Non‐European immigrants' self‐described strategies for mental health promotion and perceptions of Finnish mental health services: A qualitative descriptive analysis

Abstract Purpose This study aims to describe non‐European immigrants' perceptions toward mental health care in Finland and the factors that support their mental health. Design and Methods Participants (N = 17) were interviewed through semistructured interviews, after which interview transcripts were analyzed using a six‐phase thematic analysis process. Findings The participants reported that developing self‐help strategies benefitted their mental health. The participants primarily preferred unprofessional help over professional mental health care. Several structural and cultural barriers to help‐seeking were identified. Practical Implication Health care staff working with immigrants need proper education and knowledge to provide sufficient, holistic care; for this reason, information about the cultural differences among immigrants and cultural sensitivity should be included in basic as well as post‐graduate nursing education.

language, lack of information, attitudes, financial difficulties, logistical issues, lack of knowledge on how the local health system works, long waiting lists, dissonance between the cultural systems of the country of origin and the host country, and stigma-may prevent immigrants from accessing mental health services (Kiselev et al., 2020;WHO Europe, 2018a). Both of these factors result in unmet mental health care needs among immigrants (Lebano et al., 2020).
International immigration has increased during the last decades (WHO, 2019). Nearly 920 million people live in the WHO European Region, with approximately 10% representing immigrants (WHO Europe, 2018b). The need for mental health services among immigrants has increased linearly with the growing immigration rates. Good mental health is associated with quality of life (Van Der Boor et al., 2020) and is also pivotal for immigrants' successful integration (European Observatory for Health Systems and Policies, 2011). The successful integration of immigrants is an important issue for all European states, with the legal, moral, and economic participation of immigrants crucial to the future well-being, prosperity, and cohesion of European societies (European Commission, 2016).

| BACKGROUND
Research on mental health care service utilization by immigrants has mainly covered the barriers to treatment, with only a few studies examining which factors facilitate access to care (Byrow et al., 2020).
The barriers to mental health and psychosocial support services reported by immigrants include a lack of information, language difficulties (e.g., Doğan et al., 2019;Kiselev et al., 2020;Satinsky et al., 2019;Valibhoy et al., 2017), and negative attitudes, which can also include care providers' attitudes (Doğan et al., 2019;Satinsky et al., 2019). In addition, a lack of cultural competency among health care professionals and financial costs (Kiselev et al., 2020;McCann et al., 2016) have been reported to impede access to mental health services. Concerning care givers, their perceptions of immigrants (Bartolomei et al., 2016) and a lack of knowledge about mental health problems among immigrants (Kiselev et al., 2020) may reduce immigrants' access to mental health care.
Immigrants have also reported that the health care system is not always aligned with their perceived needs (Aggarwal et al., 2016;Kiselev et al., 2020). For example, certain problems-such as depression or anxiety-may not be viewed as an illness (Kiselev et al., 2020). Thus, immigrants often prefer other options (Satinsky et al., 2019;Valibhoy et al., 2017), such as religious healing (Bettman et al., 2015;Mölsä et al., 2017) and/or psychosocial support from their own network (Renner et al., 2020), instead of using official health services.
Besides barriers, certain factors are conducive to help-seeking among immigrants with mental health problems, namely, being open with friends and family that can facilitate help-seeking among immigrants (McCann et al., 2016). Furthermore, increasing mental health literacy, ensuring confidentiality, and engaging the family and community in care, might improve the rates at which immigrants seek help for mental health problems (Colucci et al., 2015;McCann et al., 2016). Decision-makers should improve accessibility to care (Colucci et al., 2015;Valibhoy et al., 2017) and provide interpreters (Colucci et al., 2015) with adequate training (Wamwayi et al., 2019) if health care systems are expected to respond to the unmet needs for mental health services among immigrants.
Future mental health services should be culturally appropriate (Mölsä et al., 2017), while immigrant population will require specialized mental health care services (Kien et al., 2019). In general, this means that health care systems need to become more flexible and should embrace innovative development paths to serve diverse target populations (Kiselev et al., 2020). Moreover, service development should engage the target population as it would be erroneous to assume the treatment preferences of patients without asking for their input (Aggarwal et al., 2016).
In 2019, approximately 8% of Finnish residents had a foreign background (Statistics Finland, 2020). Furthermore, previous reports indicate that-in Finland-the prevalence of mental health problems is higher among the immigrant population than the general population, yet immigrants utilize mental health services less than other members of society (Finnish Institute on Health and Welfare, 2020). Thereby, this study aims to describe non-European immigrants' perceptions of Finnish mental health care and the factors that support their mental health. The ultimate goal of the presented research is to provide knowledge that can be used to support the mental health of the immigrant population in Finland.
The questions underlying the research are as follows: (1). Which factors promote mental health among the non-European immigrant population in Finland?
(2). How do non-European immigrants in Finland view mental health services?

