Understanding integrated mental healthcare for people experiencing forced migration: a realist review protocol

Abstract

Introduction

Forced migrants (i.e., asylum seekers and refugees) experience greater mental health disparities and inequities in care. Mental health services and systems lack clear policy on integrated mental healthcare. Understanding the causal mechanisms of integrated mental health for migrants can promote a resilient and adaptive health and social care system. However, to achieve a functional mental health service integration, there is a need to understand how and why mental health system integration works and under what health systems conditions. The purpose of this realist review protocol will be to outline a process for refining an initial programme theory (IPT), developed through deliberative dialogues with key interest groups in British Columbia, Canada, and to test the IPT against the global evidence base.

Methods and analysis

A realist review is an interpretive methodological approach to synthesising the literature based on the realist philosophy of science. Realist reviews are pragmatic approaches to theory development because they involve the participation of real-world actors or people who work within complex systems. Realist reviews are particularly useful for synthesising complex knowledge. We plan to conduct a seven-step review process, with iteration between each step. Steps 1–3 have already been completed in our previous work and included the development of an IPT, which will be refined systematically by exploring the global literature and consulting with an international advisory group. These will be used iteratively to identify, test and refine the programme theory. The quality of included literature will be appraised using the relevance, richness and rigour criteria and the realist quality appraisal tool, TAPUPASM (transparency, accessibility, propriety, utility, purposiveness, accuracy, specificity and modified objectivity). Steps 4–7 will include data extraction and realist analysis through retroductive theorising using the ICAMO (intervention, context, actor, mechanism and outcome) heuristic to help distinguish actors and resources from contexts, mechanisms and outcomes.

Ethics and dissemination

Ethics approval for the deliberative dialogue interviews that inform this realist review and IPT were obtained by the University of British Columbia (ref: REB Number: H22-03195). Study recruitment occurred between 21 November 2023 and 16 January 2024. All participants provided informed consent to take part in deliberative dialogues and to have their interviews audio recorded and transcribed for the purpose of this research. We will disseminate results of the review through academic papers, conference presentations and through iterative interest group workshops and discussions.

PROSPERO registration number

CRD42024580083.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This realist review will be informed by an initial programme theory (IPT) co-developed with patient and public involvement which strengthens the reality of uptake of evidence and provides micro theories about what works, for whom and how.

• The review will be conducted by a team of realist methodological and theoretical experts (AAB, FCM) and subject matter expertise (NC) in refugee mental health services and systems.

• The application of retroductive theorising through the adoption of the ICAMO (intervention, context, actor, mechanism and outcome) heuristic analytical tool and theoretical grounding in realism has the potential to provide nuanced understanding and causal explanations promoting integrated mental health care.

• However, the initial lack of policy and government interest holders may have limited the IPT’s ability to capture some broader, more system-level considerations.

• Given the potentially large volume of data and the small international review team, clear data management systems, defined workloads and effective communication channels will be essential for successful completion of the review.

Introduction

The refugee crisis has resulted in a record high of forcibly displaced migrants, with an estimated 123.2 million people worldwide who were forcibly displaced due to persecution, conflict, violence and human rights violations.¹ Forced migrants are defined by the International Organization of Migration (IOM) as refugees or asylum seekers due to their need to move resulting from human rights violations, climate disasters or violence and who require legal protection.² With this displacement comes increased mental health challenges for refugees and asylum seekers, consequently a need for responsive mental health services and systems.3,5 A recent systematic review on the prevalence of mental health conditions in global refugee populations found that refugee groups experience post-traumatic stress disorder at a rate of 31% and 31.5% for depression when compared with non-migrant groups.⁶ The mental health impacts of forced displacement can also worsen in high-income countries because of intersecting determinants of health such as racism, discrimination, high cost of living, lack of credential recognition, underemployment and poor housing.^{7 8} Despite the increased prevalence of worsening mental health outcomes for refugee and asylum seekers (hereafter collectively referred to as forced migrants), many struggle to access mental health services and experience systemic barriers to care. Barriers to care can include cultural stigma, lack of cultural and trauma-informed supports, lack of provider knowledge about refugee backgrounds, how to provide health insurance and limited government funding, among others.9,13 This body of evidence underscores a need for the integration of mental health across systems and services and a need to evaluate mental health services that include whole systems perspectives to improve large scale transformation.^{14 15}

