Explaining psychosocial care among unaccompanied minor refugees: a realist review

The RR methodology was applied to reveal the inner workings of PSC and its strategy to improve the mental, social and physical well-being for UMRs. Following the basic pillars of critical realism, by working with methodologically ideal–typical context–mechanism–outcome configurations (CMOs), a RR aims to unravel causal mechanisms [20, 21].

The RR approach [20] offers a methodological tool to study complex PSC contexts, mechanisms and outcomes for UMRs in the European context. Realist-informed CMOs can be considered as processes with contexts and outcomes constantly altering and reformulating social reality. A definition of CMOs within the RR method and the ways to elaborate them is described and illustrated in De Souza 2013 [22]. As a synthesis of existing evidence [20], the RR allows the theoretical inclusion of professionalised and daily discourses and concepts regarding UMRs. Moreover, through the use of comprehensive CMOs and with joining the findings together coherently, it aims at summarising the key findings. These CMOs will be used to formulate critical (non-discriminatory) and practical policy recommendations.

In this study, the realist approach investigates the mechanisms (M) of how and why PSC programs and contexts (C) may produce multiple outcomes (O) for UMRs. The term context in this regard denotes conditions, structures and cultures that may cause adverse or beneficial mechanisms. For instance, under asylum and youth care policies, the access of UMRs to a PSC may be hindered or fostered depending on the age and citizenship of the UMR [23]. Accomplished transformations that move from context to outcome or that are circular can then affect agency, relations and practices [22] because different factors are associated or cease to work. As an example, limited access to care services, such as regular psychiatric care, can lead to UMRs having to go to other care facilities. As ideal–typical constructs, realist CMO configurations are presented in a mechanism (M) that might result in different outcomes, including undersupply or the need for specific care strategies (O). For instance, in a given contextual environment, a certain UMR psychosocial context comprising asylum and youth care law alters care conditions and constraints, “which then triggers mechanism(s) that produce both intended and unintended outcomes. Intervention X may work well in one context but poorly or not at all in another context” [24]. An example is the undersupply that can occur when the treatment is not youth- or migration-sensitive.

The goal is to visualise CMO configurations [25], knowing that underlying mechanisms may be hidden [24, 26]. According to realist guidelines, [20, 27] this RR applies six stages: (1) identifying the review question, (2) formulating an initial theory, (3) searching and selecting primary studies, (4) extracting evidence, (5) appraising study quality, and (6) synthesising relevant and contradictory data [20, 27, 28]. Resulting in an evidence-based framework, an initial theory will be tested, substantiated and refined by empirical data. As “realist-informed” [21], this RR is consistent with the RAMESES publication standards (Supplementary file 1) for realist syntheses [24].

Stage 1: identifying the review question

The question is how PSC works (C) and why specific mechanisms (M) determine (un-)intended PSC outcomes (O), conditioned by asylum and youth care policies.

Stage 2: formulating an initial theory

The underlying initial theory model serves as the first orientation tool of the method. As a starting point in our attempt to outline the contexts and conditions of PSC, it functions to subsequently compare the findings of the literature review. The theory aims to produce a hypothesis with an innovative character. The theory model contains a three-dimensional conceptualisation based on micro-, macro- and discursive levels. Thus, these three levels include subjective characteristics of UMRs and social phenomena in everyday life at the micro-level and political regulations that determine their PSC system at the macro-level. Discourses and stereotypes—depending on how something is talked about or defined—which form social life, comprise an intermediate level in the model (shown in the pyramid as a peak). (Fig. 1).

Fig. 1figure 1

Initial theory on PSC for UMRs

The general division between micro- and macrostructural levels of PSC allows the inclusion of the UMRs’ protective and risk factors, social conditions, societal surrounding (such as living conditions) and psychological health. All these phenomena arise and have effects on the micro-level as well as on the macro-level.

These macro and micro factors can be mediated by daily and specialised UMR-related discourses and concepts. Such a theory must reflect the PSC needs of UMRs and the context factors, including assimilation and acculturation theories [29]. The theory building offers a comprehensive sociological,process-related model that seeks to refine the key premises, general conditions and modes of operation of PSC.

First, the micro-level of the initial theory consists of predisposing factors, PSC needs and utilisation. Taking into account the variety of different spatial and gender-specific contexts, utilisation as a microsocial factor must be included in the preliminary considerations of an initial theory [30].

