In Search of Links: Overview of the State of Research on Disability, Migration, Employment and Health

Catalina Fipper and Nelly Hölter
Master Students in Ethnic and Migration Studies at Linköping University, Sweden.

1. Introduction

This paper provides the basis for a subsequent study on the health-related experiences of migrants with disabilities in the Swedish labour market conducted by the Independent Living Institute.

The study brings together four topics that are currently highly debated in Swedish as well as various international social and political discourses: Migration as a major society-shaping dynamic; Employment as a significant factor for well-being; Health as a fundamental life determining factor; and persons with disabilities as an often stigmatised and marginalised group. 

The aim of this paper is to gather background information on the individual topics of migration, disability, health and employment and to point out possible intersections between them. We will abstain from making any complete claims, but instead, exhibit fundamental correlations and dynamics as a background to further identify and analyse the challenges faced by migrants with disabilities in the labour market. This paper focuses on contemporary literature, such as studies, governmental papers or legal frameworks from the past ten years. A special focus lies on the context of Sweden. 

We write this paper from an independent living perspective, which means that we recognize and emphasize how disability and the self-determination of persons with disabilities are human rights based issues. The Convention on the Rights of Persons with Disabilities (CRPD) and especially its Article 19, which focuses on living independently and being included in the community, serve as the foundation for our work.

Research on disability comes with several topic-specific challenges, one of these being diverging definitions of the term disability and what it encompasses. Therefore, it is difficult to compare studies, particularly in an international context where institutions and countries cater to different target groups. However, we ground our analysis on the definition provided by the World Health Organization (WHO): “Disability [...] results from the interaction between health conditions and/or impairments that a person experiences [...] and a range of contextual factors related to different environmental and personal factors.” (WHO 2022). This extensive definition of disability goes beyond what is most commonly used in works we have encountered in our research process as it acknowledges that a disability is neither solely a health condition or an impairment nor a result of environmental or personal factors. Instead, disability is the result of the combination of these three factors. The experience of a health condition or impairment as a disability is affected by environmental and personal factors, including gender, age, race, economic status, access to infrastructure, discrimination experiences, and more.

The challenge of differing definitions also applies to research on migration. The term 'migrant' is commonly used to refer to individuals who have relocated from one place to another. However, there is no internationally recognized legal definition of this term, and its usage can vary depending on the context. This paper adopts the definition by the International Organization for Migration (IOM) of a migrant as a “person who moves away from his or her place of usual residence, whether within a country or across an international border, temporarily or permanently, and for a variety of reasons“(IOM 2024).

In comparison, the term 'refugee' refers to a legally defined category of migrants who “qualify for protection under the United Nations […] due to a well-founded fear of persecution based on their race, religion, nationality, membership of a particular social group, or political opinion“(ibid.).

The following paper is structured as follows: Section 2 provides a brief overview of the legal framework for migrants with disabilities and their rights to work and health. This serves as the foundation for the relevance of this paper. In the 3rd section we move to the core content of the paper, the state of research regarding the intersections between the topics of migration, disability, health and employment. None of these topics stands alone, instead they are interdependent and deeply related. Whereas some intersections, such as migration and employment or disability and health receive a lot of attention, the current research on other intersections remains underrepresented. As there is currently no research linking all four of these topics, this text aims to identify which topics have already been investigated in relation to each other, by examining them one by one. The subsequent discussion in section 4 seeks to underscore the significance of simultaneously considering these four topics.

2. Legal Framework for Migrants with Disabilities

Migrants with disabilities are affected by certain intersectional struggles that impact their living situation. In general, different international legal frameworks by the EU or the UN serve as orientation in the treatment of migrants and persons with disabilities, though these documents rarely touch the intersection of disability and migration, as can be seen below:

