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. 2025 Apr 15;20(4):e0319743. doi: 10.1371/journal.pone.0319743

Experiences of immigrants when accessing mental health services and psychosocial supports in Canada: Protocol for a scoping review

Temitayo Sodunke 1, Gerald Agyapong-Opoku 1, Omolayo Anjorin 2, Belinda Agyapong 3, Mutiat Sulyman 4, Sanjana Sridharan 4, Somtoo Rita Henry 5, Ejemai Eboreime 2,4,*
Editor: Nancy Clark6
PMCID: PMC11999126  PMID: 40233090

Abstract

In Canada, the mental health needs of immigrants from diverse ethnic backgrounds are a growing concern, as they are at a higher risk for adverse mental health outcomes compared to native-born Canadians. These challenges are often driven by stressors experienced both before and after their settlement. The limited research on immigrant experiences in accessing mental health and psychosocial support highlights the need for our study. Compounding this gap, existing data reveal significant challenges immigrants face in accessing mental health services. Therefore, to better understand and address the needs of Canada’s immigrant population, we are conducting a scoping review to identify and synthesize the existing literature on immigrants’ experiences when accessing mental health services and psychosocial support. This scoping review will follow the methodological framework outlined by Arksey and O’Malley and complimented by Joanna Briggs Institute guidelines, as well as the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping review. To ensure intercoder reliability (ICR), the team will conduct a calibration exercise before initiating the screening process. This will involve an independent screening by all reviewers followed by a team discussion to resolve any discrepancies and clarify the application of inclusion/exclusion criteria. All stages of the selection process will be conducted using Covidence, a web-based software platform designed to support systematic reviews. Our analysis will involve both quantitative and qualitative approaches to align with the nature of the included articles and address our research questions. By synthesizing the current state of knowledge, identifying gaps, and highlighting potential solutions, this protocol aims to contribute to the ongoing crucial efforts to improve mental health outcomes for Canada’s immigrant population.

Introduction

Recent trends have identified globalization, political instability, climate change, and advancement in transportation and communication technologies as drivers of the heightened migration patterns of many individuals across the globe [1]. In Canada, over 200,000 immigrants are welcomed annually, and their major roots stem from the Asian and African continents [2,3]. According to reports, the mental health needs of immigrants from diverse backgrounds remain concerning as they are at a higher risk of adverse mental health outcomes often caused by stressors before, during and after their settlement journey [2,4]. A noteworthy concept often termed the ‘healthy immigrant effect’ is a view held by most scholars. It is believed that although immigrants arrive in Canada with a higher level of physical and mental health status compared with native-born Canadians, after immigration, this state of health declines rapidly depending on the contextual stressors and support available for this group, and this includes mental health [1,2,5,6]. A review of four major national health surveys, from the 1996 NPHS Cycle 2 to the 2005 CCHS Cycle 3.1, the healthy immigrant effect was evident in data showing consistently lower rates of depression, alcohol dependence, and self-rated mental health issues, as compared to the general population [6,7]. Furthermore, this deterioration in health status has been attributable to immigration and settlement stressors as well as experiences of racialization and discrimination among these immigrants [2,8]. Research indicates that various barriers—including religion, language, geographic location, financial insecurity, systemic discrimination, racism, and cultural or social factors—are associated with multiple challenges. These challenges result in limited access to mental healthcare compared to other Canadians, largely due to a lack of cultural competency among mental health providers, as well as stigma and misconceptions about mental health within immigrant communities [1,2,9,10]. As the WHO (2014) emphasizes, racialized immigrants in Canada face compounded disadvantages due to barriers in accessing mental health services. These barriers, including language, discrimination, and lack of culturally competent care, significantly hinder their ability to seek or receive appropriate support, thus placing them at a greater disadvantage compared to other Canadians [2,10,11]. Furthermore, the need for accessible, culturally sensitive care is critical across all age groups to ensure the well-being of this diverse population, as mental health is a cornerstone of overall health and integration into Canadian society [2]. Without equitable access to such services, immigrants are disproportionately affected by unmet mental health needs, underscoring the importance of addressing these gaps for improved health outcomes.

Similarly, improving access to mental health services for diverse communities is a key component of the Mental Health Commission’s 2016 strategic direction. Meeting the needs of Immigrant, Refugee, Ethnocultural, and Racialized (IRER) populations has become an urgent priority for Canada’s mental health system and its service providers [5]. However, immigrants from diverse ethnic groups across the country still face significant challenges in accessing mental health services [5]. For example, the detrimental effect of mental ill health on immigrants have been associated with difficulties around unemployment, depression, precarious employment conditions, linguistic barriers, low self-esteem [12,13]. Additional difficulties include navigating the Canadian education system (e.g., different learning styles and approaches, bullying and inability to build friendships,) family tensions, income security among others [12,13].

Research suggests that limited access to mental healthcare is another likely explanation for how new immigrants in Canada perceive mental health and their use of related services [2,8,14,15]. This has resulted from barriers like stigma around mental illness, language barriers, cultural interpretations of the condition, lack of knowledge on existing healthcare services, and individual’s understanding of accessing services [1,16]. In corroboration with earlier viewpoints on the hindrances that could pose a threat to immigrants’ access and utilization of mental health services, cultural and religious beliefs, as well as a stigma by these individuals themselves, tend to influence their mental health seeking behaviour [16–18]. The most obvious theme to emerge from these findings demonstrates that a standardized, uniform, and non-targeted approach to mental health care is often inadequate. Such approaches, which lack cultural competence, may fail to address the diverse needs of linguistically and ethnically varied immigrant groups in Canada. Interestingly, immigrants’ perspectives on mental health, cultural and religious beliefs, and stigma are often identifiable as influential to their mental health seeking behaviour (Chaze et al., 2015; Gopalkrishnan, 2018). Borque’s (2011) study also emphasizes that even though this population is resilient, extremely resourceful, and highly adaptable in the face of adversity, poor mental health outcomes have been documented for them globally [19]. Therefore, to better address the needs of the immigrant population within Canada, this scoping review is set to map out the scope of literature available on the experiences of immigrants while accessing mental health services and psychosocial support that is obtainable.

