single or widowed (χ2 = 5,954, df = 2, p <
0.051). The reason for fleeing from Iraq was to save their
life for nearly seven out of ten (27, 69%; men: 13, 65%
and women 14, 74%), while 15% came to join relatives
and 15% for other reasons. The average number of
months with permission to stay in Sweden (the number

S. Ekblad, M. Asplund / Open Journal of Preventive Medicine 3 (2013) 12-21
16
of months as asylum seekers were not collected) was 5
(range 1 - 34; male participants: 5, range 1 - 34; female
participants 4.5, range 1 - 13).
The overall mean age was 41 years (range 20 - 61
years); the male participants were slightly older on aver-
age than the female participants (44 and 39 years, re-
spectively). A majority of the participants stated that they
had children. The overall median number of children was
2 (range 0 - 8); male participants had more children than
female participants (3, range 0 - 5, and 1.5, range 0 - 8).
The overall average number of years in school was 11
(range 2 - 18). Male participants had on average rather
more years in school than female participants (12, range
2 - 18 years, and 10, range 5 - 18).
The average number of years in the work force was 11
(range 0 - 32). Male participants (mean 17, range 0 - 32)
had significantly more years in the work force than fe-
male participants (mean 6, range 0 - 32), (t = 3.344, df =
36, p < 0.002).
Six of the 70 participants were drop-outs at the end of
the course and a total of 31 (44.3%) were drop-outs at
the six-month follow-up (Table 1). The drop-outs oc-
curred due to difficulties in contacting participants. They
moved due to dwelling difficulties, to other cities and
other unknown reasons. There were no significant dif-
ferences in background factors between the participants
and the drop-outs.
3.2. Assessment of Perceived Health by
EQ-5D
3.2.1. At Baseline
In the EQ-5D questionnaire at the start of the course
(Table 2) the participants reported the following health
problems, with no significant differences between male
and female participants:
Movement: Four out of ten (42%) perceived that they
moved without any difficulty, six out of ten (58%) with
some difficulty.
Hygiene: The majority had no problem with hygiene
(84%), the rest (16%) had some problems.
Activities: Almost six out of ten (58%) perceived that
they could do their activities without any problems,
37% had some problems and 5% could not do their ac-
tivities.
Pain: About one in ten (13%) perceived no pain, nearly
two-thirds (66%) felt some pain and one-fifth (21%) had
severe pain.
Depression: Almost a quarter (23%) felt no problems,
over half had some problems and 15% had severe de-
pression.
3.2.2. Changes from before to after the Cour se
The EQ-5D total scores (Table 2) for “No problems”
improved in trends as regards mobility, hygiene, pain
and depression and deteriorated slightly for activities but
with no significant differences.
3.2.3. Change s f rom Baselin e t o after the C o urse
and the Six-Month Follow-Up
The scores for all participants (Table 2) show that for
mobility the proportion with no problems increased to
54% at the six-month follow-up. For hygiene and de-
pression the proportion had improved at the end of the
course but decreased six months later. For pain, the pro-
portion with no problems had also improved at the end of
the course but deteriorated to the baseline level six
months later. For activities, the proportion with no prob-
lems decreased continuously from baseline to the six-
month follow-up.
Table 1. Socio-demographic data on participants and drop-outs: mean age, number of children, years in school and in work, months
in Sweden.
