Physical activity and mental health among trauma-affected refugees : associations, experiences, and intervention efficacy

Aims: The overall aim of this thesis was to increase the understanding of physical activity (PA) and its impact on mental health and wellbeing among trauma-affected refugees and asylum-seekers, and with a particular focus on posttraumatic stress disorder (PTSD) as a prevalent disorder in this context. More specifically, we sought to investigate experiences and preferences of participation in PA and exercise-based treatments from a holistic and patientcentered perspective (study I), to examine the prevalence of different levels of PA and associations with PTSD symptom severity (study II), and to evaluate the efficacy of a multi-component and trauma-informed PA intervention on symptoms of PTSD, depression, anxiety, and subjective wellbeing (study III). In study III, we also examined adherence to the intervention, changes in levels of PA and sedentary time, and a follow-up of all outcomes after six months.

Methods: The thesis comprises three studies, I) an explorative qualitative study with focus group discussions (n=33), II) a cross-sectional survey study (n=455), and III) a randomized controlled trial (n=183). Study I and III were conducted at the Swedish Red Cross Treatment Center for persons affected by war and torture (RCC Malmš) and study II at three housing facilities for asylum-seekers across Sweden. The methods for analyzing the collected data were conventional qualitative content analysis in study I, prevalence estimates, analysis of variance, and multivariable logistic regression analysis in study II, and mixed-effects linear regression models in study III. Basic descriptive statistics were also employed in all studies to describe the participants. The development of the study III intervention model and design were a part of the overall project, conducted in parallel with study I and II, and partially informed by the results of these preceding studies before the onset of study III.

Results: The results of study I outline a detailed description of trauma-affected refugeesŐ subjective experiences and preferences of participation in PA and exercise treatments, pointing to a multitude of pathways towards improvements in both mental and physical health domains, increased self-empowerment, and improved social adjustment. Treatment characteristics were experienced as highly supportive and the treatment group settings as a vehicle for overcoming social fear and isolation. The analysis resulted in one overarching theme reflecting the participantsŐ overall experiences as a process and building resilience through relief and recovery.

In study II, we found that almost half of the participants did not meet the general recommendations for a sufficient level of PA and there were significant differences in PTSD symptom severity between the groups with different levels of PA. Sufficient PA was associated with less PTSD compared to both insufficient PA and inactive, while insufficient PA was also associated with less PTSD compared to inactive. The associations between PA and PTSD persisted when controlling for sex, age, and exposure to torture, and level of PA was found to provide a high explanatory function for the variance in PTSD symptom severity.

The results of study III revealed that the multi-component and trauma-informed PA intervention had a significant impact on all primary and secondary outcomes. The between group difference in PTSD symptom severity corresponded to a large effect size. The average decrease in PTSD was clinically significant, as was the decrease in depression and anxiety, and the increase in wellbeing. The change in level PA was also significant and corresponded to a move from below to above the cutoff for a sufficient level of PA. All positive effects at postintervention persisted, or even further improved, at the 6-month follow-up. The overall intervention model appeared to be well received and tolerated, as reflected by a high adherence and a low dropout rate, and where a higher adherence was also associated with a greater reduction in PTSD.

Conclusions: The overall results of this thesis add to the empirical evidence of PA as an important factor in PTSD and support an increased focus on PA and exercise in the context of forced migration and trauma-affected refugeesŐ health and wellbeing. Increased PA promotion is justified at multiple levels, in line with the general guidelines and health benefits as associated with regular PA and exercise, and as a viable treatment modality to alleviate PTSD symptom severity and associated distress, and to increase wellbeing.

List of scientific papers

I. Nilsson, H, Saboonchi, F, Gustavsson, C, Malm, A, Gottvall, M. (2019). Trauma-afflicted refugeesŐ experiences of participating in physical activity and exercise treatment: a qualitative study based on focus group discussions. European Journal of Psychotraumatology. 2019; 10(1): 1699327.
https://doi.org/10.1080/20008198.2019.1699327

II. Nilsson, H., Gustavsson, C., Gottvall, M., Saboonchi, F. (2021). Physical activity, post-traumatic stress disorder, and exposure to torture among asylum seekers in Sweden: a cross-sectional study. BMC Psychiatry. 2021; 21(1): 452.
https://doi.org/10.1186/s12888-021-03461-2

III. Nilsson, H., Gottvall, M., Gustavsson, C., Nissen, A., Saboonchi, F. Evaluation of a trauma-informed physical activity intervention for posttraumatic stress disorder, depression, anxiety, and wellbeing in trauma-affected refugees: a randomized controlled trial. [Submitted]