Justification statement

This review holds particular significance as it draws on the lived experiences of its authors, all of whom are landed immigrants working within the healthcare sector. Despite their professional expertise and familiarity with the Canadian healthcare system, they continue to face substantial barriers in accessing mental health care.

Canada has a rich history of immigration, with millions of individuals from across the globe choosing the country as their new home. As of 2021, over 8.3 million people—approximately one-quarter (23.0%) of the population—were or had ever been landed immigrants or permanent residents, marking the highest proportion since Confederation [20]. This figure surpassed the previous 1921 record of 22.3% and represents the largest immigrant population among the G7 nations [20]. Given that 23% of Canada’s population is comprised of immigrants and continues to grow, it is essential to examine the unique barriers and facilitators that affect their access to mental health care [20].

While the healthcare system aims for equity and inclusivity, the ongoing challenges faced by immigrants reveal critical gaps that need to be addressed. This review aims to synthesize existing literature and offer evidence-based recommendations for developing a more equitable and culturally responsive mental health system that meets the needs of Canada’s diverse population.

Research Questions

We aim to answer the following questions:

  1. What are the experiences of immigrants when accessing mental health services and psychosocial support in Canada?

  2. What are the barriers and enablers for access to mental health services and psychosocial support by immigrants in Canada?

  3. What recommendations have been made in the literature for improving access to and experiences with mental health services and psychosocial support for immigrants in Canada?

Methods

This scoping review will follow the methodological framework outlined by Arksey and O’Malley [21] and complimented with Joanna Briggs Institute, as well as the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews see Prisma P S1 Table [22–24]. The five stages of Arksey and O’Malley’s approach will guide our process: identifying the research questions, identifying relevant articles, study selection, charting the data, and collating, summarizing, and reporting the results [21].

Search strategy

We will conduct a comprehensive search of the following electronic databases: MEDLINE (Ovid MEDLINE ALL), EMBASE (Ovid interface), CINAHL (EBSCOhost interface), PsycINFO (Ovid), Social Work Abstracts (EBSCOhost), SocINDEX (EBSCOhost), Web of Science Core Collection, and Scopus (Elsevier). These databases were selected to ensure comprehensive coverage of medical, health, nursing, allied health, and broader scientific fields relevant to our research questions.

The search strategy will be developed in consultation with a health sciences librarian and will include a combination of subject headings and keywords related to the following concepts: immigrants, mental health services, psychosocial support, and Canada. The search strategy is developed and will be implemented by the authors. The search will be limited to English-language peer-reviewed and no timeframe.

A draft search strategy developed by the authors and in consultation with the health librarian for MEDLINE is provided S2 Table. This strategy will be adapted for use in other databases S3, with database-specific subject headings used where available.

Study selection

Inclusion criteria

  1. Articles will be eligible for inclusion if they meet the following criteria:

  2. Focus on first generational immigrants- refugees, newcomers (permanent residents (including people who have received “approval-in-principle” from Immigration, Refugees and Citizenship Canada to stay in Canada)) [25], refugees (protected persons), temporary residents (including student, worker, or temporary resident permit holders, or asylum seekers living in Canada

  3. Address access to mental health services and/or psychosocial support

  4. Evaluate barriers and/or enablers to accessing these services

  5. Are original peer-reviewed journal articles using quantitative, qualitative, or mixed methods, case studies and grey literature

  6. Are specific to the Canadian context

Exclusion criteria

We will exclude:

  1. Systematic reviews, meta-analyses, interventional articles, commentaries, editorials, opinion pieces

  2. Articles that do not focus on mental health conditions

  3. Articles with non-immigrant or local migration (in-country) populations

  4. Non-peer-reviewed articles, graduate student theses, and conference reports

The study selection process will be conducted in two stages:

  1. Title and Abstract Screening: Three independent reviewers will screen all titles and abstracts against the inclusion and exclusion criteria. Any disagreements will be resolved through discussion, with a fourth reviewer consulted if necessary.

  2. Full-Text Review: Two independent reviewers will assess the full texts of potentially eligible articles. Disagreements will be resolved through discussion or consultation with a third reviewer.

To ensure intercoder reliability (ICR), the team will conduct a calibration exercise before initiating the screening process. This will involve all reviewers independently coding a random sample of 50 titles and abstracts as a pilot test. Intercoder reliability will be assessed using an appropriate ICR metric (e.g., Cohen’s kappa or Krippendorff’s alpha), followed by a team discussion to resolve discrepancies and refine the application of inclusion/exclusion criteria [26].

All stages of the selection process will be conducted using Covidence, a web-based software platform designed to support systematic reviews [27]. This will facilitate the removal of duplicates and the independent screening of titles, abstracts, and full texts.

