Integrated Mental Health for Refugees: A Realist Theory Building Study

Background: People with forced migration backgrounds, such as refugees, experience disproportionate mental health challenges related to complexities associated with acculturation, traumatic events and separation. There is a need for robust integration of mental health services across settlement organisations and primary (mental) health services to meet this increasing demand. This presentation provides the findings of a realist theory building study to understand how integrated mental health care and services work for people who have experienced forced migration in a Canadian context.

 

Approach: This study engaged in a realist participatory knowledge approach through integrated knowledge translation by including knowledge of practitioners, policy makers, people with lived experience and the public. This was achieved through three knowledge translation activities: (1) an online realist workshop (2) a world café participatory event and (3) deliberative dialogues with multidisciplinary interest group holders from settlement services, primary health care, mental health, a survivor advocacy group and a policy analyst (N=24) to understand how services work to promote refugee mental health in a Canadian context. We combined the strengths of realist linked coding and realist thematic analysis to develop an initial program theory on how integrated mental health works (or not) across services.

 

Results: Our initial programme theory found several overarching contextual conditions in which refugee mental health services operate, including cultural and relational factors in refugee mental health care, a complex health and social system where individuals work in silos, organisational and workforce challenges and policy, funding and governance barriers. Across these contextual conditions, trust, connection, proactivity and moral commitment were found to be key mechanisms that enabled better integrated mental health care across refugee clients, providers and services.

 

On the other hand, mechanisms which hindered integration included alienation, stagnation, burnout and fragmentation. We shared these findings with our stakeholder group, who helped refine or challenge them to ensure the theory accurately reflected the reasoning and real-world expertise of refugee mental health users, providers, and services.

 

Implications: This research highlights that refugee mental health services are underfunded and in resource-constrained contexts, limiting access to appropriate integrated mental health care. Addressing this gap involved investment in nonclinical roles such as cross-cultural health brokers, school settlement workers and system navigators to promote trust, improve access and promote long-term mental health outcomes. Expanding resources and training across services would promote ethical, culturally responsive care, improve community-based care, while stronger collaboration between policymakers, health systems and service could reduce systemic barriers.