In total, 16 leadership and 17 frontline staff from 14 organizations participated in the study. Sample characteristics are summarized in Table
1. Most respondents (87.9%) were female, 55% were first-generation immigrants (i.e., born outside Canada), and 60% identified as racialized (i.e., not White or Caucasian). On average, respondents had 14 years of experience working on refugee/immigrant or health equity issues. Participants worked in a range of sectors, including settlement, child and youth services, health, and education.
Participants described multiple intersecting barriers that prevented newcomer children and families from accessing and benefiting from mental health supports, including barriers at the structural and systemic, provider, and individual and family levels. Participants also identified recommendations for addressing these barriers and reimagining mental health care for newcomer children and families. These themes and their sub-themes, as well as linkages among them, are summarized in Fig.
1 and described further below with supporting verbatim quotations provided in Supplementary Information. While the interview guide focused on Arabic-speaking newcomers, participants noted that their responses were relevant to all newcomers as well as members of racialized groups.
Barriers
Structural and systemic barriers
Participants described intersecting structural and systemic barriers to accessing mental health care: inadequate services and funding; complexity of systems; cultural tensions; and, lack of prevention and early identification. There was consensus that existing mental health services were inadequate to meet the level of need, resulting in long wait times and delays in diagnosis and intervention. While these were universal challenges affecting timely access to care among the general population, participants observed that newcomer children and youth were disproportionately affected due to their unique language needs, cultural background, pre-migration and settlement experiences, and related mental health concerns. Providers outside the health sector noted that they were not typically funded to provide mental health programming for newcomer clients and the funding they did receive was limited and unpredictable. Participants further reflected on how newcomers’ mental health concerns typically emerged after the first one to two years in Canada, just as funding for settlement supports was typically discontinued. Constraints in level and allocation of funding had negative impacts on service providers’ ability to recruit and retain staff and provide consistent, needs-based services for newcomer children and families.
Participants described current service delivery systems as rigid, complex, and difficult to navigate, particularly for non-English speaking newcomers who lack familiarity with the Canadian healthcare system. Information and service delivery was described as scattered and disconnected, and often provided in ways that were not sensitive to newcomers’ unique circumstances. For example, several providers observed how common practices such as sending notifications about mental health care appointments or referrals through a mailed letter in English did not consider the issues of language and housing instability experienced by many newcomer families. Participants observed how issues such as families not responding to referrals or showing up for appointments were often interpreted as lack of engagement rather than indications of systems that were not responsive to the needs of newcomers.
Participants critiqued existing mental healthcare models and interventions as “Western-centric,” overly “clinical and medical,” and not relevant or adapted to the socio-cultural and religious background, migration history, and settlement experiences of newcomers. In particular, several providers highlighted the disconnect between the collectivist and family-oriented cultures from which many newcomers originate, and the individualistic and biomedical paradigm that predominates in the Canadian healthcare system. Participants observed that this disconnect resulted in newcomer families feeling misunderstood, disrespected, or even in conflict with one another when suggestions given by mental health professionals to youth were perceived by caregivers as culturally inappropriate. Language and interpretation issues exacerbated these challenges and contributed to a sense of frustration among newcomer children and youth as they struggled to discuss mental health concerns in English or through an interpreter. Participants noted the limited funding and availability of skilled interpreters and the added challenge of translating nuanced mental health concepts in an accurate and culturally appropriate way. Several providers also described instances of how for racialized newcomers in particular, these structural barriers intersected with systemic and institutional racism to foster distrust and disengagement from the mental health care system.
Participants noted a glaring absence of preventive mental health interventions for newcomer children and youth – as one provider stated: “It’s either psychoeducation or like, 18 weeks of cognitive behavioral therapy” (KI29, female, leadership role in mental health sector). The lack of prevention-focused interventions hampered early identification of child and youth mental health difficulties, resulting in newcomer families accessing services only when they were in crisis. Discussion of these challenges led to broader questioning around what constituted mental health support and whose role or mandate it was to provide such support to newcomer children and families. Some participants equated mental health support with clinical interventions such as psychotherapy delivered by a licensed mental health professional, explaining that their own lack of clinical training and concerns about liability made them hesitant to address mental health issues. In practice, however, participants acknowledged that providers such as settlement workers, childcare providers, educators, and family doctors often worked with newcomer families experiencing mental health challenges without having access to appropriate funding, expertise, or resources.