Data extraction

A standardized data extraction form will be developed in Microsoft Excel to capture relevant information from the included articles. Two reviewers will independently extract data from each included study. The extraction form will capture the following information:

  1. Study characteristics (e.g., authors, publication year, study design, objectives)

  2. Population characteristics (e.g., sample size, age range, gender, ethnicity, immigration status)

  3. Mental health characteristics (e.g., specific conditions, comorbidities)

  4. Service access and utilization details

  5. Key findings related to experiences, barriers, and enablers of access

  6. Recommendations for improving access and experiences

The complete data extraction form is provided as S1 Table

To ensure intercoder reliability (ICR) during data extraction, a random sample of 20% of the included articles will be independently coded by both reviewers. Intercoder agreement will be assessed using Cohen’s kappa coefficient, with a target reliability threshold of 0.8 or higher. Any discrepancies will be resolved through discussion or, if needed, consultation with a third reviewer

Data analysis

Our analysis will involve both quantitative and qualitative approaches to align with the nature of the included articles and address our research questions.

Quantitative Analysis: We will use descriptive statistics to summarize the characteristics of the included articles, such as publication year, study design, sample size, and geographic location. Tables and charts will be created to visually represent the distribution of articles across key variables, including types of mental health services accessed, prevalence of specific barriers and enablers, and frequency of different recommendations.

Qualitative Analysis: We will use thematic analysis to synthesize findings from qualitative articles and the qualitative components of mixed-methods articles [28]. This will involve an iterative process of coding the data, identifying patterns and themes, and developing a thematic framework that captures key aspects of immigrants’ experiences, barriers and enablers to access, and recommendations for improvement. We will follow Braun and Clarke’s six-step process for thematic analysis (23).

Integration of Findings: We will integrate the quantitative and qualitative findings to provide an equity-focused synthesis of the literature. This process will involve identifying convergent and divergent findings and developing a conceptual framework that highlights the systemic and contextual factors shaping immigrants’ equitable access to and experiences with mental health services and psychosocial supports in Canada. The framework will address systemic factors like health policies, healthcare infrastructure, and legal barriers to service access. It will also explore contextual factors such as cultural competence, social support networks, and language barriers. Psychosocial and cultural factors, including acculturation stress, stigma, and trauma, will be considered, along with equity issues related to disparities in access and outcomes for immigrants, especially those from marginalized groups. Lastly, we will synthesize the quantitative and qualitative findings to provide a comprehensive understanding of barriers and solutions to improve immigrants’ equitable access to mental health services.

Throughout the analysis process, regular meetings will be held among team members to discuss progress, resolve discrepancies, and ensure consistency in the application of analysis methods. We will keep detailed records of our analysis process, including coding schemes and theme development, to ensure transparency and reproducibility.

Consultation with Stakeholders: To enhance the validity and relevance of our findings, we will consult with specific key stakeholders, including immigrant community leaders (e.g., heads of local immigrant organizations), mental health service providers (e.g., clinicians, counselors, social workers working with immigrant populations), and policymakers (e.g., public health officials and government representatives at the municipal and provincial levels). The consultation will take place after the initial analysis of findings and will involve presenting a summary of preliminary results to stakeholders for their feedback. This consultation will be conducted online through Microsoft Teams and Outlook to increase accessibility, ensuring that stakeholders from diverse geographic locations can participate. Their input will be gathered through structured discussions and surveys, allowing them to share insights and experiences that will inform the refinement of our findings and contribute to the development of targeted recommendations for practice and polices

Ethics and dissemination

As this scoping review will only include published literature and will not involve human participants, ethics approval is not required. The results of this review will be disseminated through publication in a peer-reviewed journal, presentation at relevant conferences, and sharing with key stakeholders in the immigrant health and mental health sectors.

Results

The results of this scoping review will be presented in accordance with the PRISMA-ScR guidelines (20,21), offering a comprehensive overview of the literature on immigrants’ experiences with mental health services and psychosocial supports in Canada. Our presentation will be structured to provide a clear and detailed synthesis of the findings.

We will begin by describing the study selection process through a PRISMA flow diagram, which will illustrate the number of articles identified, screened, assessed for eligibility, and ultimately included in the review. This visual representation will be accompanied by a narrative description of the search results, including the total number of articles screened and the primary reasons for exclusion at the full-text review stage.

Following this, we will present a detailed descriptive summary of the characteristics of included articles. This summary will encompass publication trends over the 2014–2024 period, the distribution of study designs, and the geographic representation across Canadian provinces and territories. We will also describe the range of sample sizes and participant characteristics, including age ranges, gender distribution, countries of origin, immigration statuses, and length of time in Canada. Additionally, we will outline the types of mental health services and psychosocial supports addressed in the literature. To enhance clarity and highlight patterns, this information will be synthesized in tables and visualized through charts and graphs.

Our analysis of immigrants’ experiences will be presented thematically, focusing on access pathways to mental health services, the quality and cultural appropriateness of services received, interactions with healthcare providers, and the impact of services on mental health outcomes. To provide rich, contextual data, we will incorporate illustrative quotes from qualitative articles. Any quantitative measures of experiences, such as satisfaction ratings or service utilization rates, will be summarized and, where possible, presented in comparative tables or graphs.

The review will then delve into a comprehensive analysis of barriers and enablers to accessing mental health services and psychosocial supports. We will describe the prevalence of specific barriers and enablers across articles, categorizing these factors into themes such as cultural, linguistic, socioeconomic, and structural. Our analysis will explore how these barriers and enablers differ across immigrant subgroups or types of mental health services, as well as examining the intersectionality of various factors such as gender, age, or education level with immigrant status.

