Neighbourhood ethnic density and mental health service use among refugees and migrants in Sweden

Background

Refugees experience a high burden of mental health disorders but often underutilize mental health services. Neighbourhood characteristics, including ethnic density, may influence mental health needs and access to care. We examined the association between neighbourhood ethnic density and mental health service use among refugee and migrant adults in Sweden, and whether this association was modified by urbanicity.

Methods

We conducted a national register-based cohort study including all adults residing in Sweden between 1 January 2011 and 31 December 2022. Individuals were followed from study entry until first mental health service use, death, emigration, or end of follow-up. Ethnic density was measured at neighbourhood level and categorised into quartiles (QD). Survival analysis with Poisson regression was used to estimate incidence rate ratios (IRRs) and 95% confidence intervals (CIs), comparing refugees and migrants with Swedish-born individuals. Analyses were adjusted for sociodemographic factors, and an interaction term examined effect modification by urbanicity.

Results

Among 8,540,743 individuals, 987,354 (11.6%) used mental health services during follow-up. Living in neighbourhoods with the highest ethnic density (QD4) versus the lowest (QD1) was associated with higher service use among Swedish-born individuals (IRR 1.26, 95%CI 1.25–1.27), no clear association among migrants (IRR 0.98, 95%CI 0.96–1.00), and lower use among refugees (IRR 0.93, 95%CI 0.89–0.96). Mental health service use decreased with increasing rurality. Urbanicity modified the association between ethnic density and service use: in rural areas no clear association was seen, while in urban areas higher ethnic density was associated with lower use among refugees and migrants.

Conclusions

Associations between neighbourhood ethnic density and mental health service use differed by migrant status and urbanicity. Contextual factors may be important for need and equitable access to care.

Key messages

• Associations between neighbourhood ethnic density and mental health service use differed among refugees, migrants and Swedish-born adults, highlighting disparate patterns of access.

• Urbanicity modified this association: in rural areas no clear association was seen, while in urban areas higher ethnic density was associated with lower use among refugees and migrants.