Journal of Occupational Science

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Migrants’ experiences of a nature-based vocational rehabilitation programme in relation to place, occupation, health and everyday life

Lisa Ekstam, Anna Maria Pálsdóttir & Eric Asaba

To cite this article: Lisa Ekstam, Anna Maria Pálsdóttir & Eric Asaba (2021) Migrants’ experiences of a nature-based vocational rehabilitation programme in relation to place, occupation, health and everyday life, Journal of Occupational Science, 28:1, 144-158, DOI: 10.1080/14427591.2021.1880964 To link to this article: https://doi.org/10.1080/14427591.2021.1880964

© 2021 The Author(s). Published by Informa Published online: 17 Mar 2021. UK Limited, trading as Taylor & Francis Group

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Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=rocc20 JOURNAL OF OCCUPATIONAL SCIENCE 2021, VOL. 28, NO. 1, 144–158 https://doi.org/10.1080/14427591.2021.1880964

Migrants’ experiences of a nature-based vocational rehabilitation programme in relation to place, occupation, health and everyday life Lisa Ekstam a, Anna Maria Pálsdóttir b & Eric Asaba c aLisa Ekstam, Department of Health Sciences, Faculty of Medicine, Lund University, Sweden; bAnna Maria Pálsdóttir, Department of People and Society, Faculty of Landscape Architecture, Horticulture and Crop Production Science, Swedish University of Agricultural Sciences, Sweden; cEric Asaba, Division of Occupational Therapy, Department of Neurobiology, Care Sciences, and Society, Karolinska Institutet, and Faculty of Medicine, Department of Health Sciences, Lund University, and Unit for Research, Education, Development, and Innovation, Stockholms Sjukhem, Sweden

ABSTRACT ARTICLE HISTORY Forced migration has dramatically increased around the world during the Accepted 19 January 2021 last decade. Integration, including health and work among migrants, is an important topic in many European countries; thus, it is crucial to develop KEYWORDS relevant approaches to address challenges that arise in tandem with Occupational science; Social integration; Immigration; migration and work. Nature-based intervention is one such approach ff Work; Capability approach; that addresses di erent kinds of challenges related to human health Horticulture; Nature-based and social welfare. The aim of this study was to build on knowledge therapy about how a nature-based vocational rehabilitation programme influences perceived health and how it integrates into the everyday lives of migrants. Seven participants from the establishment programme run by the Swedish Public Employment Service were interviewed twice, at the start and at the end of the intervention. The semi-structured interviews focused on occupation, health in everyday life, and experiences of participating in the programme. Data were analysed and interpreted using narrative analysis. The findings are presented in three themes: meaning of place and belonging in the garden, the meaning of occupation and its transferability to everyday life, and navigating uncertainty in everyday life. The findings are discussed and interpreted using concepts such as capability, occupation, place, and work. The authors argue that successful integration in society rests on a combination of factors that need to be understood as part of a whole.

Forced migration has dramatically increased in Östergren, 2015), work is also relevant from the last years due to political instabilities, an occupational perspective (Yerxa, 2000) human rights violations, and armed conflict because it contributes to a conceptualisation of and war. A prioritised aspect of European work as more than paid employment, as well migration policies has been to support work- as being seen as important for health and well- ing-age adult migrants to enter the labour mar- being (Jahoda, 1982; Simic et al., 2018; Waddell ket and contribute to society through paid & Burton, 2006). In this study we build on a employment. Although these policies place growing body of knowledge about the work- individual and social economic aspects in related challenges faced by migrants and asylum focus (Björngren Cuadra & Carlzén, 2015; seekers, as viewed from an occupational

CONTACT Lisa Ekstam [email protected] © 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http:// creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way. JOURNAL OF OCCUPATIONAL SCIENCE 145 perspective (Bailliard, 2013; Berr et al., 2019; (Martín et al., 2016). The establishment pro- Burchett & Matheson, 2010; Huot et al., 2013; gramme includes “Swedish for Immigrants” Huot & Laliberte Rudman, 2010; Kielsgaard (SFI), work preparation, and community orien- et al., 2018; Lintner & Elsen, 2018; Mpofu & tation. Despite the available initiatives and Hocking, 2013; Nayar & Sterling, 2013; Rivas- resources to support immigrants through the Quarneti et al., 2017) and contribute to establishment programme, statistics show that understanding forced migration and work in a it takes a long time for refugees to secure gainful Swedish context. employment. In the Nordic region the time for People who stand outside the labour market refugees to enter the labour market is markedly risk occupational deprivation, ill-health, and longer than non-migrants (Simic et al., 2018). social isolation (Crawford et al., 2016; Gushulak Among those who immigrated as refugees in et al., 2010; Simic at al., 2018). Aspects that are 2015, 3.7% were employed 1 year later, 15.8% particularly at stake during forced migration 2 years later and 32.5% 3 years later (Statistics and the asylum-seeking process are feelings of Sweden, 2020). In 2018, the law changed (Act having less control, experiences of stigma and 2017:584, on the responsibility for establish- a change of roles, social identities and motiv- ment contributions for newly arrived immi- ation (Burchett & Matheson, 2010). It is there- grants, 2017) in order to emphasise the fore important that strategies addressing individuals’ responsibility in establishing them- occupational deprivation build on individual selves in the labour market. In tandem with strengths and human diversity as well as target these changes, work disparities continue to social structures (Crawford et al., 2016). Work exist between Swedish residents and residents has previously been categorised as a type of from forced migration