  • Charter of Fundamental Rights of the EU 2000
    - EU Institutions must respect fundamental rights in their actions.
    - Content among others is the integrity of the person (art. 3), the prohibition of slavery and forced labour (art. 5), the right to education (art. 14), the right to asylum (art. 18), non-discrimination, including on the grounds of disability (art. 21), or the integration of persons with disabilities (art. 26) and healthcare (art. 35).
  • Sustainable Development Goals 2030 Agenda
    - Promotes sustainable and inclusive development in the EU until 2030, including among others the aim of access to decent employment for all and the reduction of inequality within and among countries.
  • UN Geneva Convention Relating to the Status of Refugee 1951
    - Contains the internationally recognized definition of a refugee and defines which kind of legal protection, rights and assistance a refugee is entitled.
  • UN Global Refugee Compact 2018
    - Declaration to strengthen international collaboration in the refugee context to ease the plight of refugees in the world.
  • UN Convention on the Rights of Persons with Disabilities (CRPD) 2008
    - Here, migrants with disabilities are not specifically mentioned (though article 11 refers to the obligation to protect persons with disabilities in situations of risk, emergency).
    - Includes among others the right to the highest attainable standard of health (art. 25) and the right to work and employment (art. 27). 

3.  State of Research 

3.1 Migration and Disability

The thematic discussion of the intersection between migration and disability is predominantly covered by reports of political institutions such as different organisations within the EU. 

Precise numbers about persons with disabilities on the move are currently not available due to a lack of standardised data collection methods, varying definitions of disabilities and limited understanding of the different types of disabilities (Migration Data Portal 2023; FRA 2016). Data conducted by the Migration Data Portal (2023), however, suggests that taking the global disability prevalence rate of 15% into account it is estimated that at the end of 2020, 12.4 of 82.4 million globally displaced people were persons with disabilities. Not every migrant with disabilities has had his or her disability already before the migration process, some acquire or develop their disability during the often dangerous and potentially violent process (FRA 2016). 

One crucial factor leading to the insufficient reliable data is the lack of formal disability identification procedures for migrants (ibid.). Even though the identification procedure in the EU is legally binding through the Reception Conditions Directive which was adopted in 2013 it remains insufficient (ibid.). The directive calls for the member states to integrate an assessment of vulnerability status into their reception process of newly arrived migrants. In chapter four of the document, it is stated that disabled migrants are recognized as being a vulnerable population. Nevertheless, the procedures are inadequate and vary significantly between member states. Whereas the mandatory health screening in Sweden also includes a conversation about past and present mental and physical health conditions, a similar screening in Germany is mainly focused on transmittable diseases (ibid.). During those screenings, the identification often depends on information shared by migrants themselves. Though, many don’t share their disabilities with authorities due to fear that this might affect their asylum process. Additionally, staff conducting the health screenings often lack the necessary training to identify diverse disabilities, which results in many disabilities, especially the “invisible” ones remaining unidentified (ibid.).

In order for migrants to get access to support systems and the protection of their rights, identification is, however, crucial.

Even if disabilities get identified in the reception process and the migrants with disabilities should theoretically have access to support services these often lack in reception centres throughout the EU (Leenknecht 2020). These missing services can include among others assistive technologies such as language interpreters for blind or deaf persons or architectural barriers like missing ramps for wheelchair users (ibid.). 

Another challenge migrants with disabilities, especially those with intellectual disabilities, face during the migration and more specifically the asylum process in the EU is the preparation of interviews and gathering of relevant information documents for their asylum claim (ibid.). This also poses a challenge when it comes to the requirement to prove “well-founded fear” for the receiving of refugee status (ibid.). 

An overarching challenge becoming evident in several research papers is the missing training of staff working with migrants at different stages of their migration process. It, hence, goes beyond the already mentioned lack of training for medical staff conducting health screening, further to security staff at the reception centres, interpreters, and case workers (European Union 2021). 

Overall, the state of research regarding the intersection of migration and disability focuses a lot on the recognition and identification of migrants with disabilities and the obstacles leading to a successful identification. Further challenges faced by migrants with disabilities in their continued reception and integration process will be looked at in the coming sections about the intersection with labour market as well as health.  

3.2 Disability and Health

Disability and health are closely intertwined in many ways, however, a disability is not to be equated with a health condition. As mentioned in the introduction, based on the definition by the WHO, a disability is the result of the combination of a health condition, an impairment, and environmental and personal factors. This definition emphasises how a health condition can lead to a disability. When considering the intersection between disability and health it is equally important to address the relation the other way around - how a disability influences health. Precisely this relation has been the main focus of our research regarding the intersection of disability and health. 

