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ArticlePDF Available


HEALTH ACCESS FOR REFUGEES DURING THE COVID-19 PANDEMIC USING THE LEVESQUE
CLIENT-CENTERED FRAMEWORK: WHAT HAVE WE LEARNED AND HOW WILL WE PLAN FOR THE
FUTURE?

International Journal of Environmental Research and Public Health (IJERPH)
 * April 2022
 * 19:1-17

DOI:10.3390/ijerph19095001
 * License
 * CC BY 4.0

Authors:
Michaela Hynie
 * York University



Annie Jaimes
 * University of Quebec in Montreal



Anna Oda


Marjolaine Rivest-Beauregard
 * McGill University



Show all 11 authorsHide
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References (41)





ABSTRACT

During the COVID-19 pandemic, mental health services rapidly transitioned to
virtual care. Although such services can improve access for underserved
populations, they may also present unique challenges, especially for refugee
newcomers. This study examined the multidimensional nature of access to virtual
mental health (VMH) care for refugee newcomers during the COVID-19 pandemic,
using Levesque et al.’s Client-Centered Framework for Assessing Access to Health
Care. One hundred and eight structured and semi structured interviews were
conducted in four Canadian provinces (8 community leaders, 37 newcomer clients,
63 mental health or service providers or managers). Deductive qualitative
analysis, based on the Client-Centered Framework, identified several overarching
themes: challenges due to the cost and complexity of using technology; comfort
for VMH outside clinical settings; sustainability post-COVID-19; and
communication and the therapeutic alliance. Mental health organizations,
community organizations, and service providers can improve access to (virtual)
mental health care for refugee newcomers by addressing cultural and structural
barriers, tailoring services, and offering choice and flexibility to newcomers.

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Public Full-text 1



Content uploaded by Ben C. H. Kuo
Author content

All content in this area was uploaded by Ben C. H. Kuo on Apr 22, 2022
Content may be subject to copyright.
Citation: Hynie, M.; Jaimes, A.; Oda,
A.; Rivest-Beauregard, M.; Perez
Gonzalez, L.; Ives, N.; Ahmad, F.;
Kuo, B.C.H.; Arya, N.; Bokore, N.;
et al. Assessing Virtual Mental
Health Access for Refugees during
the COVID-19 Pandemic Using the
Levesque Client-Centered
Framework: What Have We Learned
and How Will We Plan for the Future?
Int. J. Environ. Res. Public Health 2022,
19, 5001. https://doi.org/
10.3390/ijerph19095001
Academic Editors: Jeanine Suurmond,
Charles Agyemang and Morten
Skovdal
Received: 3 March 2022
Accepted: 15 April 2022
Published: 20 April 2022
Publisher’s Note: MDPI stays neutral
with regard to jurisdictional claims in
published maps and institutional afﬁl-
iations.
Copyright: © 2022 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
International Journal of
Environmental Research
and Public Health
Article
Assessing Virtual Mental Health Access for Refugees during
the COVID-19 Pandemic Using the Levesque Client-Centered
Framework: What Have We Learned and How Will We Plan for
the Future?
Michaela Hynie 1, 2,*, Annie Jaimes 3,4, Anna Oda 2, Marjolaine
Rivest-Beauregard 5, Laura Perez Gonzalez 2,
Nicole Ives 4,6 , Farah Ahmad 7, Ben C. H. Kuo 8, Neil Arya 9, Nimo Bokore 10
and Kwame McKenzie 11
1Department of Psychology, York University, Toronto, ON M3J 1P3, Canada
2Center for Refugee Studies, York University, Toronto, ON M3J 1P3, Canada;
annaoda@yorku.ca (A.O.);
laurapg@yorku.ca (L.P.G.)
3Department of Psychoeducation, Sherbrooke University, Sherbrooke, QC J1K 2R1,
Canada;
annie.jaimes@usherbrooke.ca
4Sherpa University Institute, Montreal, QC H3N 1Y9, Canada;
nicole.ives@mcgill.ca
5Department of Psychiatry, McGill University, Montreal, QC H3A 1A1, Canada;
marjolaine.rivest-beauregard@mail.mcgill.ca
6School of Social Work, McGill University, Montreal, QC H3A 1B9, Canada
7School of Health Policy and Management, York University, Toronto, ON M3J 1P3,
Canada;
farahmad@yorku.ca
8Department of Psychology, University of Windsor, Windsor, ON N9B 3P4, Canada;
benkuo@uwindsor.ca
9
Department of Family Medicine, McMaster University, Hamilton, ON L8S 3L8,
Canada; narya@uwaterloo.ca
10 School of Social Work, Carleton University, Ottawa, ON K1S 5B6, Canada;
nimobokore@cunet.carleton.ca
11 Wellesley Institute, Toronto, ON M5A 2E7, Canada;
kwame@wellesleyinstitute.com
*Correspondence: mhynie@yorku.ca
Abstract:
During the COVID-19 pandemic, mental health services rapidly transitioned to
virtual
care. Although such services can improve access for underserved populations,
they may also present
unique challenges, especially for refugee newcomers. This study examined the
multidimensional
nature of access to virtual mental health (VMH) care for refugee newcomers
during the COVID-19
pandemic, using Levesque et al.’s Client-Centered Framework for Assessing Access
to Health Care.
One hundred and eight structured and semi structured interviews were conducted
in four Canadian
provinces (8 community leaders, 37 newcomer clients, 63 mental health or service
providers or man-
agers). Deductive qualitative analysis, based on the Client-Centered Framework,
identiﬁed several
overarching themes: challenges due to the cost and complexity of using
technology; comfort for
VMH outside clinical settings; sustainability post-COVID-19; and communication
and the therapeutic
alliance. Mental health organizations, community organizations, and service
providers can improve
access to (virtual) mental health care for refugee newcomers by addressing
cultural and structural
barriers, tailoring services, and offering choice and ﬂexibility to newcomers.
Keywords:
mental health care access; refugees; Canada; telemedicine; virtual therapy;
client-centered
framework
1. Introduction
In recent years, the number of refugees, asylum seekers, and internally
displaced
people has been growing; in 2021, 26.6 million refugees ﬂed life threatening
situations
due to conﬂicts, wars, and acts of violent extremism [
1
]. Refugees across the world con-
stitute a particularly vulnerable and underserved population. While forced
migration
and armed conﬂict appear to be associated with an elevated prevalence of PTSD,
anxiety,
and depression in refugee populations [
2
], various factors in the resettled country play an
Int. J. Environ. Res. Public Health 2022,19, 5001.
https://doi.org/10.3390/ijerph19095001 https://www.mdpi.com/journal/ijerph



















Int. J. Environ. Res. Public Health 2022,19, 5001 2 of 17
important role in increasing psychosocial vulnerability [
3
]. COVID-19 has starkly increased
pre-existing inequalities, disproportionately affecting vulnerable groups, such
as refugee
newcomers. Indeed, the pandemic’s burden of infection, death, and socio-economic
impacts
has largely affected poorer populations, disadvantaged ethnic groups, migrants,
low paid
essential workers, and people lacking social protection or living in crowded
housing [
4
,
5
],
making refugee newcomers particularly vulnerable to the cumulative impact of
multiple
forms of marginalization.
Access to health and mental health care, a key social determinant of health
inequal-
ities [
6
], has been a challenge for refugee newcomers, and may have worsened for them
during the global health crisis. However, the pandemic has also brought
potential op-
portunities regarding access to care, including access through virtual
modalities. Mental
health institutions and community organizations have rapidly sought to adapt to
pub-
lic health measures by offering virtual services. Virtual mental health services
include
phone, internet-based voice or video interactions, and text-based applications
or messaging.
Although virtual modalities offer interesting avenues in times of conﬁnement,
there are
limited data assessing if they uphold their promise of increasing access to care
for disen-
franchised populations, such as refugee newcomers, or even exacerbate
inequities. The
goal of this exploratory project was to document the perceptions of refugee
newcomers, as
well as those of key actors involved in the referral and delivery of virtual
mental health
(VMH) services, to understand how virtual modalities can impact access to mental
health
services for vulnerable groups.
1.1. Context of the Study
Canada has welcomed more than a million refugees since the 1980s through a host
of
different programs. In resettlement programs, refugees are selected by a host
country and
enter with permanent resident status [
7
]. In Canada, resettled refugees receive ﬁnancial
and settlement support for at least the ﬁrst year of residency, which can
facilitate access
to services. During the ﬁrst year, the Interim Federal Health Insurance Program
(IFHP)
covers supplemental health care not usually included in most provincial health
plans [
8
],
like non-physician mental health services, plus basic services until provincial
coverage
is obtained. Although the Canada Health Act aims to facilitate barrier-free
access to
health care for all residents [
9
], the availability and accessibility of mental health care
for refugee newcomers is less than ideal. Despite facing higher risks for
psychological
and mental health difﬁculties, refugees are known to present relatively low
rates of help-
seeking for mental health services [
10
,
11
]. Access to mental health care can be limited
by ﬁnancial costs, but also cultural and structural obstacles: low income;
unemployment;
racial discrimination; literacy; housing; social exclusion; stigma; perceptions
of health,
mental health, and services; and linguistic barriers, etc. [12,13].
As elsewhere, COVID-19 has forced many Canadian health and mental health
providers
to offer services through virtual platforms, with some differences across
provinces and
ﬂuctuations through different waves of the pandemic. This might have directly
affected
accessibility for vulnerable populations, but also indirectly, by making
referral to services
more challenging for their service and health providers. Settlement workers,
case managers,
and primary health care providers are the main points of contact between
refugees and
mental health and social services. These providers’ ability to assess refugee
newcomers’
needs and capacities, and the accessibility of available services, are essential
in connecting
refugee newcomers to available care [14].
1.2. Conceptualizing the Role of Virtual Mental Health Services in Promoting
Access and
Improving Service Disparity
Even prior to the COVID-19 pandemic, with the rapid advancement of digital tech-
nologies, incorporation of VMH services such as telepsychology and teletherapy
into
mainstream psychological practices was gaining increasing attention by mental
health
professionals and service providers [
15
,
16
]. Proponents of virtual care underscore the
















