Abstract
Introduction
Immigrants access mental healthcare at lower rates than native-born individuals, highlighting the need for interventions and systematic assessments of scalability to reach underserved populations.
Aim
This study (ClinicalTrials.gov ID: NCT06193161) evaluates outreach procedures and the characteristics of the first 100 immigrants who sought internet-based treatment in Sweden for post-traumatic stress disorder. It also assesses the feasibility of a battery of outreach assessment variables for systematic use in clinical research.
Methods
Recruitment strategies included targeted social media advertisements, a dedicated study webpage and psychoeducational materials. Individuals completed a comprehensive set of outreach assessment variables, including immigrant status, treatment history and mental health indicators.
Results
Digital advertisements for 6 days resulted in the enrolment of 100 immigrants including both voluntary and forcibly displaced migrant groups. The enrolled sample represented diverse cultural backgrounds as captured by the screening assessment battery.
Conclusion
Additional efforts are needed to engage socioeconomically diverse and non-English-speaking immigrant populations.
Keywords: Public Health, Community Health, Mental Health
WHAT IS ALREADY KNOWN ON THIS TOPIC.
WHAT THIS STUDY ADDS
In summary, this study demonstrates an internet-based treatment for post-traumatic stress disorder.
We succeeded in reaching a diverse group with many different cultural backgrounds.
Our assessment battery facilitated systematic evaluation of outreach.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
This study sets the stage for future studies within our Mind the Gap consortium, further fine-tuning outreach methods. One lesson learnt and which we will develop more in future treatment programmes is to target studies to participants with lower educational backgrounds (in the present study, a high proportion of participants were highly educated) and include information in multiple languages. For example, outreach through social media was limited to Facebook and Instagram, which may have excluded individuals with limited digital literacy or restricted access to the internet. Future studies could incorporate additional outreach strategies to reach a broader and more diverse population, such as advertisements in public transportation settings and posters or printed materials at churches, educational institutions, healthcare settings and community or support centres for immigrants to enhance inclusivity.
Background
Globally, more than 117 million people are currently displaced from their home countries.1 In recent decades, Sweden has received diverse immigrant cohorts, including asylum seekers from major geopolitical crises, resulting in substantial heterogeneity in countries of origin. Approximately 1.9 million individuals (≈20% of the population) are estimated to be foreign-born2 and the largest groups originate from Syria, Iraq, Finland, Poland, Iran, Afghanistan, Somalia and the former Republic of Yugoslavia.3 Migration to Sweden is shaped by both push and pull factors, including protection from conflict, family reunification and pursuit of economic, educational and safety opportunities.4 Displaced individuals including immigrants constitute a highly heterogeneous group with diverse needs and challenges, necessitating research to map both risk and resilience factors associated with different mental health outcomes. Despite the demonstrated need for psychological treatment, numerous studies have shown that immigrants seek healthcare at lower rates than native populations.5 6 The United Nations 2030 Agenda for Sustainable Development highlights the need for large-scale initiatives to improve access to mental healthcare.7 Additionally, the initiative underscores the importance of evaluating digital interventions to assess their efficacy and the need for methodological refinement. However, research remains limited in several key areas.8 Existing digital treatment approaches are typically not designed for individuals with lower digital and health literacy and often fail to address considerations of cultural equity.9,11 Furthermore, to effectively close gaps and promote access to equitable treatment among immigrant populations, clinical studies need to address and evaluate a comprehensive range of characteristics within the samples targeted by mental health interventions. In a recent review of 174 studies across countries with varying income levels, Nickerson et al1 examined sociodemographic factors associated with mental health outcomes in refugee and asylum-seeking populations. They identified key domains, including sociodemographic factors (eg, age, gender), environmental factors (eg, secure residence permits, employment) and sociocultural factors (eg, language proficiency, engagement with the host community).