backgrounds, which is occupation within occupational science, how- also an important reason to study migration ever it can also be relevant to shift focus to and work. how work is socio-politically situated and Due to increased immigration there is an experienced within a repertoire of everyday urgent need to develop methods and interven- life occupations. In this paper the authors tions that support health, work, and integration focus on empirical data from one study where of migrants into society. Nature-based solutions the individual experience is placed in the fore- have been suggested to be an effective resource ground and a broader critique of social systems to address different kinds of challenges related is part of the analysis of individual narratives, to human health and social welfare (European occupations, and situations. Commission, 2015). There is increasing evi- To situate this study, it is important to briefly dence about positive benefits of natural sur- highlight the recent background to immigration roundings on mental and physical health and in Sweden. Over the past decades many people well-being (Bosch & Bird, 2018) and increased have sought refuge in Nordic regions (Pitkänen integration can be supported by nature-based et al., 2017), and a significant peak was reached occupations (Gentin et al., 2018). More specifi- in 2015 in Sweden, with nearly 163,000 asylum cally, engaging in therapeutic horticulture occu- seekers (Migrationsverket, 2020). This called pations within a supportive social environment for interventions aiming to facilitate integration can have a positive impact on the health and into society and the labour market for newly well-being for refugees (Bishop & Purcell, arrived migrants. During the course of this 2013). However, there are still knowledge gaps study, all newly arrived migrants in Sweden, relating to how and in what way these kinds with residence permits as refugees and of work- of interventions can be effective for supporting ing age (mostly refugees seeking asylum) were integration (Gentin et al., 2019). offered the possibility to be enrolled in an estab- Because the use of nature-based rehabilita- lishment programme (Act 2010:197). The aim tion in supporting work among newly arrived of the establishment programme is to speed up migrants is a new area, it is important to exam- the entry of new arrivals into the labour market, ine processes of work-entry grounded in experi- with early introduction of interventions ences among those who have utilised the supporting work entry considered crucial support and services, in this case through the 146 L.EKSTAM,A.M.PÁLSDÓTTIR&E.ASABA

Swedish Public Employment Service (SPES) into words, can best be understood through establishment programme (Pálsdóttir, Shahrad, interpretive analyses that pay homage to con- et al., 2018). The authors drew upon empirical text. Moreover, it was important to give a rel- data from interviews juxtaposed with a critique evant space to the voices of the persons in of the migration to work-entry process using a focus in this study, integrating their words, stor- capability approach (Nussbaum & Sen, 1993). ies, and in a broader sense experiences of The capability approach can be useful in illumi- nature-based vocational rehabilitation as part nating influences, and arguably some paradig- of forced migration and integration. matic idea disparities, in the Swedish refugee The study was guided by the ethical prin- reception programme. A core assumption of ciples of respect for autonomy, non-malefi- the capability approach is that having resources cence, beneficence, and justice, in line with the is not sufficient for achieving a good life for citi- Declaration of Helsinki (World Medical Associ- zens, who also require real possibilities to trans- ation, 2013). All participants were informed that form resources into something of social and it was completely voluntary to participate in the personal value and relevance (Sen, 1995). In interviews and if they declined it would have no order to transform resources, the structural influence on the intervention. Ethical approval environment needs to promote motivation, was obtained from the Regional Ethical Board self-organisation, self-responsibility, and skills in Lund (Dr.nr.2917/167) (can be retrieved development (Lintner & Elsen, 2018). Capabili- from the Swedish Ethical Review Authority). ties have been proposed as part of the answer to In the findings, pseudonyms are used to main- questions such as, “what is the person able to do tain confidentiality and integrity of the and to be?” (Nussbaum, 2013, p. 20). This is rel- participants. evant when critically exploring the current sys- tem designed to help migrants acquire Setting language skills and enter work. Despite exten- sive resources spent on language education The study was conducted at Swedish Univer- upfront, there is insufficient flexibility and inte- sity of Agricultural Sciences (SLU) Alnarp gration of language education with individua- Rehabilitation Garden, a living lab, where lised needs, which results in a focus on one researchers, garden members, and community skill set that might be more or less relevant in partners collaborate around nature-based a given type of work. interventions. Several nature-based rehabili- The aim of this study was to build on knowl- tation projects targeting diverse groups have edge about how a nature-based vocational reha- previously been hosted by SLU Alnarp rehabi- bilitation programme influences perceived litation garden (Pálsdóttir, Stigsdotter et al., health and how it integrates into the everyday 2018; Pálsdóttir et al., 2020). The 1.5 ha SLU lives of migrants participating in the establish- Alnarp Rehabilitation Garden is divided into ment programme run by the Swedish Public two major areas: 1) the formal and cultivation Employment Service. area and 2) the informal nature area (Pálsdót- tir, 2016). The garden is designed for both doing and being. That is, it offers opportu- Methods nities for different garden occupations and This study was part of a project to evaluate a places for rest and recovery. The garden has nature-based vocational rehabilitation pro- outdoor and indoor settings, including two gramme for newly arrived migrants (Pálsdóttir, greenhouses. In the formal garden, there are Shahrad et al., 2018). The design of the current different water features with either running study is based on narrative analysis of qualitat- or still water as well as flower beds and raised ive interviews (Polkinghorne, 1995). Grounding horticultural beds in enclosed garden rooms. this study in narrative methods rests on the The informal nature area offersanopenview argument that individual experiences that are over a flower meadow framed with larger nested amid individual and social tensions, at deciduous trees (Pálsdóttir, 2016; Tenngart times also difficult for the informant to put Ivarsson, 2011). JOURNAL OF OCCUPATIONAL SCIENCE 147

