System Responsiveness to the Mental Health Needs of Refugees and Asylum-Seekers Living in England: Addressing Inequitable Access with a Theory of Change

<p dir="ltr">Refugees and asylum seekers (RAS) face significant mental health challenges due to multiple trauma experiences. Prevalence of post-traumatic stress disorder (PTSD), depression and anxiety exceeds that of host country populations yet needs remain largely unmet. In England, RAS are under-researched and often excluded from health policy agendas designed to inform system response to the needs of the population demographic. The system is not aligned to the characteristics and needs of RAS resulting in a major disjuncture between needs and response, which undermines the right to health. This thesis addresses this gap with a systems approach that defines the concept of the system, to critically explore the problem of unmet needs in two studies. Study one identified system gaps from the perspective of RAS and multi-sectoral service providers across three regions in England, revealing four system constraints (1) a lack of contextual knowledge, (2) an insufficient mental healthcare referral pathway, (3) insufficient linguistic support and (4) inadequate communication. Constraints manifest in two integrative themes, a lack of integrated working, and post-migratory living difficulties. Findings informed study two, the co-production of a multi-sectoral, multi-level Theory of Change (ToC) comprised of six system-level interventions implemented in the Northeast of England. The ToC targets an increase in access through multi-level change mechanisms that re-frame agency with resources to act. Outcomes include: the implementation of a Joint Strategic Needs Assessment specific to RAS community groups, cross-sector training in contextual knowledge, translated self-referral and self-help resources, and a service directory. Implications for policy and practice include a redefinition of trauma to encompass the experiences of forcibly displaced populations in both policy and practice and adequately resource the system. A holistic approach to healthcare policy is required to operationalise the concept of access across the system and reframe agency among service users and service providers.</p>