The experience of meaning and value in occupations for forced migrants seeking asylum,and factors that facilitate occupational engagement: A meta-ethnography using a strength-based approach

Abstract

Introduction

Asylum-seekers face significant barriers to meaningful occupation, leading to negative health and wellbeing outcomes. This study provides a strength-based approach to enhance understandings about the meaning of occupation for those seeking asylum.

Method

A systematic search of the literature identified seven qualitative research studies. A meta-ethnographic approach was used to synthesise the findings.

Results

Examination of the selected studies generated three third-order interpretations as follows: keeping busy as a coping mechanism; maintaining continuity with past life by preserving identity, roles, values and culture; and building a new future with a drive to be a productive member of society. The study also identified factors that support meaningful occupational engagement during asylum.

Conclusion

This study shows that occupations are essential to existence for asylum-seekers. They help preserve identity and life-continuity; help people make sense of disorder in their life; and provide opportunity for reflection, leading to motivation toward goal-directed occupation. Finally, engaging in occupation helps people adjust and cope with trauma. The study highlights that a lack of meaningful occupations may limit the long-term benefits of occupational engagement while seeking asylum. Recommendations are made for further research to challenge restrictive policies and promote the rights and wellbeing of this population.

Keywords

Asylum-seekers forced migrants occupational engagement value meaning strength-based ValMO model

Introduction

Human displacement is the enforced departure of people from their homes because of war, persecution, civil unrest, and disaster (World Federation of Occupational Therapists (WFOT), 2014). Globally, the number of people forcibly displaced is rising. According to the United Nations High Commissioner for Refugees (UNHCR, 2021a) there are at least 82.4 million displaced people worldwide. This population face many occupational challenges, intensified by restrictive migration polices. In response to this growing social injustice, the WFOT (2014) advocate for research and practice to help those affected.

Human displacement is complex, and terminology used across disciplines and sectors is varied. In this article the terms ‘forced migrant and displaced person’ are used interchangeably, referring to individuals subjected to any kind of displacement or involuntary movement, both across international borders and within a country. This systematic review focuses on the experiences of asylum-seekers, individuals who are not yet legally recognised as a refugee and are therefore not entitled to the same economic and social support (UNHCR, 2021b). Asylum-seekers are often excluded from paid work, face prolonged periods of waiting and segregation from society leading to a lack of choice and control over occupational engagement (Gupta and Hocking, 2018).

Existing occupational science research has demonstrated how displacement impacts upon human occupation and has helped guide occupational therapy practice (Trimboli et al., 2019). Research has focused on the impact of being excluded from work (Burchett and Matheson, 2010); challenges relating to resettlement (Mirza, 2012; Mayne et al., 2016); and the experiences of living in a refugee camp (Darawsheh, 2019). These studies found that displacement caused profound occupational deprivation, loss and disruption. This evolving evidence base of predominantly qualitative research presents the experiences of marginalised people and helps advocate policy change. However, these studies are small and limited to the specific social and legal context of the host countries, making findings difficult to generalise. They also focus on the experiences of refugees, or forced migrants as a general population, rather than examining the distinctive experiences of asylum-seekers; therefore, identifying a need for evidence synthesis to generate new conceptual insights about asylum-seekers. Studies by Steindl et al. (2008) and Morville and Erlandsson (2013) provided insights about how people adapt their occupations and cope with daily life in asylum centres. By drawing on their personal histories, values, capabilities and future hopes; participants were able to create daily life-structures to manage distressing experiences and restrictive environments. The findings from these studies lacked generalisability due to the similarity of the participants; all highly educated and selected based on having good communication skills in either English or German. To gain a broader perspective, further studies are needed with greater diversity reflected in participants.

The importance of an occupational therapy perspective on trauma and the psychological impact of being forcibly displaced is increasingly emphasised within the literature (Morville and Erlandsson, 2017). Morville et al. (2015) investigated the correlation between torture experience and Activities of Daily Living (ADL) function of asylum-seekers living in an asylum centre. They found that exposure to torture can be linked to a severe decline in ADL skills. The small sample of 17 participants limit the generalisability of this study. However, the use of standardised measures, including the Assessment of Motor and Process Skills (AMPS) (Fisher and Bray Jones, 2014) which is sufficiently powered to detect change and widely used within healthcare settings, enhance the credibility of the findings, making them applicable to practice. This study makes a strong case for occupational therapy in supporting people affected by displacement and trauma and for further research about ADL and suitable interventions for this population. Similarly, Trimboli et al. (2019) emphasised the suitability of occupational therapy for addressing the needs of forced migrants. As the profession builds a united stance for helping displaced people, further research could be instrumental to lobby for the improvement of conditions and treatment of this population and argue the case for provision of occupational therapy.

To develop theories and explanations that can be used to improve the experiences of asylum-seekers, reviews and evidence synthesis are needed. Several scoping reviews already exist (Huot et al., 2016; Siddiqui et al., 2019; Cipriani et al., 2020). Huot et al. (2016) underlined the resiliency of forced migrants and ability to draw on existing skills and experience to adapt and cope with change. The breadth of geographical area covered, and the generic characteristics of the process within the context of forced migration, make the findings rather broad and over-generalised. In fact, Huot et al. (2016) identified a need for a systematic review to provide a deeper understanding of experiences of occupational issues, which this study aims to address.