In synthesizing recommendations for improvement, we will categorize suggestions thematically, discussing policy changes, service delivery modifications, and cultural competency training, among others. We will highlight frequently cited recommendations as well as those that are particularly innovative or evidence based. Our discussion will include an assessment of the feasibility and potential impact of key recommendations.

Based on our synthesis of findings, we will develop and present a conceptual framework illustrating the key factors influencing immigrants’ access to and experiences with mental health services and psychosocial supports in Canada. This framework will visually represent the interrelationships between experiences, barriers, enablers, and recommendations, accompanied by a detailed narrative explanation.

Our analysis will also critically examine gaps in the current literature, including underrepresented immigrant populations or geographic areas, understudied types of mental health services or interventions, and methodological limitations in existing research.

Finally, we will provide a balanced assessment of the strengths and limitations of both the included articles and our scoping review methodology. This will include a discussion of potential biases in the literature and our review process, as well as the implications of these factors for interpreting and applying the findings.

Discussion

This scoping review maps the literature on immigrants’ experiences accessing mental health services and psychosocial support in Canada. It aims to highlight key challenges and factors, including the “healthy immigrant effect,” where immigrants’ health, including mental health, declines over time [1,2,6,29]. We expect our findings to synthesize literature on barriers immigrants face in accessing mental health care, including language, cultural differences, stigma, lack of awareness, and systemic discrimination [1,2,9,10]. Our review may identify how barriers vary across subgroups or regions and how factors like gender or socioeconomic status interact with immigrant status. It will also highlight enablers and strategies to improve access, such as culturally adapted interventions, language-concordant care, and community-based support. These findings could guide best practices and policy development, aligning with the Mental Health Commission’s strategic directions, and reveal emerging trends to improve access and outcomes for immigrant populations [30].

This review’s focus on Canada’s unique healthcare system and immigrant demographics allows for targeted recommendations, though findings may not be generalizable to other countries. Future research could compare different national contexts. The inclusion of both quantitative and qualitative studies offers a comprehensive view of immigrants’ experiences, aligning with calls for culturally sensitive research in immigrant mental health. (15,16). It may also help bridge the gap between statistical trends and individual narratives, providing a more holistic picture of the immigrant experience with mental health services.

Our findings on the experiences of immigrant families navigating mental health services may provide insights into the cascading effects of mental health challenges on education, employment, and social integration (11,12). This review may highlight the need for early intervention and support beyond clinical settings, emphasizing school-based programs, community outreach, and family-centered approaches for immigrant populations. It could also identify gaps in research, such as a lack of studies on specific subgroups or mental health conditions, guiding future priorities and promoting participatory research.

The conceptual framework developed could guide multi-level interventions, though further research is needed to validate it. Publication bias and the focus on peer-reviewed English literature in Canada may limit the range of perspectives. In conclusion, this review aims to advance understanding of immigrant experiences with mental health services in Canada, inform policy, practice, and research, and contribute to a more equitable mental health system for all Canadians.

Supporting Information

S1 Table. This is the S1 Table 1 Prisma-P.

(DOCX)

pone.0319743.s001.docx (21.1KB, docx)
S2 Table. This is the S2Information Draft Strategy for Medline.

(DOCX)

pone.0319743.s002.docx (16.7KB, docx)
S3 File. This is the draft search strategy.

(DOCX)

pone.0319743.s003.docx (17.2KB, docx)

Acknowledgments

The authors would like to thank Melissa Rothfus, Health Sciences Librarian at Dalhousie University’s Kellogg Library, for her invaluable assistance in developing the search strategy for this study. Her expertise and guidance were instrumental in ensuring a comprehensive and rigorous approach to the literature search.

Data Availability

All relevant data are within the paper and its Supporting Information files.

Funding Statement

Eboreime E. This work was funded by the QEII Foundation Translating Research into Care (TRIC) Award 1029792. The funders played no role in the study design, data collection, data extraction, results, and discussion. https://qe2foundation.ca/qeii-health-sciences-centre-staff/grants-health-centre-staff-physicians/translating-research-care-tric-grant-program

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Decision Letter 0

Nancy Clark

13 Jan 2025

PONE-D-24-44279Towards Equitable Mental Health Care: A Scoping Review Protocol on Immigrant Experiences in CanadaPLOS ONE

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This work was funded by a QE II Foundation Translating Research into Care (TRIC) grant awarded to EE (Grant number 1029792). The funders played no role in the study design, decisions to publish or preparation of the manuscript.

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Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows: 

Eboreime E. 

This work was funded by the QEII Foundation Translating Research into Care (TRIC) Award 1029792. The funders played no role in the study design, data collection, data extraction, results, and discussion.

https://qe2foundation.ca/qeii-health-sciences-centre-staff/grants-health-centre-staff-physicians/translating-research-care-tric-grant-program

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

3. Please provide a complete Data Availability Statement in the submission form, ensuring you include all necessary access information or a reason for why you are unable to make your data freely accessible. If your research concerns only data provided within your submission, please write "All data are in the manuscript and/or supporting information files" as your Data Availability Statement.

4. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

Additional Editor Comments :

Dear authors, we have received all required reviewers, and we recommend major revisions to address reviewer's comments. Please note that if there are comments you disagree with, please provide a rationale. We invite you to re submit your manuscript once you have attended to the recommendations.

There are some additional comments I would like to make regarding updating references.