Specifically, there is a need to understand how mental healthcare and services are integrated across systems, including but not limited to coordination of care between mainstream mental health, settlement service organisations and primary healthcare services. The WHO has outlined that there is a need to improve coordination across sectors beyond health, to promote integrated mental healthcare for migrant groups and that these efforts should be mainstreamed to promote system level capacity.^{16 17} Underpinned by human rights perspectives, integrated mental healthcare must also be accessible, equitable and inclusive of lived realities and perspectives.18,20

Increasingly, realist reviews are being used to understand how healthcare systems can respond and adapt to improve healthcare equity for diverse population groups.21,24 Realist inquiries focus on how and why an intervention works (or does not work) in different contexts by examining the underlying mechanisms that generate outcomes, distinguishing them from other types of reviews.²⁵ Informed by a realist philosophy of science, realist reviews can unearth the mechanisms (ie, known as reasoning applied to resources, opportunities and constraints) used by various actors to promote change.²⁶ The aim of a realist review is to provide a programme theory that provides richer insights and pragmatic recommendations for practice and policy, which differs from other traditional literature review methods.^{25 26} A realist review during COVID-19 showed that mechanisms of trust, social connectedness and accountability promoted integrated mental health services and system level resilience for populations with chronic care conditions and mental health challenges.²³ Compassion has also been described as a mechanism for facilitating collaboration across multidisciplinary organisations in the context of crises.²⁴ Other research suggests that better governance and partnerships across health and social services can address resource constraints thought to cause systemic fragmentation and decreased integrated care for vulnerable groups.²⁷ Research suggests that community-based interventions that promote refugee mental health must include culturally tailored support (ie, language and gender responsive care); task sharing within multidisciplinary teams; mentorship, advocacy and shared knowledge between clinicians and people with lived experience to promote better integration of mental health services.¹²

While studies have attempted to provide more contextual understanding of how integrated care works, we still lack a comprehensive understanding of how integrated mental healthcare works for forced migrant groups. What works in one setting may not be the same in another. It is therefore important to develop a more robust programme theory about how integrated mental healthcare works across settings, to reduce system fragmentation, decrease costs to the healthcare system^{28 29} and importantly enhance the mental health and well-being of forced migrants.

Expanding on our IPT

Despite the increasing flows of migration, due to political, social and environmental crisis, there has been very little theoretical development in understanding how integrated mental healthcare works to promote migrant mental health across systems and services. To help bridge this gap, we began with interest group consultations and deliberative dialogues with n=24 representatives from settlement services, specialised refugee primary care clinics, community health clinics, immigrant and refugee counselling services, a survivor advocacy group (ie, lived experience group) and a Ministry of Mental Health and Addiction policy analyst. Sample size was determined by the richness of our data set and informational power.³⁰ All participants (ie, interest group holders) provided informed written consent to take part in the deliberative dialogue sessions, to have their interviews audio recorded and transcribed for the purpose of the research. Deliberative dialogues are purposive conversations that can inform evidence-based policy.³¹ We applied Jackson and Kolla’s Dyads and Triads³² and Wiltshire and Ronkainen’s realist thematic analysis,³³ together with the ICAMO heuristic (intervention, context, actor, mechanism and outcome), to analyse the transcribed deliberative dialogues, resulting in the development of 36 ICAMO configurations (see online supplemental file 1). These were abstracted into four micro theories to provide mechanisms of change and included: (1) cultural and relational factors, included 12 ICAMOs; (2) system navigation and service access, included 7 ICAMOs; (3) organisational and workforce challenges included 11 ICAMOs and, (4) policy, funding and governance barriers included 6 ICAMOs. This allowed us to conceptualise an initial programme theory (IPT) about what works to promote integrated mental healthcare for refugees in the Canadian context (figure 1).³⁴

Figure 1. Initial programme theory (Clark et al³⁴). The figure shows four microtheory domains: (1) cultural and relational factors, (2) system navigation and service access, (3) organisational and workforce challenges and (4) policy, funding and governance barriers within which services are theorised to activate mechanisms (eg, trust, connection, proactivity) that promote, or hinder, integrated care and related outcomes. A, actor; C, context; I, intervention; M, mechanism; O, outcome.