Total (n = 39) Male (n = 20) Female (n = 19) Drop-outs Total (n = 31)
Mean age (sd) 41.46 (11.357) 44.05 (2.566) 38.74 (2.492) 37.77 (10.497)
Min-max 20 - 61 20 - 61 20 - 56 21 - 56
Number of children, Md) 2 3 1.5 1
Min-max 0 - 8 0 - 5 0 - 8 0 - 7
Mean years (sd) in school 10.82 (4.046) 11.55 (4.322) 10.00 (3.662) 11.55 (4.545)
Min-max 2 - 18 2 - 18 5 - 18 0 - 19
Mean years (sd) in work
before arrival 11.34 (11.560) 16.89 (9.933) 5.79 (10.533) 7.60 (9.796)
Min-max 0 - 32 0 - 32 0 - 32 0 - 20
Mean months (sd) in
Sweden with permission 4.74 (5.510) 4.95 (1.678) 4.53 (0.681) 6.43 (9.712)
Min-max 1 - 34 1 - 34 1 - 13 1 - 40

S. Ekblad, M. Asplund / Open Journal of Preventive Medicine 3 (2013) 12-21 17
Table 2. EQ-5D at baseline, after the course and at six-month follow-up.
(n = 39)
Baseline N (%) After the course N (%) Six-month follow-up 2 N (%)
EQ-5D Total
39
Men
(n = 20)
Women
(n = 19)
Total
39
Men
(n = 20)
Women
(n = 19)
Total
39
Men
(n = 20)
Women
(n = 19)
Mobility
No problems
Some problems
Large problem
16 (42%)
22 (58%)
-
9 (47%)
10 (53%)
-
7 (37%)
12 (63%)
-
19 (50%)
19 (50%)
-
10 (53%)
9 (47%)
-
9 (47%)
10 (53%)
-
21 (54%)
18 (46%)
-
11 (55%)
9 (45%)
-
10 (53%)
9 (47%)
-
Hygiene
No problems
Some problems
Large problem
31 (84%)
6 (16%)
-
16 (84%)
3 (16%)
-
15 (83%)
3 (17%)
-
33 (92%)
3 (8%)
-
18 (95%)
1 (5%)
-
15 (88%)
2 (12%)
-
33 (89%)
3 (8%)
1 (3%)
17 (94%)
1 (6%)
-
16 (84%)
2 (11%)
1 (5%)
Activities
No problems
Some problems
Large problem
22 (58%)
14 (37%)
2 (5%)
12 (60%)
7 (35%)
1 (5%)
10 (56%)
7 (39%)
1 (6%)
20 (55%)
15 (42%)
1 (3%)
14 (74%)
4 (21%)
1 (5%)
6 (35%)
11 (65%)
-
17 (44%)
21 (54%)
1 (3%)
10 (50%)
9 (45%)
1 (5%)
7 (37%)
12 (63%)
-
Pain
No problems
Some problems
Large problem
5 (13%)
25 (66%)
8 (21%)
2 (11%)
12 (63%)
5 (26%)
3 (16%)
13 (68%)
3 (16%)
7 (19%)
25 (68%)
5 (13%)
5 (28%)
9 (50%)
4 (22%)
2 (11%)
16 (84%)
1 (5%)
5 (13%)
28 (74%)
5 (13%)
4 (21%)
13 (68%)
2 (11%)
1 (5%)
15 (79%)
3 (16%)
Depression
No problems
Some problems
Large problem
9 (23%)
24 (62%)
6 (15%)
5 (25%)
12 (60%)
3 (15%)
4 (21%)
12 (63%)
3 (16%)
16 (43%)
16 (43%)
5 (14%)
10 (55%)
5 (28%)
3 (17%)
6 (32%)
11 (58%)
2 (10%)
12 (32%)
22 (58%)
4 (10%)
9 (47%)
7 (37%)
3 (16%)
3 (16%)
15 (79%)
1 (5%)
As shown in Table 3, on the health rating scale (0 -
100), which reflects the self-perceived health state, the
participants’ mean scores improved from baseline to the
end of the course but deteriorated slightly at the six-
month follow-up. There were no significant differences.
3.2.4. Gender Differences
At the end of the course, female participants had sig-
nificantly more problems with activities than male par-
ticipants (χ2 = 7.378, df = 2, p < 0.025). At the six-month
follow-up, some problems with depression were twice as
common among female participants compared with male
participants, a difference that is significant (χ2 = 6.909, df
= 2, p < 0.032). The health rating scale showed higher
mean values for male participants after the course as well
as at the six-month follow-up but for female participants
the mean values had increased after the course but fell
back close to baseline at the six-month follow-up. There
were no significant differences.