Mind the Gap is a consortium (MTG; https://ki.se/en/cns/research/centre-for-psychiatry-research/mind-the-gap-increasing-access-to-mental-health-treatment-for-minority-populations?auHash=gmYzAdwiyhjlX4LnsN50jvPN49Odi8RQx58hGZ25_BQ)12 of ongoing clinical and public health studies evaluating outreach, accessibility and treatment delivery for immigrant populations, within which the present study represents an initial pilot evaluation of outreach procedures. It offers digital and evidence-based cognitive behavioural treatments for various mental health disorders, specifically targeting immigrant populations. The platform provides both treatment interventions and video-based psychoeducational materials, tailored to engage diverse populations, and is available in multiple languages.
In addition to increasing access to treatment, the MTG aims to systematically assess barriers to treatment among immigrant populations,13 such as limited health literacy and challenges in accessing healthcare and its utilisation and stigma.12 To promote treatment-seeking behaviour and raise awareness of mental health issues, the MTG platform employs broad public health methodologies and outreach campaigns targeting immigrants from the general population. A key cornerstone of the MTG initiative is the continuous evaluation of which groups seek—and do not seek—the interventions. Given the priority placed on outreach efforts, it is essential to establish a systematic methodology for evaluating recruitment procedures, sample demographics and treatment-seeking trajectories. Developing such a framework not only ensures consistent evaluation but also helps identify areas for improvement in engaging target populations.
This study presents data on the first group of immigrants seeking treatment in a clinical trial for posttraumatic stress disorder (PTSD), conducted within the MTG consortium. Specifically, the study aims to (1) evaluate outreach procedures and (2) examine the characteristics of the first treatment-seeking immigrants. These analyses will determine whether the recruitment strategies used effectively reach target populations and whether the treatments are accessible to diverse immigrant groups. Additionally, the study aims to (3) assess the feasibility of a proposed battery of outreach outcome variables, which includes factors such as country of birth, migrant status, type of migration (voluntary or forcibly displaced) and language proficiency. This approach will inform and optimise future recruitment strategies within the MTG consortium. Furthermore, it will facilitate the systematic assessment of demographic variables among treatment-seeking immigrants from diverse backgrounds and across various disorders in future clinical studies.
Method
Design
This PTSD trial (ClinicalTrials.gov ID: NCT06193161) is part of the MTG consortium of studies. It emanates from a larger randomised controlled trial (RCT) with a culturally inclusive internet-delivered PTSD treatment, presented in an easy-to-read English format and delivered with therapist support. Participants were randomised to either internet-delivered treatment for PTSD or a waitlist. Participants were recruited from the general population. The recruitment was not specifically targeted towards healthcare, so it is unlikely that participants were referred from the healthcare system. A large number of participants described difficulties accessing healthcare, and that they had received previous care however not specifically targeting PTSD. In this larger RCT, feasibility, acceptability and preliminary effects were reported through a nested pilot design.14 The current outreach study analysed treatment seeking data from the first 100 participants in the larger RCT. Given that outreach is a priority within the MTG consortium,12 the current pilot study analysed descriptive screening data and outreach methods, regardless of subsequent participants’ inclusion or exclusion in the PTSD trial. Given the focus on screening data, no formal inclusion or exclusion criteria were applied in the current study, other than being among the first 100 immigrants in Sweden to seek treatment. This study, including the publication of all screening data, was approved by the Regional Ethical Review Board (Dnr: 2024–06372-02).
Patient and public involvement statement
This study is part of a larger consortium of studies where the project group aims to have active collaboration with patient representatives for the study design and dissemination of results. In the current pilot study, these structures were not yet finalised. Results from the current study will be disseminated at the consortium’s official webpage (https://ki.se/en/cns/research/centre-for-psychiatry-research/mind-the-gap-increasing-access-to-mental-health-treatment-for-minority-populations). Study participants are familiar with this page, given that they were directed to it in the recruitment process.
Outreach procedures
Targeted advertisements
Recruitment was conducted through a community outreach campaign using social media platforms (Facebook and Instagram). Advertisements were aimed at individuals born outside Sweden who had experienced a traumatic event, continued to experience related distress and were interested in internet-based psychological treatment delivered in simplified English. The advertisements were designed to be culturally inclusive and were presented in easy-to-read English. No specific demographic targeting was applied with regard to gender, country of origin or age. Advertisements were displayed intermittently over a total of 6 days between 16 February 2024 and 27 August 2024. The digital campaign received 75 823 views and reached 45 545 users. It generated 1929 link clicks resulting in a high click-through rate of 2.54%. See online supplemental material 1 for an example advertisement.