Within these contexts, interventions such as referral processes or culturally responsive care can trigger mechanisms of trust, connection, proactivity and moral commitment. These key mechanisms are theorised to enable better integrated mental healthcare across refugee clients, providers and services. When activated, these mechanisms, defined as reasoning applied to resources, opportunities and constraints,³⁵ improved client engagement with services, improved access to care and care congruence. Conversely, mechanisms which hindered integration included alienation, stagnation, burnout and fragmentation. These mechanisms are theorised to decrease client satisfaction, disengagement and delays to care. Duplication of services and restrictive mandates can also lead to stagnation and delays in care because of lack of provider knowledge, trust and connection across services. Our IPT allowed us to identify potential mechanisms that enabled integration of services to promote mental health of forced migrant groups as well as mechanisms that potentially hindered integrated mental healthcare. However, because our analysis drew on data from a single context in British Columbia, Canada, the resulting theory remains an initial, developing programme theory that has not been tested against the global literature, limiting our ability to generate a middle-range theory (MRT) and to validate and strengthen the theoretical generalisability of our claims. Our IPT model requires further refinement and robust review of the global literature and ongoing engagement with interest group holders (ie, lived experience and practitioner involvement) to ensure that the emerging theories are grounded in real-world contexts and experiences. Interest group holders is a term derived from the MuSE consortium network which advocates for inclusive and decolonising language and reflexivity around groups that are affected by colonisation, thus we deliberatively do not use the term ‘stakeholder’.³⁶

Aims and questions

This protocol outlines the intention to conduct a realist review to test, refute and refine our IPT developed from our previous interest group consultations and deliberative dialogues in Canada.³⁴ Knowing what provides better integrated mental health services for refugees in a global setting may address health inequities for refugees in displaced and resettlement contexts. Findings will be used to provide cross-contextual relevant recommendations on how to improve service integration for refugee mental healthcare and optimise use of resources. Our guiding research question is, ‘What promotes integration of mental health services and resources for refugee population groups? How do they work, for whom and in what contexts?’ Our aims are to (1) understand how integrated mental healthcare works to promote mental health of forced migrants; (2) test our IPT based on the global evidence base and (3) reach a MRT about key context conditions, range of actors, mechanisms and outcomes that promote equitable and integrated mental health for forced migration groups.

Methods and analysis

It is often difficult to capture how complex programmes work because they do not yield observable outcomes directly.^{25 37} Realist reviews are increasingly adopted in health policy and systems research as an approach to understand and work with complex social interventions or programmes within complex social systems.³⁸ The theories developed through realist reviews are used to explain the programme theory an intervention, in our case, we are seeking to explain is integrated mental healthcare for forced migrant population groups. The review process aims at testing and refining the IPT. The IPT is tested and abstracted through the review process based on existing data to formulate MRTs. See table 1 for a list of definitions of realist terminology used in this review.

Table 1. Realist definitions adopted in this review inspired from Dalkin et al 2015³⁵; Mukumbang 2018⁶⁹; Coleman et al 2020⁷⁰, Greenhalgh and Manzano 2021⁷¹; Mukumbang 2023⁶².

Term	Definition
Context	The social, cultural, institutional, relational and material conditions, both observable and dynamic, that interact with mechanisms to influence whether, how and for whom an intervention works.
Mechanism	For this project, a mechanism is the reasoning applied to resources, opportunities and constraints introduced by an intervention which, when activated in the right context, generates outcomes.
Outcome	The observed effects or changes, intended or unintended, that result from the interaction between mechanisms and context.
ICAMO statement	A heuristic tool that helps the realist researcher to hypothesise the intervention of interest, the context in which the mechanisms may be operating, the relevant actors through whom the intervention is expected to work or is implemented, the mechanisms that are likely to fire and the outcomes (intended or unintended).
Programme theory	An explanation of how and why an intervention or programme is expected to work, typically structured using a Context–Mechanism–Outcome configuration or a similar framework. An initial programme theory (‘IPT’) is a preliminary, evidence-informed explanation that outlines the assumed relationships between context, mechanisms and outcomes and provides a starting framework to be tested and refined through the realist review.
Retroduction	An explanatory inference in which the researcher goes beyond surface-level observations to identify and explain the underlying, often hidden, forces or mechanisms that may have interacted to produce the observed outcomes.

