Lead authors:

Dr. Nancy Clark, Associate Professor, School of Nursing, University of Victoria, British Columbia

Alejandro Argüelles Bullón, Graduate Mental Health Researcher and PhD Student, Division of Health Research, Lancaster University, UK

Lead collaborators:

Mita Huq (Graduate Researcher, Department of Global Health, University College London, London, UK

Ferdinand C. Mukumbang, Associate Professor, Department of Global Health, University of Washington, Seattle, USA

Location:

British Columbia, Canada

Background

Refugees experience disproportionate mental health challenges shaped not only by trauma and displacement, but also by post-migration realities like housing, employment, social support, language access, and navigating complex systems. The authors argue that because refugee needs span health and social services, mental health supports must be integrated across sectors, especially settlement services and primary health care.

To understand how integration works (or doesn’t), the research team used a participatory realist approach and held “deliberative dialogues” with 24 interest group holders across settlement services, community health, a specialized refugee primary care clinic, a mental health organization, a survivor advocacy group (lived experience), and a health policy analyst.

Findings

Rather than producing a single explanation, the study theorised its findings into four interrelated mini theories, each linked to a distinct contextual condition. Together, these mini theories explain how different system environments trigger mechanisms that either support or undermine integrated care.

The first mini-theory centres on trust-building in culturally responsive contexts. In contexts where services are culturally safe, linguistically accessible, and relationally consistent, refugees are more likely to feel understood and respected. This context activates trust as a mechanism, which in turn increases engagement, continuity, and willingness to seek and remain in care. When these conditions are absent, mistrust and alienation follow.

The second mini theory focuses on connection within coordinated service environments. When organizations are connected through navigators, cultural brokers, volunteers, and informal cross-sector relationships, clients experience smoother pathways and fewer handoff failures. In these contexts, a sense of connection, both interpersonal and inter-organizational, enables services to function as a network rather than isolated programs. Where such coordination is weak, care stagnates and client's cycle between disconnected services.

The third mini theory examines proactivity under supportive leadership and policy conditions. In systems where leaders and funders prioritize prevention, collaboration, and information-sharing, providers can anticipate needs rather than respond only in crisis. This proactive orientation supports earlier intervention, better coordination, and more efficient use of resources. Conversely, reactive and crisis-driven systems limit integration and increase pressure on frontline staff.

Together, these four mini theories show that integration is not a single intervention but an outcome shaped by context. Trust, connection, proactivity, and moral commitment operate differently depending on system conditions, producing either coordinated care or fragmentation.

How does this research apply to my work?

For settlement and social service workers, this research validates that relational work, (i.e., warm handoffs, trust-building, and consistent engagement), is not ancillary but central to refugee mental health care. It provides language to explain why clients may disengage from services, shifting the focus away from individual “non-compliance” toward system-level barriers. For health care providers, the study reinforces that culturally safe, integrated approaches are essential to effective care and that continuity matters deeply for refugee populations. Organizational leaders can use these findings to better understand why frontline burnout and system fragmentation directly undermine mental health outcomes.

What should I take away from this research?

At the practice level, the key takeaway is that integration happens through relationships, across sectors and services, not just referrals. Building trust, reducing system delays, and supporting connector roles such as through cross cultural brokering or community health works can also significantly improve engagement and outcomes. At the organizational and policy level, the study highlights the urgent need to invest in workforce capacity, fund navigator and cultural broker roles, and align mandates across sectors that are explicitly focused on healthcare equity. Relying on frontline workers’ moral commitment without structural support leads to burnout and fragile systems. Integrated refugee mental health care requires intentional design, sustained investment, and cross-sector collaboration.