Systematic reviews are integral to evidence-based healthcare practice. Whilst quantitative systematic reviews are arguably a more established research tool, their purpose is used to determine what works, from a positivist standpoint, whereas qualitative systematic reviews explore how something works in more depth, from a phenomenological perspective (Boland et al., 2017). Qualitative systematic reviews are widely used to explore the perspectives of marginalised groups (Marshall et al., 2019) which is imperative for informing person-centred practice and a priority for occupational therapy (RCOT, 2020).

Traditional occupational science theory risks perpetuating predominantly western-centric ideas about what occupations are considered meaningful or valued, particularly regarding the over-simplistic categorisation of occupations into domains of productivity, leisure and self-care (Hammell, 2009). Research that reflects diverse cultures (Hammell, 2017) and conveys the perspectives of marginalised groups is needed to enable occupational therapists to provide effective, client-centred interventions (Trimboli et al., 2019). Beyond identifying barriers to participation, understanding the meaning of occupation during the asylum-seeking experience and the factors supporting engagement, can pave the way for strength-based approaches that draw upon the resilience and capabilities of people from forcibly displaced communities. This approach avoids views that perpetuate ‘other’ or ‘deficit-discourse’ perspectives (Yeo, 2020).

Occupational therapy research is duty-bound to expose and challenge human rights violations to live up to its philosophy of enabling all people to live full and meaningful occupational lives (WFOT, 2019). Occupational value and meaning can only be fully understood when considered in relation to one another (Persson et al., 2001). This review aimed to explore how asylum-seekers experience meaningful occupational engagement and what factors facilitate their participation, asking the question: ‘how do forced migrants experience meaning and value in their occupations during the process of seeking asylum?’ It utilised a strength-based approach to identify how people use agency, despite limited opportunities and disadvantage, to engage in occupations that facilitate meaning and wellbeing. The Value and Meaning in Occupations model (ValMO) (Persson et al., 2001) provided a theoretical lens to explore the relationship between the value and meaning of occupation. Figure 1 demonstrates the three interlinking triads that comprise ValMO. A meta-ethnographic approach enabled the development of new theoretical insights, responding to calls for occupation-focused research to develop a strong theoretical knowledge base that can support this emerging area of practice and research (Delaisse and Huot, 2020).

Figure 1.

The three triads in the Value, Meaning and Occupation (ValMO) model, describing different perspectives of occupation. Adapted from Persson et al. (2001).

Method

A qualitative systematic review informed by PRISMA guidelines (Page et al., 2021) was conducted to capture existing interdisciplinary literature exploring the perspectives of asylum-seekers relating to occupational participation. The interpretative method of meta-ethnography was used to synthesise data from the selected studies to generate new insights (Noblit and Hare, 1988). Meta-ethnography is a well-established method for synthesising qualitative research in healthcare because it can enrich understandings of client experiences and was selected as an appropriate method for this study (Cahill et al., 2018). The research was guided by a critical realist paradigm which acknowledges multiple perspectives of a shared external reality (Edgley et al., 2016). This approach enabled capturing the way in which the phenomenon of being an asylum-seeker is experienced which is aligned with the meta-ethnography approach. Critical realism provides the basis for the analysis of social problems as a means of identifying solutions for social change, an approach compatible with this study (Fletcher, 2017). An awareness of the role of the researchers in co-constructing the research outcomes was adopted within this review (Noblit and Hare, 1988). To increase awareness and address bias, a reflexive diary was kept by the first author throughout the research process as recommended by Kralik (2005); and discussed by both authors.

Search strategy

Four electronic databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine (AMED), PsycINFO and PubMed were searched for articles relating to the occupational experiences of asylum-seekers. A second search identified additional articles within migration and sociology journals and led to the inclusion of SAGE and Scopus databases, ensuring an exhaustive search to identify all relevant articles published in accordance with Noblit and Hare’s (1988) guidelines. Additionally, reference lists of included papers and relevant scoping reviews were examined for relevant literature as suggested by Boland et al. (2017). The search terms contained terms related to ‘asylum-seeking’, combined with ‘occupation’ and ‘meaningful’ activities. Search syntax were adapted in accordance with the unique features of each database to ensure searches identified the relevant data, as recommended by Dundar and Fleeman (2017).

Since Huot et al.’s (2016) scoping review of the ‘occupational experiences of forced migrants’, there has been an increase in research on the occupational experiences of forced migrants. Furthermore, the past 10 years have seen an increase in the number of people forcibly displaced (UNHCR, 2021a). Therefore, the search was limited to publications between 2010 and 2021 to ensure evidence is current and less likely to overlap with earlier reviews.

Study selection

An inclusive strategy was adopted throughout the selection process to ensure that any studies where relevance was unclear were taken forward to the next stage to avoid eliminating papers of potential value to the review (Butler et al., 2016). This review only included primary data from peer reviewed journals to enhance the credibility of research. Studies presenting secondary data were not selected due to the risk of misinterpreting original findings. To maintain a focus on the occupational experiences of asylum-seekers, evaluations of interventions were excluded.

Quality assessment

The Critical Appraisal Skills Programme (CASP) checklist (2019) for qualitative literature was used to assess the methodological quality of included studies. The tool aided the recording of key findings as well as strengths and limitations of the studies, see Table 1. However, the checklist was not intended to be used to exclude studies from final selection. Figure 2 shows the articles retrieved at each stage of the search using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines (Page et al., 2021).