Inclusive and accessible study page
Information about the treatment study was provided in easy-to-read English on an official recruitment website hosted by Karolinska Institutet. From this page, individuals registered via a secure platform where they first provided informed consent and then proceeded to an online screening process. The study webpage and screening page were accessible via both computers and devices such as smartphones.
Psychoeducative material
The recruitment page featured a 3-minute and 40-second video in easy-to-understand English. The video included an introduction by a clinical psychologist with expertise in PTSD (author MB; see online supplemental material 2). The video’s goals were: (a) to provide a welcoming introduction to the treatment and study, (b) to offer a ‘meeting’ with the expert and the principal investigator to discuss PTSD and (c) to present a ‘meeting’ with a fictitious patient to illustrate how symptoms may be experienced. The overall objective of the psychoeducational material was to help individuals understand and recognise PTSD symptoms, appreciate the breadth and diversity of the symptom profile and emphasise that evidence-based mental healthcare can be accessed digitally.
Measures
Outreach outcome battery
In this pilot study, feasibility was defined pragmatically as the successful collection, completeness and interpretability of a predefined battery of outreach variables during real-world recruitment. Formal psychometric evaluation or benchmarking against population-level data was outside the scope of the current study. The battery included items in multiple-choice, numeric or free-text formats and covered five domains: demographic properties, immigrant-related factors, treatment-relevant factors, recruitment procedure evaluation and common mental disorders (see table 1).
Table 1. Outreach outcome variables.
| Domain | Variables |
|---|---|
| Demographic properties | Including gender, civil and residence status, highest level of education, source of income and sick leave |
| Immigrant-related factors | Including country of birth, language proficiency, reasons for immigration, immigration status and years of residence in Sweden. |
| Treatment-relevant variables | Including previous or current psychological or pharmacological treatment for mental health issues. |
| Evaluation of recruitment procedures | How individuals learnt about the study, their reasons for joining and their evaluation of the study information and psychoeducational video on PTSD. |
| Indication of common mental disorders | Assessed using the Web Screening Questionnaire (WSQ; 22). The WSQ is a brief initial screening measure for identifying individuals who may require further assessment or intervention. It includes several DSM-5 mental health disorders, such as depression, anxiety disorders, PTSD, alcohol use disorder and panic disorder. The WSQ consists of nine items, each corresponding to key symptoms or symptom clusters of the targeted disorders. Individuals respond to each item with a binary ‘yes’ or ‘no’ which reduces completion time and improves accessibility for individuals completing the screening in various settings. A ‘yes’ response indicates the presence of a symptom or disorder that warrants further exploration and potentially more detailed follow-up assessments. |
DSM, The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5); PTSD, post-traumatic stress disorder.
Symptom severity
As part of applicant characteristics, self-reported symptoms of PTSD were assessed using the PTSD Checklist for The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (PCL-5).15 This measure evaluates the 20 PTSD symptoms outlined in the DSM-5, based on experiences over the past month, using a five-point Likert scale (0–4). Scores range from 0 to 80, with higher scores indicating greater symptom severity. A PCL-5 score ≥50 indicates severe PTSD.16 The PCL-5 has demonstrated high internal consistency (α=0.95) and strong test-retest reliability.15 16 This cut-off was used for descriptive purposes only and not as part of eligibility or screening procedures. Depressive symptoms were assessed using the Patient Health Questionnaire (PHQ-9),17 which aligns with DSM-IV criteria for major depressive disorder. Individuals indicated the frequency of specific depressive symptoms experienced over the past 2 weeks on a scale from ‘not at all’ to ‘nearly every day’ yielding a total score between 0 and 27. The PHQ-9 has shown robust psychometric properties.17
Statistical analysis and definition of voluntary and displaced migration
Descriptive statistics (frequencies, percentages, means, SD and ranges) were used to present the study results for the total sample, as well as separately for voluntary and forcibly displaced immigrants. The categorisation of immigrant subgroups was based on individuals’ reported reasons for migrating to Sweden, according to the International Organization for Migration’s definition of forced and voluntary migration.18 Individuals were classified as voluntary immigrants if they reported family, employment or economic motives for immigration. The term ‘forcibly displaced people’ was used to refer to individuals with a forced migration background, including refugees and asylum seekers. Those who indicated that they had moved to Sweden due to war, conflict, natural disasters or to escape intimate partner violence were categorised as forcibly displaced. Five participants reported reasons that did not fit predefined response options (eg, ‘abuse’, ‘earthquake in my home country’, ‘fleeing from family’, ‘refugee’ or ‘to start a new life and distance myself from my abuser’) and were classified as forcibly displaced migrants based on the underlying presence of coercion or threat.