Int. J. Environ. Res. Public Health 2022,19, 5001 3 of 17
potential of these services to improve access to psychological interventions and
reduce
service disparity for marginalized groups, including racialized and newcomer
groups [
17
].
Despite their promises, however, there seems to be a “research to practice gap”
[
18
,
19
]
in virtual health, which has been attributed to a lack of user input in natural
(vs. lab)
settings. Indeed, online psychological interventions have been met with some
resistance,
including from mental health clinicians, around perceptions of telepsychology,
lack of
training, concern over legal and professional regulations, and reimbursement
issues, for
example [
20
,
21
]. Moreover, new health interventions can initially widen health inequal-
ities, selectively improving services only for privileged or relatively
advantaged users,
suggesting that the shift to virtual care may not have beneﬁtted refugee
newcomers, who
face multiple barriers to access [
22
]. Access and implementation of VMH care thus needs
to be conceptualized from the perspectives of all relevant stakeholders,
including clients,
therapists, the operational frameworks of organizations, the larger health
systems, funders,
and policy makers [23].
1.3. Theoretical Framework
This project is grounded in Levesque, Harris, and Russell’s [
24
] Client-Centered Frame-
work for Assessing Access to Healthcare (referred to as the Client-Centered
Framework
from here on). The framework describes access to health care services as a
function of
the complex interface between the characteristics of the services, service
providers, health
systems, and organizations on one side, and clients/patients and their
environments, on
the other. To fully understand the complexities of access, Levesque and
colleagues separate
out ﬁve supply-side factors (approachability, acceptability, availability and
accommoda-
tion, affordability, and appropriateness) and ﬁve demand-side factors (ability
to perceive,
ability to seek, ability to reach, ability to pay, and ability to engage) taking
into account
environmental contexts.
There are multiple opportunities for different trajectories depending on the
health
systems and the population perspectives. Adopting this framework to assess
newcomers’
and service providers’ perceptions of VMH services during the COVID-19 pandemic
allows
for understanding how these trajectories behave in the context of system-wide
regulations,
impacting all stages in the health care seeking continuum for all service users
in the same
time period. Thus, this project aimed to better understand the accessibility of
VMH care
during the COVID-19 pandemic from the perspective of both refugee newcomer
clients
and providers offering or referring to VMH services, to support access to more
equitable,
effective, and appropriate VMH services for refugee newcomers across Canada.
2. Materials and Methods
2.1. Study Design and Context
This paper describes ﬁndings from the qualitative arm of a larger mixed-methods
exploratory study examining refugee newcomers’ access to VMH care, conducted
between
November 2020 and May 2021 in Alberta, British Columbia, Ontario, and Quebec—the
four Canadian provinces with the highest numbers of resettled refugee newcomers.
Ques-
tions regarding providers’ perceptions of challenges in the delivery of VMH care
and
access to resources and training made up the mixed-methods part of the study.
This
paper reports on the qualitative assessment of access to VMH services using data
from
interviews with community leaders, health and mental health providers, managers
and
newcomer clients, and front-line providers. Focus groups were planned with
providers,
but aside from
6 small
group interviews, individual interviews were utilized instead due
to recruitment challenges.
The study was guided by two advisory committees. The ﬁrst was composed of
11 providers
and policy makers working with refugee newcomers in the four provinces,
the second of 11 newcomers from the Afghan, Congolese, Eritrean, Ethiopian,
Iranian, and
Syrian communities in these same provinces. Advisory committee members supported
par-










Int. J. Environ. Res. Public Health 2022,19, 5001 4 of 17
ticipant recruitment and interpretation of ﬁndings, and co-developed interview
materials
and strategies for dissemination.
2.2. Participant Recruitment and Procedures
2.2.1. Key Informants
Service providers (program coordinators, managers and directors of settlement
orga-
nizations, settlement workers, health and mental health care providers, and
interpreters)
and community leaders were recruited through emails sent through the project’s
advisory
committees and the research team’s networks, and national and regional networks
working
with refugees across Canada. Inclusion criteria for service providers included a
minimum
of three years working with refugees, ﬂuency in English or French, and
engagement in
either settlement or (mental) health care work. Inclusion criteria for community
leaders
included arriving in Canada as a refugee in the past 15 years, knowledge of
mental health
issues in their communities, being over 18, being able to provide consent, and
being able
to understand and speak English or French. No additional demographic information
was collected.
2.2.2. Refugee Newcomer Clients
Recruitment of refugee newcomers was conducted through group emails and public
invitations sent through community groups, settlement agencies, university
health ser-
vices, health networks, and through snowball sampling by peer researchers, and
through
research team member networks, and advisory committee networks. Inclusion
criteria for
refugee newcomers included living in Canada for 5 years or less, being over 18,
having
personal or family member experience with mental health services, being able to
provide
consent, and being able to understand and speak Amharic, Arabic, English, Farsi,
French,
Somali, Spanish, or Tigrinya. Refugee newcomers were offered a small honorarium
for
their participation.
2.2.3. Front-Line Service Provider Interviews
Front-line service providers were recruited through the same networks as the key
informants plus targeted snowball sampling to ﬁll particular categories of
services (e.g.,
serving francophone clients, serving children and youth) or regions.
All participants provided e-mailed written consent prior to the interviews. Key
infor-
mant interviews and service provider follow-up interviews lasted approximately
60 min,
while refugee newcomer client interviews lasted approximately 30 min. All
interviews were
audio recorded, transcribed, and translated into English or French where
necessary. Written
notes were also taken during the interviews.
2.3. Data Collection
The participation of service providers and refugee newcomers involved phone or
online interviews in the language of their choice, where possible, with one or
two team
members. Interview grids for each category of actors (newcomer versus provider)
were
derived from the Client-Centered Framework [
24
], modiﬁed to probe elements of virtual ac-
cess, and thus addressed similar themes but emphasized different
stakeholder experiences.
Semi-structured key informant provider interviews were broader and included more
probes and questions around the impact of COVID-19 on newcomer mental health and
the
broader context of virtual care in their agency and/or profession.
Semi-structured follow-
up provider interviews addressed new issues emerging from key informant
interviews.
They included a brief professional history and focused on front-line provision
of services
or referrals to elicit more focused information on barriers and facilitators to
access, and
training and support for providers (the latter is reported elsewhere). No other
demographic
information was collected.
Semi-structured interviews with community leader key informants explored commu-
nity mental health experiences and issues prior to and during the COVID-19
pandemic,



Int. J. Environ. Res. Public Health 2022,19, 5001 5 of 17
as well as determinants of needs, and access and accessibility factors. Again,
no other
demographic information was collected.
Refugee newcomer clients answered a short demographic questionnaire during the
interview. Interview questions were structured and assessed determinants of
needs, ac-
cess, and accessibility as identiﬁed by the key informant interviews, with
focused probes
relevant to technology access, literacy, satisfaction, and preferences.
Interview questions
were translated by a professional translator into Amharic, Arabic, English,
Farsi, French,
Somali, Spanish, or Tigrinya, and linguistically and culturally validated by the
project’s
peer researchers.
Ethics approval was granted by the Institutional Review Boards of three
institutions.
2.4. Qualitative Analysis
Data analysis followed Thomas and Harden’s [
25
] thematic analysis stages but with
some modiﬁcations to manage the large amount of data. Six team members
collaborated
to develop a codebook for deductive analysis based on the Client-Centered
Framework,
plus codes generated inductively through the reading of the transcripts. Three
coders
conducted holistic coding of all transcripts. Detailed coding was conducted
within the
holistic codes by a fourth team member, who then organized the detailed codes
into
‘descriptive’ themes. ‘Analytical’ themes were decided by assessing the
richness, breadth,
and depth of descriptive themes, signiﬁcance, and commonality among interviews,
and
ﬁt with the conceptual framework. The process was iterative and multiple
meetings were
scheduled during each phase. Validity was addressed by checking and conﬁrming
coding
and interpretations with the full coding team in each phase, and by actively
searching for
disconﬁrming evidence in the data.
Given the heterogeneity of VMH services offered/experienced by participants
across
provinces, organizations, and individuals, the perspectives of newcomers and
providers
are described together mainly as complementary perspectives, enriching our
emerging
understanding of the phenomena.
3. Results
3.1. Participants
This study used a convenience sample and snowball recruitment strategies across
four
provinces. Across 108 key informant and follow-up interviews, there were 45
representa-
tives of refugee communities (Alberta, n= 9; BC, n= 5; Ontario, n= 26; Quebec,
n= 5) and
63 providers and managers (Alberta, n= 4; BC, n= 10; Ontario, n= 25; Quebec, n=
24).
3.1.1. Front-Line Provider Professional Information
Providers were asked in the interview how long they had worked with refugee
populations and what proportion of their clients were refugees. We had intended
to include
a brief survey with the consent form for sociodemographic information including
gender
and age, but unfortunately, this was not sent. Professionals had worked a median
of
5 years
, ranging from a year to 27 years; almost a third (n= 19) reported more than 10
years’
experience. About 84% reported that refugees and/or asylum seekers made up more
than
half of their clientele. The distribution of professions by province is
presented in Table 1.
3.1.2. Representatives of Refugee Communities
Key informants: Key informant community leaders were residents of Ontario (n= 4;
50%), Québec (n= 2; 25%), and Alberta (n= 2; 25%). Community leaders in some
cases
saw themselves representing and describing speciﬁc ethno-cultural communities
(Eritrean,
n= 2; Ethiopian and Eritrean, n= 2; Syrian, n= 1), but in other cases saw
themselves as
representing broad categories of newcomers (West Asian/Arabic speaking, n= 1;
Muslim,
n= 2), and describing shared experiences of these broader communities.
Clients: Refugee newcomer clients ranged in age from 20 to 56 years old (M=
35.4,
SD = 9.8)
, and had been in Canada from a few months to up to ﬁve years. More than half




Int. J. Environ. Res. Public Health 2022,19, 5001 6 of 17
(n= 21, 58.3%) self-identiﬁed as female. The majority (n= 27) reported personal
experience
accessing mental health services, four reported a family member accessing, and
six a mix
of family member, own experience, and community experience. More information
about
refugee newcomer clients can be found in Table 2.
Table 1. Distribution of Service Providers’ Interviews by Province and Role.
Key Informant Service Provider Interviews
(n= 32)
AB 1BC 2ON 3QC 4Total
Program coordinators 0 0 1 2 3 (9.4%)
Managers and directors 0 2 3 1 6 (18.8%)
Settlement workers 0 0 1 4 5 (15.6%)
Primary care providers 0 1 0 0 1 (3.1%)
Mental health providers 1 2 7 4 14 (43.8%)
Interpreters 0 0 2 1 3 (9.4%)
Follow-up Service Provider Interviews
(n= 31)
Program coordinators/ intake workers 2 2 0 0 4 (12.9%)
Settlement workers 0 0 4 6 10 (32.2%)
Primary care providers 1 0 2 3 6 (19.4%)
Mental health providers 0 3 5 3 11 (35.5%)
1AB = Alberta. 2BC = British Columbia. 3ON = Ontario. 4QC = Québec.
Table 2. Sociodemographic Information of Refugee Newcomer Clients (n= 37).
Refugee Newcomer Clients (n= 37)
Province of residence n%
AB 7 18.9
BC 5 13.5
ON 22 59.5
QC 3 8.1
Country of origin
Syria 7 18.9
Eritrea 7 18.9
Iran 5 13.5
Ethiopia 4 10.8
Columbia 3 8.1
Somalia 2 5.4
Other 9 24.3
Years residing in Canada
<1 4 10.8
1–2 20 54.0
2–3 6 16.2
4–5 7 18.9
Refugee Newcomer Clients (n= 37)
First language
Arabic 7 18.9
Spanish 7 18.9
Farsi 6 16.2
Tigrinya 6 16.2
Amharic 5 13.5
Somali 2 5.4
Other 4 10.8