Table 1.

Summary of included studies.

Author, year, country	Aims	Method	Participant characteristics	Findings	Summary of usable data	Limitations and CASP score
Smith (2015) UK	To capture the refugee experience, as it occurs through the medium of occupation	Informal conversational interviewing	4 women and 6 men aged between 25 and 45. From a range of nations in Africa and the Middle East. Had lived in the UK for between 1 and 8 years, with a mean of 5 years 4 months. X2 refugee status X3 seeking asylum X5 failed asylum claims	Phenomenological approach to analysis reflecting principles of ‘doing, being, belonging and becoming.’ Participants strive to move beyond simply ‘keeping busy’ to find occupations of real meaning that foster connections and purpose, and in particular feed their need to feel valued	Occupations undertaken for the benefit of others tap into culturally appropriate collectivist ideals, using the desire to be altruistic to promote ‘doing, being, belonging’ and ‘becoming’	Small-scale study and is limited not only by the number of participants, but the inherent lack of homogeneity of people within the asylum process. Only 3 of the 10 participants were in the process of seeking asylum
Morville and Erlandsson (2013) Denmark	To explore how and if asylum-seekers experienced occupations as occupations in a Danish asylum centre	Narrative interviews, observations, and everyday conversations. Thematic analysis approach	3 asylum-seeking men from Iran and Afghanistan living in an asylum centre. Aged 25, 28 and 30. 25, Iran, Literature student at university , book seller and student. No religion. 30, Iran; MSc sports sciences, teacher and journalist. No religion. 28, Afghanistan, doctor, translator and teacher. No religion	Data analysis using a thematic analysis approach. Participants experienced occupational deprivation, even though they did have occupations. Their occupations were to some extent based on earlier occupations but seemed to be used as a coping tool more than a meaningful way to fill time. Despite occupational deprivation, participants managed to build a structure and tried to cope by using occupations as a diversion and a way to maintain an identity- ability to do so may be due to educational background	Being well-educated assisted the participants to build a structure around their routines and opportunities in the centre, whereby they used their occupations as diversions and a way to enable life. Although occupations had value in the immediate context, this did not necessarily mean that daily occupations provided meaning in the longer term. Their occupations were to some extent based on earlier occupations but seemed to be used as a coping tool more than a meaningful way to fill time	Small sample of 3 male participants. Criteria of participants included ability to speak English to college level
Heartley et al. (2017) Australia	To explore engagement in physical activity as a potential coping strategy for asylum-seekers living in the Australian community without the right to work	Semi-structured, in-depth interviews	Asylum-seekers living in the community whilst awaiting decision regarding their application for asylum. Participants did not have the right to work. 29 adult asylum-seekers: 23 men and 6 women. 10 participants were from Afghanistan. 7 participants were from Sri Lanka. 12 participants were from Iran. The length of time that participants had been living in the community after their release from immigration detention and without the right to work ranged from 2 weeks to 9.5 months	Living without the right to work and with minimal financial support made it difficult to fill each day with activities. Most participants spent waking hours with very little to do. Despite the mental distress that participants were enduring, many were trying to structure their days with some of the very few activities available and affordable to them, including physical exercise	Physical activity was important for some asylum-seekers coping with ongoing uncertainty and no right to work. Restrictive government policy, such as limited welfare support, hindered some asylum-seekers’ access to physical activity. In the face of restrictive policy, programmes enabling asylum-seekers’ engagement in physical activity may foster positive health and wellbeing. Physical activity was a coping strategy that was utilised by nine of the participants, an additional six participants highlighted several barriers that prevented them from using it as a coping tool	The participants’ physical activity in their country of origin was not ascertained, and future research might seek to address this limitation. As only six women were interviewed, the gendered nature of physical activities could not be gauged
Smith (2018) UK	To examine the meaning of occupation for asylum-seekers. In particular, why asylum-seekers choose altruistic occupations	In-depth interviews with 10 participants	Participants were accessed via local refugee support agencies. All were over the age of 18 and had sought asylum within the past 5 years. 5 participants spoke English as a first language, 3 others spoke English with varying degrees of fluency and only 1 elected to use an interpreter. At the time of the interviews, participants had lived in the UK for between 1 and 8 years (with a mean of 5.6 years)	Five main themes relating to altruism emerged from the analysis: Occupational opportunities; finding meaning through altruism; drivers for altruism, which has four subthemes; intrinsic gains; and being the recipient	Participants most purposeful occupations tended to be ones they did for the benefit of others. Doing for others mat help asylum-seekers deal with the difficulties associated with transitioning into a new society. Occupations that foster altruism may provide opportunities for consistency with life narrative and identity, leading to positive wellbeing and health outcomes	Lacks a clear statement of the aim of the study. The UK asylum process is unique, and different nations present different challenges. Small sample size- refugees are not a homogeneous group and their diverse experiences and backgrounds limit generalisability