Results
Outreach procedures
The first 100 immigrants applied to the study over a period of 193 days, resulting in an average rate of 3.6 treatment-seeking immigrants per week, or one individual every other day. However, due to clinical recruitment procedures, targeted social media advertisements were only displayed at brief intervals. The majority of immigrants (n=53) applied during the 8 days when advertisements were shown, resulting in an average rate of 6.6 individuals per day. Screening data indicated that most immigrants (82%) learnt about the study via social media (eg, advertisements), while 17% reported other sources, such as searching online for help, being recommended to the study by a significant other or learning about it through the media. Virtually all immigrants (98%) reported that they felt the study was relevant to their mental health situation when they first read about it.
A third of the sample reported having seen the psychoeducational video about PTSD, while 59% had not seen it and 8% were unsure. Among those who had viewed the video on the study recruitment page, the majority indicated that the psychoeducational content was applicable to their PTSD symptoms. Among those who had not seen the video, some reported being unable to locate it, while others stated that they did not feel the need to watch psychoeducational material related to PTSD.
Immigrants reached by the study
Among the first 100 treatment-seeking immigrants, the majority were women, middle-aged, highly educated, employed and held either a permanent residence permit or Swedish citizenship. Two-thirds of the sample were voluntary immigrants, while one-third were forcibly displaced people. In this study, the term ‘displaced people’ is used to refer to individuals with a migration background, including refugees and asylum seekers. The forcibly displaced and voluntary subgroups displayed similar demographic characteristics in terms of age, gender and years lived in Sweden. For voluntary immigrants, the most common residence status was Swedish citizenship, while forcibly displaced immigrants more often held temporary residence permits. Voluntary immigrants typically lived with a spouse/partner, while most forcibly displaced immigrants lived alone. Education levels were high across both groups, with most immigrants holding university degrees of 3 years or more. Lastly, full-time employment was more common among voluntary immigrants than forcibly displaced people, and a larger proportion of forcibly displaced immigrants were engaged in studies (see table 2).
Table 2. Demographic properties.
| Total sample (n=100) | Voluntary immigrants (n=68) | Forcibly displaced immigrants (n=32) | |
|---|---|---|---|
| Gender, n (%) | |||
| Male | 12 (12%) | 9 (13.2%) | 3 (9.4%) |
| Female | 84 (84%) | 55 (80.9%) | 29 (90.6%) |
| Other alternative | 4 (4%) | 4 (5.89%) | 0 (0%) |
| Age, mean (SD) | 39.0 (10.0) | 39.7 (9.4) | 37.4 (11.0) |
| Years lived in Sweden, mean (SD) (range) | 8.8 (8.3) (1–50) | 8.7 (6.8) (1–37) | 9.1 (10.9) (250) |
| Reasons for coming to Sweden, n (%)* | |||
| Family | 36 (36%) | 36 (52.9%) | 0 (0%) |
| Employment opportunities | 34 (34%) | 34 (50%) | 0 (0%) |
| War/conflict | 20 (20%) | 0 (0%) | 20 (62.5%) |
| Economic reasons | 8 (8%) | 7 (10.3%) | 1 (3.1%)† |
| Other‡ | 16 (16) | 4 (5.9%) | 12 (37.5%) |
| Residence status in Sweden, n (%) | |||
| Acquired Swedish citizenship | 41 (41%) | 32 (47.1%) | 9 (28.1%) |
| Permanent residence permit | 17 (17%) | 15 (22.1%) | 2 (6.3%) |