Int. J. Environ. Res. Public Health 2022,19, 5001 7 of 17
3.2. Dimensions of VMH Service Accessibility
Consistent with Levesque et al.’s [
24
] Client-Centered Framework, the ﬁndings are
organized by the characteristics of the services and resources of the newcomer
clients. Both
clients and providers commented on each aspect of access. Results from the key
informants
and subsequent interviews, and the different participant groups, are presented
together,
but the participant roles are identiﬁed for each quote.
3.2.1. Approachability
Approachability refers to the ease with which services can be identiﬁed and
reached.
Networks: Newcomers and providers of health and social services both described
how
informal and formal networks played an important role in ensuring awareness of
mental
health services. Newcomers relied on networks of friends, sponsors, health and
social
providers for information about services. This highlights the importance of
communities’
knowledge of existing services, but also the value of holistic services;
accessing one service
increased the opportunities for information and awareness of other services,
including
those related to mental health.
For service providers referring clients to specialized care, the challenge was
identifying
what services were currently available for their clients, and in what modality.
Providers
who relied on previous referral relationships easily continued referring their
clients for
specialized care. Where those relationships were less well-deﬁned or
established, providers
reported resorting to arduous online searching in the altered service
environment.
Online outreach and resources: Making services visible to clients and providers
was
more challenging in a virtual environment. Agencies used direct outreach to
their existing
clients, a strategy that clients noted was important for ensuring awareness of
available
services and acting on that awareness. This highlights the relative
vulnerability of isolated
newcomers who were not connected to social or settlement services. Providers
noted that
reaching new clients outside of their existing networks was more challenging
during the
pandemic and required a greater use of intentional promotion.
...with COVID and with the isolation, many persons would probably–could have
been
going out to libraries or to a community center for something, I mean, [and]
just by
chance heard somebody talking about, “oh, you know, there’s a service, do we
miss that
piece?” So, no, it’s, it’s more so on organizations really trying to put a lot
on perhaps
their websites or on social media. (Mental health intake and assessment worker
1)
Websites, social media, and online events like Facebook live community
discussions
became the main method used by both newcomer communities and agencies to
increase
awareness or visibility of mental health services. Agencies in some sites also
reported
efforts to build and support searchable databases of available services for both
providers
and clients, to facilitate access to information about which services were
available, who
had waiting lists, and in which modality services were offered.
3.2.2. Acceptability
Acceptability refers to social factors that make services acceptable (or not)
for clients,
with a recognition that care can be offered in ways that make it more acceptable
to some
members of the population than others.
Not ideal, but at least available: Both providers and newcomer clients generally
saw
virtual services as helpful and acceptable and they were grateful that services
were at least
available. However, both clients and providers suggested that VMH services are
not always
ideal and many preferred in-person services.
I ﬁnd virtual, somehow, even if it doesn’t cover everything we’re supposed to
cover as
before- but trying to do the service from home and virtually—I’m being there for
them,
all the time; making them happy and feeling like there’s some people behind
their back,
they[‘re] helping them. (Mental health provider key informant 1)



Int. J. Environ. Res. Public Health 2022,19, 5001 8 of 17
Which modalities are acceptable for whom: Cultural acceptability played a role
in
preferences for same-culture therapists and in some cases intersected with
delivery modality.
While VMH services were generally seen as acceptable, some methods of virtual
services
were deemed to be less culturally appropriate than others in certain
communities, as noted
by this newcomer client:
[...] we are from an oral tradition. We talk much more than we write. So by
textos or
online, such as chatting with someone and e-mailing, it is not our tradition or
nature.
But talking with someone, like I told you, like now
. . .
At least you feel that there is
someone on the other side. (Refugee newcomer 2)
The use of cameras, in particular, was described as making some people
particularly
uncomfortable, such as older adults. Discomfort with cameras may be particularly
salient
in group settings. Although we anticipated gendered concerns around the use of
cameras,
this did not emerge in our data except in the context of transgendered clients.
I recently created support group for the LGBT community speciﬁcally for
transgender
female to male... Some of them,
. . .
They don’t want to appear on the camera because
they belong to the same community. [...]they don’t want anybody to know that
they are
transgender or LGBT so I’m going to try again to do it in a different way.
(Mental health
provider key informant 2)
Providers in particular raised concerns about the acceptability of virtual
modalities
for people coping with serious mental illnesses or with clients who were dealing
with
trauma. One gendered concern that emerged was that virtual services were
described as
challenging in situations of domestic violence, which in this study was always
raised in the
context of violence against women; ﬁnding safe spaces in which to access virtual
services
was difﬁcult when one shared their home with the perpetrator of the violence.
I remember I had a woman, she used to talk when her husband was outside. They
try to
ﬁgure out a time, yeah. Sometimes she calls and she says a few words, and she
doesn’t
discuss her situation—it’s really hard, it’s not easy. (Mental health provider
key
informant 3)
Language preferences in virtual modalities: One of the greatest advantages of
virtual
care was increasing the ability to accommodate language needs because it was
possible to
connect with clinicians or interpreters outside of the immediate community.
If they have to go in person, it could be a challenge. We have to arrange for
interpretation.
We have to arrange for transportation. We have, you know, but with virtual
services they
can even reach out to mental health therapist in [names different cities]...
(Settlement
service provider 1)
Findings around virtual interpretation were mixed. Many providers felt that it
went
smoothly and enhanced accessibility, and even that their clients preferred to
have a virtual
interpreter because they felt that their privacy was better protected. However,
some
newcomers and providers also reported technological barriers, such as dropped
calls or
discomfort, as noted by this provider:
Again you know a lot of my staff team aren’t techie so trying to do a three-way
call or
getting someone outside of our organizations to join into a video has not been
as efﬁcient.
(Agency director key informant 1)
Some providers also reported that clients could be less trusting of interpreters
in
the virtual space, as in the following discussion about issues of trust and its
relation to
past trauma:
[...] one of the considerations for the virtual platform is that the interpreter
has to be able
to easily access that platform, they have to be linked in, but just over the
phone. I think if
it’s three anonymous people [i.e., the client, the therapist, and the
interpreter]
. . .
when
it’s you as the provider (that maybe they’ve not met before), the patient, and
then there’s


Int. J. Environ. Res. Public Health 2022,19, 5001 9 of 17
this other person who speaks their language that they can’t see... I think
sometimes, it’s a
little bit- it depends again. It depends on the individual or even the group. I
know that
we’ve had a lot of issues with our Yazidi just because they are so distrustful
because of
their trauma. (Primary health care provider 1)
Providers also noted that some interpreters had limits on the kinds of
technology
they would use, and this was a challenge when dealing with interpreters of less
prevalent
languages, where there were fewer interpreters to choose from. Interpretation
services
in group settings with multiple languages were also described as more
challenging with
virtual modalities.
3.2.3. Availability and Accommodation
Availability and accommodation refer to being able to access services physically
(in
our case virtually), and in a timely manner.
Bridging the challenge of distance: Both newcomer clients and providers noted
that
clients were spared the time, cost, and inconvenience of having to travel long
distances to
appointments, noting also the high cost of public transportation. This may be a
particular
advantage for caregivers of young children. Virtual modalities also allowed for
more fre-
quent check-ins and greater ﬂexibility for staff to accompany clients on their
appointments.
Thus, virtual services enhanced availability in a number of ways.
Navigating changes and negotiating accommodations: Many providers employed
important service adaptations to ensure that care remained available and ideally
adapted
to clients’ preferences. Although some newcomers reported having no choice of
modality,
most providers reported being able to offer some choices to their clients, and
about half
also provided some in-person care, as permitted, when clients needed such
services. Ac-
commodating clients’ modality preferences was valued not just for enhancing
access but
also as a way to build a therapeutic relationship and validate clients.
Our ﬁndings also underline how policies at provincial and institutional levels
sup-
ported different options for providers, in terms of modalities, applications and
software, as
well as training and support. Providers were often limited by security concerns
and/or
professional body standards and could ﬁnd themselves caught between the
preference of
clients for speciﬁc modalities and expectations of their agency for speciﬁed
options.
Sometimes you just have to see somebody and it just- I don’t have a sanctioned
way to
access people over video conferencing.
. . .
if I have them try to connect through Microsoft
Teams, which is 100% conﬁdential but it requires so much digital literacy people
can’t
access it, people just can’t. So I have to say this is a huge—it’s a huge
frustration for me
and telephone calls work only so far. (Primary health care provider 1)
Flexibility of schedules: Newcomer clients also reported wanting more ﬂexibility
in terms of time of day or days of the week that services were offered. Although
some
providers noted that they had more ﬂexible schedules now that they were working
virtually,
they generally did not identify this as a need. Rather, providers and managers
noted that
working from home could make it harder to maintain boundaries around staff work
hours.
There is a potential conﬂict here between refugee newcomers’ need/preference for
ﬂexible
hours and providers’ need to protect work–life balance when working from home in
a time
of increased demands on mental health services and staff.
3.2.4. Affordability
Affordability refers to the cost of appropriate services, in both material
resources
and time.
The cost of technology: In most Canadian provinces, non-physician mental health
services for Canadian residents can involve fees, and virtual modalities can add
additional
costs. Both clients and providers noted challenges in terms of the cost of
devices, data
plans, and reliable internet services. Some providers and agency directors
described
ﬁnancial/resource support for virtual services that helped them build and
support virtual


Int. J. Environ. Res. Public Health 2022,19, 5001 10 of 17
service infrastructure to respond to COVID-19 restrictions. Some agencies tried
to ensure
access to devices and sometimes also subsidies to ensure access to data plans.
Providers
sometimes adapted by changing delivery modalities to those requiring less
bandwidth to
accommodate those unable to afford good internet packages. Finding donated
phones and
computers for clients was frequently successful, but the cost of data and
internet plans was
a recurrent and ongoing problem.
The issue with refugees, they have allowances from the federal government, it’s
the
resettlement assistance program and the allowance, so it’s not enough to pay for
the
Internet. (Mental health provider key informant 2)
3.2.5. Appropriateness
Appropriateness refers to the quality of care, and its ﬁt to client needs. In
this study,
we focused on the appropriateness of mental health care delivered virtually,
rather than the
appropriateness of mental health services as such.
Preferences for in-person care: Both clients and providers reported that virtual
services
were meeting client needs but many noted a preference for in-person care.
[T]he hardest thing is you’re feeling
. . .
[exhales] You don’t feel yourself connected to the
person you are talking to, as if you are watching tv [...]. (Refugee newcomer 4)
Many clients reported that they were very satisﬁed with the mental health
services
they were receiving, but there was also a theme in many interviews of “making
do” with
the modality that was available, as in this quote below.
I try to adapt to the situation, you know. But yeah, I don’t necessarily like
it, but it’s not
bad. It’s better than nothing. (Refugee newcomer 1)
Virtual modalities complicating communication: Several newcomers reported
prefer-
ring to communicate directly with their mental health provider, without an
interpreter,
even if they did not understand all of what was said. But both newcomers and
providers
commented that communicating directly when you are not ﬂuent in each other’s
language
can be even more challenging in virtual settings and that they did not always
feel they could
express themselves appropriately in some virtual modalities. Inhibited
communication
could further complicate cultural barriers to care. For example, phone
conversations, in
which non-verbal information is not available, could lead to misinterpretation,
making
interactions more difﬁcult, as in the following quote.
When it comes to a phone call, let us say now we may have language barrier and
the
way we talk as well; you may be talking with strong tone, which might seem that
even
if you are talking good words, they may feel you are yelling. [ehmmmm] this is
because
you have language problems you cannot express everything you want to say.
(Refugee
newcomer 5)
Privacy: Clients, providers, and interpreters frequently noted that a lack of
privacy
was an issue. Privacy could be an issue for providers and interpreters who were
offering
services from home and did not have appropriate ofﬁce spaces from which to do
so. For
clients, crowding, interruptions, and thin walls were a challenge, with clients
sometimes
having their sessions in their cars, in parks, in libraries, or in coffee shops.
Sometimes I would go outside. I was like “well, strangers, they will listen to
me” but
they don’t know me right? (Refugee newcomer 3)
Presumably those who were unable or uncomfortable being outside on their own
would not have access to even this form of privacy.
Challenges to building a therapeutic relationship: For a variety of reasons,
providers
noted that it could be difﬁcult to build therapeutic relationships online. Some
providers
noted that clients had distractions at home and were less engaged, which could
make
virtual service provision more challenging.