Ingvarsson et al. (2016) Iceland	To gain an understanding of the experience of living as an asylum seeker in Iceland	Semi-structured interviews. A constructivist grounded theory approach was applied to categorize and synthesize data	6 participants from Afghanistan, Iran, and Iraq and were 23–38 years old. All had lived outside their country of origin for 5–18 years and in Iceland for 6–30 months. 2 participants lived in Reykjanesbær when first interviewed, and due to a change in their living conditions a second interview was added. The other 4 lived in Reykjavik, sharing an apartment with 2–4 other men. The men typically had 3–6 years of formal education except for one who had attended college in his home country but not graduated. Most spoke English at intermediate level as a minimum	Four major categories emerged that reflected he participants’ experience of seeking asylum in Iceland: ‘It’s the worst place’, ‘Nothing to do’, ‘this is survival, not living the life’, and ‘I want a normal life like everyone else’. Living conditions were experienced as being categorised in four main ways: 1) Lack of opportunities for participation 2) Lack of belonging and feelings of powerlessness. 3) the long processing time of their applications was enormously stressful 4) Not being in charge of one’s life, living conditions or income	Participants sought opportunities to do occupations that enabled them to fulfil productive roles, practice culturally valued occupations relating to their home such as church and work. Participants sought opportunities to be in the city where there were more opportunities to connect with others and blend into society. Participants sought opportunities to fill time, even if it was not through meaningful occupation	All participants were required to speak basic English which limits the generalisability of the findings but also meant participants may have been limited in how they expressed their feelings about the topic. However, this was justified by the researcher as all participants were able to answer and respond to questions. Furthermore, the researcher argued that the lack of interpreter made for enhanced relationship between interviewees and researcher enhancing ethical strengths. Small sample size. Findings were predominantly focused on negative impacts of restrictive environment, rather than meaningful engagement or facilitating factors
Lintner and Elsen (2018) Italy	To examine the role of social dimension of wellbeing in the context of asylum-seekers. And to examine how work as a meaningful occupation is seen as a key element of social integration	Data were collected via narrative interviews, informal discussions and semi-structured interviews	Snowball sampling 25 asylum-seekers in South Tyrol, Italy. Asylum-seekers were living in refugee houses in South Tyrol. All interviewees had reached Italy by boat. 15 came from Nigeria, 5 from Gambia and 5 from Somalia. All had requested asylum in Italy and were currently waiting for a decision on their asylum application. Aged between 22 and 38 years old and had fled from their homeland because of different forms of persecution: 10 for religious/political persecution, 5 for sexual persecution, and 15 to escape from family/traditional obligations	Data analysis was based on the grounded theory coding processes described by Strauss and Corbin and involved three levels of analysis: Open coding, axial coding and selective coding. Themes included: - Spatial isolation and its impact on wellbeing. - Enforced passivity in the context of asylum-seekers. - The meaning of work in the context of asylum-seekers	Opportunities to work were perceived to be a central element in promoting social integration and wellbeing. Work was found to be more than a rational and economic activity for asylum-seekers, but an important human occupation necessary for improving wellbeing. Work promotes a sense of self, identity, agency and identity which helps overcome social and spatial isolation in society	Based on a sample in Italy where the asylum policy allows asylum-seekers to work after 3 months of waiting for application to be reviewed. Did not include a 'limitations' section. No acknowledgement of researcher/interviewee power dynamic or about language barriers and how this may or may not have impacted results. Just states interviews were carried out in English. No statement of ethical approval
Robleda (2020) Norway	To explore the everyday life of women seeking asylum and living in asylum centres in Norway. It aims to answer the question of what everyday tactics they use to deal with their challenges and what empowers or constrains the development of these	Ethnographic fieldwork and interviews with asylum-seeking women	Ethnographic study following nine women while they lived in an asylum centre. The women were aged between 23 and 45 years and had various national, ethnic and religious backgrounds as well as different educational levels and family circumstances	The authors analysis suggests that although asylum-seekers find themselves in situations of serious repression, there are still sparks of agency in the form of everyday tactics. Tactics employed depend on the ‘field of power’ they are in. There are factors that shape the kinds of tactics that they are able to draw on including family circumstances, their educational level, the structure of the asylum centre and opportunities for bridging and bonding as well as their religious background and religiosity	People use daily activities to find meaning in life, enhance wellbeing and reject stereotype associated with being a refugee/asylum seeker. The participants are well educated and have social capital from their old lives which appears to help them in their transition into their new situations	This study includes limited direct quotations therefore much of the ‘data’ is formed of secondary constructs, that is, interpretations of the author. Sample size is only women. Only two people are included in the in-depth interview therefore difficult to generalise the findings. No statement of ethical approval or clear statement acknowledging power dynamics and position of researcher