Provider-level barriers
Provider-level barriers related to lack of representation, mental health knowledge and cultural competency, and staff shortages and burnout. Participants observed that the sociodemographic characteristics of mental health care providers did not reflect those of newcomer children and families with most providers being white, female, English speaking only, and having no lived experience of migration. Lack of diversity and representation was noted as a systemic issue at the policy and leadership levels all the way through to frontline service provision. Several participants stated that Canadian educational and certification requirements (e.g., graduate or post-graduate degree) for delivering mental health services were barriers to hiring more diverse staff, thereby limiting availability of services in families’ native language and reducing trust and engagement with the mental health care system.
Participants explained how culture, language, stigma, and experiences of migration and acculturation resulted in mental health being conceptualized and expressed differently by newcomer families, often in ways that were not understood by providers. As one participant noted, newcomers use “a different language than the DSM-5” to talk about mental health (KI1, male, leadership role in settlement sector). Providers who were not mental health professionals, such as settlement and youth workers, further reflected on how their own lack of knowledge and training limited their ability to identify potential mental health concerns and make appropriate referrals, with some describing themselves as “helpless” and afraid to “do the wrong thing.”
Participants described how the general lack of cultural competency in all service delivery systems – not only mental health – meant that they were constantly pulled into the role of “middle person” between newcomers and other service providers, contributing to a high level of staff burnout. Burnout appeared to be particularly acute among providers who identified as racialized and/or had lived experience of migration. While these characteristics contributed to increased trust and rapport with newcomer clients, racialized and immigrant-background providers described bearing a greater workload burden due to a personal sense of obligation as well as the limited number of staff with language and cultural competency. As one provider noted, “racialized people in mainstream agencies tend to do double or triple the work because our work doesn’t go from 9 to 5” (KI58, female, frontline staff in youth development sector). Staff burnout was further exacerbated by inadequate staffing, large caseloads, and the prolonged personal and professional impacts of the COVID-19 pandemic.
Individual and family-level barriers
Participants identified several individual and family-level barriers related to mental health literacy, primacy of settlement needs, stigma, fear, and a high threshold for help-seeking that influenced newcomer families’ demand for and access to mental health support. Lack of mental health literacy related to recognition and perceptions of mental health symptoms and knowledge of available supports was seen as a major impediment to help-seeking. Participants noted that newcomers’ material, financial, and other basic needs often took precedence over their mental health, and caregivers had little time or “emotional energy” to recognize and address their own or their children’s mental health concerns. Previous negative experiences with the healthcare system was identified as an additional barrier.
Participants emphasized the deep-seated stigma and fear associated with disclosing mental health concerns. For many newcomers of Middle Eastern and other ethnocultural backgrounds, the concept of mental health was often equated with being “crazy” and having a psychiatric illness that required hospital or clinic-based care. Participants described fears expressed by newcomer children and caregivers around potential negative repercussions of disclosing a mental health concern, such as the reaction of their family or community, impacts on their immigration status, and the risk of children being removed by child protection services. Younger children’s access to care may be particularly constrained due to their reliance on caregivers as gatekeepers to services. Participants observed how these individual- and family-level barriers intersect to result in newcomer families accessing care only when the child or youth is already in crisis.
Reimagining care
Participants’ recommendations for improving access to and quality of newcomer mental health care clustered around the following sub-themes: engagement; person- and family-centered care; cultural responsiveness; mental health promotion and prevention; workforce diversity and development; collaborative and integrated models of care; and, knowledge generation and uptake. Phrases such as “reimagining” care, “unlearning and relearning,” and “disrupting and dismantling the status quo” were used, indicative of a consensus that the current system was failing to address newcomers’ mental health needs. Providers noted that while “small pockets” of innovative practice existed, they were not “joined up” and progress was slow, patchwork-like, and incremental at best.
Engagement
First, participants emphasized the need to move away from ad hoc and tokenistic attempts at newcomer engagement towards a more robust, planned, and integrated mechanism for amplifying and listening to newcomer voices. Participants noted that newcomer engagement around their needs and preferences for support should take place at all levels – from client feedback to co-creation of programs and services to representation at policy and program planning fora. Several providers described examples of successful newcomer engagement strategies, such as the formation of newcomer youth committees to co-design program offerings and working with ethnocultural organizations to reach underserved groups. Respondents also noted, however, that truly impactful engagement was time and resource-intensive, and that most mainstream organizations were not designed or resourced to meaningfully integrate newcomer voices into program design and delivery.
Person- and family-centred care
Second, person- and family-centered and community-based care was seen as essential to improving access to and quality of mental health supports for newcomer children and families. The phrase “meeting people where they’re at” was frequently used as a metaphor for a fundamental shift in the model of care whereby systems and services adapt to the needs, priorities, and preferences of newcomer communities rather than the other way around. Participants described the need to meet newcomers where they are physically – in terms of where newcomers live, learn, and receive services – as well as psychologically – in terms of where they feel safe and a sense of trust and belonging. Embedding mental health supports in community settings such as schools and ethnocultural associations could reduce transportation barriers as well as alleviate stigma and mistrust by locating services in spaces where newcomer children and families feel safe with trusted providers or community members. Participants also highlighted the need for systems and services to embrace a family-centered approach to mental health given the collectivist and family-oriented societies from which many newcomers originate. For example, providers noted the importance of sensitively engaging parents in identifying and responding to newcomer children’s mental health needs to ensure that care does not clash with cultural values, thereby causing or exacerbating intergenerational conflict.