The nature-based vocational Recruitment and description of rehabilitation programme participants All participants were part of the 24-month As part of the establishment programme in this establishment programme run by SPES and study, there were four intervention groups had been identified, by a rehabilitation expert, implemented during April 2017 to July 2018. to be in need of vocational rehabilitation in Participants were consecutively recruited, and order to continue their participation (Pálsdóttir we aimed to interview two persons from each et al., 2016, Figure 1, page 9). The vocational of the four groups, in order to gather individ- rehabilitation programme intended to support uals’ experiences from different groups and and strengthen the participants’ function and across different seasons. work ability through nature-based occupations Inclusion criteria for the project and this (Millet, 2008; Pálsdóttir, Shahrad et al., 2018). study were: being part of the establishment The intervention took its theoretical stamp programme and in need of vocational rehabili- from a salutogenic point of view of health and tation due to ill health, with resultant lack of focus on supporting the participants’ capability motivation or strength to participate in other and perceived health (Antonovsky, 1979; Lillef- occupations within the programme; being jell et al., 2017). aged between 20 and 65 years and Arabic or The programme was carried out in groups Farsi speaking; reported sleep disturbance; of 6-9 people attending the intervention for and wanting to participate in the programme 12 weeks, 3 days per week for 4 hours per of their own free will. Also, they needed to be day. It included various garden and horticul- able to commute from their home to the gar- tural occupations such as horticulture den. Exclusion criteria were showing signs of (propagation, growing, harvest, and post- severe depression and anxiety and presence of harvest) and different garden work including suicidal risk. The assessments for inclusion maintenance and planting trees, plants, and were conducted by a rehabilitation coordinator bulbs. These tasks have different cognitive at SPES. and physical challenges intended to improve Seven participants (4 females, 3 males) were the participants’ mental and physical func- recruited for this study. Their ages ranged tioning as a part of their vocational rehabili- from 39 to 63 years old. All of them had fled tation. All garden and horticultural their home countries and been granted a resi- occupations followed the seasonal changes. dence permit in Sweden. Some had family con- The intervention was carried out by a team nection in Sweden; others had their family of two: The occupational therapist respon- spread out in different countries. They had sible for the vocational rehabilitation and a been in Sweden between 6 months and 4 years gardener responsible for all garden and hor- before entering the programme. Their edu- ticultural tasks. All participants had a work cational level varied from no formal education ability assessment conducted by the occu- to a university degree. Most of the women had pational therapist during the 12-week inter- never worked outside the home nor had formal vention, based on the individual treatment education, whereas the men had worked, for goal set at the beginning of the programme. example in trade or machinery. Participants The outcomes of assessments were provided came mainly from urban settings, that is, den- to the SPES after completion of the interven- sely populated cities and only a few had prior tion, for further planning of suitable gardening or horticultural experience. interventions to be included in the establish- ment programme on individual basis. For Data gathering more detailed information about the pro- gramme and the specific occupations Semi-structured interviews were conducted offered as vocational rehabilitation please with each informant during the first and last see the study protocol (Pálsdóttir, Shahrad week of participation in the nature-based inter- et al., 2018). vention, which resulted in 14 interviews. The 148 L.EKSTAM,A.M.PÁLSDÓTTIR&E.ASABA interview guide covered how the participants codes. The themes where continually dis- experienced occupation and health in their cussed between all the authors and re-organ- everyday life and during the intervention, and ised through the analytic process, resulting in what life events and/or aspects of the interven- three main themes. Comprehensive examples tion might have influenced any changes in are provided in the findings for the reader to their health and everyday life. The goal of the determine confirmability and trustworthi- first interview was to establish a trusting ness. The quotes included in this manuscript relationship and was based on questions about were translated into English by the first and their personal history, current life situation, last author separately and compared for con- and expectations about the intervention. In the sistency. When there were inconsistencies all second interview the questions focused on the authors discussed the wording, prioritis- changes in everyday life, experiences of taking ing meaning over semantic detail. Final part in the intervention, and thoughts of the translations were discussed and agreed future. The interviews were conducted by the among the authors. In the external pro- first author in a room at Alnarp Rehabilitation fessional language review, both the English garden together with an interpreter and the and Swedish version of the quotations were interviewee. The interviews where audio reviewed. The language reviewer was asked recorded, lasted approximately 1 hour, and to specifically review the accuracy of the were transcribed verbatim. translated quotations.

