How do immigrants in Norway interpret, view, and prefer to cope with symptoms of depression? : A mixed method study

Background. Depression is a common mental health problem worldwide. Delays in seeking treatment, misdiagnosis, and non-specific treatments are barriers to receiving appropriate care for people with depression. People with an immigrant background are especially vulnerable and are more likely than the majority population to have unmet mental health care needs. The overall aim of this thesis was to explore how specific immigrant groups settled in Norway interpret, view, react, and prefer to cope with symptoms of depression. The following research questions were formulated to illuminate the overall aim: i) What do various immigrant groups settled in Norway perceive to be appropriate coping strategies with depression? ii) What do various immigrant groups settled in Norway perceive to be appropriate help-seeking sources for depression? iii) How are immigrants’ views of appropriate coping and help-seeking associated with acculturation orientation? iv) How can immigrant’s conceptualization of depression influence their coping and help-seeking preferences? Methods. The thesis is based on a multiphase mixed-method design, which contains data collected, analyzed, and discussed from both a quantitative and a qualitative approach. The rationale for this approach is that, on the one hand, the quantitative data and results provide a general answer to the research question, while, on the other hand, the analysis of qualitative data refines, extends, and explains the general picture. In the quantitative part, a survey was administered to immigrants from Russia (n=164), Poland (n=127), Pakistan (n=128), Somalia (n=114), and Norwegian students (n=248). The survey consisted of a vignette describing a moderately depressed person based on the criteria found in the 10th version of the International Classification of Disorders. Respondents were asked to provide advice to the vignette character by completing the Cross-Cultural Depression Coping Inventory (CCD-CI) that was developed for the purpose of this thesis and a modified version of the General Help-Seeking Questionnaire (GHSQ). The immigrant sample also responded to questions about acculturation orientations using the Vancouver Index of Acculturation (VIA). In the qualitative part, focus-group interviews with immigrants from Somalia (n=10) were conducted separately for males and females to examine the relationship between the explanatory models of depression and preferred coping strategies. Videotapes from the focus group interviews were transcribed verbatim into Norwegian. Data were analyzed in accordance with the principles of Template Analysis. Results. Paper 1. Immigrants from Pakistan and Somalia endorsed more spiritual coping strategies than immigrants from Russia and Poland and the Norwegian student sample. Together with the Russian immigrants, two former groups also endorsed disengagement coping to a greater extent than other groups in the study. The Russian immigrant group endorsed engagement coping as well and to a greater degree than other ethnic groups. Maintenance of origin culture as acculturation orientation was associated with preferences for engagement and spiritual coping. Paper 2: Immigrants from Pakistan and Somalia endorsed traditional (e.g., religious leader) and informal help sources (e.g., family) more than immigrants from Russia and Poland, and the Norwegian student sample. There were no ethnic differences in preferences for formal mental help sources (e.g., medical doctor). Maintenance of origin culture as acculturation orientation was associated with preferences for traditional and informal help sources, while adaption to mainstream culture was associated with preferences for semiformal help-seeking sources (e.g., internet forums). Paper 3. Focus groups with Somali immigrants showed that depressive symptoms were conceptualized as a problem related to cognition (thoughts) and emotion (e.g., sadness), but not to biological mechanisms. They were thought to result from spiritual possessions, stress from social isolation, and past trauma. Independent of time in exile, the participants showed a strong identification with their ethnic origin and associated values. As participants emphasized the need to obey and follow the viewpoint of elders, fathers, and spiritual leaders, these authorities seemed to be “gatekeepers” for access to mental health services. Conclusions. The findings reveal similarities and differences in how different ethnic groups settled in Norway prefer to cope with depression and how these differences can be associated with acculturation orientation. Somali immigrants were the group that differed the most from the Norwegian respondent group. Findings in the qualitative study indicate that conceptualization of depression among the Somali immigrants differs from the Western biomedical model of depression in terms of cause and treatment. Specifically, spiritual coping and traditional health sources seem to be important when coping with depression among Somali immigrants. Implications: The findings of this thesis can help inform culturally-centered health promotion, interventions, and policies that encourage timely and appropriate use of health care. Ethnic differences in understanding preferences toward help-seeking sources and coping strategies for depression need to be considered in the design and implementation of mental health services. The results highlight that mental health programs for ethnic minorities, especially of Somali descent, should actively involve the ethnic community, including spiritual leaders, in order to reach patients in need and to foster treatment compliance