The following section is mainly based on the comprehensive report Global Report on Health Equity for Persons with Disabilities by the WHO in 2022 regarding health inequities for persons with disabilities (WHO 2022). 

The right to health for every person, with or without disability, is a fundamental human right codified in a number of international and national documents. The right to health for persons with disabilities has been recognized and promoted in international policy strategies and frameworks since the 1980s with the World Programme of Action Concerning Disabled Persons in 1982 being the first international policy document with a specific section dedicated to the health of persons with disabilities. The WHO recognised an improvement of health standards for persons with disabilities in recent years, however, persons with disabilities remain to have worse health outcomes than persons without a disability. Many of those differences do not stand in relation to the underlying health condition influencing the disability and are, hence, termed health inequities. Health inequities are avoidable and a result of unfair factors determining the health care and do, therefore, not align with the human right to the same standard of healthcare for everyone. 

Some of the ways in which persons with disabilities are stronger affected are: a relatively earlier death, poorer health and functioning and a stronger vulnerability by health emergencies. These outcomes are determined by diverse factors which can be categorised as follows: 

Structural factors: persons with disabilities are compared to persons without a disability more likely to experience discrimination and stigmatisation in the wider civil society as well as in the health care system. This can lead among others to a delayed seeking of health care services which results in poorer long and short-term health outcomes.  

Social factors: The conditions a person with disabilities is born, raised, and aged in are crucial for the health outcome. Among the long list of social determinants brought forward by the WHO are, to name a few, poverty and added costs, education and employment and transportation. Households which include persons with disabilities face additional costs, in several ways: accessible housing, personal assistance, transportation, added costs for healthcare etc. This results in relatively more persons with disabilities living in poverty compared to persons without a disability. Regarding education and employment, it has become evident how persons with disabilities are less likely to have access to education and work which has a strong negative effect on the health outcome due to inactivity and effects on mental health. Last but not least, unreliable or unavailable transportation for persons with disabilities prevents them from accessing health care services.  

Risk factors: Exposure to risk factors including noncommunicable diseases, physical inactivity, drug use (tobacco, alcohol, etc.) and diet are crucial for health outcomes. However, public health interventions are often not inclusive which leads to persons with disabilities being relatively more exposed to these risk factors.

Health system factors: Several characteristics of the health system itself influence the health outcome of persons with disabilities. One of such being the lack of knowledge and training of healthcare professionals regarding the needs of persons with disabilities. Also, barriers in the health information system, limiting financing of special health services needed by persons with disabilities or general unavailability of appropriate health services determine health outcomes of persons with disabilities. (WHO 2022)

Despite this categorization it is important to note that all of these factors do not stand alone but are closely interrelated. 

Going beyond the already mentioned negative effect on health outcomes if a person is unemployed, the WHO further stresses the effect a bad health condition can have on the job seeking abilities. Good health for persons with disabilities enables them to participate more in society which includes the conducting of a job. 

Though not the focus of this paper, we briefly want to mention some recommendations to advance health equity for persons with disabilities formulated by the WHO. These include the prioritising of persons with disabilities in any health care action and the planning of such; the empowerment, hence, inclusion of persons with disabilities into decision making processes particularly into those by organisations representing persons with disabilities; to monitor and evaluate the progress of health equity in the health sector (ibid.). 

Data collected by Statistiska Centralbyrån (SCB), the Swedish governmental agency for official national statistics, supports the findings about the general health situation for persons with disabilities, portrayed by the WHO on the global level, on the national scope (SCB 2021b). The data collection of SCB even goes one step further and also considers the intersection with migration background. A further elaboration of their findings will be done in section 3.7.

3.3 Employment and Disabilities

As research on disability is difficult due to different definitions and approaches, especially comparative studies on disability and employment are rare. The International Labour Organisation (ILO) states in a report from 2018 that persons with disabilities are generally less likely to be employed than people without disabilities (ILO 2018; Barnay 2016). They analyse this especially as a problem affecting women (ILO 2018) and certain disabilities (Barnay 2016): A study from 2016 by Thomas Barnay on the link between health, work and working conditions in Europe identifies it as a positive influence on the probability of employment to be disabled from birth and to be male. Also, it has a positive influence to have a disability resulting from a traffic accident, for both men and women. At the same time, the form of disability has much less influence on income than on employment itself (ibid.). Barnay also states that disability does not lead to a decrease of earnings or hours worked at least during the first three following years after the occurrence of a disability, when the disabled person remains employed. His study could also find out that becoming disabled reduces the probability of being employed by 9% and approximately 13% for those with a high degree of disability three years after its onset (ibid.). While the findings should not be disregarded, it is important to note that they are based on a single study and should be approached with caution. It is not appropriate to assume that they are universally valid.