Data analysis Findings Narrative analysis (Polkinghorne, 1988, 1995) For participants in this study, the rehabilita- was used to analyse the data. All interviews tion garden at Alnarp was not only a place were read by all three authors to grasp a sense to reach goals and measurable outcomes, it of meaning in context and as a whole. The was also described as a place to do and be, first author applied open coding to the first six yet it was filled with challenges and uncer- interviews to organise data inductively and tainty. This was expressed through the three achieve meaningful expressions. Thereafter, main emerging themes that influenced partici- the first and third author explored and dis- pants’ perceived health and everyday life cussed the logic of the codes and if the level of whilst participating in the programme: 1) abstraction was adequate to the aims of analysis. Meaning of place and belonging in the garden, In the iterative coding process, codes were 2) The meaning of occupation and its transfer- added, refined, and merged in order to themati- ability to everyday life and 3) Navigating cally organise the data. After this, the second uncertainty in everyday life. Each theme author read through all coded text to check includes sub-themes on specificaspects,illus- for accuracy between codes and the interview trating the participants’ experiences. text. All three authors engaged in discussions where codes were compared and clustered Theme 1: The meaning of place and according to shared meanings or where codes belonging in the garden were identified as illuminating various aspects of a phenomenon. The nature-based vocational rehabilitation pro- This was an extensive process where the gramme contributed with a place where the par- authors’ different disciplines and areas of ticipants could find peace and quiet. For some, it knowledge contributed to analyse the data evoked memories from their home country. from different perspectives. Themes were Being there and engaging in occupation was written to illustrate common and diverse nar- described as contributing to integration into ratives and experiences of the nature-based Swedish society. It was also a place that vocational rehabilitation programme at offered the possibility of relating to other per- Alnarp, and its integration into everyday sons. Most of the time, the meaning of place life, based on and grounded in the analytic contributed to a sense of well-being. JOURNAL OF OCCUPATIONAL SCIENCE 149

To settle in at Alnarp were all in pain. The leaders were described as Being at Alnarp was described as being able to “friends” or “sisters” with whom the participants land in another context and take a break from expressed good collaboration and for many, one worries that imbued everyday life. Some partici- of the rare contacts with “Swedish people”. Gor- pants experienced that nature in itself had a gis was grateful that the leaders had helped him calming effect, reduced stress, and gave energy. to become more aware of his feelings. He Josef described the time at Alnarp as “escaping explained how they had encouraged him to lis- from the truth”, in a positive sense. He forgot ten to his body and be tentative towards its about difficulties and worries when he left the limits, something that he found helpful and city to get there, and he expressed feeling so that he could practice in his everyday life. free when he “came out into nature”. This experience was shared by Zarah, who also felt Theme 2: The meaning of occupations free from disturbances, stress, and discomfort and its transferability to everyday life when in the garden. For some, Alnarp sparked earlier experiences of gardening and memories While in the garden at Alnarp, participants felt of their homeland. Zarah, Abir, and Maria they were caring for the garden, learning new spoke about being and doing in the garden at things, and that they were contributing and Alnarp as reminding them of their home village being useful. However, transferring what they and of how life was before the war. For Josef, learnt and experienced at Alnarp into everyday spending time in the nature at Alnarp was like life was challenging. regressing to when he was young. “When I get to be out in nature here at Alnarp, I feel like Caring for the garden and trying out new when I was little and out in nature playing”. things His father was a garden engineer and taught Many of the participants experienced caring for him to plant when he was little. These emotional the garden as meaningful and providing them ties to the garden can be seen as starting points with a purpose. For example, to prepare and in connecting with Swedish society. Zarah also eat what they had grown themselves was satisfy- explained that “one important thing that had ing. Abir expressed the meaning of caring for an impact is the way we were received by the the garden as she was giving life while working staff here”. in the garden: I mean, for me it’s life here. A bush or what A place to meet other people I grow. When I see this, that it gets a little Being at Alnarp was also a place that opened up yellowish and I give water and it grows. I fi interactions with other people. Several found feel like life [the interpreter clari es - she new friends among the participants in the pro- says human (life), but it is like life, like I gramme. Lukas experienced a strong fellowship save a life but she says like a human (life)]. within his group, talking about them as his Spontaneous occupations, unrelated to garden- family. He said: ing, also contributed positively to community Exactly, it’s been like we who are here are and capacity building in the group. For instance, around the same age, so we are many that Zarah learned to ride a bicycle during the have almost or yeah almost similar mental- breaks. She emphasised the feeling of liberation ity and everyone has some form of problem while speeding by on the bike and also gratitude with health. It can be diabetes or something towards having the opportunity to learn how to “ else, so we understand one another well; so, ride. I feel like the happiest of all to have had the ” we have been like one big family and we chance to learn to ride a bike . Abir raised the fi help each other and collaborate. physical bene ts of bicycling and how this occu- pation filled her body with energy and led to less However, whereas Lukas placed value in being pain in her back and hips. Josef emphasised the able to share experiences, Hanna found it doing perspective in the programme as some- exhausting to spend time with people who thing positive. He said that at Alnarp they 150 L.EKSTAM,A.M.PÁLSDÓTTIR&E.ASABA