ICAMO, intervention, context, actor, mechanism and outcome.

Overview of the steps of realist review

We integrated Pawson’s five steps for conducting a realist review, with Hunter et al.’s six step process^{39 40} to obtain a seven-step process outlined in table 2. While the table presents a linear process, the realist review is iterative in nature. The iterative nature of realist reviews benefits the theory building process by supporting the testing of evolving theories, and ultimately theoretical saturation: patterns of cause and effect become repetitive that one can qualitatively glean some truth around the theoretical generalisability of the inferred phenomenon.⁴¹ The Realist and Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) will be used when reporting study results.⁴²

Table 2. Adapted six steps of realist review adapted from Hunter et al⁴⁰.

Steps	Activity
Patient and public involvement (ie, interest group holders) (Winter 2023–2025)	Conducted realist interest group holder interviews. Conducted a realist thematic analysis on interest holder data and linked coding. Developed an IPT based on the Canadian interest holder interviews. Registered initial realist review with PROSPERO.
Pre-review work (Spring, 2025)	Develop a preliminary list of theories. Develop preliminary search strategies. Developed a realist review protocol based on the Canadian IPT. Confirmed research scope, question and tools. Develop an international advisory panel from known deliberative dialogue networks.
Searching for primary studies (Summer–fall 2025)	Database and grey literature searches.
Quality appraisal (Winter 2025)	Bespoke screening and appraisal tools developed by the research team to filter the literature results (ie, Rayyan and TAPUPASM). Quality appraisal assessment.
Data extraction (Spring 2026)	Theory-driven extraction (based on IPT mechanisms). Coding and detailed record keeping around each piece of primary data to contribute to the synthesis. Bespoke extraction templates.
Data synthesis (Spring–summer 2026)	Identify theories that require further searching and conduct iterative searches to complete the search process (repeat as many times as necessary until theoretical saturation is reached). Conduct outreach with interest holders to share and refine the programme theory. Refine the programme theory.
Dissemination (Fall–winter 2026)	Consult interest group holders on MRT for phase 2 realist evaluation.

IPT, initial programme theory; MRT, middle-range theory; TAPUPASM, transparency, accessibility, propriety, utility, purposiveness, accuracy, specificity and modified objectivity.

Health equity and implementation science framework

Articulating existing theories to be explored can aid researchers in formulating their IPT.⁴³ We have selected two substantive theories to complement our IPT. The first is around health equity. This corresponds with evidence showing that health inequities experienced by people with a forced migration background are increasing and unjust.^{6 44 45} The UN Sustainable Development Goal three aims to ensure the health and well-being for all, leaving no one behind.¹⁶ This includes making mental healthcare accessible, affordable and acceptable, thereby improving health outcomes and promoting respect for human rights.^{1 45} This calls for an equity-focused approach to health research and requires a critical lens to better understand how complex health systems work, for whom and why. Health equity theory posits that the distribution of health resources must consider the diverse contexts, backgrounds and intersecting determinants of refugee mental health.⁴⁶ To advance understanding about integrated mental healthcare we will also apply the theoretical lens of intersectionality, an emerging theory which offers nuanced understanding about equity factors across micro, meso and macro level contexts and settings that shape mental healthcare such as racism, classism, ableism and so on.⁴⁷

Our substantive theory derives from the implementation science (IS) approach. Decision-makers and practitioners in fields of refugee mental health face increased challenges to providing timely and appropriate care for refugee populations.⁴⁸ These challenges require tangible, efficient and evidence-based solutions and nuanced perspectives about how underlying social, individual and institutional contextual dynamics influence the implementation of integrated mental healthcare strategies. The goal of IS is to increase knowledge about what works, where, when and why it is necessary to sustain integration of evidence-based interventions into routine practice.⁴⁹ Adopting an IS approach will help address barriers and facilitators to implementation of our MRT and practical approaches to enhance equity, efficiency and scale-up approaches that improve the mental health of people with forced migration backgrounds.^{46 50}