Detailed statistics on the relationship between persons with disabilities and the labour market are generally lacking. This is partly due to the fact that in some countries, persons with disabilities are not automatically captured as job-seekers. However, it can be said that a larger proportion of persons with disabilities are self-employed. The ILO interprets this as an involuntary outcome of a lack of opportunities and lower levels of education for persons with disabilities, which leads to informal employment more often. As persons with disabilities are a very heterogeneous group with very different needs and struggles it is difficult to implement effective political strategies to tackle that problem (ILO 2018). One of the most urgent hurdles for the integration of persons with disabilities is the lack of adequate education. The education of disabled persons is too often not sufficiently included into mainstream education so that persons with disabilities are not well enough prepared for the skills demanded on the labour market. Other barriers analysed by ILO are the necessity of commuting to work and the accessibility of transport related infrastructure and existing misconceptions concerning the capability and productivity of persons with disabilities at work. Employers often think their employment is more expensive, more risky and less effective than the employment of people without disabilities (ibid.). ILO recommends to ensure that persons with disabilities have the skills as demanded by the labour market, aiming to match demand and supply, to advocate for entrepreneurship for persons with disabilities and for their inclusion in the private and public sector (ibid.). Also new technologies should be used more frequently and efficiently as an enabling factor in the working environment (ibid.).

As at the international level, it is also evident at the national level in Sweden that the lack of consistent statistics and comparable data on disability and the labour market poses a challenge. The SCB writes a yearly report on the situation on the labour market for persons with disabilities. Their survey for the year 2022 includes people between the age of 16-64 years who are being asked after limitations on the labour market through their disability and they are asked four questions about discrimination in their working life (SCB 2023). Their report of 2022 is, to bring an example for the difficulties in comparable statistics and data, not comparable with the report from 2021, as there has been a shift to new questions to define the group of people with disabilities (ibid.). 

In the theoretical framework of SCB about 10% of the people in the age between 16-64 years registered as Swedish residents in 2022 have a disability, which corresponds to 669.000 people. 71% of these people see a reduction of their ability to work through their disability. Even if there are as many men as women having a disability, it is more women than men who consider their disability to have an impact on their ability to work. According to the source, individuals between the ages of 50 and 64 are more likely to experience limitations in their work due to a disability. Furthermore, the report states that a higher proportion of Swedish-born people have a disability than foreign-born people (12% compared to 8%) (ibid.).

In Sweden, 63% of persons with disabilities are in the labour force, meaning they are either registered as employed or unemployed in 2022. Among persons with disabilities with a reduced ability to work 55% are in the labour force. In comparison, the labour force participation rate for the non-disabled population aged 16-64 in Sweden is 88%. Although as many women as men with disabilities are in the labour force, the number of women is lower than that of men in the non-disabled population (ibid.).

The SCB report (2023) provides further insights beyond the number of people in the labour force by presenting the number of employed individuals. Around 5 million people aged 16-64 are employed in Sweden, with 346,000 of those having a disability (SCB 2023). While the employment rate for people without disabilities in this age group was 81% in 2022, only 52% of people with disabilities are employed, and this figure drops to 44% for those with reduced work ability. Although men have a higher employment rate than women in the general population, there is no significant difference registered among persons with disabilities (ibid.). 