were doing things together in the garden, which worries and tensions awaiting at home. Josef, led to shared moments that gave birth to new who felt free and forgot his worries when he things to talk about. In reference to another pro- came to Alnarp, later described that when he gramme in which he had participated, they did returned home to “reality”, the problems and not do anything, thus he had only talked everything that needed to be done bounced about his history and problems; since they had back at him. He described that “when you nothing else to talk about. come here to Alnarp, you escape from your wor- Some of the occupations that participants ries, but when you get home, the first two hours engaged in at Alnarp were experienced as pro- are nice and easy with no problems, but then moting integration into Swedish society. Cook- [you get into] the same routine”. ing was such an occupation, with several of the He thought that even though the place, other women appreciating spending time in the nature, and the time at Alnarp was good, it is kitchen and preparing what they had harvested too short a time to have a lasting effect on every- in the garden. Zarah explained: day life. In contrast, other participants described how they managed to integrate new knowledge ff I have learned [from the sta ] how to cook in their everyday life. For Abir, it was about certain Swedish dishes, also what kind of integrating bicycling into her daily routines, ’ plants you use in cooking and I think it s and for Zarah it was about cooking healthy important because you are going to live food. When asked if they would benefit from ’ in this country and it s not possible to what they had learned, Zarah replied: “Of just ignore this integration, but you have course, no doubt and a big part is the cooking. to integrate yourself. Here, I have learned to cook in a healthier way Although learning the Swedish language was compared with how I am used to cooking, ” not a primary aim in the programme, several which is rather heavy . She explained that every- participants expected to learn Swedish at Alnarp thing she experienced as positive at Alnarp she and they also felt that they did. Further, they had tried to transfer into practice at home. learned to communicate in other ways than words. For example, Maria said: “We under- Theme 3: Navigating uncertainty in stand each other even though I can’t answer everyday life because of the language, but I still understand ’ when they talk to me and they understand me Participants lives were characterised by their fi ’ too”. Abir believed that language was the key own and signi cant others health being unstable to entering a new society and Zarah expressed and everyday life uncertain. They were uncertain the importance of learning the language: “The about the enrolment process and what they were Swedish language is important; for me, first supposed to do or gain from being in the pro- and foremost, it allows me to not be dependent gramme. When leaving the programme, they on someone, such as people from social service, described being uncertain about what to do in terms of the financial part that I can arrange next and how the future would be. The partici- fi ff my own finances”. pants identi ed many di erent strategies and resources to handle all this uncertainty, such as going for a walk to clear one’sthoughts,finding Transferring experiences from Alnarp to strength in praying (to God) or through relation- the everyday was possible but challenging ships with family and friends, including the other Although the temporary escape from worries participants at Alnarp and the staff,aswellas that some participants experienced was positive, from Swedish people and society. it was challenging to transfer what they learned at Alnarp into everyday life and when leaving To feel worried and uncertain about one’s Alnarp the problems resurfaced. Some partici- own and significant others’ health and pants described how already on the bus journey well-being on their way home from Alnarp the positive Health and well-being was affected by life events energy began to subside, being replaced by that occurred during the programme, both JOURNAL OF OCCUPATIONAL SCIENCE 151 positively and negatively. For some, their hous- told them that they should go to Alnarp and ing situation resolved for the better, but others that it would do them good and they relied on explained that concerns about their housing that. Josef described how Alnarp was intro- situation, their significant others, and how duced by his case officer as: “This place should they would be able to support themselves in make you feel a little better mentally; you will the future were constantly present. Even though forget the worries you have, [when you] work most participants experienced problems related with plants and flowers in nature; it can be heal- to their health, many described that they felt ing”. However, he kept wondering how a pro- better while being at Alnarp. Zarah described gramme over 12 weeks could have the power how she felt free from the hassles, stress, and to change his health status and everyday life. discomfort she had known before and that she Although most participants understood that had got more energy and felt better since com- participation in the programme was voluntary, ing to Alnarp. some described the opposite: “The Employment Many felt burdened by their relatives’ health Service sent a mail saying that we should come problems and worried about relatives who were here. … They didn’t ask us if we wanted to or in a war zone or were a refugee in another not, but they said we should take part in this country. Zarah had been denied a family activity and I went there”. reunification application. Some had children When expectations did not match reality, who were too old to be reunified; others had dissatisfaction could easily arise. Hanna was dis- children who had chosen to stay in the home appointed that the group was not bigger and country. Josef was constantly thinking about filled with liveliness and playfulness. She had how to get his fiancée to Sweden. Maria was also expected that she would receive physical worried about her son, who had just been called (passive) treatment for her pain through the to reserve duty in Syria. When asked what were programme, which was not the case. While her thoughts, she replied: “Well, it is hard to some were very happy to attend, others were describe the feelings actually; it is hard because not. The participants who had enjoyed gardens sometimes I sit and think that he has passed and gardening before had a more positive atti- away because in the