“It’s the modern way of doing things”: a qualitative study of user-experience, acceptability, and content validity of a digital mental health screener for refugees

Navigating mental health services in a new country presents a formidable challenge for displaced populations, who frequently experience heightened rates of psychological distress stemming from conflict, forced migration, and ongoing post-settlement stressors. To address systemic barriers such as language constraints, logistical hurdles, and the social stigma often associated with psychological care, researchers across Sweden developed an internet-based tiered assessment procedure, known as the i-TAP. Designed specifically to screen for common psychiatric symptoms—including depression, anxiety, post-traumatic stress disorder, and insomnia—among individuals with a refugee background, the tool dynamically adapts to user responses to reduce survey fatigue while maximizing clinical accuracy. Following initial psychometric validation across multiple languages, a comprehensive qualitative study was conducted to examine the user experience, acceptability, and content validity of the i-TAP from the perspective of the end-users themselves.

The findings from this qualitative investigation, which utilized semi-structured interviews with 71 adult participants residing in Sweden, offer critical insights into the intersection of digital health innovation and refugee welfare. Published in the academic literature, the study sheds light on how digital screening tools are received, where they succeed in capturing lived realities, and the essential operational prerequisites required before such technologies can be integrated into mainstream healthcare delivery.

Background and Context of the Refugee Mental Health Gap

Refugees face an accumulation of compounding stressors throughout their migration trajectories. Exposure to war, violence, and persecution in countries of origin is frequently followed by protracted ongoing stress during resettlement, such as long asylum evaluation processes, the issuance of short-term residence permits, underemployment, social isolation, and discrimination. Decades of public health research demonstrate that these cumulative pressures result in significantly elevated levels of psychiatric symptoms and disorders among refugees compared to general host populations.

Despite this disproportionate burden of psychological need, refugees remain consistently underrepresented in formal mental health systems. Access is routinely blocked by a complex array of supply- and demand-side barriers. On the demand side, patients frequently cite a lack of trust in institutions, fear of confidentiality breaches, difficulties navigating unfamiliar bureaucratic health frameworks, and deep-seated cultural stigmas surrounding mental illness. On the supply side, healthcare providers grapple with severe communication difficulties, a lack of culturally tailored diagnostic mechanisms, and restricted outreach capabilities.

Digital mental health interventions have increasingly been championed by global health experts as a scalable, cost-effective avenue to bridge this treatment gap. By decoupling initial assessments from rigid physical infrastructure, digital tools offer flexibility, cost reduction, and the capacity to deliver standardized evaluations in multiple native languages. The i-TAP was engineered directly in response to these demands, providing a tailored, adaptive screening procedure available in Arabic, Dari, Farsi, Swedish, and English.

Chronology and Methodology of the Qualitative Evaluation

The qualitative study was executed between June and October 2022 as part of the broader SAHA project—a collaborative multi-university research initiative involving Linköping University, Karolinska Institute, Stockholm University, and Mid Sweden University focusing on digital health solutions for refugees and migrants. Ethical approval for the protocol was granted by the Swedish Ethical Review Authority under reference number 2020-00214.

Data collection took place across diverse non-clinical settings throughout Sweden, including asylum housing facilities, adult education immigration centers, non-governmental organizations, and community language cafés. Recruitment relied on local community collaborators, personnel, and interpreters. To be eligible, participants were required to have a self-defined refugee background in accordance with the United Nations High Commissioner for Refugees (UNHCR) criteria, maintain literacy in one of the study languages, be at least 18 years of age, and currently reside in Sweden. Legal status was intentionally kept broad; the final cohort included individuals with permanent residence permits, temporary permits, and those currently awaiting a final decision on their asylum applications.

The final sample comprised 71 adult participants—32 females and 39 males—ranging in age from 19 to 69 years, with a mean age of 39.2 years. The cohort represented multiple nationalities, predominantly originating from Syria (35.2%), Afghanistan (26.8%), Iran (18.3%), and Palestine (7.0%), alongside smaller representation from Iraq, Eritrea, Tajikistan, Somalia, Sudan, and Kurdistan. Participants had resided in Sweden for varying durations, ranging from less than one year to over nine years.

Interviews were conducted in the participant’s preferred language, resulting in 31 sessions in Arabic, 14 in Dari, 15 in Farsi, and 11 in Swedish. Nearly half of the non-Swedish interviews utilized authorized professional healthcare interpreters bound by strict legal confidentiality, while the remainder were executed by bilingual clinical psychologists with personal migration or refugee backgrounds. The study protocol required each participant to complete a three-step procedure: filling out background questionnaires and the digital i-TAP screener, participating in a semi-structured interview regarding their user experience, and undergoing a standardized clinical assessment.