In Sweden in 2022, the unemployment rate among people with disabilities is 17%, which is 8% higher than those without disabilities. For persons with disabilities with a reduced ability to work, the unemployment rate is even higher at 20%. Additionally, only 61% of persons with disabilities work full time compared to 82% of those without disabilities (ibid.). Furthermore, women are less likely to work full-time than men. Permanent employment is less common among persons with disabilities than among those without a disability (ibid.). Women are more likely to work in the municipal sector, while men are more likely to work in the private sector in both groups. Looking at the occupational distribution, individuals with disabilities tend to work more in service, healthcare, social work, sales, administration, and customer services than those without disabilities. They are less likely to work in managerial positions or in professions that require higher education (ibid.). Among persons with disabilities 32% have experienced discrimination in their workplace related to their disability, and this number increases to 37% among those with reduced ability to work, compared to 20% of those without reduced working ability. Discrimination against people with disabilities is most commonly seen in job applications, where they do not have the same opportunities as applicants without disabilities who have the same qualifications. Additionally, it is common for individuals with disabilities to experience bullying, offence, or harassment from managers or colleagues (ILO 2018).

3.4 Migration and Employment

The EU identifies the participation of migrants in domestic labour markets as a core approach for successful integration. However, the process of labour market integration differs depending on the migrant's status. Refugees tend to have a slower integration process compared to labour migrants or those coming through family reunification. One reason for this is that the skills of refugees, unlike those of labour migrants, may not match the demands of the labour market they are trying to enter (Bevelander and Irastorza, 2016). 

As migrants with disabilities, on which we focus in this paper, in most cases do not come initially as so-called labour migrants, the following examination of the intersection between migration and labour market will focus on people seeking protection.

According to EU legislation, more precisely the Qualifications Directive, the scope of access to the labour market depends on the status of the individual seeking protection (European Commission 2016). Whereas refugees legally have unrestricted access to the labour market and employment-related support services, asylum seekers merely have restricted access (ibid.). Restrictions on access for asylum seekers vary considerably between Member States but can include a number of hours, age restrictions, eligible occupations, undergoing labour market tests and wage restrictions (ibid). Despite the legally defined access to work, migrants, both with refugee status and during the asylum process, face a variety of obstacles of administrative, institutional, economic, educational or social obstacles that prevent them from finding work in an EU country (ibid.). The report Challenges in the Labour Market Integration of Asylum Seekers and Refugees by the European Commission (2016) summarises these diverse challenges as follows:

A.  Administrative challenges include for example the lengthy asylum procedure, which can take several months or years depending on the country. This process leads to a gap in employment history, poor social integration and has a psychological impact that affects the migrant's ability to find a job. The required documents and the potentially difficult process of obtaining them is another administrative challenge that migrants face.

B.  At the institutional level, inadequate integration programmes, often linked to a lack of project funding, create difficulties for successful participation. For example, programmes such as language courses, which are theoretically available to refugees and, in some countries, asylum seekers, are often not accessible in practice. In addition, a lack of staff in government agencies responsible for or supporting access to the labour market, as well as a lack of cooperation and coordination between relevant institutions, exacerbate the difficult situation.

C.  As economic and labour market challenges the EU identifies in their report among others the often restricted working permits for asylum seekers. This restriction may cause employers to be hesitant or unwilling to hire individuals with such permits due to uncertainty and limited employment opportunities. Furthermore, the highly competitive EU labour market presents a challenge for migrants, often resulting in job offers with low pay and poor working conditions, or even forcing them into the 'shadow economy'. The language barrier many migrants face is identified as being one of the most significant barriers to successful participation in the labour market in EU countries.  It affects competitiveness during the job application process and accessibility to relevant information. Another significant barrier to employment is the lack of recognition of qualifications and professional experience gained outside of the EU. Often, skills acquired in the country of origin are not acknowledged by EU member states. 

D.  On a societal level, the lack of social and occupational networks and discrimination pose further significant obstacles. The often reported discrimination with prejudices against refugees and asylum seekers within larger societies is also evident from the side of the employers throughout the application processes. 

E.  The EU report's final category of challenges focuses on the specific vulnerabilities of refugees and asylum seekers. It highlights the physical and psychological traumas that many migrants face and the impact these have on their health. A person's physical and psychological state can affect their ability to meet their daily needs, such as finding suitable housing or supporting their families, which in turn can affect their ability to seek and perform work. (European Commission 2016)

Like most EU member states, Sweden has identified labour market integration as one of their main approaches of migration response. The language skills and labour market integration are targeted by the government through the introduction programme (Etableringsprogrammet) (Bevelander and Irastorza 2016). 

