”Putting words to their feelings”– civic communicators’ perceptions and experiences of an in-depth course on mental health for newly settled refugee migrants in Sweden

Al‑Adhami et al. BMC Health Services Research (2023) 23:510 https://doi.org/10.1186/s12913-023-09524-2 BMC Health Services Research Open Access RESEARCH ”Putting words to their feelings”– civic communicators’ perceptions and experiences of an in‑depth course on mental health for newly settled refugee migrants in Sweden Maissa Al‑Adhami1,2*†, Josefin Wångdahl2,3†, Raziye Salari2 and Eva Åkerman4 Abstract Background Newly settled refugee migrants face psychological stressors stemming from pre-, during- and postmigration experiences. In Sweden, mental health promotion is part of the health module in the civic orientation classes for newly settled refugee migrants. Training courses are offered to civic communicators and workshop leaders to facilitate communication about mental health; however, the training is seldom evaluated. In the current study, we aim to explore civic communicators’ perceptions and experiences of an in-depth mental health training course in rela‑ tion to observed needs among newly settled refugee migrants. Method We interviewed ten civic communicators that had partaken in the in-depth training course on mental health. All respondents had prior migratory experience and worked as civic communicators in their native languages. The interviews were semi-structured and data were analyzed using thematic analysis. Results Three themes were identified: (1) Intertwined mental health needs related to migration, (2) Multi-layered bar‑ riers to addressing mental health, and (3) Becoming aware of the mental health journey. One overarching theme was arrived at through synthesizing the three themes ‘Acquired new tools to lead reflective conversations about mental health and well-being’. Conclusion The in-depth mental health training course led to the attainment of new knowledge and new tools enabling civic communicators to lead reflective conversations about mental health and well-being with newly set‑ tled refugee migrants. Mental health needs were related to pre- and post-migration experiences. Barriers to talking about mental health included stigma and a lack of arenas to promote the mental health of refugee migrants. Increas‑ ing knowledge among civic communicators can facilitate the promotion of mental self-help capacity and resilience among newly settled refugee migrants. Keywords Mental health training, Refugee migrants, Mental health literacy, Health promotion, Sweden † Maissa Al-Adhami and Josefin Wångdahl contributed equally to this work. *Correspondence: Maissa Al‑Adhami Full list of author information is available at the end of the article © The Author(s) 2023. 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The Creative Commons Public Domain Dedication waiver (http://creativeco mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Al‑Adhami et al. BMC Health Services Research (2023) 23:510 Background In the last decade, Sweden has received a relatively large number of refugees compared to other European countries, fleeing the war in Syria and other conflicts. From 2015 to 2019, over 250 000 permanent or temporary residence permits were granted based on refugee status, subsidiary protection status and family reunification [1]. Recently, in the first half of 2022, about 40 000 Ukrainian refugees received temporary residence permits [1]. The mental health of newly settled refugee migrants is affected by structural and contextual barriers in the resettlement phase, such as inadequate housing and employment opportunities [2, 3], acculturation stress, isolation and discrimination [4–6]. The need for mental health promotion aimed at refugee migrants has been increasingly recognized by regional European and local authorities, leading to the initiation of public and nonprofit services and programs [7–10] but we need a better understanding of how mental health programs targeted at newly settled refugee migrants should be designed and delivered [11, 12]. To reduce the impact of mental ill health, it is essential to ensure that clinical, as well as the non-clinical staff who lead interventions and programs aimed at refugee migrants, possess relevant knowledge and skills [13, 14]. Despite being heterogeneous in many aspects, at group level, refugees are more likely to suffer from mental ill health and experience specific disorders such as post-traumatic stress and depression than the general populations in hosting high-income countries [15–19]. The WHO defines mental health as “a state of well-being in which an individual realizes his or her abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community” [20]. In the case of refugees, mental health is affected by factors occurring pre-, during- and post-migration. Examples of pre-migration adverse factors are persecution, physical and psychological violence, forced migration and involuntary separation from family members [2, 21]. During the flight, hazardous elements include traveling in unsafe ways, witnessing death and violence, and being detained at borders [22]. In the early post-migration phase, mental stressors are linked to, for example, uncertainty about the asylum process and worrying about family members left behind [23] as well as structural and contextual factors linked to the resettlement [3, 24]. Refugee migrants are also more likely to have difficulties accessing and utilizing mental health services in comparison with the majority population [25, 26], because of language barriers, poor knowledge about mental health as well as the health care system in hosting countries [26–28]. Other Page 2 of 15 reasons for not seeking mental health care include fear of disclosure due to the stigma surrounding mental illhealth common in many cultures as well as different help-seeking behaviors and coping mechanisms [29– 31]. For example, Syrian migrants report that they turn to their own close family and friends for support when facing depression [32]. However, with migration, social networks are interrupted and it takes time to form new ones [33, 34]. Mental h (...truncated)