The micro-level of the initial theory is moreover combined with theories of developmental psychology as well as a flight phase model that might include preflight experiences (e.g., war). Insights into the psychological processes of personal development and its challenges are given by Rossman et al. [31]. The theory model’s editing information concerning the phases of flights is provided by the flight phase model, which connects flight experiences with a processual understanding of trauma [32]. Both models can nurture the proceeding by giving insights into the UMRs’ specific challenges related to their young age as well as the particularities of their flight experience [33].

Second, within the theoretical framework, the individual level is fundamentally linked with macrostructural factors, such as health and migrations policies, on different regulatory levels.

Third, another element of the theory construct covers the discourses and concepts of PSC for UMRs and links micro- and macrosocial outcomes. Here, the theory aims at capturing intersections of individual, structural, and discursive contexts that influence PSC. This part is strongly inspired by approaches and recent debates of intersectionality and othering discourses that focus on public and migrant health [34,35,36]. The inclusion of intersectional perspectives enables the model to consider overlapping inclusions and exclusions, i.e., discrimination and privileges. The approach can also be helpful with regard to public and global health research that focuses on care situations for migrants and refugees [37].

Within the focussed discourses, othering denotes a sociopsychological differentiation process from people (or the self) in relation to the host community. In this process, migrants are perceived as “others” and as alienated from the in-group (e.g.,german host society).

For example, the sequential trauma concept (as part of special scientific discourses) that understands trauma as processual and contextual [38] everyday discursive events, such as othering and narratives about UMRs, are conceptually included. The barriers of PSC might then become effective on a general language-based, cultural or juridical level.

The first overview of the possible conditions and mechanisms of the PSC of UMRs now offers the starting point for the literature search. The theoretical considerations are first kept in mind and are presented again in the evaluation of the search results, which makes it possible to compare the preliminary considerations with the results. Therefore, the aim of the RR is to explain different findings from the literature on different theoretical bases and not to only use one initial theory as a basis for interpretation.

Stage 3: Searching and selecting primary studies

To refine the initial theoretical framework, based on a search query for empirical evidence dating from 2005 until 2019, the studies’ search was performed between January and March 2019. The publication period was chosen because of the particular interest in the European migration context since 2005, the year when the council of the European Union published a directive on the minimum standards for the procedures for granting and withdrawing refugee statuses [39]. Since then, the directive has become effective as a set of common rules for dealing with asylum seekers across the EU.

Using the electronic databases Social Sciences Citation Index (Web of Science), PubMed/MEDLINE and GBV (German library network), the primary research articles and review studies were chosen and considered to be of the highest relevance to the scope and focus of the study. The RR focuses on the PSC situation of UMRs in Germany, not least due to Germany’s special position as a receiving immigration country in 2015 and 2016. Still, the body of literature, which includes important theoretical approaches from the pan-European context, and empirical data are included.

Search terms pertaining to UMRs in all topics and fields in articles in the above-mentioned electronic databases were chosen and included. First, common acronyms for UMRs and Unaccompanied Refugee Minors as well as Unbegleitete Minderjährige Ausländer were searched in the following style: “UMR” OR “URM” OR “UMA”. A second step included broadening the search by using fully written forms in a single search procedure: “asylum seeker OR asylum-seeking OR refugee OR migrant OR displaced OR Flüchtling OR Geflüchtet AND Minor OR young OR adolescent OR minderjährig OR junge OR youth AND Unaccompanied OR separated OR unbegleitet”.

In total, 974 potentially relevant titles were imported into the electronic literature database (Fig. 2). The articles’ exclusion due to their allegiance to the research period and the deletion of duplicates led to 517 left publications. Non-English or non-German articles were excluded (n = 5) because of the focus explained above, and the large majority of the screened evidence was published in peer-reviewed English and German language journals.

Fig. 2figure 2

Flowchart Stage 5: appraising study quality

With regard to their relevance for the study scope and their matching against the exclusion criteria displayed in Table 2, these 517 titles and abstracts were screened and independently checked by HSU and EK. Based on the previously mentioned criteria, 448 studies were excluded, as the main focus of these studies was not UMRs, their mental health (as for psychological problems and psychiatric symptoms), their legal situation or the European context. The non-European evidence was excluded. The excluded literature mainly focused on refugees in general, accompanied minor refugees or on refugees in the South American and Oceanic contexts. Moreover, editorials, letters and commentaries were excluded.