Step 1: patient and public involvement

Interest group holder involvement is key to realist reviews.²⁶ Collectively, we describe our patient and public involvement groups as interest group holders. In our case, we have built relationships with previous interest groups that represent various actors across settlement service organisations, community health centres, specialised refugee primary care clinics, mental health organisations and people with lived experience from a survivor advocacy group. A critical aspect of this step is the formation of an expert panel (ie, our interest groups) to advise our IPT testing, refinement, development of the MRT and review process. We plan to work within our interest group networks to inform our programme theory development and consult with approximately two to three global experts to form an advisory panel. This consultation is characterised by review and discussion, where the advisors will get the chance to learn about our research tools, the IPT under interrogation, initial results of the review and updated drafts of the MRT. We anticipate approximately three to four consultations over a 1 year period. At each consultation, they will be invited to provide feedback based on their expertise. This expert advisory panel will include both our existing interest groups and global experts to help build and refine our programme theory. NC (first author) held a series of knowledge translation activities with interest groups including (1) a realist workshop; (2) deliberative dialogues; (3) a World Café event and (4) a consensus building exercise using Miro board (an online collaborative workspace) to brainstorm and share findings from our deliberative dialogues. The findings from the deliberative dialogues were used to co-develop an IPT which will guide our realist review of the global literature.

Step 2: pre-review work

The search strategy is informed by the IPT and developed from our interest group dialogues and substantive theories mentioned above which include (1) cultural and relational factors; (2) system navigation and service access; (3) organisational and workforce challenges; (4) policy, funding and governance gaps. These contextual conditions were analysed to develop our key mechanisms thought to promote integration of mental healthcare across services and sectors; four key mechanisms of action which include trust, connection, proactivity and moral commitment. In contrast, alienation, stagnation, burnout and fragmentation were hindering mechanisms which led to fractured and delayed service delivery and client disengagement from care (see figure 1).

Step 3: searching for primary studies

A search strategy of initial databases was conducted on 26 June 2025 and included MEDLINE (OVID), CINAHL, PsycINFO and Web of Science. A librarian and search hedges were consulted to develop the search strategy and following iterations of the search should further theory mining be required. Search results were saved on Mendeley and reviewed by the research team using Rayyan.⁵¹ The search retrieved 581 records after deduplication. Following title and abstract screening, 187 articles were deemed eligible for full-text review. Title and abstract screening were conducted by two reviewers (AAB and MH), with a random 20% of each reviewer’s decisions cross-checked for agreement. Any disagreements were resolved by a third reviewer (NC) to reach consensus. Full-text screening was also undertaken by AAB and MH, with 20% of full-text decisions cross-checked for consistency and any discrepancies again resolved by NC. In total, 72 articles were included in the final review. In parallel with the academic database search, a grey literature search was conducted to capture relevant evidence not published in peer-reviewed journals. Inclusion of grey literature is a recognised quality standard in realist reviews, as it can provide critical ‘nuggets’ of evidence to refine, refute or confirm the IPT.^{52 53} An academic librarian supported the development of the search strategy. Searches were conducted between 8 and 13 October 2025 across Google, ProQuest Dissertations and Theses Global and the IOM and WHO repositories. These sources were selected for their breadth (Google, ProQuest) and field-specific depth (IOM, WHO), as recommended by stakeholders and experts. For each source, the first 100 records were screened against the inclusion criteria based on titles and webpage content to identify items for full-text review. Searches were documented iteratively using the University of Toronto Grey Literature Documentation tool.⁵⁴ In total, 43 documents were screened at title and abstract, with two reviewers (AAB and MH) reaching full consensus in the first round; 26 documents met the criteria for full-text review, of which 12 were included in the final synthesis. The first set of search terms is provided in boxes1 2. There will be additions to the search terms used, but these will be developed as the IPT is developed following the first round of searching. This iterative search process is a key feature of realist reviews and allows for the investigation and testing of emerging and rival theories in real time.⁴⁰ In other words, as new explanations or data emerge from the literature review literature, they will be tested against existing evidence. We will not restrict based on study methodology and will include both quantitative and qualitative literature and maintain an open literature inclusion criterion.²⁶ This will augment the process if the literature is scarce, or theoretically less rich, allowing us to be flexible in our theory mining.