Figure 2.

Number of studies identified and screened. Based on the PRISMA flow diagram (Page et al., 2021).

Data analysis

The analysis was principally inductive; however, literature relating to the occupational experiences of asylum-seekers informed the analysis of studies by orienting the researcher to potential themes. Noblit and Hare’s meta-ethnographic approach (1988) was followed. This involved selecting a topic of interest, carrying out a systematic search of the literature to identify relevant articles and then identifying salient concepts within each study. Data was collected in the form of first-order evidence; quotes from participants in the studies, and second-order evidence; the researcher’s description of the participant’s experience. Where participant quotes were limited, authors’ descriptions were used as first-order evidence. The concepts from the various studies were amalgamated to identify reciprocal or refutational categories (Britten et al., 2002). Finally, the translations were synthesised into a line of argument to explain the conceptual categories, see Table 2. The ValMO model was then used as a lens to discuss the findings.

Table 2.

Synthesis: Concepts, second and third-order interpretations.

Categories	Second-order interpretations	Third-order interpretations (themes)
Filling time	‘They performed these occupations to pass time, as one put it ‘to kill time’, but not necessarily because the activities fulfilled their need to do something meaningful’ (Ingvarsson et al., 2016: p. 421)	Keeping busy as a coping mechanism Participants focused on filling their days with activities to find structure, routine and meaning. In many cases, the activity itself held little meaning, but within the context of seeking asylum, served as a way of distracting them from challenging experiences. Some participants found activities held soothing effects, providing momentary escapism and a method of coping with anxiety and emotional distress
Coping mechanism	‘Physical activity was seen by some of the participants as an important strategy to pass time and to alleviate the stress resulting from being denied the right to work or engage in formal study’ (Hartley et al., 2017, p.1194).‘The participants’ motives for participating in occupations were related to their experience of distress and knowledge of the effects of insufficient occupations. They stated that they used occupations as diversions and tried to keep busy to avoid falling into depression’. (Morville and Erlandsson, 2013: p.217)
Doing to create structure and purpose in daily life	‘Despite the mental distress that the participants were enduring, many were trying to structure their days with some of the very few activities available and affordable to them, including participating in free courses, visiting local public libraries and connecting with other community members.’ (Hartley et al., 2017: p.1195)
Doing to help others	‘They each identified altruistic drives, showing investment in their connections – actively supporting others and developing mutually beneficial relationships, voluntary work roles and community support’ (Smith, 2015: p.619)	Maintaining continuity with past life by seeking to preserve identity, roles, values, and culture Despite experiencing little control over occupational choice, participants sought opportunities to adapt their occupations. Many drew on education and existing skills to creating opportunities. Some found value in supporting others. Engaging in pre-migration hobbies, interests, and cultural practices- such as cooking and eating rituals-helped preserve identity
Drawing on past occupations	‘Pınar had studied literature in university, and she loved to read; thus, reading served at first as a pastime and, then, when she got increasingly anxious, as a way to relax.’ (Robleda, 2020: p.87)
Using skills and experiences	‘Being well-educated assisted the participants to build a structure around the routines and opportunities in the centre, whereby they used their occupations as diversions and a way to enable life’. (Morville and Erlandsson, 2013: p.221)
Spirituality as a source of comfort and guidance	‘They often resorted to their religious beliefs and practices, in particular to prayer, to maintain hope whenever they felt depressed and disheartened’ (Robleda, 2020: p.89)
Identity and roles	‘People strive to move beyond simply ‘keeping busy’ to find occupations of real meaning that foster connections and purpose, and in particular feed their need to feel valued. Participants managed to build a structure and tried to cope by using occupations as a diversion and a way to maintain an identity’ (Smith, 2018: p.87)
Desire to work	‘Having a job not only helps to recreate a sense of normality, but also a sense of control over one’s life… It contributed to peace of mind; secondly, it allowed a broadening of the radius of action; and thirdly, it helped to promote social integration (Lintner and Elsen, 2018: p.82)	Building a new future and a drive to be a productive member of society Value was attributed to occupations that were considered to contribute to future lives, beyond their existence as asylum-seekers. Consistent in the findings was a desire to work. Social connection held different value- some wanted to connect with others for support whilst others sought social connection as a tactic for building connections and skills to help them move forward. Ultimately people wanted to have control over their lives, this is largely related to economic resources and meaningful time-use
Social connection	‘For participants who had been in the UK for the longest, and whose claims had failed, there was far less connectivity with others and no contact with family. They felt they had less to offer to others, and less energy to bring to occupations involving others’. (Smith, 2018: p.92) ‘Living in Reykjavik, conversely, afforded more feelings of control and possibilities to enact choices. It eased the men’s integration into society, and provided them with opportunities to participate in social events and to do volunteer work for charity organizations. Within this larger and more diverse community, they also felt less visible as foreigners, less marginalized and even had some feeling of belonging’. (Ingvarsson et al., 2016: p. 421)

Results

The search generated 1047 papers, which were reduced to seven for inclusion in the review (Figure 2). Two papers (Smith, 2015, 2018) used overlapping data from an ethnographic study, but as both had different aims and interpretations of findings they were treated as two separate sets of data with repetition excluded. Of the seven papers, four included asylum-seekers as their sole participants, one included a combination of asylum-seekers and refugees, and two studies included participants whose application for asylum had been refused. Aside from Smith’s (2015, 2018) UK-based studies, each article focused on the experiences of people seeking asylum in different countries, specifically Norway, Australia, Denmark, Iceland and Italy. All studies described the specific socio-political context to their study and acknowledged this as a limitation to the generalisability of their findings. One study was based on a sample of exclusively female participants (Robleda, 2020), and another, only men (Morville and Erlandsson, 2013). The rest of the studies included a mixed sample and represented a range of cultural backgrounds. The CASP tool (2019) showed all the selected studies to be of high quality which supports the reliability of findings. Reasons for slightly lower scores were due to unclear reporting on study limitations and/or a lack of consideration of the relationship between the researcher and the participants.

An initial reading of the studies produced 20 concepts across the data, many of which shared similarities. The concepts were then translated into 10 categories which represented the broad findings of the studies. These translations were then further analysed for connections and structured into three clearly defined themes or ‘third-order interpretations’ incorporating the 10 categories (Table 2).