Table 2 Inclusion and exclusion criteria used for the screening of the study’s scope: inclusion/exclusion criteria

For full-text screening, the selection included 34 articles (Fig. 2); articles based on the “realist review’s focus on relevance and rigor.” were chosen. This required an appraisal of the “study quality” [24]. In a realistic synthesis, relevance assesses whether an article is capable of contributing to the construction of CMOs, while rigor influences the validity and trustworthiness of the evidence. The screened empirical evidence was tested, substantiated, and refined with CMO configurations regarding the PSC of UMRs. The results relate to outcomes pertaining to PSC barriers, sociological outcomes (e.g., discourses) and medical outcomes (Table 2), such as the levels of access and (health) care claims of UMRs. In total, 7 articles were added by reference checking, and 42 texts were dropped, as their relevance was too thin and their rigor was found not to be valid enough for the study’s scope. For example, some of the excluded studies were mainly concerned with medical issues, such as tuberculosis, or juridical details around asylum law.

Stage 4: extracting evidence

Finally, 34 articles that contained empirical evidence of sufficient rigor and relevance were retained, and these articles were included in the extracting and synthesising process (Fig. 2). Studies on the psychological and mental well-being of UMRs were dominant (n = 21). A MAXQDA document served as a variables’ manager, by which for each article, eight categories were applied to document characteristics, such as study design, data or methods, journal or publisher, year, country, scientific discipline, relevance and rigor [21]. This document is provided in Supplementary file 2. To ensure collaborative and gender-sensitive insights, one male and two female sociologists, namely, HSU, EK and MM, interpreted the data. Furthermore, by collaboratively comparing the topics and theoretical approaches, the empirical evidence was checked against the theoretical frameworks, to potentially integrate it into a refined theory and final framework.

Stage 5: appraising study quality

The final screening of full-texts functioned as a quality appraisal process for the evaluation of relevance, rigor and outcomes. Using MAXQDA software [40], HSU openly and axially coded the extracted evidence, and after the content was allocated to codes within categories, EK and MM carried out a subsequent and collaborative review of the generated code and category system. Followed by qualitative (n = 6), quantitative approaches (n = 4), mixed-methods designs (n = 3), and monographs (n = 3), reviews and systematic syntheses (n = 15) were used in the majority of the selected articles. The relevance of the selected papers was classified by the “thick/thin continuum” [21], which refers to a paper’s density of evidence regarding CMOs that are relevant to the study’s scope. Thick titles included rich and detailed accounts of relevant CMOs pertaining to PSC among UMRs, whereas thin contributions offered sparse data [21, 28]. Thin articles predominantly measured just one relevant aspect, such as psychological interventions for UMRs, without revealing much about mechanisms that could have mediated any observed effect and could have provided a wider context. By taking into account the rigor and richness of the evidence, the relevance of the selected papers was categorised as a thick, moderate or thin contribution [21, 28]. The multiple occurrences of the term “UMR” as well as the potential of the texts to provide extensive or specific knowledge about the sought-after topic’s rigor and richness were measured constantly. Qualitative and mixed-methods studies tended to provide thicker evidence than did quantitative works, whose content was predominantly moderate or thin with respect to relevant CMO compositions (Supplementary file 2).

Stage 6: synthesising relevant and contradictory data with propositions

Four steps were taken to synthesise the final empirical evidence. First, based on the extraction of the interrelated CMOs—concepts explaining mechanisms-, the superordinated CMO propositions were formulated. As a kind of summary heading, these propositions did not entirely reflect all mechanisms, but they were “close enough to observed data to be incorporated in propositions that permit empirical testing” [41].

Second, according to a realist synthesis, HSU identified mechanism patterns, also known as “demi-regularities” [28], which are “semi-predictable patterns or pathways of programme functioning” [25]. What is meant here are findings from processes described in the literature, which then constitute a starting point for an assumption that other comparable processes could proceed in a similar way. These observed patterns were formulated into continuously revised and refined realist CMOs, such as “If programme activity (PA) xn + 1 in context (C) xn + 1, then mechanism (M) xn + 1 is put in place that will then lead to outcome (O) xn + 1 [20].” These patterns are represented in process formulations in CMO form.

Third, the formulated sub-processes and mechanisms summarizing CMO propositions were again checked by re-reading the papers and considering the initial theory. Throughout the synthesis process, they were tested with primary evidence and against contradictory findings [21, 28]. Finally, HSU, EK and MM checked whether the evidence was used properly in the interpretative synthesis, and after discussions, all authors agreed upon potential misreadings and ambiguities [28, 42].

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