Box 1. Search terms for MEDLINE.

Search terms (MEDLINE)

((force or forced or forcibly or displaced) adj3 (migrant* or migration or immigrant* or immigration or emigrant* or emigration or incomer* or “in comer*” or “new-comer*” or newcomer* or refugee* or resettl* or “re-settl*")).tw,kf.

(“asylum seeker*” or asylee* or “displaced person*” or “displaced people”).tw,kf.

Refugees/

1 or 2 or 3

((“mental health carehealthcare” or “mental health service*“) adj3 (integrat* or share* or sharing or partnership* or collaborat* or coordinat* or “co-ordinat*")).tw,kf.

exp Mental Health Services/ and (integrat* or share* or sharing or partnership* or collaborat* or coordinat* or “co-ordinat*").tw,kf,hw.

“Delivery of Health Carehealthcare, Integrated”/

5 or 6 or 7

4 and 8

Box 2. Search terms for Grey literature.

Search terms (Grey literature)

“mental health” integrated services AND (refugees OR “forced migration”).

Step 4: screening and quality appraisal

Articles that pass the screening criteria (shown in table 3) will be assessed for quality based on realist standards. The inclusion and exclusion criteria will be iteratively refined and applied as the search strategy evolves in tandem with the emergence of new theories and our IPT. This approach adheres to RAMESES training materials, which recommend a different interpretation of quality such that theories can be effectively collected and tested.^{42 55}

Table 3. Screening criteria.

Inclusion criteria
Interventions	Strategies, approaches, initiatives, policies, methods, programmes and services designed to promote coordination, collaboration and integration of mental health services and supports for people of forced migration.
Contexts	Care settings which provide mental health services and support for people with forced migration backgrounds, including care settings such as primary care sector (eg, urgent care, community health centre, web-based), immigrant/settlement sector, mental health sectors. Policy contexts that impact refugee mental healthcare, including: COVID-19; immigration; health system; health equity; social contexts that impact the experience of refugee mental healthcare implementation, such as structural racism.
Actors	People who have experienced forced migration. Institutional actors (eg, social workers, community health workers, cross-cultural brokers). Care providers (eg, nurses, doctors, therapists). Decision makers (eg, policymakers, hospital administrators, settlement agency leadership). Public health practitioners (eg, governmental public health agency workers). SWIS—Settlement workers in schools. There are no age restrictions on the patient population.
Mechanisms	Reasoning applied to resources, opportunities and constraints.
Outcomes	Outcomes reported and discussed are implementation outcomes. Indicators of system coordination: increased accessibility of care, integration of social determinants of health, efficiency, collaboration, enhanced knowledge, relationships, change in care delivery. Practitioner-related outcomes: increased knowledge, trust, connection, shared decision making. Patient-related outcomes: health service utilisation, satisfaction, accessibility, affordability, quality of care and improved mental health and well-being.
Exclusion criteria
	Articles written in a language other than English. Primary articles published before 2020.

Quality appraisal in realist reviews differs from other types of literature reviews in that the quality of an article depends on contribution to theory building. To select quality articles, our review will follow the steps developed by Dada et al⁵⁶ which focus on assessing for relevance, then richness, followed by two levels of rigour: at the evidence level, and the programme theory level.

Relevance is defined as the data’s ability to contribute to both theory testing and theory building.⁵⁵ In this review, we will assess relevance against its relation to our IPT (ie, whether the data are related to key themes such as mechanisms and contexts in our IPT), and the relatability of the data to our research context (integrated mental healthcare for refugees). Richness appraises data for its ability to contribute to theory building: can a given article provide enough information about the context and mechanism, for example, and how they relate to one another such that we can make definitive statements about that data. Rigour is the extent to which the data is trustworthy. In realist terms, this can be assessed through the coherence of developing programme theories, and the structure of the research (eg, sample size, data collection techniques/appropriateness and analytical processes).³⁷

We will also assess the articles against the TAPUPASM criteria which focuses on transparency, accessibility, propriety, utility, purposiveness, accuracy, specificity and modified objectivity.⁵⁷ In addition to the familiar concepts of ethics and study aim alignment, these concepts broadly define quality as a piece of work that uses a broad approach to theory mining, with an emphasis on open reporting and practical use of results, grounded in the nuances of its contextual focus and privy to change. We have developed a rubric that combines the concepts of each quality appraisal category (table 4). The matrix depicts three levels of quality, and the TAPUPASM attributes have been organised to correspond to Dada et al’s⁵⁶ larger subcategories of relevance, richness and rigour to articulate what each subcategory means for our review.