Cultural responsiveness
Third, participants highlighted the importance of cultural responsiveness, which they described as involving three interrelated components: first, practicing cultural humility and acknowledging the biases inherent in one’s own training, knowledge, and background; second, learning how cultural and religious background and the migration experience shape different conceptualizations and expressions of mental health; and third, learning to speak the “language of mental health” in a way that resonates with families from different ethnocultural and religious backgrounds. Some providers, for example, described using words such as “stress” or “pressure” to discuss mental health concerns rather than depression or anxiety, which in their experience had more negative connotations among newcomers. Other recommendations included more thoughtful and rigorous cultural adaptation of evidence-based mental health interventions to reflect newcomers’ lived experience, which may include experiences of trauma and displacement-related adversity. Some providers also suggested a “champion model” in which community members act as cultural brokers or interpreters who help newcomer families bridge communication gaps and navigate cultural differences. Several participants noted the untapped potential for ethnocultural organizations to play this role and called for greater funding and engagement of these small, typically informal groups by mainstream service providers.
Fourth, participants highlighted the need for greater investments in mental health promotion and prevention as part of the continuum of mental health supports for newcomer children and families. More focus on prevention could help to bolster protective resources, mitigate the effects of risk factors, and improve early identification and intervention, thereby relieving pressure on tertiary mental health services. Participants also described the need for a more holistic approach to mental health, with greater attention to mental health promotion and awareness raising in families, schools, and communities to normalize discussions of mental health and help-seeking. Youth-focused providers noted that overtly mental health-focused interventions can be stigmatizing and intimidating for children and youth, emphasizing the importance of engagement and trust-building through recreational activities such as sports or creative arts. Creation of more youth-friendly “safe spaces” would provide an entry point for newcomer children and youth to discuss mental health issues and be connected to further support if needed. Participants recommended building capacity for “mainstreaming” mental health promotion and prevention activities as integral components of all programs and services that serve newcomer families – regardless of sector – as well as piloting preventive interventions that are tailored to the strengths and challenges of newcomer families and communities.
Workforce diversity and development
Fifth, participants discussed the need to “change the face” of mental health care by hiring and retaining a more racially and culturally diverse workforce that better reflects newcomer communities. In addition, they recommended more learning and peer support opportunities for staff – particularly those working in non-health sectors – to increase their cultural competency and ability to identify and refer newcomers with mental health concerns to available supports. Some providers went further to state that it was “time to decentralize” the workforce and train “different types of mental health workers” (KI18, male, leadership role in youth development sector). Specific suggestions included the mobilization of peer support workers to enhance service delivery and reach, thereby leveraging existing knowledge, language skills, and trust to support their own communities. Several participants, however, cautioned that mental health was a regulated profession to ensure duty of care and client safety, and emphasized the need for clearly defined roles and appropriate training, supervision, and accountability structures.
Collaborative and integrated care
Sixth, participants advocated for new models of collaborative and integrated care to improve service access and address social determinants of newcomer mental health [
24]. Specific suggestions included a holistic and multi-sectoral approach in which mental health services are embedded and co-located with settlement and other social services to simplify service navigation as well as address material and social conditions that may increase risk of poor mental health. Participants noted that this integrated approach to service delivery would require a shift from existing referral and coordination mechanisms towards more collaborative, cross-sectoral, and interdisciplinary models of care. Some providers, however, also expressed concerns around potential ‘role creep’ and ensuring that mental health professionals were not being diverted away from clinical work to provide case management or settlement services.
Knowledge generation and uptake
Finally, participants called for more effective knowledge generation and uptake to inform improvements in program design, implementation, and evaluation. Participants noted the need for systematic and long-term data collection and monitoring to identify patterns in newcomer mental health and service utilization that could inform service delivery and planning. As noted above, cultural considerations should be embedded in research and evaluation activities, particularly when adapting and contextualizing mental health assessments. Participants further emphasized the importance of translational and applied research so that findings can be communicated back to provider and newcomer communities to co-develop, test, and scale up interventions. Several providers also noted the need for more concerted efforts to learn from innovative practices in other parts of Canada and around the world, and to partner with researchers and newcomer communities to co-create and pilot new models of care.