Int. J. Environ. Res. Public Health 2022,19, 5001 11 of 17
[...] Yeah, I had clients run around the room or maybe sometimes you know it’s
not
attentive, surﬁng, browsing website while they talk to you or they use their
phone or they
talk to other people on social media during the meeting with you, that happened
a lot.
(Mental health provider 1)
In most cases, however, providers observed that VMH services just required
different
strategies, for instance, offering a ﬁrst meeting in person before moving
online, or adapting
communication styles, reinforcing the need for training in virtual therapy
techniques as
well as technology.
[B]ody language is missing quite a lot now and so generally it’s just upper
body, so a lot
more facial
. . .
I use my arms more so, to ﬁll up this space, making a point. For example
when a client’s crying
. . .
previously I might be able to pass a tissue box, and that is a
message already. Meanwhile, now I have to compensate more verbally, [...] I
might just
have to ﬁll up that he’s letting them know: “it’s OK, I’m still here, do you
have a cup
of water?” Do, you know, just whatever to ﬁll up that space verbally. (Mental
health
provider key informant 4)
3.3. Dimensions of Service User’s Ability
3.3.1. Ability to Perceive
The ability to perceive the need for care reﬂects potential clients’ knowledge
and
beliefs about health and sickness.
Stigma and lack of knowledge of symptoms/treatment: Both newcomers and providers
noted that awareness that care is needed can be delayed or denied due to stigma
in society
or communities, or due to a lack of awareness of mental health symptoms and
potential
treatments. Friends, family members, or private sponsors were particularly
important in
helping to identify the need to seek care.
. . .
the wife comes complaining about the husband or my client has been referred by
the
sponsor because they saw an issue when they went, like how he’s treating his
wife, how
he’s behaving. (Settlement service provider 2)
Interestingly, many newcomers and providers felt that the growing awareness of
stress during the COVID-19 pandemic may actually have made it easier for people
in the
community to reach out for care, as noted by this community leader.
Distress was so much by COVID that they were going into a breaking down point,
if
it makes sense, and so some of them were actually kind of daring to kind of ask
for help.
COVID had made it possible for people to kind of seek help in a way because they
were
kind of breaking down that stigma; this is too much, I can’t manage it, the
isolation and
homeschooling and people was too much. (Community leader key informant 1)
3.3.2. Ability to Seek Care
The ability to seek care is about clients’ autonomy and capacity to seek care.
Issues
of equity emerge here, as individuals or groups can face barriers to access care
because of
various structural or symbolic obstacles.
Feeling welcomed: Newcomers reported that feeling welcomed, as opposed to
stigma-
tized, was an important part of accessing and continuing to access services; in
the context
of virtual care, they linked this to how they were treated in their initial
(virtual) contacts.
Even if you got the information to connect with them, since you are newcomer and
settling
in a new place, it may not be convenient to contact them. However, their
welcoming
attitude and support was important. (Refugee newcomer 6)
3.3.3. Ability to Reach
The ability to reach focuses mostly on being physically able to reach services;
we
interpreted this as including physical access to the technology.


Int. J. Environ. Res. Public Health 2022,19, 5001 12 of 17
Inequality in technology access: Especially at the beginning of the pandemic,
there
were challenges accessing technology and the internet. These challenges were not
dis-
tributed equally across the populations, they were common with higher poverty
and lower
education. Thus, some individuals and communities had better access to
technology and
devices and better digital literacy than others, and this difference tended to
be gendered.
I think for people who have difﬁculties are elderly, in navigating technology,
and also for
some women as well. The adult women, not the youth. [...] they may come from a
village
or they may never work before they came to Canada, so they just be home most of
the time.
So they’re not very computer literate as well. So those women [...] may have
difﬁculties,
and elderly. (Mental health provider 1)
As more community services moved online, however, the general comfort with and
access to technology increased.
Now there were very few clients who said: “I can’t do this, I have to stop
therapy because
I just don’t know how to do this online”. But our clients were actually more
ingenious
in adapting, [...] once we got used to Zoom, which we didn’t have very much time
to
get used to. Zoom, it’s quite comfortable, because there is space for the
counselor, the
interpreter, often other people join the client. You can see the whole family if
you want to
. . .
It’s a little bit like a home visit and so things have worked surprisingly well.
In fact,
so well that when the time comes that we can go back to the in-person they
probably still
want to keep a mixture of in-person and online. (Agency director key informant
3)
Online schooling of children and online language classes facilitated digital
literacy
for the family as a whole. Newcomers also noted other community and peer
supports
were transitioning into virtual spaces as community members became more familiar
with
navigating physical distancing restrictions.
3.3.4. Ability to Pay
The ability to pay refers to clients’ ability to access or generate the
resources required
to use the services.
The ongoing costs of virtual care: The cost of reliable internet or data plans
was a
pervasive issue for those refugee newcomers who struggled with low income, and
it shaped
which modalities of care were possible.
I think I was lucky to be on O.W. [supplemental assistance for those with
disabilities] and
then I had a, like, a little bit of money to have, like, data on my phone,
right? Otherwise,
I know like some people...especially going to [name of organization removed],
there are
some people who are, like, struggling a lot with ﬁnancial stuff and I wonder,
like, how
they get the services. And then if you, for example, if you prefer, like, a Zoom
call, right,
and you don’t have data or if you don’t have Wi-Fi, then how– that’s challenging
right?
(Refugee newcomer 3)
This was balanced against managing the costs of transportation. Those refugee
new-
comers residing in areas that are far from services and who rely on public
transportation
face high costs for transportation, in time and money. The most vulnerable were
those
lacking the means for either technology or transportation.
3.3.5. Ability to Engage
Ability to engage describes clients’ ability to participate in decision making
regarding
treatment. In the case of VMH, it could refer to making choices about the
modality of
treatment, type of interpretation services, and type of service itself, such as
group versus
individual therapy, as well as other aspects of treatment.
Feeling conﬁdent about engaging: Many newcomers stated that they actively en-
gaged and made choices, but others described feeling there were no real choices
and so
not engaging:


Int. J. Environ. Res. Public Health 2022,19, 5001 13 of 17
[...] she just asked me which one I would prefer, and I said whatever, since I
would want
to have in-person service. This might be the reason that she chose for me, I
didn’t give her
clear answer. (Refugee newcomer 7)
More could be done to ensure that clients are supported in knowing about their
options and feeling able to engage in making choices, especially given that both
clients and
providers have stated that having choices is important.
4. Discussion
This study used Levesque et al.’s Client-Centered Framework to assess key stake-
holders’ perceptions of access to VMH care for refugee newcomers, a vulnerable
and
underserved population. In line with Cu and colleagues’ scoping review [
26
], we found
that the framework’s multiple dimensions could overlap; however, it provided a
useful
structure in the analysis, making visible the shared agency of providers and
users in the
process of accessing services. Our research also underlined the beneﬁts of
situating the
model in a socioecological perspective, considering adaptations of providers and
services
to an unfolding health crisis.
This study on access to VMH care for refugee newcomers was conducted amid the
public health restrictions of the COVID-19 pandemic. The transition to virtual
services was
abrupt, as most organizations were unprepared and unequipped to offer online
services.
Yet, providers and agencies were resourceful and committed to deliver care for
their clients;
all actors developed new knowledge, strategies, and preferences over the course
of the
pandemic, changing the prevalence and nature of barriers to care.
Byrow and colleagues’ [
12
] pre-pandemic review showed that refugees seeking mental
health support encountered important barriers of three sorts: (1) structural
(ﬁnancial strain,
language, housing, lack of information); (2) cultural (perceptions of health,
mental health,
and appropriate care; stigma); and (3) speciﬁc to refugee experience
(immigration status,
mistrust, preoccupation with conﬁdentiality). With the move to virtual care
during the
pandemic, we found technology can reduce, exacerbate, or reconﬁgure these
obstacles,
particularly at the structural level, adding new challenges and opportunities.
Our analysis uncovered several themes related to the accessibility of VMH
services
and refugee clients’ abilities to access VMH care. First, virtual modalities
offered the
major advantage of allowing access to services across distances, removing the
burdens of
travel costs and time. They also created opportunities for access to services
for refugee
newcomers that might not otherwise be available, such as ﬁrst-language
therapists, also
allowing connections for people living in rural or remote areas. However, the
cost of
technology and the complexity of virtual platforms and devices were a barrier
for several
clients. Interpreters themselves could face technological challenges. Internet
service quality
and fees as well as phone data plans were major concerns related to poverty.
Connectivity
issues, known to hinder access to VMH services [
27
,
28
], were frequently cited as a challenge
in this study. For those in remote regions, where technology could bridge
providers or
interpreters who might not otherwise be available, such issues are a greater
concern and
may reduce the value of certain modalities in these regions. Respondents noted
that refugee
newcomers in Canada face elevated rates of poverty, and may have lower digital
literacy
and access to technology than other newcomers. The settlement agency ISSofBC [
29
] found
that less than 40% of recently arrived refugees in British Columbia had a
computer, and
digital literacy was mostly limited to using WhatsApp. Greer and colleagues [
30
] found
that the lack of digital literacy was the greatest barrier to using the internet
for mental
health services, highlighting the relevance of this barrier for refugee clients.
Although
additional resources were made available during the pandemic to support virtual
services,
they may be removed with the end of public health restrictions. Even as we
transition to a
growing use of technology, questions about sustainability thus remain.
The impact of technology on communication affected VMH appropriateness and ac-
cess to care. Virtual care was often perceived as “making do” by refugee
newcomers and
providers, as in-person services were limited by the pandemic. Participants
mentioned