1. For example, reference to mental health commission of Canada strategies see 2016 vs 2009 line 71. https://www.mentalhealthcommission.ca/wp-content/uploads/drupal/2016-10/case_for_diversity_oct_2016_eng.pdf

2. Please also clarify what is meant related to intergenerational stress throughout you make reference to youth however is the scoping review focused on all ages or youth only?

3. Also, if the scope of the review is to understand immigrant's experiences of mental health services and address their needs; would you consider explaining if and why people with lived experience are or are not included in the review? I would recommend explaining also inclusion criteria related to who are newcomers? e.g. are refugees included as a subcategory see line 133, because their experiences maybe different in terms of equity?

4. The overall focus on experience, it is not clear why quantitative studies will also be included unless you are focusing on structural issues related to health outcomes? This could be addressed in the ethics section.

5. I appreciate the inclusion of inter-rater reliability however it is a quantitative method you may want to consider intercoder ICR reliability but that is up to you line 158 see article by O'Connor: https://journals.sagepub.com/doi/full/10.1177/1609406919899220

6. p.9 Table 1 there is nothing listed under mental health characteristics? do you mean mental health problems based on DSM V criteria? you may wish to exclude this as you already have a category listed below this one?

Integration of findings should relate to equity centred design or approach to analysis? - analysis should be equity focused.

7. Re healthy immigrant effect, research has also documented same effects for mental health over time for immigrants you want to include a reference to this https://www.researchgate.net/publication/325338568_Canadian_Immigrant_Mental_Health and or other references related to mental health decline specifically.

Again, thank you for this important work, I hope the reviewer's comments and these recommendations will be helpful in your work,

We look forward in receiving your revised manuscript,

Kindest regards,

Nancy Clark PhD

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #1: Partly

Reviewer #2: Partly

**********

2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions (e.g. necessary controls, absence of floor or ceiling effects) to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory.

Reviewer #1: Partly

Reviewer #2: Partly

**********

3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Descriptions of methods and materials in the protocol should be reported in sufficient detail for another researcher to reproduce all experiments and analyses. The protocol should describe the appropriate controls, sample size calculations, and replication needed to ensure that the data are robust and reproducible.

Reviewer #1: No

Reviewer #2: Yes

**********

4. Have the authors described where all data underlying the findings will be made available when the study is complete?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception, at the time of publication. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Dear authors,

Thank you for the opportunity to review the manuscript #PONE-D-24-44279. I agreed to review this scoping review protocol as it has a focus on mental health care for immigrant communities in Canada.

I would like to commend the reviewers on this very important work and congratulations on receiving funding.

Please see my recommendations below.

Abstract:

- Please clarify if you are focusing on immigrants or newcomers. Please make this clear throughout the protocol.

- For example, you have stated, “There is a dearth of articles around newcomer experiences while accessing mental health and psychosocial support which has necessitated our current study.”, but then focus on “immigrants”.

- This sentence is not clear: “Therefore, to better address the needs of a diverse immigrant population, we are conducting a scoping review is to map out the scope of literature available on the experiences of immigrants while accessing mental health services and psychosocial support in Canada.” While the study appears to be sound, the language at times is unclear, making it difficult to follow. I advise the authors work with a writing coach or copyeditor to improve the flow and readability of the text.

- I am not sure references are used in abstract. I will defer this to the editor’s decision.

Introduction:

Please provide a reference for the following:

- “healthy immigrant effect”

- Not clear on “diverse immigrant population” is meant. Please clarify your definition of diversity for the reader.

- The word ‘migrant’ is introduced here. Please see my suggestion above in clarifying terminology for the reader.

- Although important, this is a very broad topic. There is extensive diversity within the immigrant communities. I would suggest a much narrower focus. Are you focusing on a category of immigrants? Within that category, are you focusing on a particular group (e.g. ethnicity, age, religion, gender identity and expression, sexual orientation, education, those who escaped war, etc.)?

Review question:

- The word “experience” lend itself to a qualitative systematic review

Method:

- Please clarify the rational for not using a more up to date scoping review approaches (e.g. JBI) compared to Arksey and O'Malley's

Search strategy:

- You have stated, “search strategy will be developed in consultation with a health sciences librarian…” Has this librarian been involved in the methods of this scoping review protocol? Please clarify who developed the search strategy in Appendix B.

- Please provide references to support the limitation for the last 10 years

- Are you selecting studies or articles? At times you have said articles and other times you have stated studies. Please clarify this for the reader. Would you only be selecting research studies or go beyond studies? What about grey literature? What about relevant websites and etc.

- As this is a Scoping review, please provide a rational for only selecting peer-reviewed journal articles.

- The reason for excluding the following for a scoping review is not clear: “Case reports, systematic reviews, meta-analyses, interventional studies, commentaries, editorials, opinion pieces, and grey literature”

- Please provide a detail plan for pilot testing of each stage of review and data extraction. E.g. how many will be pilot tested for each stage, what inter-rater reliability will you consider satisfactory?

Data extraction:

- Please add “Notes” and “relevant articles from the reference list” for your data extraction table

Data analysis and results:

- Usually “thematic analysis” is not used in SR because we are not interpreting the extracted data. This would fall within qualitative Systematic review. I would suggest the team to consider content analysis. There is a newly published scoping review by Limoges et al. that you may find extremely helpful in your data analysis approach.