Table 4. Quality appraisal rubric.

Category TAPUPASM attribute	3—High	2—Medium	1—Low
Relevance Specificity Modified objectivity	Article provides a detailed description and definition of nearly all of the relevant IPT components in addition to meeting the baseline eligibility criteria.	The article provides a surface level description of several IPT components in addition to meeting the baseline eligibility criteria.	Meets the baseline eligibility criteria. Article provides a brief description of a few components of the IPT but does not describe these components in great detail.
Richness Utility Purposivity	The article provides a clear, logically progressive and cohesive description about the links between IPT components. Data referring to refugee clients is ample and well-discussed, especially in articles where refugee clients are one of a few target populations.	The linkages between IPT components are clear, but perhaps not coherently described or immediately identifiable. Data around refugee clients is discussed, but it is not consistently clear how their experiences relate to the context, mechanism and/or outcome, especially in articles where refugee clients are one of a few target populations.	The article minimally links how different IPT components interact with one another. Data around refugee clients is discussed, but only at the surface level, making it difficult to relate to the context, mechanism and/or outcome, especially in articles where refugee clients are one of a few target populations.
Rigour Transparency Propriety Accuracy Accessibility	Data and/or consultation collection processes are described with detail, allowing appraisers to identify and judge the extent to which engagement allowed for unrestricted feedback.	Data and/or consultation collection process is discussed; however, details are missing, making it difficult to see if participants could provide feedback in an unrestricted way. Low risk for external influence.	Credibility of the source is low: it demonstrates high risk for external influence (eg, newspaper article that is biased against refugee populations). The scientific method is poorly developed, where the sample is not representative or sourced appropriately or ethically; methods are unclear. Theoretical coherence of the article is poorly constructed: it is inconsistent and diverges from existing evidence to support its claims.

IPT, initial programme theory; TAPUPASM, transparency, accessibility, propriety, utility, purposiveness, accuracy, specificity and modified objectivity.

We will pilot test at least two purposefully sampled articles. A clear rationale will be documented for articles that are excluded, and discrepancies will be discussed among the review group. Two reviewers will screen search results independently for inclusion. Once selected, articles will be further screened for rigour and relevance. The risk of bias assessment will be conducted using the first 10 articles which will be reviewed by each reviewer separately for verification. Clear documentation for any excluded literature will be noted. Any disagreement will be resolved through discussions with the review team.

Step 5: data extraction

Data extraction will be conducted by NC and AAB. A matrix will be developed based on the ICAMO heuristic. Main headings of the table will include intervention, context, actor, mechanism and outcome (‘ICAMO’), and will aid us in identifying data that supports, refutes or adds to the theory. The extraction table will also include headings derived from concepts from Woodward et al⁵⁸ and Hankivsky et al⁴⁷ to ensure that our foundational interest in health equity is woven into the analytical process (see online supplemental file 2).

Step 6: data analysis and synthesis

The goal of data synthesis is to co-develop ‘a chain of inference’ which is a connection that can be made across articles based on the themes identified. Our analytical strategy integrates Jackson and Kolla’s linked coding, Fryer’s critical realist thematic analysis and Peters’ tools for consolidation and conceptual mapping to develop MRT from complex and heterogeneous bodies of literature.^{32 59 60} Published qualitative, mixed-methods and theoretical studies are treated as sources of reported experiences and events, which are first organised into linked Context–Mechanism–Outcome (CMO) dyads and triads using Jackson and Kolla’s framework to make initial causal propositions explicit. Fryer’s critical realist thematic analysis is then applied to these CMO configurations to identify and refine the underlying generative mechanisms that explain how and why particular outcomes occur in specific contexts, while also identifying initial intervention components and key actors in order to develop provisional ICAMO statements. Finally, Peters’ analytical tools are used to consolidate, conceptually code and map these causal explanations across studies, enabling the construction of refined ICAMOs and transferable MRTs. Retroductive logic is used to explain how things work by mapping the context conditions that determine what mechanisms are triggered by an intervention within a system to produce a specific outcome.^{59 61} In our case, we will use the ICAMO framework as a heuristic link . Like other interpretive reviews, our realist review process is iterative with overlapping steps of analysis which requires moving back and forth between phases of analysis as the project unfolds. A range of tools will be used for synthesis, including writing textual descriptions (writing a descriptive paragraph on each included study); grouping and clusters (organising studies into smaller groups related to different questions or issues being explored); realist thematic analysis and idea webbing and conceptual mapping (exploring relationships within and across studies using schematic models and diagrams).