Int. J. Environ. Res. Public Health 2022,19, 5001 14 of 17
the ways in which various modalities affected the communication quality and
challenged
the creation of a trusting relationship and alliance, a major component of care.
Indeed, the
relationship between therapist and client is one of the most important factors
in therapeutic
efﬁcacy [
31
,
32
]. When working with refugees and other displaced populations, therapists
already must contend with language barriers, interpreters [
33
], cultural
differences [34,35]
,
and lack of familiarity/comfort with Eurocentric-based models when building the
thera-
peutic relationship [
36
]. These challenges may have been exacerbated by VMH, hindering
the connection between service providers and service users in speciﬁc ways [
37
]. Providers
however developed strategies to accommodate the virtual modality, including
offering
initial in-person sessions or by compensating with gestures or more words.
Issues of
comfort, privacy, and safety when using VMH services were also discussed as
impacting
access in important ways. Ensuring safe and private physical environments for
care was a
major challenge, often linked to poverty, crowding, and/or poor-quality
housing—known
barriers to VMH services [
30
]. Our results also echo a study of online mental health con-
sultations in 13 European countries during the pandemic, showing that the
concern most
cited by participants was “privacy and security” [
27
]. On a related note, however, given
that mental health stigma also appears to be an important barrier to mental
health care
for refugees [
38
], and VMH could provide a more discreet way to have access, if provided
services are perceived as safe. Achieving perceptions of safety may be
challenging though;
forced migrants’ speciﬁc experiences often involve violence, persecution, and
trauma,
leading some individuals to develop profound difﬁculties with trust and worries
about
conﬁdentiality (risks for oneself and relatives if trust is broken) [
39
], affecting the capacity
to engage in care [
40
]. In our study, some found building trust in virtual platforms with
interpreters or providers was an additional challenge.
Considering all previously mentioned themes and dimensions, perhaps the most
important and overarching theme concerns ﬂexibility, as a key element favoring
access.
While the population had very little choice regarding conﬁnement measures, our
ﬁndings
suggest that providing a choice of different modalities to newcomers (including
for in-
person services) could improve access in different situations, for different
kinds of services,
for different mental health concerns, and different individuals. Given the
heterogeneity
of refugee newcomers’ experiences and needs, offering alternatives, and ensuring
clients
are supported in making choices, including for in-person care, appears to be an
important
factor to reduce each person’s singular set of obstacles to mental health
services. There
is still limited research on refugee clients’ ability to exercise their rights
in choosing their
service modality however, including in contexts where choice would be limited
and affected
by a global crisis such as the pandemic [
41
]. Finally, our ﬁndings underline the importance
of support and training for providers who refer and who offer mental health
services.
4.1. Limitations and Future Research
A few considerations should be taken into account when examining our ﬁndings. We
collected the perspectives of refugee newcomers who could and did use virtual
modalities,
and who had experience with the mental health care system (most likely not for
severe
mental health problems). Those who found VMH care unacceptable or inaccessible
would
not have been able to participate in the study, both because of our inclusion
criteria, but
also because we used virtual technologies to conduct the interviews. Moreover,
although
we recruited from different provinces, this article did not explore comparisons
between
sites in terms of pandemic health measures and coverage of mental health
services for
refugees. Finally, we documented perceptions regarding any VMH care, although
this
term encompasses very different services and modalities. Yet, our research
highlights
important and still unexplored issues regarding access to (virtual) mental
health care for
a vulnerable and underserved population during the pandemic. Future studies
could
examine the perceptions of a wider range of newcomers, including those unable to
use
virtual modalities, or go more deeply into unique barriers experienced by
individuals















Int. J. Environ. Res. Public Health 2022,19, 5001 15 of 17
suffering from severe mental health problems, women, seniors, and people
identifying
as LGBTQ.
4.2. Conclusions
As we transition back to more in-person care, almost all providers noted a
desire
to retain some elements of VMH care in the future. Thus, although the
circumstances of
delivering mental health services during the pandemic were unique, they also
offered
opportunities to learn more about whether, for whom, when, and how virtual
mental
health care increases access to services. VMH services rapidly expanded in the
COVID-19
context and have the potential to bridge gaps between refugee mental health care
needs
and available services. However, most virtual health initiatives are not
sustained because
of a lack of research on user needs, goals, and perceptions [
17
,
18
], and fail to address
accessibility barriers for disadvantaged patients [
42
]. This study identiﬁed a number of
characteristics of VMH services that could interact with clients’ abilities, to
either limit or
enhance access to needed mental health care. Importantly, virtual modalities
differed in
accessibility as a function of the services offered, client needs, abilities,
and preferences,
and the resources available, reinforcing the importance of ﬂexibility and choice
in VMH
services to reﬂect the diversity of refugee client circumstances and needs.
Author Contributions:
Conceptualization, M.H., N.I., F.A., B.C.H.K., N.A., N.B. and K.M.; method-
ology, M.H., A.J., A.O., N.I., F.A., B.C.H.K., N.A., N.B. and K.M.; formal
analysis, M.H., A.J., A.O.,
M.R.-B. and L.P.G.; writing—original draft preparation, M.H., A.J., A.O., N.I.,
F.A., B.C.H.K. and
N.B.; writing—review and editing, M.H., A.J., A.O., M.R.-B., L.P.G., N.I., F.A.,
B.C.H.K., N.A., N.B.
and K.M.; supervision, M.H., A.J. and N.I.; project administration, M.H., A.O.
and N.I.; funding
acquisition, M.H., N.I., F.A., B.C.H.K., N.A., N.B. and K.M. All authors have
read and agreed to the
published version of the manuscript.
Funding:
This research was funded by a grant from the Canadian Institutes of Health
Research
(#173101) in partnership with the Ontario Ministry of Health and Long Term Care
(#714).
Institutional Review Board Statement:
The study was conducted in accordance with the Declaration
of Helsinki, and approved by the Institutional Review Board (or Ethics
Committee) of NAME OF
INSTITUTION BLINDED (protocol code 124/2020-01, 21 December 2020), NAME OF
UNIVERSITY
1 BLINDED (protocol code e2020-333, 9 November 2020), and NAME OF UNIVERSITY 2
BLINDED
(protocol code 20-10-026, 11 November 2020).
Informed Consent Statement:
Informed consent was obtained from all subjects involved in the study.
Data Availability Statement:
Data available on request due to restrictions. The data presented in
this study are available on request from the corresponding author. The data are
not publicly available
due to privacy concerns of qualitative data.
Acknowledgments:
The authors wish to acknowledge the support given by the peer researchers and
advisory committee members through this project. The authors would like to thank
two anonymous
reviewers for their helpful suggestions and feedback.
Conﬂicts of Interest: The authors declare no conﬂict of interest.
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CITATIONS (20)


REFERENCES (41)




... Several studies described the need for an intensified focus on digital
literacy in designing AI [38][39][40]43,54,57,59,60]. The importance of digital
literacy was described in relation to virtual care and assumptions of acceptance
by all patients for AI supported technology such as . ...
... [60]. Poor digital literacy was also linked to equity in studies that
described the negative impacts for populations with lower socioeconomic
backgrounds, older patients, patients with disabilities, and refugee and
immigrant populations [38,39,42,59]. ...
... While another study noted "financial costs, but also cultural and structural
obstacles: low income; unemployment; racial discrimination; literacy; housing;
social exclusion; stigma; perceptions of health, mental health, and services;
and linguistic barriers. . ." [59] as structural inequities refugees face
accessing virtual mental health services. ...

Artificial intelligence and social accountability in the Canadian health care
landscape: A rapid literature review
Article
Full-text available
 * Sep 2024

 * Alex Anawati
 * Holly Fleming
 * Megan Mertz
 * Erin Cameron

Background Situated within a larger project entitled “Exploring the Need for a
Uniquely Different Approach in Northern Ontario: A Study of Socially Accountable
Artificial Intelligence,” this rapid review provides a broad look into how
social accountability as an equity-oriented health policy strategy is guiding
artificial intelligence (AI) across the Canadian health care landscape,
particularly for marginalized regions and populations. This review synthesizes
existing literature to answer the question: How is AI present and impacted by
social accountability across the health care landscape in Canada? Methodology A
multidisciplinary expert panel with experience in diverse health care roles and
computer sciences was assembled from multiple institutions in Northern Ontario
to guide the study design and research team. A search strategy was developed
that broadly reflected the concepts of social accountability, AI and health care
in Canada. EMBASE and Medline databases were searched for articles, which were
reviewed for inclusion by 2 independent reviewers. Search results, a description
of the studies, and a thematic analysis of the included studies were reported as
the primary outcome. Principal findings The search strategy yielded 679 articles
of which 36 relevant studies were included. There were no studies identified
that were guided by a comprehensive, equity-oriented social accountability
strategy. Three major themes emerged from the thematic analysis: (1) designing
equity into AI; (2) policies and regulations for AI; and (3) the inclusion of
community voices in the implementation of AI in health care. Across the 3 main
themes, equity, marginalized populations, and the need for community and partner
engagement were frequently referenced, which are key concepts of a social
accountability strategy. Conclusion The findings suggest that unless there is a
course correction, AI in the Canadian health care landscape will worsen the
digital divide and health inequity. Social accountability as an equity-oriented
strategy for AI could catalyze many of the changes required to prevent a
worsening of the digital divide caused by the AI revolution in health care in
Canada and should raise concerns for other global contexts.
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... The issue of language barriers in access to care is an ongoing challenge in
Canada and Ontario (Bowen, 2001;McCalman et al., 2017). Language issues are
often more pronounced for newer immigrants and contribute to inequities in
access to care (Ariste & di Matteo, 2021;Hynie, 2022;Laher et al., 2018). While
an individual may be proficient in everyday use of the official languages,
fluency is often more limited in healthcare interactions because of factors such
as the technical features of the language or different cultural contexts and
understandings (Al Shamsi et al., 2020). ...
... The COVID-19 pandemic accelerated the shift towards online service delivery
and virtual care (Glazier et al., 2021;Hynie et al., 2022;Shahid et al., 2023),
revealing pre-existing disparities in technology access and exacerbating digital
divides (Andrey et al., 2021;Shahid et al., 2023;Statistics Canada, 2022d). As
described by service providers in this study, Latin Americans faced obstacles
accessing essential services online such as counseling and mental health
therapy, especially those unfamiliar with navigating online platforms and facing
language barriers. ...

Assessing the impact of COVID-19 on Toronto's Spanish-speaking Latin American
population: Qualitative study
Article
Full-text available
 * Mar 2024

 * Irma Molina
 * Sarah Sanford
 * Raul Oyuela
 * Frank Sirotich

Background: The COVID-19 pandemic has intensified pre-existing health, social,
and economic disparities in Canada, particularly affecting racialized,
immigrant, refugee, and newcomer communities. While existing research indicates
that Latin Americans have been disproportionately impacted by the pandemic,
questions remain about why this group faces greater risk and worse health and
other outcomes compared with the rest of the population. Despite knowledge of
inequities in Toronto and elsewhere, research remains limited on the
perspectives and experiences of specific communities throughout the pandemic.
Methods: This qualitative research focuses on the experiences of
Spanish-speaking Latin Americans in Toronto who contracted COVID-19, had family
members and friends who were sick from the virus, and/or provided services to
Latin Americans in the city during the pandemic. Results: The study highlights
challenges related to informal caregiving, language barriers in accessing
healthcare, digital inequities, and difficulties faced by individuals with
precarious immigration status. Conclusion: Understanding the experiences of
Spanish-speaking Latin Americans in Toronto can help identify necessary support
and services to address these inequities in a post-pandemic scenario.
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Show abstract
... Providing interpretation services requires reliable technology and internet
connectivity, which can present additional challenges for patients, healthcare
providers and interpreters. 39 Our study's findings support the notion that
language ability and refugee status may be barriers to virtual care utilisation.
Alternatively, given the clinical limitations of virtual care, findings may
reflect patient preference and clinically appropriate use of the right care
modality for this patient group. ...