- You may find these helpful: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0295914

- Limoges J, Chiu P, Dordunoo D, Puddester R, Pike A, Wonsiak T, Zakher B, Carlsson L, Mussell JK. Nursing strategies to address health disparities in genomics-informed care: a scoping review. JBI Evid Synth. 2024 Sep 11;22(11):2267–312. doi: 10.11124/JBIES-24-00009. Epub ahead of print. PMID: 39258479; PMCID: PMC11554251.

Discussion:

- It is not clear how this will be ‘comprehensive’ with a limited focused on peer-reviewed research articles.

- There is a lot of information in the discussion section. Please note that you cannot take anything verbatim from your protocol into your paper that will be focused on the report of scoping review. I would suggest the authors to consider condensing this section.

Timeline:

- I am not clear on the timeline section. I think it can be removed, but I will leave it for the editor’s decision.

I hope you find this feedback helpful as you continue publishing your work.

Reviewer #2: General comments

Check for grammar throughout the manuscript

Specific comments

Title: the idea of equitable as used in the title is not explicit in the body of the manuscript. Is it assumed that immigrants don’t have equitable access to mental health services? If so, that should be evident in the text. It should be argued in the background section.

Introduction

The intext reference starts at [2]. Please indicate reference for [1].

Page 3 line 55- give example of these incidences and elaborate on how they compare with the general population

Line 61- healthy immigrant effect is often applied to physical health. Please provide a brief writeup on how immigrants have better mental health status at the time of migration and worsen with the length of stay, to demonstrate how this concept is relevant to mental health.

Line 63- there are other factors that determine the access to services that deserve mention. Perhaps doing a thorough review will unearth them- including cultural competency of providers, mental health literacy, stigma, misconception, differences in the way mental health is conceptualised between home and host country, differences in culture etc.

Substantiate all the statements you make- like in line 66.

Page 4 line 71- more information about mental health strategy and if it has any reference to immigrant mental health is warranted.

Line 74- too long and would read better if divided into two

Line 77- statement on comprehension curriculum is stigmatising and blaming the student and prejudicial. Consider changing the language to different learning style and approaches.

Line 80- clarify what you mean with inadequate accessibility, and statement as expressed by other reviewers- do you mean scholars or researchers?

Line 88 clarify what one size fits all approach looks like

Page 5- a justification statement is required on what necessitated the study. A case study drawn from a clinical experience with immigrants would suffice. Also, if authors are themselves immigrants, they can draw from their own lived experiences.

Line 95- clinical significance of this work is vital.

Research questions are broad and need to be revised and made more focussed

Focussing on Canada alone may not give adequate materials to work with. In addition, you need to make a justification as to why you are limiting to Canada and not traditionally to other immigrant accepting countries.

Page 7- line 139. Why limit the search to 10 years?

Table 1- broad and are at risk of not finding the information you are looking for if you intend to populate each section. A typical data extraction sheet usually has 8 columns. Might be better to familiarise yourself with a similar scoping review and learn what information ends to be extracted for analysis.

Line 189- develop the section on analysis further

Line 195- what will be the component of the conceptual framework? This section needs to be developed further.

Line 204- be specific on who the stakeholders are and where the consultation will be and how it will be conducted.

Results- line 266- not necessary for a protocol as there are none to report.

Discussion- should be summarised and focus on what the scoping review will achieve especially on implication for clinical practice. Two paragraph are adequate.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #1: No

Reviewer #2: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step.

PLoS One. 2025 Apr 15;20(4):e0319743. doi: 10.1371/journal.pone.0319743.r003

Author response to Decision Letter 1

29 Jan 2025

RESPONSES TO REVIEWRS

Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

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Thank you for this we have revised the manuscript according to the style requirements

Thank you for stating the following in the Acknowledgments Section of your manuscript:

This work was funded by a QE II Foundation Translating Research into Care (TRIC) grant awarded to EE (Grant number 1029792). The funders played no role in the study design, decisions to publish or preparation of the manuscript. We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form. Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows: Eboreime E. This work was funded by the QEII Foundation Translating Research into Care (TRIC) Award 1029792. The funders played no role in the study design, data collection, data extraction, results, and discussion.

https://qe2foundation.ca/qeii-health-sciences-centre-staff/grants-health-centre-staff-physicians/translating-research-care-tric-grant-program

Funding: This scoping review is funded by the QE II Foundation Translating Research into Care (TRIC) grant. Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

We have removed the funding statement from the acknowledgement section, and the statement has not changed, so it can remain the same as it is on the online submission

Please provide a complete Data Availability Statement in the submission form, ensuring you include all necessary access information or a reason for why you are unable to make your data freely accessible. If your research concerns only data provided within your submission, please write "All data are in the manuscript and/or supporting information files" as your Data Availability Statement.

This has been included in the submission form. Given that this is a protocol for a study yet to be conducted, we currently have no data to share.

Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

A caption for the table, captioned S1Table Draft search strategy for MEDLINE has been included as part of the supporting information

Additional Editor Comments:

For example, reference to mental health commission of Canada strategies see 2016 vs 2009 line 71. https://www.mentalhealthcommission.ca/wp-content/uploads/drupal/2016-10/case_for_diversity_oct_2016_eng.pdf

Thank you for sharing the more recent strategy. We have replaced the 2009 reference with the 2016 strategy and updated the information accordingly. Please see line 79 for the revised section.

Please also clarify what is meant related to intergenerational stress throughout you make reference to youth however is the scoping review focused on all ages or youth only?

Thank you for your comment. The paper is focused on first-generation immigrants of all ages, not specifically on youth. This has been consistently reflected throughout the paper. Additionally, the term "intergenerational stress" is no longer used in the paper.