Keeping busy as a coping mechanism

Within this theme, participants used occupations as a means of distracting themselves from their problems, and to help cope with the lack of opportunity to participate in personally meaningful occupations. Participants filled their days with activities to find structure, routine, and purpose. For many, the activity had little intrinsic meaning, but within the context of asylum-seeking, served as a distraction from challenging experiences. Some participants found activities had soothing effects, providing momentary escapism to cope with anxiety and emotional distress.

Filling time

Some participants acknowledged the effects of insufficient occupations and the importance of keeping busy. In many cases participants reported that their activities were instrumental in distracting them from negative emotions and helped to avoid depression.

‘… if I don’t do something, I will go crazy’

(Morville and Erlandsson, 2013: p.217)

Coping mechanism

Some participants used activities to regulate emotions and alleviate stress.

‘… when I wake up, I go to the gym and I take out all the stress out of my body, out of my mind, lifting heavy weights. That's how pretty much I spend my day.’

(Hartley et al., 2017, p. 1194)

Doing to create structure and purpose in daily life

Participants focused on living day-by-day, filling time so as not to allow the lack of meaningful occupation and existence in liminal space weigh them down.

‘It was the small routinised activities of cooking, doing grocery shopping, preparing the children for school, [etc.] that seemed to help Pınar maintain a certain stability and purpose.’

(Robleda, 2020: p.87)

Maintaining continuity with past life by seeking to preserve identity, roles, values, and culture

Participants experienced significant imposed occupational deprivation due to lack of meaning and relevance in their daily occupations (Morville and Erlandsson, 2013). However, despite the restrictions to occupational choice, they endeavoured to move beyond simply ‘keeping busy’. Participants sought occupations that fostered connection with identity, provided a sense of purpose, and fulfilled their need to feel valued.

Doing for others

Many participants were motivated to engage in occupations to benefit others, linking these with cultural ideals and their own desired outcomes of value and purpose.

‘I always like volunteering, since when I was young … in places where there are under-privileged people … they brought us up like that, try doing something for people’

(Smith, 2015: p.91.)

Past occupations

Many maintained customs and occupational choices which enabled continuity with past life and an assertion of sense of self and identity.

‘Every Sunday, they would have pancakes and a big breakfast, just like they did ‘back home’ before moving to Norway … following the same family customs … can be seen as a tactic through which Pınar seeks to maintain normality and familiarity for her family in such unstable and foreign circumstances’

(Robleda, 2020: p.88).

Using existing skills

Drawing on past interests and experiences enabled some participants to establish new roles despite challenging context and limited choice.

‘Mohammad maintained his earlier occupations … writing articles for the centre’s weekly paper, and other media about the situation in the centres and in his homeland. He considered it important and a continuation of his work against the dictatorship in Iran’ (Morville and Erlandsson, 2013: p.218)

Identity and roles

Some participants used engagement in activity to resist stereotypes and express identity and self-worth.

‘When I start working, I will be a normal person, not the poor refugee girl. I will be a normal person. You don’t want someone to pity you, this is not a good feeling you know?’

(Robleda, 2020: p.90)

Spirituality as a source of comfort and guidance

For many, religion and spirituality were important in guiding occupational habits and helped to make sense of their difficult circumstances.

‘The Islamic practice of praying five times a day gave her several opportunities a day to reflect on her situation … consulting the Qur’an would provide her with guidance on how to deal with her circumstances, in this way, she was able to regain hope and motivation through this particular religious practice.’

(Robleda, 2020: p.89)

A drive to build a new future and be a productive member of society

This theme is the value attributed by asylum-seekers to occupations considered to contribute to their future lives

Work

Work was perceived as a valuable occupation, improving the subjective wellbeing of asylum-seekers through connecting and contributing. Although most participants were restricted from paid employment, they all chose to engage in work-like occupations including volunteering, education and helping others which they associated with opportunities to learn skills and improve their sense of self-worth.

‘When you are working, you’ll gain more experience. You will be meeting foreign people. You always go out. You always learn more. You improve in a language. You improve in a respect. You improve in a manner’

(Lintner and Elsen, 2018: p.83)

Social connection

Engaging in occupations that facilitated social connection were valued by asylum-seekers. Opportunities to interact with people from host communities were deemed important for integrating within the new society, developing language skills and gathering social capital that would support their endeavours to build a future.

‘It helps me, at least you socialize with the people around the shop, and I can practise Icelandic.’

(Ingvarsson et al., 2016: p.420)

For others, connecting with people with shared experiences provided opportunities for emotional support, helping them to share and cope with difficulties.

‘knowing that she had a friend whom she could write to when she needed it and meet for a coffee once in a while was essential.’

(Robleda, 2020: p.88)

Discussion

This study aimed to explore the meaning and value of occupations during the process of seeking asylum. The results show that asylum-seekers experience meaning and value in occupation, despite having little choice or control over occupational engagement. The meaning gained from occupational engagement supported wellbeing in the short-term, but due to lack of choice and control over occupational engagement, the long-term benefits of meaningful occupational engagement are questionable. Without employment rights, people’s lessened ability to contribute to society was damaging to their self-worth, identity, health and wellbeing. Despite this, participants found meaning through engaging in occupations within the context of asylum-seeking. These included: drawing on past skills and experiences related to education and work to adapt occupations, and creating relevant and purposeful opportunities; channelling personal and cultural values to shape adapted occupations. These were focused on occupations that contributed to future goals; and applying insight about the intrinsic benefit of keeping busy for maintaining health and wellbeing. The most meaningful experiences were related to occupations that involved drawing on personal experiences and skills to help others.