Language ability and virtual mental healthcare utilisation among immigrant and
refugee youth: a population-based cohort study
Article
Full-text available
 * Sep 2024

 * Hodan Mohamud
 * Alene Toulany
 * Sonia M Grandi
 * Natasha Saunders

Background and objectives The widespread adoption of virtual care during the
pandemic may not have been uniform across populations, including among
paediatric immigrants and refugees. We sought to examine the association between
virtual mental healthcare utilisation and immigration factors. Methods This
population-based cohort study of immigrants and refugees (3–17 years) used
linked health administrative databases in Ontario, Canada (March 2020 to
December 2021). Exposures included self-reported Canadian language ability (CLA)
at arrival and immigration category (economic class, family class and refugee).
The primary outcome was the visit modality (inperson/virtual) measured as a rate
of physician-based mental healthcare visits. Modified Poisson regression model
estimated adjusted rate ratios (aRRs) with 95% CIs. Results Among 22 420
immigrants, 12 135 (54%) did not have CLA (economic class: 6310, family class:
2207, refugees: 3618) and 10 285 did (economic class; 6293, family class: 1469,
refugees: 2529). The cohort’s mean age (SD) was 12.0 (4.0) years and half
(50.3%) were female. Of 71 375 mental health visits, 47 989 (67.2%) were
delivered virtually. Compared with economic class immigrants with CLA
(referent), refugees with and without CLA had a lower risk of virtual care
utilisation (CLA: aRR 0.89, 95% CI 0.86 to 0.93; non-CLA: aRR 0.80, 95% CI 0.77
to 0.83), as did family class immigrants with CLA (aRR 0.96, 95% CI 0.92 to
0.99). No differences in virtual care utilisation were observed among economic
class immigrants with CLA and other immigrant groups. Conclusions Language
ability at arrival and immigration category are associated with virtual mental
healthcare utilisation. Whether findings reflect user preference or inequities
in accessibility, particularly for refugees and those without CLA at arrival,
warrants further study.
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... This approach enables us to uncover unique insights into how patient-level
challenges, differ from rescheduled, delayed, or single missed appointments. We
use Levesque's framework, which views healthcare access as a complex interplay
involving services, providers, systems, organizations, and patient environments
(23), to explore these perspectives thoroughly. ...

Factors influencing multiple non-utilized healthcare appointments from patients’
and healthcare providers’ perspectives: a qualitative systematic review of the
global literature
Article
Full-text available
 * Jul 2024

 * Asrar Aldadi
 * Kathryn A. Robb
 * Andrea Williamson

Background The term "non-utilised appointments" emerged in 2019 but lacks a
clear definition. We focus on multiple non-utilised appointments due to recent
advances in understanding 'missingness' in UK healthcare. Studies on missed
appointments show conflicting results regarding interventions like text
messaging due to oversight of occasional versus repeated missed appointments.
Understanding patient and healthcare-related factors in multiple non-utilised
appointments is crucial for improving interventions and patient engagement. Aim
To identify factors influencing multiple non-utilised appointments from
patients' and healthcare providers' perspectives. Design & setting A systematic
review of qualitative research identifying factors that influence multiple
non-utilised appointments across diverse global health care settings. Method The
review employed a qualitative systematic approach, encompassing diverse papers
from multiple databases, irrespective of patient or healthcare provider age,
location, or setting. Data analysis followed Thomas and Harden’s thematic
synthesis method. Themes are presented in alignment with both the health service
and patient perspective aspects of the Levesque access model. Results Ten
thousand and eighty-six records were retrieved. Five studies met the inclusion
criteria and were analysed. Six key themes influenced appointment utilisation.
Healthcare system determinants highlighted provider-patient relationship and
professionalism, and healthcare organisation factors role in appointments
utilisation. Patient experience and decision-making explored personal factors.
Additionally, communication, support, and engagement delved into challenges with
communication and language, family and social support, and socio-familial
barriers to appointment utilisation. Health and well-being factors encompassed
medical conditions, mental and emotional factors, and psychosocial determinants
affecting appointment utilisation. Moreover, financial constraints and
socioeconomic factors were identified as significant contributors. Lastly,
healthcare access and barriers addressed transportation challenges,
accessibility issues, and geographical barriers impacting healthcare access.
Conclusion The analysis reveals complex factors influencing multiple
non-utilised appointments. Strong provider-patient relationships improve care
accessibility. Flexible scheduling and patient-centred approaches are pivotal,
alongside addressing workplace discrimination. Tailored healthcare services and
overcoming geographical barriers are essential. Ensuring safety, accessibility,
and communication, while supporting vulnerable groups and mental health needs,
are necessary. Equitable access to services and alternative transportation
solutions are essential for comprehensive healthcare delivery. Systematic review
registration PROSPERO CRD42023429465.
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... nukv3). It has been difficult to access these vulnerable groups, recruit
enough participants and convince stakeholders to take action; now recruitment
for our research project was blocked due to online bullying (Hynie et al.,
2022). ...

Research breakdowns: A constructive critique of research practice involving
grief, trauma and displaced people
Article
Full-text available
 * May 2024
 * GMH

 * Clare Killikelly
 * Hannah Comtesse
 * Franziska Lechner-Meichsner
 * John Ogrodniczuk

Impactful research on refugee mental health is urgently needed. To mitigate the
growing refugee crisis, researchers and clinicians seek to better understand the
relationship between trauma, grief and post-migration factors with the aim of
bringing better awareness, more resources and improved support for these
communities and individuals living in host countries. As much as this is our
intention, the prevailing research methods, that is, online anonymous
questionnaires, used to engage refugees in mental health research are
increasingly outdated and lack inclusivity and representation. With this
perspective piece, we would like to highlight a growing crisis in global mental
health research; the predominance of a Global North-centric approach and
methodology. We use our recent research challenges and breakdowns as a learning
example and possible opportunity to rebuild our research practice in a more
ethical and equitable way.
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... Refugees face individual, institutional and systemic barriers to healthcare
including language barriers [128]. The delivery of interpreting services
continues to evolve, especially during and following the COVID-19 pandemic,
resulting in more funding and support for telephone-based and video-conferencing
services [2,129], at least on a temporary basis [87,130]. This has resulted in
growing use and encouraging providers to consider (and validate) how and when
remote interpreting could be used as an effective alternative to in-person
interpreting. ...

Medical Interpreting Services for Refugees in Canada: Current State of Practice
and Considerations in Promoting this Essential Human Right for All
Article
Full-text available
 * May 2024
 * Int J Environ Res Publ Health

 * Akshaya Neil Arya
 * Ilene Hyman
 * Tim Holland
 * Grace Eagan

Language barriers, specifically among refugees, pose significant challenges to
delivering quality healthcare in Canada. While the COVID-19 pandemic accelerated
the emergence and development of innovative alternatives such as telephone-based
and video-conferencing medical interpreting services and AI tools, access
remains uneven across Canada. This comprehensive analysis highlights the absence
of a cohesive national strategy, reflected in diverse funding models employed
across provinces and territories, with gaps and disparities in access to medical
interpreting services. Advocating for medical interpreting, both as a moral
imperative and a prudent investment, this article draws from human rights
principles and ethical considerations, justified in national and international
guidelines, charters, codes and regulations. Substantiated by a cost-benefit
analysis, it emphasizes that medical interpreting enhances healthcare quality
and preserves patient autonomy. Additionally, this article illuminates
decision-making processes for utilizing interpreting services; recognizing the
pivotal roles of clinicians, interpreters, patients and caregivers within the
care circle; appreciating intersectional considerations such as gender, culture
and age, underscoring the importance of a collaborative approach. Finally, it
provides recommendations at provider, organizational and system levels to ensure
equitable access to this right and to promote the health and well-being of
refugees and other individuals facing language barriers within Canada’s
healthcare system.
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... LGBTQ+ people -has limitations in terms of generalizability, the
intersection of different vulnerability mechanisms faced by these groups, such
as discrimination, resource insecurity, and precarious housing, has enabled a
more indepth examination of the various aspects of the access issue. The
Levesque access framework, which is also commonly employed to conceptualize the
access to mental healthcare for migrants [33,34] was adapted for this particular
group and mental health through the iterative process we followed. Based on
expert interviews conducted using this modi ed model, 17 recommendations for
improving migrants' mental healthcare access have been developed, which can also
be used by countries and cities in similar situations. ...

Exploring the Dimensions of Mental Healthcare Accessibility for Vulnerable
Migrant Groups and Actions to Improve Access: A Qualitative Study Conducted in
Munich, Germany
Preprint
Full-text available
 * Mar 2024

 * Sophia Baierl
 * Zeliha Aslı Öcek
 * Caroline Jung-Sievers
 * Michaela Coenen

Background: The experience of migration is often associated with stressors that
affect mental health. Furthermore, migrants face barriers to accessing mental
healthcare. This study aims to explore the dimensions influencing mental
healthcare access for migrants in Munich, Germany and to develop recommendations
for action. Methods: The study used a two-phase qualitative approach. Phase 1
included individual interviews with 24 migrants from three vulnerable groups
(students, refugees, and LGBTQ+ people). Based on the data gathered, seven
interviews with health professionals experienced in mental health services for
migrants were conducted in Phase 2. The framework from Levesque et al. was
applied for analyzing and conceptualization of the dimensions of healthcare
access. The health professionals’ proposed actions were grouped based on their
respective levels as macro, meso, and micro. Validation was achieved by
reviewing the data analysis during a meeting attended by all authors and a
professional who was not involved in the interviews. Results: The dimensions of
mental healthcare access encompassed: 1) ability to perceive mental problems,
including stigma and knowledge about mental health; 2) ability to seek care,
encompassing knowledge about the new healthcare system and social support; 3)
acceptability of services, involving provider identity and gender; 4)
availability and affordability, including insurance coverage, bureaucratic
processes, and capacity and geographical distribution of services; 5)
appropriateness including providers’ and patients’ understanding of mental
healthcare, and providers’ competence. Language and culture exhibited a strong
interplay across all dimensions. The analysis yielded 17 action recommendations.
Macro-level recommendations target barriers caused by discrimination and
inequality. Meso-level recommendations included increased care capacity and
coordination and eliminating language and culture barriers in health services.
The micro-level recommendations included activities to promote mental health.
Conclusion: Migrants face numerous barriers to mental healthcare due to health
system and providers in Munich. However, culture and language remain the most
important access factors, necessitating social support. Actions pertaining to
acceptability, accessibility, affordability, and appropriateness of health
services are required to ensure that all individuals, including migrants, have
access to mental healthcare. However, improving migrant mental health begins
with the removal of structural barriers created by discrimination and inequality
at the macro level.
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Evaluating access during change: A qualitative exploration of access impacts to
Canadian primary care rehabilitation providers during the COVID-19 pandemic
Article
Full-text available
 * Dec 2024

 * Tory Crawford
 * Louise Chartrand
 * Cara Liane Brown
 * Patricia Thille

The COVID-19 pandemic required substantial changes in delivery of team-based
primary care, impacting both how and which patients accessed the more
comprehensive services teams provide. We sought to explore changes in access to
primary care rehabilitation services during the first year of the COVID-19
pandemic to identify potential new problems and improvements. In this
longitudinal study, sixteen rehabilitation professionals working on primary care
teams in Manitoba and Ontario recorded audio-diaries and later participated in
interviews throughout the first year of the pandemic. Qualitative analysis
included data immersion, coding to identify the practice changes and associated
access impacts, then applying Levesque and colleagues’ Patient-Centred Access to
Healthcare framework to interpret findings. Participants described service
changes that both enhanced and reduced access, including redeployment, outreach,
virtual care, discontinuation of some services and start of new ones, and new
risk management strategies. Some implied equity-specific impacts. Virtual care
and outreach activities created access for patient populations who previously
may have been underserved, while virtual care, redeployment, and new risk
management activities created new access barriers and inequities, leaving some
patients completely unable to reach care. Changes to team collaboration
activities could help or hinder access. Continuing outreach activities,
strengthening team collaboration, and thoughtfully integrating virtual care can
improve access to comprehensive primary care. As the primary care sector works
to recover from pandemic impacts and address population health needs, applying a
patient-centred access framework during practice redesign offers a meaningful
way to strengthen services.
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Evaluating an Intervention to Promote Access to Mental Healthcare for Low
Language Proficient Migrants and Refugees across Europe (MentalHealth4All): A
Study Protocol
Preprint
Full-text available
 * Sep 2024