Also, if the scope of the review is to understand immigrant's experiences of mental health services and address their needs; would you consider explaining if and why people with lived experience are or are not included in the review? I would recommend explaining also inclusion criteria related to who are newcomers? e.g. are refugees included as a subcategory see line 133, because their experiences maybe different in terms of equity?

Thank you for your suggestion. We have clarified that our population includes first-generation immigrants, which encompasses newcomers such as refugees, whose experiences may differ in terms of equity. We have expanded the explanation based on IRCC guidelines (see lines 158 to 162. As this is a scoping review, depending on the types of papers extracted, it could potentially include individuals with lived experiences.

The overall focus on experience, it is not clear why quantitative studies will also be included unless you are focusing on structural issues related to health outcomes? This could be addressed in the ethics section.

Thank you for your comment. Depending on the types of papers that meet our inclusion criteria during the extraction process, quantitative studies will also be included, especially if they address and measure relevant factors such as structural issues related to health outcomes. This approach is in line with the scoping review guidelines. It is unclear why this should be an ethical issue, particularly as review articles typically do not require ethics approvals

I appreciate the inclusion of inter-rater reliability however it is a quantitative method you may want to consider intercoder ICR reliability but that is up to you line 158 see article by O'Connor: https://journals.sagepub.com/doi/full/10.1177/1609406919899220

Thank you for your advice. We have changed to refect intercoder ICR reliability.

p.9 Table 1 there is nothing listed under mental health characteristics? do you mean mental health problems based on DSM V criteria? you may wish to exclude this as you already have a category listed below this one?

Thank you for this, we have removed the row, and left the row for mental health conditions as they are representing the same things, see Table 1 from the supporting information

Integration of findings should relate to equity centered design or approach to analysis? - analysis should be equity focused.

Thank you for your suggestion. We have rewritten the section on the integration of findings to emphasize how the paper adopts an equity-focused approach. Please see line 225 for the updated content.

Re healthy immigrant effect, research has also documented same effects for mental health over time for immigrants you want to include a reference to this https://www.researchgate.net/publication/325338568_Canadian_Immigrant_Mental_Health and or other references related to mental health decline specifically.

Thank you for your comment. This has been addressed, and references to the mental health effects, including the suggested reference, have been added. Please see lines 53 to 61 for the updated content.

Reviewer #1:

Abstract:

Please clarify if you are focusing on immigrants or newcomers. Please make this clear throughout the protocol.For example, you have stated, “There is a dearth of articles around newcomer experiences while accessing mental health and psychosocial support which has necessitated our current study.”, but then focus on “immigrants”.

Thank you for pointing this out. While we initially used the term “newcomers,” we have clarified that our focus is on immigrants in general, particularly first-generation immigrants, which includes newcomers. To ensure clarity and consistency, we have removed the term “newcomers” and specified that the study encompasses all immigrants, as reflected in line 25.

This sentence is not clear: “Therefore, to better address the needs of a diverse immigrant population, we are conducting a scoping review is to map out the scope of literature available on the experiences of immigrants while accessing mental health services and psychosocial support in Canada.” While the study appears to be sound, the language at times is unclear, making it difficult to follow. I advise the authors work with a writing coach or copyeditor to improve the flow and readability of the text.

This sentence has been improved to ensure readability and clarity see line 28

I am not sure references are used in abstract. I will defer this to the editor’s decision.

The reference has been taken out

Introduction:

Please provide a reference for the following:

- “healthy immigrant effect”

Thank you for your comment. This has been addressed, and we have included a broad definition and references for the “healthy immigrant effect”. Please see lines 54 to 58 for the updated content.

Not clear on “diverse immigrant population” is meant. Please clarify your definition of diversity for the reader.

"Diverse immigrant population" was unclear and has been revised to "immigrant population" throughout the document for accuracy and clarity.

The word ‘migrant’ is introduced here. Please see my suggestion above in clarifying terminology for the reader.

This has been changed across the document to immigrant, to maintain consistency of terminology

Although important, this is a very broad topic. There is extensive diversity within the immigrant communities. I would suggest a much narrower focus. Are you focusing on a category of immigrants? Within that category, are you focusing on a particular group (e.g. ethnicity, age, religion, gender identity and expression, sexual orientation, education, those who escaped war, etc.)?

Thank you for this and we agree it is a broad category, which is why we are focusing on first generational immigrants. Considering that this is a scoping review, the focus is typically broad and exploratory, in contrast with a systematic review. The purpose is to map evidence towards future more focused research and/or policy.

Review question:

The word “experience” lend itself to a qualitative systematic review

The term “experience” is appropriate for a qualitative systematic review; however, scoping reviews can also explore experiences as well. For reference, see Mak, S., & Thomas, A. (2022). Steps for Conducting a Scoping Review. Journal of Graduate Medical Education, 14(5), 565–567. https://doi.org/10.4300/JGME-D-22-00621.1. Further, we are not excluding quantitative articles from our review considering that this is a scoping review and there is the possibility that some articles may apply quantitative measures to experiences, which we do not want to miss out. For example, a similar study in Europe found 5 quantitative vs 3 qualitative articles on immigrant experiences. For reference see Kjøllesdal, M.K.R., Iversen, H.H., Skudal, K.E. et al. Immigrant and ethnic minority patients` reported experiences in psychiatric care in Europe – a scoping review. BMC Health Serv Res 23, 1281 (2023). https://doi.org/10.1186/s12913-023-10312-1

Method:

Please clarify the rational for not using a more up to date scoping review approaches (e.g. JBI) compared to Arksey and O'Malley's

Arksey and O'Malley's framework is a widely recognized and established method for conducting scoping reviews. We have chosen to complement this approach with the JBI methodology to enhance the review process. Please see line 135 for further details.