Key Findings on Content Validity, Usability, and Acceptability

Using inductive reflexive thematic analysis from a critical realist perspective, researchers synthesized the interview data into four principal themes and six subthemes, illuminating how end-users evaluate the tool’s relevance, accessibility, and functional utility.

Capturing What Matters—And Its Inherent Limitations

Participants widely reported that the i-TAP successfully captured core elements of psychological distress relevant to the refugee experience. Sleep disruption emerged as the single most frequently cited issue, with respondents emphasizing its fundamental connection to daily functioning, cognitive health, and overall well-being. Questions addressing pain, fatigue, anxiety, depression, and trauma history were viewed as appropriate and reflective of their daily realities.

However, participants noted clear boundaries regarding what a screening tool can achieve. Many expressed a strong desire to elaborate on their personal stories, noting that the survey failed to capture the full complexity of their lives. Specifically, respondents called for broader inquiry into post-migration determinants of health, such as employment status, income stability, housing, structural discrimination, social relationships, and family dynamics. Furthermore, several participants noted the complete absence of positively framed questions regarding personal strengths, future aspirations, or psychological resilience, highlighting that the screener focused exclusively on pathology.

A User-Friendly Digital Interface Dependent on Health Literacy

The usability of the i-TAP received overwhelmingly positive marks, with participants frequently describing the interface as intuitive, easy to navigate, and well-suited to the modern digital era. The digital format was praised for offering privacy and allowing respondents time for introspection at their own pace—an advantage over face-to-face questioning, which some found intimidating.

Despite these positive evaluations, researchers identified critical dependencies regarding literacy and language proficiency. While predefined response options streamlined completion for digitally literate users, others found the fixed choices restrictive and expressed a desire for free-text fields to nuance their answers. Moreover, while native-language availability was acknowledged as a crucial facilitator, variations in dialect—such as distinctions between Dari and Farsi—and limited formal educational backgrounds occasionally impaired comprehension, demonstrating that digital tools cannot completely bypass the foundational need for adequate health and language literacy.

Prospective Healthcare Implementation: Facilitator, Not a Replacement

When evaluating the prospective integration of the i-TAP into routine clinical workflows, participants expressed broad support. Many viewed pre-visit digital screening as a practical mechanism to save time during clinical consultations, allowing physicians and psychologists to understand baseline symptoms prior to the appointment and reducing the emotional burden of repetitive storytelling.

Nevertheless, participants drew a sharp boundary regarding the limits of digital automation. Respondents repeatedly emphasized that a computerized questionnaire must never replace genuine human interaction or a clinical care visit, particularly for individuals experiencing acute psychological distress. Crucially, participants conditioned their willingness to engage with the i-TAP on institutional follow-up: digital screening was deemed acceptable only if the data were actively reviewed by trained professionals and linked directly to tangible, accessible support services.

Emotional Resonance, Cultural Negotiation, and Trust

Completing the screener frequently evoked emotional responses, ranging from feelings of validation and comfort at being listened to, to painful recollections of past trauma and grief. Importantly, participants framed these emotional reactions not as a deterrent, but as a normal and meaningful part of self-reflection.

The study also mapped the complex interplay between cultural background and mental health stigma. While some participants noted that discussing psychological distress remains taboo in their countries of origin, many observed that the Swedish societal context fosters a normalized, safer environment for seeking psychological care. However, opening up was universally described as contingent upon establishing deep institutional trust. Participants voiced concerns regarding data privacy and the potential misuse of mental health records by extraneous authorities, underscoring that confidentiality and professional competence are absolute prerequisites for successful engagement.

Analysis of Implications for Digital Health Policy

The qualitative findings surrounding the i-TAP carry profound implications for the future implementation of e-health technologies in clinical practice. As healthcare systems across Europe grapple with systemic shortages in mental health staffing and growing migrant populations, digital self-assessment tools offer a viable mechanism to triage and streamline care delivery.

From a policy perspective, the high concurrent acceptability of the i-TAP proves that refugee populations are not inherently resistant to digital mental health interventions. On the contrary, when tools are linguistically tailored and culturally sensitive, users recognize their utility in expediting access to care. However, the study issues a clear cautionary note against the uncritical automation of healthcare. Digital screeners cannot operate in an administrative vacuum; their utility is strictly bound to the presence of responsive clinical infrastructure, transparent data governance, and trusted human-to-human medical relationships.

Future iterations of digital screening instruments must balance diagnostic efficiency with comprehensive person-centered care. Developers should consider incorporating optional open-ended text fields, modules addressing socioeconomic post-migration stressors, and balanced inquiries focusing on psychological resilience alongside symptom tracking. Furthermore, healthcare institutions deploying such tools must actively invest in building trust, verifying digital literacy, and ensuring that every patient who completes a digital assessment receives timely, compassionate follow-up from qualified healthcare professionals.