The overall aim of this study was to examine and compare preferred help-seeking sources for depression among different immigrant groups (Poles, Russians, Somalis, and Pakistanis) in Norway, and to provide more insight into how such preferences relate to individual differences in acculturation orientation. Factor analysis suggested four main categories of help-seeking sources, labelled traditional, informal, semiformal, and formal. A similar classification into informal, semiformal, and formal help-seeking sources was suggested by Rickwood and Thomas(15) following a systematic review. They noted that classifications are not absolute, since different countries have different health and social care systems. For example, traditional healers could be a critical source of formal health care in a traditional indigenous population group. In the present study, traditional sources emerged as one distinct factor, comprising help-seeking from religious leaders, alternative medicine providers, and ethnic community members. It is also possible that the emergence of the semiformal help-seeking factor (that included internet forums), was influenced by the fact that the majority of participants being recruited from social media and therefore likely to be familiar with using digital platforms.
The results indicate that independent of ethnicity, respondents preferred to rely on informal sources of help, such as friends and family, before turning to semi-formal (e.g., telephone helplines) or formal (psychologists/psychiatrists and general practitioners) help sources. This is in line with previous research (36, 37) highlighting the importance of social networks in coping with mental health problems. Surprisingly, and contrary to previous studies(11, 38, 39), there were no differences between ethnic groups in preferences for formal help-seeking sources. This is an important finding since earlier research has indicated that some ethnic groups may have a lower preference for formal sources of help due to lower mental health literacy(40). Our findings indicate that all groups recognize formal sources of help as valuable. One possible explanation for these different findings is that all legal residents in Norway have access to public health care and that costs are low. All citizens are entitled to a general practitioner. Once a person reaches an annual limit (currently about NOK 2000), services are free. However, when interpreting the findings, it should be kept in mind that some immigrants, in particular from countries where mental health services are sparse or non-existent, may not have a clear understanding of what a psychologist is or the nature of psychological treatment. Moreover, one should be mindful that the formal help factor only consisted of two items, which may explain why the internal consistency was rather low. We cannot rule out that the introduction provided to the respondents when they were invited to participate could have made them more inclined to endorsing formal help sources as they were informed that the study concerned how “one could best deal with feelings such as sadness” and that “the results could inform the development of health services adapted to the needs of minority groups”. According to Wright, Jorm, and Mackinnon (41) labelling a disorder has implications for help-seeking preferences and beliefs. However, the term depression was deliberately not used in the information provided to the participants. Therefore, we overall regard it unlikely that the instructions impacted substantially on the results.
Immigrants and refugees from Somalia and Pakistan endorsed more traditional and informal sources of help than immigrants from countries culturally closer to Norway (Russia and Poland) and the Norwegian sample. Thus, as the cultural distance grows, the conceptualization of what constitutes effective help-seeking sources seems to diverge. If informal and traditional sources are influential in determining treatment choices in depressed friends and family, this may highlight their potential role as gatekeepers or gate-openers for public mental health services(36). The Norwegian student sample scored significantly lower than most ethnic groups on preference for traditional sources of help. This is consistent with previous research(42). However, the lower endorsement of help-seeking from traditional sources may be due to the possible perceived irrelevance to the Norwegian respondents of some of the questions loading on the traditional factor (e.g., “seeking help from a leader in my ethnic community or from the same country as me”).
The results of the hierarchical regression analysis showed that acculturation orientation explained only a modest portion of the variance in preferred help-seeking sources. However, the pattern of correlations was in accordance with previous findings (38, 43). Orientation towards heritage culture was associated with a preference for traditional and informal sources of help, while orientation towards mainstream (Norwegian) culture was associated with endorsement of semiformal and formal sources of help.
The current findings suggest that demographic variables should also be taken into consideration when designing interventions for immigrants. Women took a more positive view of formal help-seeking sources, while males took a more positive view of traditional help-seeking sources(19). There may be several explanations for these findings, for example, the stigma attached to mental health among male respondents that have been reported in previous findings (20, 44). Years of higher education was positively associated with endorsement of formal sources and negatively associated with endorsement of traditional help-seeking sources. These findings suggest that immigrants with lower education are more likely to seek help from sources outside the existing health services. This may give cause for concern because lower education, often associated with lower socio-economic status, is a risk factor for poorer mental health.
Our results should be interpreted in light of certain limitations. The use of a vignette is useful in studies of nonclinical populations to attempt to determine what people who are not experiencing symptoms would do if they were to experience symptoms (15). This approach may also have reduced the impact of social desirability since the respondents were not asked to report their mental health behavior. It can still be questioned whether the response to the question of what a hypothetical person should do reflects how the respondents themselves would have acted if they or someone in their family were depressed. Issues related to the representativeness of the samples need to be kept in mind. Participants in the present study were recruited through convenience sampling, primarily via emails, social media, and through snowball sampling. The latter sampling method is recommended when working with hard-to-reach population groups, such as ethnic minorities (26, 27). In terms of recruitment through social media, it has been noted that this may lead to a mismatch between the target population and those recruited, especially regarding demographic variables (45). The use of social media for recruitment may thus explain the preponderance of young participants. Taken together, lack of familiarity with social media platforms, low reading literacy, lack of acquaintance with questionnaires, and access to the internet are factors likely to have prevented participation in the study.
Readers should be mindful that these and other factors may influence the comparability of the samples. Ethnic differences in response styles (46) represent a possible bias, but we believe that the influence of this possible bias was minor as there was no evidence suggesting that specific ethnic groups consistently scored higher or lower on the scales. Educational attainment varied much between the groups. For the Pakistani, Polish and Somali samples, the portion with higher education are close to being representative for these immigrant groups in Norway, but in the Russian sample, a larger portion had higher education compared to the Russian immigrant population in Norway (47). Also, the Norwegian students were on average somewhat younger and had a higher education level than the other groups. Except for the Somali immigrants, females were in the majority. To control for the possibility that gender, age, or level of education or interactions between these variables are responsible for the differences between the ethnic groups observed, we adjusted for these variables in the regression analyses. We acknowledge that it may be problematic to generalize from students to the general public(48). Nonetheless, in Norway, the population’s education level is high, particularly in the younger age groups. Among those aged 15–64 years in 2019, 38% have a university or college degree compared to 28%% in the European Union (49). As a general rule, higher education is free of charge and Norwegian students are entitled to loans and grants from the State Educational Loan Fund. Therefore, the student population in Norway is probably more heterogeneous regarding backgrounds than in many other countries(50). Recent research on Norwegian students enrolled in higher education showed higher levels of mental health problems than the general population (51). The high prevalence of mental health problems in university students correspond with data from other countries (52), indicating that this group may be particularly relevant when examining help-seeking behavior for mental health problems