| Temporary residence permit | 34 (34%) | 21 (30.9%) | 13 (40.6%) |
| Refugee status | 7 (7%) | 0 (0%) | 7 (21.9%) |
| Asylum seeker | 1 (1%) | 0 (%) | 1 (3.1%) |
| Civil status, n (%) | |||
| Living with spouse/partner | 49 (49.0%) | 40 (59.7%) | 9 (27.3%) |
| Having children | 36 (36.0%) | 25 (37.3%) | 11 (33.3%) |
| Living alone | 35 (35.0%) | 21 (31.4%) | 14 (42.4%) |
| Living with another adult | 6 (6.0%) | 3 (4.5%) | 3 (9.1%) |
| Highest education, n (%) | |||
| Pre-high school education | 1 (1%) | 1 (1.5%) | 0 (0%) |
| High school education | 5 (5%) | 2 (2.9%) | 3 (9.4%) |
| Post-high school education, not university/college | 6 (6%) | 5 (7.3%) | 1 (3.1%) |
| University/college | 88 (88%) | 60 (88.2%) | 28 (87.5%) |
| Source of income, n (%) | |||
| Working full time | 39 (39%) | 31 (46.3%) | 8 (24.2%) |
| Working part time | 18 (18%) | 13 (19.4%) | 5 (15.2%) |
| Studies | 20 (20%) | 9 (13.4%) | 11 (33.3%) |
| Job seeker | 22 (22%) | 14 (20.9%) | 8 (24.2%) |
| Retired | 2 (2%) | 1 (20.9%) | 1 (3.0%) |
| Other§ | 17 (17%) | 14 (20.1%) | 3 (9.1%) |
| Sick-leave (part time or full time) | 12 (12%) | 9 (13.2%) | 3 (9.4%) |
Immigrants could report several reasons for migration.
One individual reported both wars and economic reasons, and was categorized as Forcibly displaced immigrant
Classification into voluntary and forcibly displaced migration was based on selfreported reasons for migration. All reasons involving violence, coercion, or lack of meaningful choice were classified as forcibly displaced migration, including responses originally reported under “other reasons.”
This category included various sources of income, for example contractual work or substitute, doctoral student, freelancing, starting own business, or self-employed.
Symptom severity and treatment experiences
Screening measures indicated a high symptom burden among both voluntary and forcibly displaced groups. Overall, nearly half of the sample exhibited severe levels of PTSD12 with a slightly higher prevalence among forcibly displaced immigrants compared with voluntary immigrants. Screened common mental health comorbidities were high in both groups, particularly anxiety disorders. In contrast, alcohol use disorder and suicidality were less frequently observed (see table 3).
Table 3. Symptom severity and screening of common mental disorders.
| Symptom severity | Total sample (n=100) | Voluntarily immigrant (n=68) | Forcibly displaced immigrant (n=32) |
|---|---|---|---|
| PTSD (PCL-5), mean (SD) | 47.9 (14.8) | 47.0 (14.0) | 49.9 (15.7) |
| ≥50, severe PTSD, n (%) | 44 (44.0%) | 27 (39.7%) | 17 (53.1%) |
| Depression (PHQ-9), mean (SD) | 14.6 (6.7) | 14.3 (6.5) | 15.3 (7.2) |
| Current common mental disorders (WSQ screener) | |||
| Number of disorders, mean (SD) | 3.8 (1.5) | 3.8 (1.6) | 3.7 (1.4) |
| Major depression, n (%) | 41 (41%) | 30 (44.8%) | 11 (33.3%) |
| Generalized Anxiety Disorder, n (%) | 63 (63%) | 41 (61.2%) | 22 (66.7%) |
| Panic disorder, n (%) | 71 (71%) | 45 (67.2%) | 26 (78.8%) |
| Specific phobia, n (%) | 83 (83%) | 60 (89.5%) | 23 (69.7%) |
| Social anxiety disorder, n (%) | 45 (45%) | 31 (46.3%) | 14 (42.4%) |
| Obsessive-compulsive disorder, n (%) | 69 (69%) | 48 (71.6%) | 21 (63.6%) |
| Alcohol use disorder, n (%) | 3 (3%) | 3 (4.5%) | 0 (0%) |
| Suicidality, n (%) | 0 (0%) | 0 (0%) | 0 (0%) |
PCL-5, PTSD Checklist for DSM-5; PHQ-9, Patient Health Questionnaire; PTSD, post-traumatic stress disorder; WSQ, Web Screening Questionnaire.