Search strategy:

You have stated, “search strategy will be developed in consultation with a health sciences librarian…” Has this librarian been involved in the methods of this scoping review protocol? Please clarify who developed the search strategy in Appendix B.

The search strategy attached was done in consultation with a health sciences librarian at Dalhousie University’s Kellog Library (please see acknowledgement).

Please provide references to support the limitation for the last 10 yea

We have removed the specified time frame.

Are you selecting studies or articles? At times you have said articles and other times you have stated studies.

We have reflected this to include one uniform terminology that is articles as they represent a broad range of papers. This shown throughout the paper

Please clarify this for the reader. Would you only be selecting research studies or go beyond studies? What about grey literature? What about relevant websites and etc.

We have expanded our inclusion criteria to include grey literature please see line 165

As this is a Scoping review, please provide a rational for only selecting peer-reviewed journal articles.

We have expanded our inclusion criteria to include grey literature and case reviews please see line 165

The reason for excluding the following for a scoping review is not clear: “Case reports, systematic reviews, meta-analyses, interventional studies, commentaries, editorials, opinion pieces, and grey literature”

Thank you for the suggestion. We have clarified our inclusion criteria. Grey literature, including case reports, will now be included. However, as this is not a scoping review of systematic reviews, we will still exclude those. Please see line 171 for the updated information.

Please provide a detail plan for pilot testing of each stage of review and data extraction. E.g. how many will be pilot tested for each stage, what inter-rater reliability will you consider satisfactory?

Thank you for the suggestion. We have included a detailed plan for pilot testing, specifying that we will pilot test 50 titles and abstracts. We will also use inter-rater reliability as a measure, with the acceptable level outlined in the revised section. Please see lines 184 to 187 for the details.

Data extraction:

Please add “Notes” and “relevant articles from the reference list” for your data extraction table

Data analysis and results:

Thank you for this suggestion, we have included this on our Draft search strategy table

Usually “thematic analysis” is not used in SR because we are not interpreting the extracted data. This would fall within qualitative Systematic review. I would suggest the team to consider content analysis. There is a newly published scoping review by Limoges et al. that you may find extremely helpful in your data analysis approach.

- You may find these helpful: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0295914

- Limoges J, Chiu P, Dordunoo D, Puddester R, Pike A, Wonsiak T, Zakher B, Carlsson L, Mussell JK. Nursing strategies to address health disparities in genomics-informed care: a scoping review. JBI Evid Synth. 2024 Sep 11;22(11):2267–312. doi: 10.11124/JBIES-24-00009. Epub ahead of print. PMID: 39258479; PMCID: PMC11554251.

Thank you for this. However, thematic analysis can be used in qualitative research. Please see Mak, S., & Thomas, A. (2022). Steps for Conducting a Scoping Review. Journal of Graduate Medical Education, 14(5), 565–567. https://doi.org/10.4300/JGME-D-22-00621.1. We have also referenced its use in the manuscript—please see line 218.

Discussion:

It is not clear how this will be ‘comprehensive’ with a limited focused on peer-reviewed research articles.

This has been removed

There is a lot of information in the discussion section. Please note that you cannot take anything verbatim from your protocol into your paper that will be focused on the report of scoping review. I would suggest the authors to consider condensing this section.

We have summarized this to include the main points

Timeline:

I am not clear on the timeline section. I think it can be removed, but I will leave it for the editor’s decision.

This was taken out

I hope you find this feedback helpful as you continue publishing your work.

Reviewer #2: General comments

Check for grammar throughout the manuscript

Thank you.

Specific comments

Title: the idea of equitable as used in the title is not explicit in the body of the manuscript. Is it assumed that immigrants don’t have equitable access to mental health services? If so, that should be evident in the text. It should be argued in the background section

The title refers to the experiences of immigrants, in accessing health care and does not talk about equity.

Introduction

The intext reference starts at [2]. Please indicate reference for [1].

The in-text references now start at [1]. The reference previously in the abstract has been removed, and

Attachment

Submitted filename: Response to Reviews_VF.docx

pone.0319743.s005.docx (86.9KB, docx)

Decision Letter 1

Nancy Clark

7 Feb 2025

Experiences of immigrants when assessing mental health services and psychosocial support in Canada: Protocol for a scoping review

PONE-D-24-44279R1

Dear Dr. Eboreime

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Nancy Clark, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Thank you for your updated and detailed response to the reviewers that were integrated into the manuscript. I have read the updated manuscript and your response to reviewers and find it satisfactory for publication.

Reviewers' comments:

Acceptance letter

Nancy Clark

PONE-D-24-44279R1

PLOS ONE

Dear Dr. Eboreime,

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    Supplementary Materials

    S1 Table. This is the S1 Table 1 Prisma-P.

    (DOCX)

    pone.0319743.s001.docx (21.1KB, docx)
    S2 Table. This is the S2Information Draft Strategy for Medline.

    (DOCX)

    pone.0319743.s002.docx (16.7KB, docx)
    S3 File. This is the draft search strategy.

    (DOCX)

    pone.0319743.s003.docx (17.2KB, docx)
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    Submitted filename: Response to Reviews_VF.docx

    pone.0319743.s005.docx (86.9KB, docx)

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