3.3. Qualitative Findings at the Six-Month
Follow-Up
According to Table 4, there was one general theme:
The group participants had different backgrounds and
needs but answered that the dialogue had given them
valuable general health information, though they wanted
to continue with future focused courses. This theme as-
sesses three categories: before the course, impact of the
course and future stress management and coping. These
categories have 10 sub-categories.
Before the course: as new-comers to Sweden, some
participants had been separated from family members
and had poor bad housing. They felt that access to health
care was very difficult and found it hard to understand
the health system. Opinions differed as to when they
wanted to have this health information; some preferred
early, others later but the majority wanted to have
two-hour meetings in the group for a longer period and
to learn more from clinical health professionals and sup-
port each other as new-comers. During the six months
after the course they felt there had been few improve-
ments in the reception program and they also wanted
more opportunities to talk Swedish. One of the coordi-
nators (second author) considered that the participants
had forgotten the Arabic version of “Vårdguiden” on the
web with information about access to health care. At the
six-month follow-up, the coordinator brought a plastic body

S. Ekblad, M. Asplund / Open Journal of Preventive Medicine 3 (2013) 12-21
18
Table 3. VAS at baseline, after the course and at six-month follow-up.
Baseline mean (sd)
(n = 39)
After course mean
(sd) (n = 39 ) T-test Df P Six-month follow-up mean (sd) (n = 39) T-test Df p
Total
n = 39 57.21 61.41 −0.905 37 0.371 59.33 −0.347 37 0.730
Male
n = 20 60.70 61.90 −0.184 19 0.856 64.70 −0.516 19 0.612
Female
n = 19 53.33 60.89 −1.632 17 0.121 53.68 0.252 17 0.804
Table 4. Overview of general theme, three categories and ten sub-categories.
General Theme Categories Sub-categories
Received valuable general health
information in dialogue but wish for
more and focused courses
Before the course
_____________________
Impact of the course
_____________________
Future stress management and coping
Chaos and insecurity
Illness
Problems with teeth
____________________
Increased knowledge
Increased security
Motivation to be active
Wish to continue
____________________
Preventive tools
Knowledge
Empowerment
doll and gave a lecture about important organs and their
functions. The participants were very excited. Further,
not having health information and adequate knowledge
about health, some participants felt chaotic with concen-
tration problems, others were anxious, mentally tired and
insecure or felt illness or pain from unhealthy teeth; at
the same time, negative attitudes to medicine for their
symptoms were common as the root cause was often
existential stress:
-Before seven months I did not feel OK and very tired
and I had too much thoughts.
Impact of the course: The majority of participants
mentioned that they felt the course had had a positive
impact on their perceived health and that it played a ma-
jor role in providing advice to new-coming refugees,
how to maintain health and how to use primary health
care and mental health staff to solve mental and physical
problems. Those who had health care needs had a better
understanding of the encounter with health care after the
course as they knew more about the system. The peda-
gogic and the group setting for men and women together
enabled them to share important experiences. As the
group content was confidential, they developed trust
during the sessions in the group. Several mentioned that
they wanted to continue the course to get more relevant
information, for instance, separate courses on how to rear
children in Sweden, cultural information about Swedish
society, information about first aid, self-care (e.g. how to
check body temperature, blood pressure and how to use
clothes in Sweden), dentist, eye specialist, mental health
promotion, mental health treatment, nutrition, tattooing,
skin diseases and severe diseases.
-We need more knowledge about how to handle chil-
dren and how to rear them. Especially, as they are in a
society (Swedish) which is quite different from Arabic
society. The family needs advice.