Most immigrants reported current (20.0%) or previous (56.0%) experiences with psychological treatment, with minimal differences observed between voluntary and forcibly displaced immigrants (20.6% and 18.8% for current treatment and 58.8% and 50.0% for previous treatment, respectively). The psychological treatments included a range of approaches, such as cognitive behavioural therapy, psychodynamic therapy, group therapy and supportive counselling. Additionally, 39% of the sample reported using medications for mental health issues, with similar proportions between voluntary and forcibly displaced immigrants (38.2% and 40.6%, respectively).
Country of birth
Immigrants reported their countries of birth as part of the baseline outreach outcome set. Overall, Europe was the most common continent of birth (49%), followed by Asia (23%), North America (11%), South America (9%), Africa (7%) and Oceania (1%). More specifically, the UK, the USA and Ukraine were the most frequently reported countries of birth (8%), followed by Germany and India (5%). Among voluntary immigrants, the UK, Germany, the USA and India were the most common countries of birth, while most forcibly displaced immigrants originated from Ukraine (due to the ongoing war) and the USA (due to factors such as abuse). See figure 1 for a full specification of countries of origin.
Figure 1. Country of birth.
Language proficiencies
Approximately one-third (28%) of the study sample reported English as their native language, while 72% indicated a different mother tongue, such as Spanish, Ukrainian, Arabic or German. Among both voluntary and forcibly displaced immigrants, English was the most common native language. For voluntary immigrants, Spanish and German followed English in frequency, while Ukrainian and Arabic were the most common non-English languages among forcibly displaced immigrants.
Immigrants also reported proficiency in languages beyond their native tongues. Nearly half (49%) of the total sample indicated proficiency in English, followed by Swedish (35%), French (6%) and German (6%). English and Swedish were the most frequently reported secondary languages among both immigrant subgroups, with some forcibly displaced immigrants also indicating knowledge of Russian. Figure 2 provides a detailed breakdown of specific languages by immigrant subgroup.
Figure 2. Languages. Note: Immigrants were able to report several proficient languages.
Discussion
This study evaluated outreach methods, analysed the characteristics of the first 100 treatment-seeking immigrants in a PTSD trial and assessed the feasibility of a proposed outreach outcome battery. By mapping a comprehensive set of background and mental health factors within the sample, the study aims to refine the methodology for future clinical studies within the MTG consortium.
The outreach procedures engaged a culturally diverse group, including both voluntary and forcibly displaced immigrants, within a short time. Notably, the study assessed the specific impact of targeted social media advertisements, leading to a nearly tenfold increase in treatment-seeking behaviour when the advertisements were active. Overall, the study results indicate that multimodal digital outreach strategies, particularly social media campaigns, are effective in engaging immigrant populations with mental health concerns on a large scale.
The use of easily readable English likely influenced the sample’s demographic characteristics, attracting immigrants proficient in English, including native speakers from English-speaking countries and highly educated immigrants from non-English-speaking countries. Although the study included participants from various countries, few were from African nations, about one in 10 were from Ukraine and very few were from Arabic-speaking countries. Both voluntary and forcibly displaced immigrants exhibited high symptom severity and reported prior treatment experiences. This suggests that the sample had some prior contact with the healthcare system. The unmet needs observed in the study may stem from a lack of accessible, trauma-focused PTSD treatment options within existing services.