The ValMO model (Figure 1) was used as a lens to interpret the results with an occupational focus. The results are presented within the three dimensions of value: concrete, symbolic and self-reward. These support the analysis of how occupations are experienced as meaningful contributions to personal life-narratives from micro, meso and macro perspectives (Persson et al., 2001). Finally, the person-occupation-environment triad will be used to discuss the factors facilitating occupational participation.

Concrete value

Concrete value represents the tangible outcomes resulting from engaging in occupation. The results suggest that many of the occupations performed by asylum-seekers hold predominantly concrete value, as in the theme: ‘doing to fill time and as a coping mechanism’. Due to limited occupational choice and lack of control over time-use, many perceived their occupations as essential for survival. Here, the value attributed to occupation is related to the avoidance of negative consequences. This reflected other research which shows the potential for occupations to provide relief and distraction from pain (Millar and Warwick, 2019). Other occupations that appeared to hold concrete value included those relating to the skill-acquisition to help move beyond asylum. Language learning, volunteering and opportunities to integrate with host societies can be understood as holding concrete value, as depicted most clearly in the theme ‘building a life for the future’. These perspectives support the importance of occupations in a pursuit for a life beyond asylum (Steindl et al., 2008).

Many occupations were a means to forget and cope with distress, and not necessarily valued and meaningful in themselves. However, when performed regularly within the specific circumstance of seeking asylum, they formed routines, which generated purpose and meaning in daily life. Thus, occupations can be considered from a meso perspective (Persson et al., 2001). Alternatively, the value attributed to skill-development and time-filling that supported a new future can be interpreted from a macro perspective. Therefore, these occupations can be considered as a pathway out of and beyond asylum, reflecting personal identity, continuation of culture and personal narrative (Persson et al., 2001).

Symbolic value

The symbolic value of an occupation opens opportunities for communication with others (Persson et al., 2001). The results show that people valued occupations that enabled them to communicate hidden aspects of themselves. For example, through volunteering and doing occupations for the benefit of others, people expressed values of altruism, community and collectiveness (Ingvarsson et al., 2016; Morville and Erlandsson, 2013; Smith, 2015, 2018). In doing so, they asserted some agency and refuted the imposed identity of ‘asylum-seeker’. The symbolic value of occupations that enabled a positive expression of self was important. At the personal level, this supported the expression of personal values and identity; at the cultural level it connected to past cultural values and customs. At the universal level, certain occupations, such as helping others or participating in sport, are valued and recognised as positive across cultures.

Hammell (2020) states that occupational choice is largely shaped by the social environment. In most instances, occupations conformed with the cultural norms and values of the host nations, including seeking opportunities to learn the native language and gain employment. However, whilst people wanted to be able to perform occupations that conformed with the host nation’s norms and values, such as work and education, restricted rights and opportunities prevented them from doing so. Consequently, they needed to draw on the symbolic value of the norms and values inherent in their lives prior to seeking asylum, achieved through identification with sub-groups such as family, church or profession. This conflicted between wanting to maintain continuity with their established culture and adapting to new environmental demands. The theme ‘building toward a future’ reflected occupation choice that can be linked to ‘symbolic value’. People drew on existing skills and values to communicate a sense of self but also to demonstrate a willingness to conform and adapt to their new environment.

Another symbolic dimension of occupational value is the concept of ‘catharsis’ (Persson et al., 2001), meaning temporary relief from inner pressures. For some, engaging in physical activity, listening to music, reading and prayer provided brief opportunities for cathartic relief from the constant worry about their past, present and future.

Occupations providing symbolic reward closely aligned with a macro perspective of occupation and are represented, notably within the themes of ‘maintaining continuity with past…’ and ‘building towards the future’. This finding supports the importance of occupations that reflect interests, culture, and life-stories (Kielhofner, 2008). Occupations associated with altruistic ideals (e.g. volunteering) were apparent across all studies, supporting the idea that a sense of belonging, through connecting and contributing, is integral to wellbeing. However, the aim of working, studying and earning to build a future life were considered more desirable. This reflects the economic, social and wellbeing outcomes associated with work and education (Marmot, 2010).

Self-reward value

This value dimension focuses on the experience of immediate rewards, such as enjoyment and pleasure, when engaging in occupations. This was only described in a few accounts of reading, listening to music and exercise possibly due to limited opportunities for this experience. This echoes Morville and Erlandsson’s (2013) conclusion that despite these occupations holding some value, they were not seen as intrinsically valuable and meaningful.

By examining the results of this systematic review through the ValMO model, there was an imbalanced relationship between the concrete, symbolic and self-reward values in the daily occupations of asylum-seekers. For occupational engagement to provide health and wellbeing benefits in the long-term, there should be a balanced relationship between the three value dimensions (Persson et al., 2001). From this research, many occupations appeared to hold concrete value but there was a scarcity of self-reward and symbolic value attributed to daily occupations. The findings show that although people experienced value and meaning in occupations during asylum, the long-term health and wellbeing benefits of occupational engagement may not be achieved due to limited occupational choice, long periods of waiting and enforced passivity.