Future stress and management coping: At the six-
month follow-up, several participants mentioned that
they continued to use the knowledge and tools from the
course for stress management and coping. They felt more
empowered when they get knowledge and can handle
their health situation in a proper way. They know more
about how to get access to health care when needed, they
and their family felt more secure. One of the participants
mentioned that in the Arabic tradition (as well as in the
West) there is a saying that “using preventive methods is
much better than receiving treatment.”
-Before, I could not walk a long distance. But nowa-
days I can walk daily 2.5 and 3 hours.
-The information about health has had an impact on
me, what I can do to stay healthy and sometimes I do
relaxation.
-I had elevated cholesterol and fat and used advice
and exercise and increased other activities, but not with

S. Ekblad, M. Asplund / Open Journal of Preventive Medicine 3 (2013) 12-21 19
the help of medicine. The nurse has taken new tests
which showed reduced cholesterol. I followed a food
program (diet circle) and with all this advice I have lost
weight. Now I feel active.
4. DISCUSSION
4.1. Discussion of the Results
With the aim to assess self-perceived health-related
quality of life among newly-arrived Arabic-speaking
refugees, before and after they participated in a HPIC,
the results show that prior to the course, participants
perceived illness and that such a health promotion inter-
vention shortly after resettlement for new-coming refu-
gees is relevant and useful for stress management, coping,
empowerment and to build up trust. The baseline data
shows a similar level of “no problems” as in the study
with such a course with Arabic-speaking refugees in
Malmö, southern Sweden [8], but far more perceived
illness compared with responses of newly-arrived Iraqis
with residence permits in Sweden, regardless of health
problems [15], who responded to the Swedish postal
questionnaire. This study and the one in Malmö [8] per-
ceived a need for health education but the participants
were not identified as patients. In keeping with the lit-
erature, the data indicate that our target group needs tai-
lor-made and culturally-sensitive mental health promo-
tion programs in order to respond to their health needs
[8]. Responses of “no problems” to four of the five
health state issues (mobility, hygiene, activities, pain and
depression) had improved immediately after the course,
although the changes are not significant. This indicates
that the identification of post-migration stress problems,
such as pain, depression and activities should be a part of
an early medical examination of newly-arrived refugees
[16]. Further, the data shows that female participants
perceived significantly worse health than male partici-
pants. This finding is supported by Swedish epidemiol-
ogical data showing that female refugees are a risk group
for mental illness [17]. It is therefore important to ask
new-comers about the reason for migration and not
mainly about the country they were born in.
The results are also in line with Eriksson-Sjöö et al. [8]
in Malmö in that a majority of the participants described
not only post-migration stress but also a lack of trust in
the Swedish health care system because they found it
hard to access it. In a meta-analysis study, Porter and
Haslam [18] showed a correlation between psychosocial
factors and poorer mental illness among asylum seekers
and refugees and concluded that prevention of psychoso-
cial shortcomings may have a positive influence on refu-
gees’ mental health. Psychological acculturation, which
may be prevented refers to the dynamics process that the
new-coming refugees experience as they adapt to the
new reception culture [19].
According to Silove [5], the structure and content of
the HPIC have resulted in a sense of security, less stress
and improved perceived health. At the same time, the
course, with a relatively small and preventive investment,
can accomplish quick changes for both the target group
and society. However, from a longitudinal phase, the
participants showed on the last follow-up after six
months that their improvements in EQ-5D decreased (not
significant) after the first follow up. It can be interpreted
that the post-migration stress influenced them and they
needed regular support from a HPIC. These signs
showed face validity during the six group interviews as
they wanted to continue the course in a group with the
focus on special content, they felt engaged and con-
firmed. They felt secure in the group and the opportunity
to build up a more or less new social network to com-
pensate for lost ones was important for being perceived
by others. Gorst-Unsworth and Goldenberg [20] found in
a study on male refugees from Iraq that a social network
after reception in a host country was central for preven-
tion of mental illness. For those who are not working or
studying Swedish, for instance, away from home, this
social support group, meeting an optimal number during
five weeks, may also prevent isolation and marginalisa-
tion.