city where he is there are tude. Gorgis expressed that he enjoyed being bombings everywhere. So, it’s painful for me”. in nature, planting flowers, and watching them She was in contact with her children every grow. He saw the time as work training, where day. “I call them daily. Although I cry quickly, I he could learn more about cultivation and am strong actually; because sometimes you hear plants. Many expressed a hope that they would bad news and instead of just breaking down, feel better after participating in the programme. you can stand on your own legs if you are Learning the Swedish language was not a central prepared”. part of the programme and a common ambition among participants was to combine the pro- Ambiguity and unclear expectations gramme with SFI, but this did not prove to be regarding participation in the intervention possible for various practical reasons. Hanna at Alnarp expressed great dissatisfaction with having to All participants had previously attended SFI quit SFI, as she very much wanted to learn (Swedish language course for immigrants), and Swedish but thought she had forgotten many some described that they had felt bad because Swedish words and grammar. of the stress and pressure they felt there, and that the pace was too fast for them. The pro- An uncertain future gramme at Alnarp was then offered based on When the programme at Alnarp ended, the their described health problems in order to pro- future was uncertain for most of the partici- vide occupations that suited their needs. How- pants. Most wanted to find a job and stay in ever, several participants expressed that they Sweden. Possible employment could be any- had received limited information about why thing from office work, cultivation, gardening, they should be at Alnarp or what the pro- working with animals or children, or cooking gramme would lead to. Their case officers had and sewing. How to enter the labour market 152 L.EKSTAM,A.M.PÁLSDÓTTIR&E.ASABA was for most participants still filled with uncer- Wästberg et al., 2020), and only a few hours of tainty. But having a job was important for sev- engagement per week can contribute to signifi- eral of them, as exemplified by Maria’s cant improvements (Corazon et al., 2019). statement: “If I get a job, it would be so good The participants described how being in the for me because I cannot imagine being at home garden milieu brought back pleasant memories and staring at the walls when the children are from times before the war back home. To in school. I have to do something”. experience familiarity through pleasant mem- ories evoked by nature-based occupations can support emotional ties and give a place mean- Discussion ing. As such, the rehabilitation garden can The nature-based vocational rehabilitation pro- serve as a meaningful place for the participants gramme at Alnarp had a clear foundation in (Lillefjell et al., 2017). When people are forced doing meaningful occupations in a garden into migration, narratives, roles, identities, environment. The participants all experienced health, and the possibility of creating a future difficulties with committing to the regular estab- can be negatively impacted (Huot & Laliberte lishment programme. Being in the garden gave Rudman, 2010). Our findings show that the gar- the participants a break from everyday hassles den can be seen as a place that offered a possi- and stress, where they could engage in occu- bility to connect to the new country and spark pations with others and feel a sense of calm. thoughts about a possible future. Gardens can be viewed as a refuge and a safe This leads us to the garden as a place for place, where people can let go of their everyday doing, where the second theme of the findings worries (Kaplan & Kaplan, 1989; Pálsdóttir captures the participants’ subjective occu- et al., 2014) and instead experience self- pational experiences. Hammell’s(2009) categor- rewarded values of engaging in enjoyable occu- isation of occupations and Doble and Santha’s pations (Persson et al., 2011). This experience of (2008) occupational needs can be applied to the garden environment could also be referred how the participants experienced their occu- to as being away, an attribute of a restorative set- pations. Through doing things and caring for ting (Kaplan & Kaplan., 1998, Pálsdóttir, Stigs- the garden, the participants felt responsible dotter et al., 2018). In such a setting, people and needed, and this doing also helped them can rest and recover from everyday worries to connect and facilitate integration. The need and just for a moment feel enjoyment (Poulsen for affirmation was addressed when doing et al., 2016). The participants with experiences things together and for others. For example, of forced migration expressed an urgent need several participants brought food to Alnarp, for mental recovery, and several described the and in doing so received some kind of affirma- feeling of returning to tiredness and worries tion from others, which highlights the impor- after pleasant time spent in the garden. tance of contributing. Being allowed to stabilise and feel safe is the As the programme was a group intervention, first step in trauma treatment (Herman, 1992), the need for companionship was easily allowing people to process information, be cur- addressed for the majority; however, there ious, and learn new things in a social context were participants who were dissatisfied with first when they feel sufficiently safe (Gerge, the liveliness, playfulness, and size of the 2017). This is in line with the first theme, group. Agency was experienced by choosing “The meaning of place and belonging in the gar- what occupations to do, also for how long and den”. This first step can be seen as a condition to with whom to perform them. The leaders’ being able to try out and learn new things, tasks were to guide the participants in finding which are important attributes to being able to meaningful occupations in which to engage, enter the labour market. Several studies indicate taking appropriate breaks, and listening to that individuals in need of mental recovery can their individual needs. The need for accom- benefit from engaging with the natural environ- plishment was addressed when the participants ment through meaningful occupations (Hartig were engaged in different kinds of doing, learnt et al., 2014; Sonntag-Öström et al., 2014; and mastered new skills, and met the JOURNAL OF OCCUPATIONAL SCIENCE 153 expectations of others and their own goals. The stories about uncertainty and ambiguity. Uncer- participants also experienced restorative occu- tainties were grounded in a broader