Integrated mental health for refugees: A realist theory building study

People with forced migration backgrounds, such as refugees, experience disproportionate mental health conditions related to complexities associated with acculturation, separation from family, traumatic events due to war or persecution and precarious journeys in their effort to find protection and care. Intersecting social determinants of refugee mental health include navigating and finding health care resources, employment, housing and social support. Because of the complexity of health and social needs that refuges experience, there is a need for robust integration of mental health services across services such as settlement organizations and primary health care services. Robust service integration to address mental health for refugees can benefit from a theory-driven approach to understanding integrated mental health service delivery. This study engaged in 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. Adopting a participatory realist approach, we developed an initial program theory on the integration of refugee mental health across services. We found trust, connection, proactivity and moral commitment to be key mechanisms that enabled better integrated mental health care across refugee clients, providers and services. Mechanisms which hindered integration included alienation, stagnation, burnout and fragmentation. Findings indicate that, when funding is allocated to settlement programs, supports like cross-cultural brokers, community health workers and navigators can then be implemented. These resources then address social determinants of refugee mental health and trigger positive mechanisms for equitable, just policy approaches to integrate services for refugee mental health.