 * Liza G G van Lent
 * Soňa Hodáková
 * Saskia Hanft-Robert
 * MentalHealthAll Consortium

Background Migrants and refugees with low language proficiency (LLP) have a
higher risk of experiencing certain mental health disorders compared to
non-migrant populations. They are also more likely to experience a lack of
access to mental healthcare due to language- and culture-related barriers. As
part of the MentalHealth4All project, a digital multilingual communication and
information platform was developed to promote access to mental healthcare for
LLP migrants and refugees across Europe. This paper describes the study protocol
for evaluating the platform in practice, among both health and/or social care
providers (HSCPs) and LLP migrants and refugees. Methods We will conduct a
pretest-posttest cross-national survey study to perform the platform’s
effect-evaluation (primary objective) and process-evaluation (secondary
objective). The primary outcomes (measured at T0, T2 and T3) are four dimensions
of access: availability, approachability, acceptability, and appropriateness of
mental healthcare. Secondary outcomes (measured at T2) are: actual usage of the
platform (i.e. tracking data), ease of use, usefulness of content,
comprehensibility of information, attractiveness of content, and emotional
support. Participants will be recruited from nine European countries: Belgium,
Germany, Italy, Lithuania, the Netherlands, Poland, Slovakia, Spain, and the
United Kingdom. Using convenience sampling through professional
networks/organisations and key figures, we aim to include at least 52 HSCPs
(i.e. 6-10 per country), and 260 LLP migrants (i.e. 30-35 per country). After
completing a pretest questionnaire (T0), participants will be requested to use
the platform and HSCPs will participate in an additional personalised training
(T1). Next, participants will fill out a posttest questionnaire (T2), and will
be requested to participate in a second posttest questionnaire (T3, about 6-8
weeks after T2) to answer additional questions on their experiences through a
brief phone interview (T3 is optional for migrants/refugees). Discussion The
findings of this prospective pretest-posttest cross-national study will deepen
our understanding of how a multilingual platform may promote access to mental
healthcare services for LLP migrants and refugees. If successful, this
intervention could be used to improve access to mental healthcare services, as
well as HSCPs’ competencies in delivering such services, for any LLP migrants
and refugees across Europe (and beyond).
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Roles and Dynamics within Community Mental Health Systems During the COVID-19
Pandemic: A Qualitative Systematic Review and Meta-Ethnography
Article
Full-text available
 * Apr 2024

 * Cheryl Sim
 * Asharani PV Nair
 * Mythily Subramaniam
 * Huso Yi

Globally, COVID-19 had an immense impact on mental health systems, but research
on how community mental health (CMH) systems and services contributed to the
pandemic mental health response is limited. We conducted a systematic review and
meta-ethnography to understand the roles of CMH services, determinants of the
quality of CMH care, and dynamics within CMH systems during COVID-19. We
searched and screened across five databases and appraised study quality using
the CASP tool, which yielded 27 qualitative studies. Our meta-ethnographic
process used Noblit and Hare’s approach for synthesizing findings and applying
interpretive analysis to original research. This identified several key themes.
Firstly, CMH systems played the valuable pandemic role of safety nets and
networks for the broader mental health ecosystem, while CMH service providers
offered a continuous relationship of trust to service users amidst pandemic
disruptions. Secondly, we found that the determinants of quality CMH care during
COVID-19 included resourcing and capacity, connections across service providers,
customized care options, ease of access, and human connection. Finally, we
observed that power dynamics across the CMH landscape disproportionately
excluded marginalized groups from mainstream CMH systems and services. Our
findings suggest that while the pandemic role of CMH was clear, effectiveness
was driven by the efforts of individual service providers to meet demand and
service users’ needs. To reprise its pandemic role in the future, a concerted
effort is needed to make CMH systems a valuable part of countries’ disaster
mental health response and to invest in quality care, particularly for
marginalized groups.
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Show more

The Role of the Therapeutic Alliance in Psychotherapy
Article
Full-text available
 * Aug 1993

 * Adam O Horvath
 * Lester Luborsky

The article traces the development of the concept of the therapeutic working
alliance from its psychodynamic origins to current pantheoretical formulations.
Research on the alliance is reviewed under four headings: the relation between a
positive alliance and success in therapy, the path of the alliance over time,
the examination of variables that predispose individuals to develop a strong
alliance, and the exploration of the in-therapy factors that influence the
development of a positive alliance. Important areas for further research are
also noted.
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Online consultations in mental healthcare during the COVID-19 outbreak: An
international survey study on professionals' motivations and perceived barriers
Article
Full-text available
 * May 2021

 * Nele A J De Witte
 * Per Carlbring
 * Anne Etzelmüller
 * Tom Van Daele

Introduction While the general uptake of e-mental health interventions remained
low over the past years, physical distancing and lockdown measures relating to
the COVID-19 pandemic created a need and demand for online consultations in only
a matter of weeks. Objective This study investigates the uptake of online
consultations provided by mental health professionals during lockdown measures
in the first wave of the COVID-19 pandemic in the participating countries, with
a specific focus on professionals' motivations and perceived barriers regarding
online consultations. Methods An online survey on the use of online
consultations was set up in March 2020. The Unified Theory of Acceptance and Use
of Technology (UTAUT) guided the deductive qualitative analysis of the results.
Results In total, 2082 mental health professionals from Austria, Belgium,
Cyprus, France, Germany, Italy, Lebanon, Lithuania, the Netherlands, Norway,
Portugal, Spain, and Sweden were included. The results showed a high uptake of
online consultations during the COVID-19 pandemic but limited previous training
on this topic undergone by mental health professionals. Most professionals
reported positive experiences with online consultations, but concerns about the
performance of online consultations in a mental health context (e.g., in terms
of relational aspects) and practical considerations (e.g., relating to privacy
and security of software) appear to be major barriers that hinder
implementation. Conclusions This study provides an overview of the mental health
professionals' actual needs and concerns regarding the use of online
consultations in order to highlight areas of possible intervention and allow the
implementation of necessary governmental, educational, and instrumental support
so that online consultation can become a feasible and stable option in mental
healthcare.
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Assessing healthcare access using the Levesque’s conceptual framework– a scoping
review
Article
Full-text available
 * May 2021

 * Anthony Cu
 * Sofia Meister
 * Bertrand Lefebvre
 * Valéry Ridde

Introduction Countries are working hard to improve access to healthcare through
Universal Healthcare Coverage. To genuinely address the problems of healthcare
access, we need to recognize all the dimensions and complexities of healthcare
access. Levesque’s Conceptual Framework of Access to Health introduced in 2013
provides an interesting and comprehensive perspective through the five
dimensions of access and the five abilities of the population to access
healthcare. The objectives of this paper are to identify and analyze all
empirical studies that applied Levesque’s conceptual framework for access to
healthcare and to explore the experiences and challenges of researchers who used
this framework in developing tools for assessing access. Methods A scoping
review was conducted by searching through four databases, for studies citing
Levesque et al. 2013 to select all empirical studies focusing on healthcare
access that applied the framework. An initial 1838 documents underwent title
screening, followed by abstract screening, and finally full text screening by
two independent reviewers. Authors of studies identified from the scoping review
were also interviewed. Results There were 31 studies identified on healthcare
access using the Levesque framework either a priori , to develop assessment
tool/s (11 studies), or a posteriori , to organize and analyze collected data
(20 studies) . From the tools used, 147 unique questions on healthcare access
were collected, 91 of these explored dimensions of access while 56 were about
abilities to access. Those that were designed from the patient’s perspective
were 73%, while 20% were for health providers, and 7% were addressed to both.
Interviews from seven out of the 26 authors, showed that while there were some
challenges such as instances of categorization difficulty and unequal
representation of dimensions and abilities, the overall experience was positive.
Conclusion Levesque’s framework has been successfully used in research that
explored, assessed, and measured access in various healthcare services and
settings. The framework allowed researchers to comprehensively assess the
complex and dynamic process of access both in the health systems and the
population contexts. There is still potential room for improvement of the
framework, particularly the incorporation of time-related elements of access.
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The COVID-19 Telepsychology Revolution: A National Study of Pandemic-Based
Changes in U.S. Mental Health Care Delivery
Article
Full-text available
 * Aug 2020

 * Bradford S. Pierce
 * Paul B. Perrin
 * Carmen Tyler
 * Jack Watson

The COVID-19 pandemic has altered mental health care delivery like no other
event in modern history. The purpose of this study was to document the magnitude
of that effect by examining (a) the amount of psychologists’ telepsychology use
before the COVID-19 pandemic, during the pandemic, and anticipated use after the
pandemic; as well as (b) the demographic, training, policy, and clinical
practice predictors of these changes. This study used a cross-sectional,
national online design to recruit 2,619 licensed psychologists practicing in the
United States. Prior to the COVID-19 pandemic, psychologists performed 7.07% of
their clinical work with telepsychology, which increased 12-fold to 85.53%
during the pandemic, with 67.32% of psychologists conducting all of their
clinical work with telepsychology. Psychologists projected that they would
perform 34.96% of their clinical work via telepsychology after the pandemic.
Psychologists working in outpatient treatment facilities reported over a 26-fold
increase in telepsychology use during the pandemic, while those in Veterans
Affairs medical centers only reported a sevenfold increase. A larger increase in
percentage telepsychology use occurred in women, in psychologists who reported
an increase in telepsychology training and supportive organizational
telepsychology policies, and in psychologists who treated relationship issues,
anxiety, and women’s issues. The lowest increases in percentage telepsychology
use were reported by psychologists working in rural areas, treating antisocial
personality disorder, performing testing and evaluation, and treating
rehabilitation populations. Although there was a remarkable increase in
telepsychology use during the COVID-19 pandemic, individual and practice
characteristics affected psychologists’ ability to adopt telepsychology.
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Cultivating online therapeutic presence: strengthening therapeutic relationships
in teletherapy sessions
Article
Full-text available
 * Jul 2020

 * Shari M. Geller

With the recent global pandemic, therapists have had to shift their
psychotherapy practice online, as they have been unable to maintain a face to
face relationship due to physical distancing measures. This has created an
immediate need to understand how to build and maintain strong therapeutic
relationships while navigating this new online therapeutic environment. With the
removal of face to face therapy, there is a question of how the therapeutic
relationship is to be maintained and fostered over the internet, through
considering the necessity of cultivating and maintaining therapeutic presence.
This article will discuss therapeutic presence as a precondition to effective
therapeutic relationships and a positive therapeutic alliance. An exploration
will follow of the challenges of cultivating therapeutic presence in online
therapy ; followed by tips to encourage and support both the therapist and the
client to remain present while engaging in telepsychotherapy. A final discussion
will include implications for future research and clinical training for
cultivating presence in telepsychotherapy as well as integrating what has been
learned during the pandemic back into face to face sessions.
View
Show abstract
From Research to Practice: Ten Lessons in Delivering Digital Mental Health
Services
Article
Full-text available
 * Aug 2019