socio-pol- pations in the garden, by walking around and itical environment exemplified by having finding their own peaceful corner. The need family members trapped amid migration pro- for pleasure, contentment, happiness, and joy cesses, feeling down, and not understanding was, for example, addressed by the woman how to navigate through different public sys- who rode a bicycle for the first time. Finally, tems. Utilising the capability approach, nuances the need for a sense of coherence was something that emerge when people receive training and that many participants struggled with, and it is support in developing particular skills (internal illustrated across the three themes how their capabilities) can be teased out, such as when engagement in occupations in the garden learning a language or acquiring skills for a helped them to connect to the past, the present job, while there can still be socio-politically and, to an uncertain but for some participants, a hinderances or barriers to expressing internal possible future. capabilities. This is what has been referred to Although participating in the programme as combined capabilities, which are the sum of seemed to have had several benefits for the par- complex internal and external factors. ticipants, several of them felt unsure about the The capability approach is relevant in under- next step and their future work-life. They standing the results from this study because it expressed that they did not understand the pro- provides a frame in which to socially situate cess they were involved in nor what to expect and operationalise factors that contribute to after the intervention was ended. Other poor work integration among persons who approaches such as Individual Placement and have undergone forced migration, refuting an Support (“Place then Train”) that have been over simplistic ascription of the problem to shown to be effective in gaining employment the individual. For example, as a consequence and community integration among people of the passing of 2010 Act (2010: 197), there with severe mental illness (Bejerholm et al., was a shift in responsibility from municipalities 2015) might be worth evaluating in vocational to SPES for supporting work among recent rehabilitation programmes for migrants. migrants. The introduction of, and continued In relation to the long-term goal to enter the change in, Acts exemplifies an external factor labour market, we drew on a capability that impacts on work possibilities among approach as a tool in arguing that it is not just migrants. In tandem with the change in the a matter of providing resources; a person must law and shift in responsibility, the ‘work line’ also have the ability to use and apply the (arbetslinjen) was introduced for immigrants resources and there must be supportive struc- who did not have work. Its aim is to ultimately tures that allow this to unfold. A capability enable a 40-hour work-week through support approach can provide relevant conceptual over a 2-year period that would include compul- tools in exploring how work entry is supported sory activities such as community information, for recent immigrants who have faced difficul- Swedish language courses, and workplace ties in securing paid employment. Capabilities internships. The work line initiative was are about “freedoms or opportunities created intended to increase employability, and it par- by a combination of personal abilities and the ticularly targeted persons who were deemed to political, social, and economic environment” be able to work at least 25% of full-time. (Nussbaum, 2013, p. 20). Using this lens, a per- Systematically working with health pro- son’s abilities are part of capabilities, but capa- motion and health education in the same bility is not conceptualised as a solely group has thus far not been introduced in the individual endeavour. Swedish refugee reception programme (Eriks- Participants in this study reflected on the son-Sjöö et al., 2012). After the completion of importance of language as an ability and impor- the vocational rehabilitation programme in the tant prerequisite to being able to obtain work current study, the law changed again (Act and be part of Swedish society. However, the 2017:584, 2017). This new law also emphasises participants’ narratives are also laden with the individual’s responsibility to establish 154 L.EKSTAM,A.M.PÁLSDÓTTIR&E.ASABA themselves on the labour market. The law is future. When participants lost confidence that reinforced so that individuals who do not par- capabilities exist, feelings of precarity arose ticipate in proposed efforts risk getting their and this in turn was exponentially more corros- compensation withdrawn, with the intention ive than strengthening. For the participants in of incentivising people to establish themselves. this study, experiences of precarity cut through There is a risk that when the causes of ill-health stories about family, work, friendship, being are put on individuals instead of social struc- part of society to revisit just some of the results. tures, so too will the demands for solutions be The participants’ expressions of uncertainty linked to the individual instead of changing about what would happen after the programme the external social structures that contribute to ended likely contributed to insecurity concern- ill health (Asaba et al., 2020). ing capabilities. The need to plan ahead for When seen from a broader occupational per- future occupations before the end of the rehabi- spective, the social context in which migrants in litation programme is crucial to limit unnecess- this study seek work can be seen as what has ary uncertainty and worries for the future been described as “activated but stuck” (Rudman (Nordh et al., 2009) and thereby set a focus on &Aldrich,2016, p. 4). In other words, each indi- constructive thoughts and actions. vidual who participated in the nature-based reha- The occupational nature of refugee resettle- bilitation programme had been and was activated ment stresses the need to develop resettlement in a process towards gaining paid employment, life skills, such as finding information, accessing however many other occupations in their daily services, and managing money, tenancy issues, lives pertaining to family, friends, and balancing employment, and education (Suleman & White- anewcultureweremadeinvisiblewithinaformal ford, 2013). Resettlement life skills is dependent system. One interpretation of the nature-based on the transferability of existing skills and the rehabilitation site as a safe haven can be that it individuals’ occupational needs, which can be hin- wasaplaceinwhichmemberswereallowedto