| Study design
The presented research applied a descriptive qualitative approach (Polit & Beck, 2012), which is commonly used when gathering information on participants' experiences, opinions, and perceptions of the studied phenomenon (Palinkas, 2014;Polit & Beck, 2012).

| Sampling, study population, and procedure
The participants were recruited via several third sector nongovernmental organizations working with immigrants in southern Finland. Recruitment notifications, including contact information, were placed in the bulletin boards of the organizations. Researchers also visited the organizations to host events during which potential participants could ask questions and volunteer to participate. In addition, staff at these organizations disseminated information about the study and, thereby, were involved in the recruitment process.
Participants could sign up to participate in this study either through ROTH ET AL. | 3017 the researchers or staff working at the organizations, who would then contact the researchers and schedule an interview time.
Purposive sampling (Polit & Beck, 2012) was used to recruit participants representing a wide range of immigrant backgrounds, as immigrants are not a homogeneous population. Participants were then selected based on their ability to provide the requested information. The inclusion criteria for participation were: (1) at least 18 years of age; (2) voluntarily participating in the study; (3) the participant, or both of his/her parents, was born in another country not included in the European Union; (4) being able to participate and give informed consent; and (5) being able to understand and speak Finnish, Swedish, or English.
A total of 17 participants took part in this study. Out of these 17 participants, 1 was male and 16 were females. The average age of participants was 34.8 years, which varied between 23 and 58. The participants had varying educational levels, ranging from no education at all (n = 3), secondary school (n = 2), high school (n = 2), adult education (n = 4), vocational education (n = 2), to a bachelor's degree (n = 2), and other (n = 2). They had arrived in Finland between the years 1989 and 2017, and had spent an average of 13 years in the country. One of the participants was born in Finland to parents who had immigrated from an non-European country. The participants were originally from Afghanistan (n = 1), Guinea (n = 1), Iran (n = 1), Iraqi Kurdistan (n = 2), Japan (n = 1), Kosovo (n = 1), Pakistan (n = 1), Somalia (n = 8), and Vietnam (n = 1).

| Data analysis
The collected data were analyzed using a six-phase thematic analysis process presented by Brown and Clark (2006). First, the researchers familiarized themselves with the data, that is, the written transcripts from the interviews were read through several times to obtain a general understanding of the material and formulate tentative ideas of the content. During Phase 2, the researchers produced initial codes from the data while keeping the research questions in mind, for example, which factors support mental health and views of professional mental health care in Finland. In the Phase 3, the researchers analyzed the codes and organized them into categories by clustering related codes into broader themes. Next, in Phase 4, the researchers reviewed the themes, first based on how they were related to the coded data and secondly based on how they were related to the entire data set, to ensure they form a coherent patter. During the Phase 5, the themes were defined and named, while Phase 6 entailed the reporting of the results (Brown & Clark, 2006). An example of the thematic analysis process is presented in Table 1.

| ETHICAL CONSIDERATIONS
Good scientific practices and principles of publication ethics were followed throughout the research process (ALLEA, 2017). Ethical approval was obtained from the ethical committee of Turku University of Applied Sciences (2/2019). Participants received both written and verbal information before they were asked to participate. Participants volunteered to take part in this study and signed a form of informed consent regarding data collection via interviews and taping of the interviews. The participants were also allowed to drop out from the study at any point. The researchers highlighted participants to respect the privacy of fellow participants and the data were reported so that participants could not be identified. The researchers obtained permission to conduct the study in a way that was aligned with organizational policies.

| RESULTS
The analysis identified four themes from the data, namely, (1) promoting mental health, (2) preferring unprofessional help over professional services, (3) barriers to help-seeking, and (4) hopes and ideas for service development.
T A B L E 1 Example of the thematic analysis process

| Preferring unprofessional help over professional services
In relation to treatment for mental health problems, the participants of this study primarily preferred unprofessional mental health care, that is, that provided by themselves, family members or religion, over professional help. The participants felt that they were capable of treating their own mental health problems, with some expressing that it was their own responsibility, or a family responsibility, to care for mental health problems. Few participants reported having been offered professional mental help, but they all declined because it was considered unnecessary. "Where do I get help? from a doctor or where? If it is just a little depression, I would not seek help" (P9).
Professional help was seen as a grave, almost radical option, with a majority of the mental health problems considered so mild that neither medical nor professional care would be necessary. In contrast, self-care, care from the family or religious help were perceived as sufficient care for most situations or should at least be tried out first.
Despite these perceptions, many of the participants were familiar with situations in which professional help had resulted in positive outcomes. "At first Quran, this person is ill" (P6).
A majority of the participants knew that help could be requested from a doctor, psychiatric nurse, or psychologist at health care center.
However, this approach was seen as the last resort. The participants reported that all possible self-help strategies should be tried before going to doctor could be considered.
But if it is really bad then the doctor is needed. (P2)