The available evidence indicates that the longer migrants spend in Sweden, the higher their employment rate on the Swedish labour market becomes. However, their employment rate remains below the Swedish average (ibid.). According to data conducted by SCB in 2021 the unemployment rate among Swedish-born persons was below 5% whereas the rate among foreign-born was above 20% (SCB 2021a). The mentioned increase in employment over time seems to be linked to increasing language skills and growing knowledge about the culture and societal structures. 

It remains to be seen to what extent the recognition of the importance of labour market integration, including the introduction programme, will remain a crucial component of Sweden's migration response, given the anti-migration agenda of the newly elected Swedish government in 2022.

Research regarding the intersection of migration and labour market identifies a variety of challenges faced by refugees and asylum seekers. However, migrants with disabilities and their particular challenges are barely considered. 

3.5 Employment and Health

Since the Covid-19 pandemic, and to a lesser extent even before 2020, various studies have been conducted on the relationship between employment and health. These studies examine the correlation between personal health and job loss (Griffiths et al. 2021), low-quality jobs (The Health Foundation 2022b), and unemployment (The Health Foundation 2022a; von der Noordth 2014).

Already in the 90s studies on the relation between employment and health show that unemployment leads to severe mental health issues (von der Noordth 2014; Griffiths et al. 2021; The Health Foundation 2022a). The cause of this issue is likely due to five mechanisms: poor core self-evaluations, financial strain, strong stress appraisal, social undermining, and the work role centrality of the unemployed (von der Noordth, 2014). Maaike von er Noordth et al.'s (2014) literature review indicates that studies published between 1990 and 2012 consistently show a correlation between unemployment and an increased risk of depression, psychological distress, general mental health issues, and psychiatric morbidity. The same studies also consistently show that (re-)employment decreases the risk of these illnesses (ibid.). General health improves for people who are re-employed, and less for people who are long-term unemployed. At the same time, the analysed studies show that re-employment can cause both positive and negative effects. On the one hand, a clear structure of the day, meaningful goals, social interaction, financial security or opportunities to improve personal skills have positive effects on health. On the other hand, heavy physical work, stressors and exposure to radiation have negative effects on health (ibid.).

Studies during the Covid-19 pandemic clearly indicate that job loss is associated with physical distress and poor mental and physical health, compared to those whose work remained unaffected (Griffiths et al. 2021; Bogliacino 2023). It is important to consider factors such as variations in social security systems across different countries and Covid-19 measures.

Additionally, a correlation can be made between poor health and low-quality jobs. Research shows that individuals in low-quality jobs are more likely to have poorer health (The Health Foundation 2022b). Employees who experience low job security or job satisfaction are more than twice as likely to report poor health compared to the average employee. This indicates that low-quality jobs have a similar negative impact on health as unemployment. Factors contributing to low job satisfaction may include a lack of financial security, autonomy, or well-being (ibid.).

As demonstrated above, studies examining the relationship between employment and health primarily focus on mental health rather than physical health. Only a limited amount of evidence regarding physical health can be gathered from existing studies, which is not as consistent as that for mental health. Firstly, studies indicate a correlation between physical illness and mental distress (Barnay 2016). Physical health effects are often attributed to poor living standards and unhealthy behaviour (von der Noordth, 2014). Positive effects of employment are also commonly reported. However, job loss has been associated with an increased risk of mortality, particularly from circulatory disease, suicide, and hospitalization due to traffic accidents, alcohol-related disease, and psychiatric disorders (Barnay, 2016; von der Noordth, 2014). Generally, improving material living conditions leads to better access to healthcare and, consequently, improved health status (Barnay, 2016).

All in all, the analysed studies show strong evidence that employment improves general mental health and reduces the risk of depression, while the pieces of evidence for an impact on physical health are not as congruent.