The sample was not fully representative of Sweden’s immigrant population; immigrants from English-speaking countries constitute <1%, whereas the largest groups originate from Syria, Iraq, Finland, Poland, Iran, Afghanistan, Somalia and the former Republic of Yugoslavia.3 Future outreach studies should adopt more fine-grained comparative approaches that extend beyond native country of birth to assess external generalisability and better capture immigrant heterogeneity. While English serves as a unifying language for many immigrants, offering materials in other widely spoken languages, such as Arabic, Spanish, Ukrainian or French, could enhance inclusivity and improve access for a broader segment of the immigrant population. Reaching immigrant populations with lower socioeconomic status and educational levels remains a top priority in future clinical studies. Most immigrants in the study had lived in Sweden for 8–9 years and held permanent residence or citizenship. Expanding outreach to recently arrived immigrants is crucial, as mental health is influenced by migration reasons, resettlement and host country experiences. This could be enhanced through targeted multilingual advertisements and active involvement of local communities and networks.1
Assessing outreach at the screening level provides an objective measure of treatment-seeking behaviour, independent of clinical trial procedures such as exclusion criteria. Our proposed battery of outreach outcome variables included several key factors associated with immigrant mental health in high-income countries, such as age, gender, secure visa status, language proficiency and employment.1 Overall, the outreach outcome variables seemed to have identified key factors in immigrants who pursued PTSD treatment and identified groups that may face additional barriers, demonstrating promising feasibility.
However, additional factors require further assessment and incorporating these variables into the outreach outcome battery would enhance comparability across immigrant populations and studies: socioeconomic status (eg, income level),18 neighbourhood status (eg, postal code), psychosocial stressors19 and loneliness.20 Key MTG factors, such as stigma, health literacy and healthcare utilisation and barriers,12 should also be considered.
Conclusions
This outreach study successfully recruited immigrants from diverse cultural backgrounds despite targeting a highly educated population. The findings highlight the importance of tailoring and evaluating outreach methods as a standard practice to engage diverse immigrant populations in clinical studies.
Limitations and future directions
The sample may not fully represent the broader immigrant population with PTSD, as reliance on digital platforms and English materials likely excluded groups with limited access or proficiency. Moreover, the rate of participant recruitment was dependent on the initial assessment over telephone. The distinction between forcibly displaced and voluntary migration is often complex, involving diverse motivations and movement patterns and necessitating a nuanced approach to classification. The coding of forcibly displaced versus voluntary migration was based on several independent demographic variables, including free text answers, which could have introduced classification bias. Future outreach MTG studies should assess this within a single variable to improve accuracy. Only one-third of participants viewed the video at the study page, suggesting future studies could integrate psychoeducational videos during screening. The WSQ screened for common mental disorders but did not distinguish between overlapping conditions like PTSD and anxiety. A full diagnostic assessment, such as the DSM-5 Cultural Formulation Interview,21 could enhance understanding of prevalence and healthcare needs. Regarding the evaluation of outreach procedures, it should be noted that the study lacks a control group, and therefore the procedures used cannot be compared with a control condition. Randomisation to different recruitment procedures could be challenging, so a more reasonable way to track different methods in future studies could be through a ‘stepwise model’ where additional recruitment procedures are added over time and evaluated accordingly.
Future outreach studies should include a broader battery of outreach methods going beyond social media and digital advertisements to be able to reach community members in their everyday settings, for example, through the use of adverts in tube stations and posters or printed materials at churches, educational institutions, healthcare settings or support centres for immigrants to enhance inclusivity. In the current study, outreach procedures were evaluated descriptively. Future outreach studies should include formal and systematic criteria to evaluate outreach methods using different types of psychometric evaluations and relating our work to clear, theoretical frameworks.
Supplementary material
Acknowledgements
The authors would like to thank the participants in the study.
Footnotes
Funding: Study is financed by The Health and Medical Care Administration, Region Stockholm 2022–2024 and ALF medicine 2025 (FoUI-1002488) to PI Nitya Jayaram-Lindström. The funders had no role in the design of the study and interpretation of results.
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient consent for publication: Not applicable.
Ethics approval: This study involves human participants. This study, including the publication of all screening data, was approved by the Regional Ethical Review Board (Dnr: 2024-06372-02). Participants gave informed consent to participate in the study before taking part.
Patient and public involvement: Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.
Data availability statement
No data are available.
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