Exploring Multilevel Factors in the Effectiveness and Implementation of Community-Based Mental Health and Psychosocial Support Groups for Refugee Newcomers

Background and Purpose: Resettlement agencies have made efforts to implement interventions and programs to promote mental health among refugees and asylum seekers in the U.S. There is a growing need to examine the multilevel factors and processes that impact mental health outcomes within complex implementation settings, and yet few studies have addressed this knowledge gap. Informed by a critical systems approach, this study aims to evaluate the effectiveness of community-based MHPSS (CB-MHPSS) group interventions implemented in 11 states, exploring implementation barriers and facilitators for CB-MHPSS intervention and considering the interplay between the intervention and various inner and outer contextual factors.

Methods: A mixed method research design was used, applying a realist evaluation approach to assess the processes and outcomes of CB-MHPSS group interventions with a total of 235 adult refugees and asylum seekers in 31 groups implemented by 11 refugee resettlement programs. Pre- and post-intervention surveys were conducted, which were analyzed by bi-/multivariate and multilevel modeling (MLM). Community leaders and partners and co-facilitators of the intervention provided bi-weekly and fidelity reports along with final and follow-up surveys with open-ended feedback, which was analyzed using a framework analysis informed by MHPSS Theory of Change.

Results: The MLM analyses revealed the multi-level effects of individual, group, and community settings on MHPSS outcomes, highlighting the impacts of intervention facilitator types (b=16.20, p<.001 ) and group composition (b=-9.35, p<.05), as well as county-level unemployment rates (b=-28.37, p<.001). Differences in the efficacy of MHPSS intervention were found based on the location of the agency (F=4.534, p<.001), facilitation type (F=2.564, p<.05), group composition (F=6.557, p<.01), agency reception capacity (F=3.496, p<.001), certified welcoming (F=3.762, p<.001) in the community, and primary care provides ratio (F=2.227, p<.05). Qualitative analyses using a framework approach revealed the implementation process characterized by a ripple effect that resulted in positive change in capacity and partnership, highlighting the community's capacity to build knowledge together and co-create interventions that respond to the unique needs of diverse refugee communities. The establishment of trust and support within the community serves as a contextual factor that facilitates subsequent phases of service provision, ultimately facilitating sustainability as well as effectiveness of the intervention.

Conclusions: This study emphasizes the complex needs of growing refugee communities who interface fragmented systems and systematic and structural barriers to healthcare and services. The findings underscore the value of community-based, participatory approaches to psychosocial interventions, with a particular emphasis on the substantial roles of refugee community leaders and bi-cultural staff in MHPSS activities. This study recommends recentering the way mental health interventions are implemented and assessed with refugee populations by considering the multi-level effects and interactions of contextual and community information, as well as implementation factors. The study's findings suggest the need for more community-based, participatory approaches that prioritize the voices and lived experiences of refugees to create meaningful change and improve health outcomes for marginalized communities.