dered or facilitated by environmental and political make the otherwise invisible visible. Moreover, aspects. Based on our findings, we argue that it is balancing a repertoire of migrants’ occupations, not only a matter of multiple life skills, but a mat- including seeking work, has been described as ter of situating these in a context of occupations something that can involvemultipleinjustices needed to meet individual needs in society and as requiring more attention (Rivas-Quarneti (Aldrich et al., 2017). Our findings show how par- et al., 2017). ticipants were struggling to navigate uncertainty When integrated with a capabilities in everyday life and had difficulty transferring approach, a basic tenet is that civic and social experiences they made in the garden into everyday participation should not only be a basic right, life. It can be assumed that this transferability but also cannot be fulfilled unless other basic requires more time than was available in this pro- needs such as bodily health and senses, imagin- gramme and according to the capability approach ation, or freedom of thought are also met. In the (Nussbaum & Sen, 1993), participants also require first theme of the results, the importance of actual possibilities to transform resources into being at Alnarp is illustrated. Although the con- something of social and personal value and rel- cept of ‘being’ can be seen as passive, there is a evance (Sen, 1995). potency in being in this context because it can be seen, not as betwixt and between (Bamber Limitations and further research et al., 2017; Turner, 1986), but as the liminal space in which people can build skills, energies, We faced similar methodological challenges in and hopes to move forward (Mondaca & conducting research involving ethnic minorities Josephsson, 2013; Peralta-Catipon 2009; as discussed by Morville and Erlandsson (2016). Turner, 1986). The concurrent building of Performing interviews through an interpreter potential and establishing a sense of safety in challenged the development of a respectful, being are conditions for planning ahead. Par- confident, and trusting relationship. The inter- ticipants raised needs for reasonable expec- viewer used strategies such as observations tations that given capabilities still exist in the and communications in simple language to JOURNAL OF OCCUPATIONAL SCIENCE 155 build rapport with the interviewee. Member migrants process of integration into work. checks were done at the end of each interview Further, studies, policies, and interventions should when the interviewer summarised her under- focus on individual, social, and political factors to standing of what the interviewee had been talk- support work entry for migrants. ing about and asked the interviewee to determine accuracy. Other studies have Conclusion reported that the interviewees did not always have trust in the interpreters (Ikonen, 2015), The nature-based programme in a rehabilitation but this was difficult to judge here. garden gave the participants a break from every- Another challenge was the use of several differ- day hassles and stress, which allowed for a tem- ent interpreters. Using a specific interpreter trained porary feeling of calmness through engaging in for the project could probably have reduced those meaningful occupations and subsequently feeling challenges and improved the chances that the safe. However, the temporary feeling of calmness interpreter would capture the meaning of the could be paradoxical when juxtaposed with a interviewer’s questions (Ingvarsdotter et al., sense of uncertainty and feeling stuck in everyday 2012). Cultural and language barriers during the life. Supporting work entry for migrants in Swe- interviews, for example talking about feelings and den rests on a combination of social, political, experiences with an unknown person, seemed and individual factors; furthermore, the detri- difficult for some participants and resulted in ments of societal discourses that place blame at some interviews being more descriptive in nature. the individual level should be dealt with in future There were also challenges related to analysing the policy and intervention work. data. In the present study, only the Swedish state- ments of the interviews were transcribed. The tran- scriptions show how the interpreters sometimes Acknowledgements interpreted in the third person, like “he is saying This project is the joint work of three governmental that he likes weeding”. Triangulating the data in agencies: The Swedish Public Employment Service in a translation and back-translation process, as Scania, the health care authorities in Scania (Region Skåne), and the Swedish University of Agricultural describedbyMorvilleandErlandsson(2016), Sciences, Alnarp. Our gratitude to members of SLU could improve the trustworthiness of the data. staff and the intervention team in Alnarp Rehabilitation Several participants had experienced post-trau- Garden as well as the staff members at the Swedish Pub- matic stress disorders triggered from war and lic Employment Services for their professional work in forced migration, which could have been a limit- running the nature-based programme. Also, our sincere gratitude to all individuals who participated in the study. ation. However, participants that needed specific therapy or treatment due to pain, trauma, or sleep disturbances were referred to the regular Disclosure Statement healthcare system. The exclusion criteria of severe No potential conflict of interest was reported by the depression, anxiety, and suicidal risk allowed for author(s). exclusion of participants with needs that could not be handled in this programme. Despite existing challenges and limitations, it is ORCID important to take on the challenges of including Lisa Ekstam migrants and ethnical minorities in studies, in http://orcid.org/0000-0002-7965-5530 order to live up to the World Federation of Occu- Anna Maria Pálsdóttir pational Therapists’ (WFOT) position statement http://orcid.org/0000-0002-4561-5792 on human rights (2019), highlighting the impor- Eric Asaba http://orcid.org/0000-0002-6910-3468 tance of cultural sensitivity. The authors encou- rage advancement of methods that include people with other native languages or minorities References in research to develop socially relevant research Act 2010:197, on the responsibility for establishment knowledge. Future studies would benefitfrom contributions for newly arrived immigrants. [Lag having a longitudinal approach, following (2010:197) om etableringsinsatser för vissa 156 L.EKSTAM,A.M.PÁLSDÓTTIR&E.ASABA

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