3.6 Migration and Health

In our research on the link between migration and health, we specifically focused on the context of Sweden. This is because results on this topic may vary depending on the healthcare system in the country of residence. According to the Swedish Migration Agency, asylum seekers in Sweden are entitled to emergency healthcare, dental care, and other healthcare that cannot wait (Migrationsverket Sverige 2023). This covers services such as childbirth care, abortion care, contraception advice, maternity care, and healthcare related to the Swedish Communicable Diseases Act, aimed at preventing the spread of contagious diseases. The responsibility for deciding which type of healthcare can be provided lies with the county council or region. Minors who seek asylum are entitled to the same healthcare and dental care as children living in Sweden (ibid.). Furthermore, asylum seekers have the right to be accompanied by an interpreter. All asylum seekers are offered a free health assessment, shortly after having applied for asylum. The migration agency states that the outcome will not affect the asylum process (ibid.). Concerning refugees with disabilities, the Migration Agency recommends that refugees having or thinking to have a disability should inform the healthcare staff at the health assessment. If the disability makes it more difficult to communicate during the asylum process support can be received. The agency states that a disability will not prevent migrants from obtaining a residence permit (ibid.). If the asylum application is rejected and thereby the right to financial support by the Migration Agency expires the LMA card has to be returned and allowance for medicine or doctor’s appointments cannot be received any longer (ibid.). 

What might sound good on paper comes with different struggles in real life. The Swedish Red Cross reports in relation to their care for persons without a residence permit that they meet migrants who have experienced struggles accessing health care in Sweden on a daily basis (Svenska Röda Korset 2018). They identify the following problems:

A.   The legislation does not provide clear criteria for determining which healthcare services are absolutely necessary, instead placing the responsibility solely on healthcare staff. This can create ethical dilemmas for healthcare workers as it challenges their understanding of the equal value of all humans, resulting in differences in care for people with the same health condition. It is not uncommon for individuals without an LMA card to be turned away upon arrival at hospitals due to insufficient knowledge of their rights among staff. The social board recommends that all migrants seeking healthcare undergo a medical examination.

B.   Healthcare workers may lack information and knowledge about healthcare for migrants, which can be problematic as they are responsible for deciding which healthcare is accessible for this group of patients. This is particularly dangerous for pregnant women who may not receive the necessary healthcare during birth, risking complications that can lead to further illnesses or even death.

C.   Migrants without legal documentation may fear being reported to authorities, while others may be unaware of the duty of confidentiality within healthcare and fear negative implications for their asylum process.

D.  Migrants, particularly those without documentation, may not be aware of their entitlement to healthcare due to a lack of information in their native language. Consequently, they may not seek medical attention or face difficulties in communicating their rights to healthcare providers.

E.   Administrative routines, like telephone services, are often only available in Swedish, which makes it more difficult to book appointments. Additionally, the absence of interpreters complicates the process. Furthermore, health care institutions usually send letters which might be difficult to receive for migrants who lack a stable place of residence.

F.  These insecure legislations make it difficult for minors seeking asylum, who have the same right to healthcare as Swedish minors, to access it. Healthcare measures are often postponed because staff are unsure how long they will stay in Sweden, resulting in important treatments being missed and leading to more severe health problems. (Svenska Röda Korset 2018)

Regarding the general health status of migrants in Sweden, the Public Health Agency reported in 2019 that individuals born outside of Sweden are, in part, in worse health condition than those born in Sweden. People who came to Sweden recently have generally better health than migrants who have lived in Sweden for several years. It suggests that there are health factors that come into play after the migration process, which have a significant impact on health status (Folkhälsomyndigheten 2019). This is evident in the prevalence of 'welfare illnesses' such as diabetes, high blood pressure, or obesity, which are more common among individuals who have lived in Sweden for more than five years compared to those who have not. Mental health problems are generally more common for migrants. Especially minors who came to Sweden alone have more often reached out for psychological help than others. Some infectious diseases like Tuberculosis or HIV are more likely among migrants, most of whom have been infected before coming to Sweden (ibid.). According to the source, migrants generally experience poorer dental health. However, individuals who have lived in Sweden for more than five years tend to have better dental health (ibid.). In general, the living conditions of migrants are worse than those of Swedish-born people. They are more likely to be unemployed and earn less money (ibid.). Furthermore, migrants often lack a permanent housing situation (Svenska Röda Korset 2018.). The notion of the healthy migrant effect, which suggests that migrants often have better health than residents in their home countries and in the hosting country shortly after their arrival, while their health status deteriorates after a few years, is not entirely applicable to Sweden. A longitudinal study conducted between 1985 and 2008 found that the healthy-migrant-effect is only valid for migrants from Western countries who come to Sweden liberally. This effect cannot be consistently proven for migrants from other parts of the world, mostly consisting of refugees and family reunions (Helgesson et al. 2019).