This discussion has shown it is not the occupation itself, but rather the context and purpose it serves that provide value and meaning. Therefore, although the model was helpful for conceptualising the results, its usefulness was limited by the complex and subjective nature of human occupation.

Factors facilitating occupational engagement

A further aim of this study was to identify factors that supported occupational engagement for asylum-seekers. Most participants had high levels of education and qualifications enabling them to apply skills and experience to their circumstances. For example, the men in Morville and Erlandsson’s (2013) study sought out opportunities to work in roles that matched their experience: working as translators, teachers, sports coaches and in journalism. Participants also understood the importance of keeping busy, exercising and social interaction to promote health and wellbeing. Some participants highlighted spirituality as important for guiding them through difficult times and finding meaning. Their religion presented other opportunities including volunteering, social interaction, routine and rituals.

Facilitating factors relating to the social environment included opportunities to participate in productive occupations such as volunteering, work and education. Lintner and Elsen (2018) found that work provided significant value and meaning for their participants who were allowed to do so. Supportive relationships with others reinforced meaningful engagement in occupation, provided opportunities to share problems, express personal and cultural identity and fostered a sense of belonging. For participants in Ingvarsson et al.’s (2016) study, living in the city was preferred because of more opportunities to volunteer and join social groups, enabling them to blend in and disassociate with the label of ‘asylum-seeker’.

Implications for practice and research

This review has shown that opportunity to fill time with meaningful occupations is severely restricted for asylum-seekers. Considering a person’s occupations in the context of meaning provides some understanding of occupation beyond the confinements of self-care, leisure, and productivity. This has the potential for occupational therapists to: develop a more significant relationship with the client; expose the possibility of outcomes beyond function and performance; uncover the potential for working with people and communities that do not fit into the medical model; and help clients to maintain a sense of identity and meaning in contexts that are perceived to be out of control (Reed et al., 2011). This study also raises considerations for other practitioners, policy makers, healthcare providers about how asylum-seekers cope with ongoing uncertainty while they wait for their refugee claim to be finalised, and the types of coping strategies they may engage in.

To reduce the influence of researcher/participant power dynamic for more authentic results, future studies conducted in the first language of participants are needed. Ethnographic studies completed by asylum-seekers/forced migrants, might provide a more nuanced and deeper exploration of the occupational experiences of this population and could lead to more targeted interventions.

Strengths and limitations

The inclusive search strategy and scope of databases, leading to the selection of relevant studies and an extensive representation of perspectives was a strength of this study. It has identified facilitating factors, promoting a strength-based approach to supporting asylum-seekers and contributed insights to the existing literature, which has predominantly focused on the barriers to meaningful occupation. Additionally, utilising the ValMO model to interpret the results offers unique occupation-focused insights from a multidisciplinary evidence base.

A limitation of conducting a qualitative systematic review is the risk of misinterpreting the primary data. To mitigate this, a high number of quotes and extracts from articles were included. The decision to exclude studies published in languages other than English should also be noted. Additionally, accessing first-order evidence was difficult because data extracts included in the primary papers was already selected from the full dataset by the study authors. These extracts do not therefore reflect the totality of participant experiences. Schutz’s (1971) notion of first, second and third-order constructs were used in the analysis to provide more insight by explaining the phenomena observed. However, the level of interpretation offered in some of the papers was minimal, with many papers highly descriptive in nature. This made it difficult at times to distinguish first from second-order interpretations.

Conclusion

This review has illustrated some of the multifaceted meanings that occupations hold for asylum-seekers. Notably, occupations are an essential element to existence for asylum-seekers in their various forms and contexts. They helped to preserve identity and continuity of their life-narrative; helped people make sense of disorder in their life, provided opportunity for reflection leading to motivation toward goal-directed occupation; and provided soothing effects, enabling momentary escapism to cope with anxiety and emotional distress. However, the ValMO model has highlighted an imbalance between construct, symbolic and self-reward value in the occupations during asylum-seeking. This suggests that although providing some meaning in context, the long-term benefits might not be achieved. The profound and multifaceted human occupational injustices experienced by asylum-seekers is highlighted, calling for further research and policy review to address this humanitarian crisis. In light of the current situation in Ukraine, it is likely that the future needs of all asylum-seekers will be an important challenge for occupational therapists in the coming months and years. The authors hope that this paper will provide a useful and relevant contribution to those affected by displacement.

Key findings

Despite being subjected to significant occupational deprivation, asylum-seekers seek meaning and purpose in life by engaging in occupations that help cope with distress, promote sense of identity and support future goals.

What the study has added

• Synthesis of available evidence about the occupational experiences of asylum-seekers using the ValMO model.

• Identification of factors supporting occupational engagement for asylum-seekers.

• Identification of future research and practice implications.

Research ethics approval was not required for this study.

Footnotes

Acknowledgements

I would like to acknowledge the participants represented in the included studies for sharing their experiences.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Statement of contributorship

AM researched literature and conceived the study. AM and AY were involved in protocol development and data analysis discussing method/methodology/data analysis. AM wrote the first draft of the manuscript. All authors reviewed and edited the manuscript and approved the final version of the manuscript.

ORCID iDs

Anna McGovern

Audrey Yong

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