| DISCUSSION
The findings of the present study shed light on immigrants' perspectives of which factors they consider to support their mental health. Mental health promotion and understanding which factors positively influence mental well-being are both essential to preventing mental health problems (WHO, 2013). While immigrants' mental health can be promoted on a societal level through, for example, political decision-making concerning social integration (WHO Europe, 2018a), small, everyday actions were also identified to relieve stress. It is noteworthy that despite cultural differences, some of the factors that support mental health identified by participants, such as enjoyable activities, align with previous findings from different populations (Fusar-Poli et al., 2020;Shimazaki et al., 2020). It has also previously been argued that nature can positively impact mental health by relieving stress, aggression, and mood-related problems (e.g., Bratman et al., 2012).
Furthermore, the participants shared that participating in activities arranged by third sector organizations benefitted their mental health. However, it should be acknowledged that this result can partly be explained by the fact that the participants were recruited via these organizations, so each participant was familiar and already involved with these kinds of activities. Nevertheless, it can be argued that organizations like these create a safe space for immigrants, enable them to be involved in the community and openly communicate with others in a trustworthy environment. This corresponds well with the findings of Robertson et al. (2018), namely, promoting the mental health of males strengthens the social integration process by decreasing isolation.
In addition to meaningful activities, engaging with family, friends, and the whole community was mentioned by almost all participants in relation to their mental health. It is well established that maintaining close relationships with friends and family is beneficial to mental health (Fusar-Poli et al., 2020), yet the immigrants seemed to highlight the support from their network as very important (Renner et al., 2020). Concerning mental health treatment, immigrants preferred unprofessional help over professional services, which corroborates previous findings (Bettman et al., 2015;Mölsä et al., 2017;Renner et al., 2020;Satinsky et al., 2019;Valibhoy et al., 2017). The participants also mentioned several cultural barriers toward helpseeking. Nevertheless, a majority implied that they would seek professional help if they felt the need. At the same time, most of the immigrants' comments suggested that they did not consider mental health problems, such as depressive symptoms, worthy of professional help. This indicates, at least to some degree, a lack of knowledge of mental health problems, which could be ameliorated by improving mental health literacy (Gele et al., 2016). Furthermore, the immigrants' comments also imply that the mental health issue has potentially continued for an extended period of time, and reached a severe level, by the time professional help is requested. This can significantly prolong the recovery process. In relation to severe mental health illnesses, participants were in agreement that these required professional services. When asked about structural barriers to help-seeking, immigrants mentioned a lack of knowledge regarding services and language difficulties, which agree with what has been reported in previous studies (e.g., Doğan et al., 2019;Kiselev et al., 2020;Renner et al., 2020;Satinsky et al., 2019;Valibhoy et al., 2017).
The participants of this study did not readily seek professional mental health services, but rather turned to peer support from their community. This possible barrier to help-seeking can be removed by developing culturally sensitive mental health services that immigrants are comfortable using. This type of development would require experts with an immigrant background who can provide reliable insight into which aspects of care the immigrants are most uncomfortable with. Moreover, the provision of community-based services that involve people with immigrant backgrounds could make mental health services more acceptable to immigrants from different cultures.
The participants also shared their ideas for how the utilization rates of mental health services among immigrants could be improved.
The immigrants stressed that these services should be more flexible and include a low threshold for seeking help. In addition, they emphasized that recruiting staff from the immigrant population could improve access to mental health services. These types of interventions, that is, ensuring that people with immigrant backgrounds are employed in public services, have already shown promising results (WHO Europe, 2018a, 2018b. The participants also demonstrated a need for diverse information among immigrants, with some respondents suggesting that they would require information outside of the mental health sphere.

| CONCLUSIONS
Immigrants use self-help strategies to maintain their mental health at similar rates as the rest of the Finnish population. However, immigrants tend to seek professional help only once their mental health problems have reached a severe point; this shows that culturally sensitive mental health services need to be developed to meet the diverse needs of the immigrant population.

CONFLICTS OF INTEREST
The authors declare no conflicts of intrest.

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.