3.7 Health, Migration and Disability

There is limited research on the relationship between health, migration, and disability. The International Organisation of Migration (IOM) has published a report examining the implications of Covid-19 responses for migrants in vulnerable situations, including those with disabilities (IOM, n.d.). The report notes that measures against Covid-19 were applied to all migrants, but not all groups were able to follow the rules effectively. Migrants with disabilities are often referred to as particularly vulnerable due to their dependence on personal assistance, which can be difficult to access due to various restrictions. The reasons for this vulnerability include experiencing stigma and exclusion, as well as difficulty in taking appropriate steps to protect themselves due to their reliance on others for everyday tasks. The virus poses a threat not only to the health but also to the independence of persons with disabilities. Additionally, information about Covid-19 and related measures is often not available in accessible formats such as audio, braille, large print or sign language. The closure of residential schools and day centres can also put persons with disabilities at risk of abuse when they have to be taken care of at home (ibid.). Other than that, reports or studies on disability, migration and health could hardly be found on an international level.

In 2021, the SCB conducted a study on disability and health in Sweden. The study found that healthcare for people with disabilities is worse than for those without disabilities. The research also highlights differences in the situation of migrants with disabilities compared to those without a migratory background. 12% of migrants with disabilities reported not having access to medical care when needed, compared to 7% of those with a Swedish background. Similar percentages are reported for the self-evaluation of health status by persons with disabilities in Sweden, regardless of migratory background. Specifically, 11% of persons with disabilities without migratory background and 19% of those with migratory background evaluate their health as 'bad' (dålig). Also, no differences were found among individuals without disabilities living in Sweden, with or without a migratory background. (SCB 2021b) 

4. Conclusion

This analysis examines the existing research on the links between migration, health, employment, and disability. It is evident that there is a significant research gap in this area, as no academic papers, reports, or studies were found that consider all four factors and their relation to each other. This highlights the need for further research into the impact of employment situations on the health status of migrants with disabilities. Deeper knowledge of the influencing factors is crucial when addressing these challenges for political or societal actors. Furthermore, three factors can be identified that should be considered by doing further research: (1) intersectionality, (2) two-way-causal links, and (3) comparability.

1. Intersectionality

Numerous studies have demonstrated that migrants encounter particular obstacles when attempting to access healthcare and secure employment, both internationally and in Sweden.  This is also the case for migrants with disabilities, despite the varying factors that influence their experiences. To fully understand the challenges faced by migrants with disabilities, it is important to take an intersectional approach that considers the impact of their migratory background and disability, particularly the combination of the two. The majority of research on employment and health focuses on only one intersection, either being a migrant or having a disability. However, this approach alone may not be adequate for identifying and addressing the challenges faced by migrants with disabilities in the labour market with regard to their health. This aligns with the definition of disability mentioned in the introduction, which states that environmental and personal factors impact the disability experience. Therefore, it can be concluded that the disability experience of migrants may differ from that of individuals without a migratory background. Therefore, any future research on the health of migrants with disabilities with relation to employment and unemployment should be theoretically grounded in intersectional perspectives when designing surveys or other qualitative research tools.

2. Two-way-causal link

Research on disability and health shows a two-way-causal link between health and employment. This should be considered when designing appropriate research. Not only does inclusion in the labour market affect the health status of persons with disabilities, but assumptions about the health of persons with disabilities also impact their inclusion in the labour market. This connection should be taken into account when conducting further research on the health of migrants with disabilities in the labour market.

3. Comparability

Internationally, as well as in Sweden, studies on disability and migration are based on different definitions of these terms. This lack of standardisation makes it difficult to compare research results, as previously discussed in the introduction. When designing research on the health of migrants with disabilities in the labour market, it is important to consider the definitions of terms such as 'migrant', 'migratory background', 'health', and 'disability' that underlie the research design or survey. To ensure comparability between survey results from different actors and studies, it is important to make sure that the methodology is clearly defined and consistent.

Overall, this literature review indicates that there is a lack of research on the health of migrants with disabilities in the labour market. However, it is crucial to gain a deeper understanding of these intersectional challenges and how to address them.

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