 * Nickolai Titov
 * Heather Hadjistavropoulos
 * Olav Nielssen
 * Blake F. Dear

There is a large body of research showing that psychological treatment can be
effectively delivered via the internet, and Digital Mental Health Services
(DMHS) are now delivering those interventions in routine care. However, not all
attempts to translate these research outcomes into routine care have been
successful. This paper draws on the experience of successful DMHS in Australia
and Canada to describe ten lessons learned while establishing and delivering
internet-delivered cognitive behavioural therapy (ICBT) and other mental health
services as part of routine care. These lessons include learnings at four levels
of analysis, including lessons learned working with (1) consumers, (2)
therapists, (3) when operating DMHS, and (4) working within healthcare systems.
Key themes include recognising that DMHS should provide not only treatment but
also information and assessment services, that DMHS require robust systems for
training and supervising therapists, that specialist skills are required to
operate DMHS, and that the outcome data from DMHS can inform future mental
health policy. We also confirm that operating such clinics is particularly
challenging in the evolving funding, policy, and regulatory context, as well as
increasing expectations from consumers about DMHS. Notwithstanding the
difficulties of delivering DMHS, we conclude that the benefits of such services
for the broader community significantly outweigh the challenges.
View
Show abstract
The Transition of Academic Mental Health Clinics to Telehealth During the
COVID-19 Pandemic
Article
 * Jun 2021
 * J AM ACAD CHILD PSY

 * Johanna Bailey Folk
 * Marissa A. Schiel
 * Rachel Oblath
 * Kathleen Myers

Objective A consortium of eight academic child and adolescent psychiatry
programs in the United States and Canada examined their pivot from in-person,
clinic-based services to home-based telehealth during the COVID-19 pandemic. The
aims were to document the transition across diverse sites and present
recommendations for future telehealth service planning. Method Consortium sites
completed a Qualtrics survey assessing site characteristics, telehealth
practices, service utilization, and barriers to and facilitators of telehealth
service delivery prior to (pre) and during the early stages of (post) the
COVID-19 pandemic. The design is descriptive. Results All sites pivoted from
in-person services to home-based telehealth within two weeks. Some sites
experienced delays in conducting new intakes and most experienced delays
establishing tele-group therapy. No-show rates and utilization of telephony
versus videoconferencing varied by site. Changes in telehealth practices (e.g.,
documentation requirements, safety protocols) and perceived barriers to
telehealth service delivery (e.g., regulatory limitations, inability to bill)
occurred pre/post-COVID-19. Conclusion A rapid pivot from in-person services to
home-based telehealth occurred at eight diverse academic programs in the context
of a global crisis. To promote ongoing use of home-based telehealth during
future crises and usual care, academic programs should continue documenting the
successes and barriers to telehealth practice to promote equitable and
sustainable telehealth service delivery in the future.
View
Show abstract
The neglected health of international migrant workers in the COVID-19 epidemic
Article
 * Feb 2020

 * Andrian Liem
 * Cheng Wang
 * Yosa Wariyanti
 * Brian J. Hall

View
Telepsychology: A Primer for Counseling Psychologists
Article
 * Nov 2019
 * COUNS PSYCHOL

 * Stewart E. Cooper
 * Linda F. Campbell
 * Sara smucker Barnwell

Telepsychology is having a profound influence on professional practice.
Currently, however, many psychologists lack the requisite knowledge and skill to
provide ethical and competent telepractice services. Moreover, the field has
lagged in developing the educational and supervised experiences required to
achieve competency. Yet, there is great opportunity as well. The purpose of this
article is to identify the natural integration of the pillars of counseling
psychology with the major domains of telepractice and to link telepractice to
the values and mission of counseling psychologists. We present aspects of
telepsychology including ethical and legal factors, asynchronous and synchronous
practice, and group-focused practice along with technologies and the rules that
govern them. We also describe interjurisdictional practice, and introduce a
proposed curriculum based upon the benchmark competencies for infusion of
telepsychology into training across the professional lifespan.
View
Show abstract
Perceptions of mental health and perceived barriers to mental health
help-seeking amongst refugees: A systematic review
Article
 * Dec 2019
 * CLIN PSYCHOL REV

 * Yulisha Byrow
 * Rosanna Pajak
 * Philippa Specker
 * Angela Nickerson

Despite elevated rates of psychological disorders amongst individuals from a
refugee background, levels of mental health help-seeking in these populations
are low. There is an urgent need to understand the key barriers that prevent
refugees and asylum-seekers from accessing help for psychological symptoms. This
review synthesises literature examining perceptions of mental health and
barriers to mental health help-seeking in individuals from a refugee background.
Our analysis, which complies with PRISMA reporting guidelines, identified 62
relevant studies. Data extraction and thematic analytic techniques were used to
synthesise findings from quantitative (n = 26) and qualitative (n = 40) studies.
We found that the salient barriers to help-seeking were: (a) cultural barriers,
including mental health stigma and knowledge of dominant models of mental
health; (b) structural barriers, including financial strain, language
proficiency, unstable accommodation, and a lack of understanding of how to
access services, and (c) barriers specific to the refugee experience, including
immigration status, a lack of trust in authority figures and concerns about
confidentiality. We discuss and contextualise these key themes and consider how
these findings can inform the development of policies and programs to increase
treatment uptake and ultimately reduce the mental health burden amongst refugees
and asylum-seekers.
View
Show abstract
Show more




RECOMMENDED PUBLICATIONS

Discover more
Article
Full-text available


ACCESS TO VIRTUAL MENTAL HEALTHCARE AND SUPPORT FOR REFUGEE AND IMMIGRANT
GROUPS: A SCOPING REVIEW

July 2023 · Journal of Immigrant and Minority Health
 * Michaela Hynie
 * Anna Oda
 * Kwame Mckenzie
 * [...]
 * Michael Calaresu

Immigrant and refugee populations face multiple barriers to accessing mental
health services. This scoping review applies the (Levesque et al. in Int J
Equity Health 12:18, 2013) Patient-Centred Access to Healthcare model in
exploring the potential of increased access through virtual mental healthcare
services VMHS for these populations by examining the affordability,
availability/accommodation, ... [Show full abstract] and appropriateness and
acceptability of virtual mental health interventions and assessments. A search
in CINAHL, MEDLINE, PSYCINFO, EMBASE, SOCINDEX and SCOPUS following (Arksey and
O'Malley in Int J Soc Res Methodol 8:19-32, 2005) guidelines found 44 papers and
41 unique interventions/assessment tools. Accessibility depended on individual
(e.g., literacy), program (e.g., computer required) and contextual/social
factors (e.g., housing characteristics, internet bandwidth). Participation often
required financial and technical support, raising important questions about the
generalizability and sustainability of VMHS' accessibility for immigrant and
refugee populations. Given limitations in current research (i.e., frequent
exclusion of patients with severe mental health issues; limited examination of
cultural dimensions; de facto exclusion of those without access to technology),
further research appears warranted.
View full-text
Article
Full-text available


CORRECTION: ACCESS TO VIRTUAL MENTAL HEALTHCARE AND SUPPORT FOR REFUGEE AND
IMMIGRANT GROUPS: A SCOP...

July 2023 · Journal of Immigrant and Minority Health
 * Michaela Hynie
 * Anna Oda
 * Kwame Mckenzie
 * [...]
 * Michael Calaresu

View full-text
Article
Full-text available


HEALTH CARE NEEDS AND USE OF HEALTH CARE SERVICES AMONG NEWLY ARRIVED SYRIAN
REFUGEES: A CROSS-SECTI...

May 2017 · Canadian Medical Association Journal
 * Anna Oda
 * Kwame Mckenzie
 * Andrew Tuck
 * [...]
 * Branka Agic

Background: Canada welcomed 33 723 Syrian refugees between November 2015 and
November 2016. This paper reports the results of a rapid assessment of health
care needs and use of health care services among newly arrived Syrian refugees
in Toronto. Methods: A cross-sectional study was conducted in Toronto among
Syrian refugees aged 18 years or more who had been in Canada for 12 months or
less. ... [Show full abstract] Participants were recruited initially through
distribution of flyers in hotels and through direct referrals and communication
with community and settlement agency partners, and then through snowball
sampling. We collected sociodemographic information and data on self-perceived
physical health and mental health, unmet health care needs and use of health
care services. Results: A total of 400 Syrian refugees (221 women [55.2%] and
179 men [44.8%]) were enrolled. Of the 400, 209 (52.2%) were privately sponsored
refugees, 177 (44.2%) were government-assisted refugees, and 12 (3.0%) were
refugees under the Blended Visa Office-Referred Program. They reported high
levels of self-perceived physical and mental health. Over 90% of the sample saw
a doctor in their first year in Canada, and 79.8% had a family doctor they saw
regularly. However, almost half (49.0%) of the respondents reported unmet health
care needs, with the 3 most common reasons reported being long wait times, costs
associated with services and lack of time to seek health care services.
Interpretation: Many factors may explain our respondents’ high levels of
self-perceived physical and mental health during the first year of resettlement,
including initial resettlement support and eligibility for health care under the
Interim Federal Health Program. However, newly arrived Syrian refugees report
unmet health care needs, which necessitates more comprehensive care and
management beyond the initial resettlement support.
View full-text
Article


DEPRESSION-LEVEL SYMPTOMS AMONG SYRIAN REFUGEES: FINDINGS FROM A CANADIAN
LONGITUDINAL STUDY

May 2020 · Journal of Mental Health
 * Michaela Hynie
 * Kwame Mckenzie
 * Farah Ahmad
 * [...]
 * Nasih Othman

Background: Canada launched the Syrian Refugee Resettlement Initiative in 2015
and resettled over 40,000 refugees. Aim: To evaluate the prevalence of
depression-level symptoms at baseline and one year post-resettlement and analyze
its predictors. Methods: Data come from the Syrian Refugee Integration and
Long-term Health Outcomes in Canada study (SyRIA.lth) involving 1924 Syrian
refugees ... [Show full abstract] recruited through a variety of community-based
strategies. Data were collected using structured interviews in 2017 and 2018.
Depression symptoms were measured using Patient Health Questionnaire 9 (PHQ-9).
Analysis for associated factors was executed using multinomial logistic
regression. Results: Mean age was 38.5 years (SD 13.8). Sample included 49%
males and 51% females settled in Ontario (48%), Quebec (36%) and British
Columbia (16%). Over 74% always needed an interpreter, and only 23% were in
employment. Prevalence of depression-level symptoms was 15% at baseline and 18%
in year-2 (p < 0.001). Significant predictors of depression-level symptoms at
year-2 were baseline depression, sponsorship program, province, poor language
skills, lack of satisfaction with housing conditions and with health services,
lower perceived control, lower perceived social support and longer stay in
Canada. Conclusion: Increase in depression-level symptoms deserves attention
through focusing on identified predictors particularly baseline depression
scores, social support, perceived control and language ability.
Read more
Last Updated: 22 Oct 2024
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