The participants’ needs and possibilities for post-mi-
gration stress management do not seem to be in line with
the new refugee reception law [11]. The results are sup-
ported by a Swedish government report about how the
authorities have implemented the introduction reform
[21]. The report shows, for instance, that “activities are
not sufficiently adapted to the target group needs and
requirements” (page 8).
4.2. Discussion of the Methods
Methodological limitations of this study are the ab-
sence of a control group and the selection bias because
we could not control who was invited from the Swedish
Public Employment Service. However, it seemed that the
participants obtained support from the Service’s assis-
tants, who became more sensitive to the impact of post-
migration stress as they participated as observers in the
HPIC. The target group was small and a single language
was used. Outside control of the present project, the tar-
get group is less settled than the general population,
which influenced the high numbers of drop-outs, but the
drop-out is in line with other prospective studies [8] and
there were no significant differences in background fac-
tors between the participants and the drop-outs. Another
limitation of the qualitative data is that we communi-
cated through a professional interpreter and because of
the challenges with translated research data [22] we were
unable to analyse latent data. Further, we cannot con-

S. Ekblad, M. Asplund / Open Journal of Preventive Medicine 3 (2013) 12-21
20
clude that the changes in perceived health were a result
of the HPIC. However, the study has strength in that it is
prospective, used an established instrument in Arabic
(EQ-5D) and is based on both quantitative and qualita-
tive data, partly mixed-method design as qualitative data
was only used at the six months’ follow up. The qualita-
tive data explored the quantitative data at the six months
follow up and showed that having the health promotion
course was relevant and user-friendly for the target group,
and the narrative interview group data had face validity
with the quantitative data. Due to the sixth months’ fol-
low up data from the group interviews, in the future
some objective questions may be developed regarding
future stress management and coping after HPIC. A key
unanswered question is whether or not the benefits last
for more than 6 months. A related question is what is
required to maintain these benefits over time. At the
six-month follow-up, the participants mentioned several
post-migration stress factors that was beyond their con-
trol but had an impact on their perceived health. In gen-
eral, altering attitudes is very difficult but information
may change a person’s inner welfare, which in a next
step, influences that person’s behaviour in a way that
improves his or her perceived health and health-related
beliefs [23].
5. CONCLUSION
Our findings contribute to the small but growing body
of evidence that a relatively short and culturally tailored
health promotion education, with clinically interdiscipli-
nary health professionals, a coordinator and an inter-
preter, strengthens the prerequisites for new-coming re-
fugees, who are a risk group for poor health, especially
mental, and at risk of marginalisation, to improve their
post-migration stress management and coping and pre-
vent poor access to health care. Health is a human right
and knowledge heightens empowerment. The data are in
line with the literature that healthy new-comers will be
productive members of the host country.
Practical Implications
Such a preventive approach should be incorporated in
a comprehensive model of community-based health pro-
motion and integrated patient-centred primary care. Fur-
ther, an interdisciplinary and intercultural approach for
collaboration between service reception staff and clinical
staff is recommended [24]. These interventions should
also be spread to other social and economic disadvan-
taged groups at risk of poor health and be accompanied
by regular evaluation and quality improvement.
Despite the limitations mentioned above, this study
provides sufficient evidence to assert that the relatively
short health promotion courses for unidentified patients
are a promising intervention worthy of further imple-
mentation and investigation. However, in order to be-
come more efficient, reception staff both with and with-
out medical training need to be trained in how to col-
laborate in the short and long term in intercultural and
interdisciplinary communication.
6. ACKNOWLEDGEMENTS
The authors wish to thank Professor Richard Mollica, MD, and his
team for introducing us to the health promotion course. We also thank
physiotherapist Niklas Johnson and Gona Jafaar, MD, for their great
contribution as team leaders in the course. The project was financed by
a public health budget (Folkhälsoanslaget), Stockholm county council
(HSN 0803-0349, 2008-2011). Special thanks to Mr. Patrick Hort for
language editing of the text.
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