As discussed in our initial discussion of health equity and IS approach, we will also intentionally investigate the literature for experiences referring to differences in care and social identities to capture themes around intersectionality and the importance of the social determinants of health. For example, experiences with settlement and mental health services that meet/overlook gender responsive care. This approach is an extension of our contextual investigation. We will seek to understand nuances associated with the structural dynamics surrounding mental health service experiences of forced migrants with intersecting identities, and ultimately the process and impact outcomes affiliated with structural inequities. This way, we will be able to identify how health inequity as a context condition which may interact with mechanisms to produce unique outcomes. These codes will be tagged using conceptual components from Woodward et al and Hankivsky et al’s conceptual frameworks to help make sense of the data during later analysis.^{47 58} As ICAMO statements are developed, we will use retroductive reasoning to develop a MRT by attempting to understand the conditions that must be in place for a phenomenon to occur.⁶² The advisory panel will be invited to critique iterations of the IPT to ensure that the theory aligns with existing evidence and experience relevant to integrated mental healthcare for refugees.

Researcher positionality

Researcher reflexivity and transparency will add rigour to our analytical process. NC (first author), who identifies as a first-generation immigrant from Palestine and the former Yugoslavia, is a community mental health researcher focusing on equitable health systems and services for refugees and has some previous expertise with working with expert interest groups in applying realist methodology for understanding how self-management interventions work for disadvantaged populations.⁶³ AAB (second author) is an early-career mental health researcher, a naturalised British citizen of Spanish heritage with dual nationality and has methodological expertise in realist approaches. MH (third author) originates from the USA and identifies as a health researcher with growing roots in realist methods and social researcher with personal and professional motivations for addressing structural discrimination and health injustices. FCM (last author) originates from Cameroon and is an early career researcher with extensive realist methodological expertise to evaluate mental health services and policies. Our collective experiences and differences will be informing our coding and analysis and help move the IPT toward a MRT: a moderately abstracted theory that explains how and why certain mechanisms produce outcomes in specific contextual conditions but are not specific to one event in time.⁶⁴ Subsequently, realist philosophy can help explain how components of programmes (underlying mechanisms) work or not, and under specific contexts.⁶⁵

Step 7: dissemination

The final phase of a realist synthesis involves knowledge dissemination with interest group holders and public policy. A key part of realist work is to continuously engage with communities who are most affected by research that aims to improve programmes. Interest group holder engagement is therefore not a one-time validation check; rather, it is a relational and a continuous process. Participatory realist approaches require ongoing integrated knowledge from citizens.^{66 67} This method of triangulation aims to interrogate the IPT for applicability and accuracy.⁶⁸ To do this, we will continually engage with existing and new interest group holders and our expert advisory panel to refine and refute our IPT. As a part of our dissemination process, we will also develop a policy brief, blogs, podcasts, infographics, and host publicly available webinars.

Ethics and dissemination

Ethics approval for the deliberative dialogue interviews that inform this realist review and IPT were obtained by the University of British Columbia (ref: REB Number: H22-03195, see online supplemental file 3). This protocol is submitted as part of a realist review of the global literature on integrated mental healthcare for refugees. Data of the articles for review will be stored on the University of Victoria OneDrive, a Microsoft secure server accessible to only the research team. This review is informed by a participatory realist process.⁶⁷ We will seek validation and communicate findings with interest group holders who deliver integrated mental health support to refugees. The study results will also be shared through publications in peer-reviewed journals, conference presentations and formal and informal reports such as infographics and public webinars.