Several research traditions, such as neuroscience, anthropology, public health, psychology and psychiatry, have investigated acculturation and mental health. Discipline-specific training has resulted in scholars adopting varied theoretical, conceptual, methodological and instrumental approaches to similar research questions [35]. An anthropologist may envisage acculturation to be a fluid process that is part of the resettlement experience and qualitatively explore the mental health effects of settlement. Conversely, a psychiatrist may describe acculturation to be a bi-dimensional construct that is quantifiable and statistically correlated with mental health outcomes, such as post-traumatic stress disorder, depression or anxiety. The different approaches to acculturation and mental health inquiry pose several challenges in conventional systematic review data synthesis.
A narrative synthesis is a traditional approach to reporting qualitative and mixed methods systematic reviews. This approach textually summarises quantitative and qualitative data, identifies and explores the relationship between emerging themes and assesses the robustness of the review findings [36]. Constructing narratives requires reviewers to consider the contextual factors of articles in the review, but a meta-narrative approach further analyses the narratives to explore how the phenomenon has changed over time. Documenting how this research agenda has evolved is an essential component of this review, as capturing the research progression in various academic traditions will delineate how methodologies have evolved. The evolution of this research is especially relevant and timely due to the dramatic increase in mass migration and refugee mental health research.
A meta-narrative systematic review synthesises the breadth of literature from various academic domains, critically assesses how the study contributes to the literature and constructs overarching meta-narratives that informs policy, practice and future research [37]. This approach highlights how research traditions evolved, the differences in their approach and the similar and contrasting methods and outcomes [35]. A meta-narrative approach is most suitable for this review because it provides a pragmatic and descriptive approach to literature synthesis that recognises and highlights the diversity of the various research traditions.
A meta-narrative systematic review consists of six phases: planning, searching, mapping, appraising, synthesising and providing recommendations [35]. The planning phase includes seeking collaborators to assist with refining the review questions and conducting the systematic review. The searching phase involves creating a search strategy and systematically identifying eligible studies. The mapping phase requires identifying characteristics of various research traditions and academic domains of the literature being assessed. The appraisal phase includes critically evaluating each article for its relevance and inclusion in the review. The synthesis phase consists of synthesising the relevant literature, constructing overarching narratives and highlighting contradictory findings. Lastly, the recommendation phase will include policy, practice and research recommendations.
A meta-narrative approach is sufficient in reporting findings to a broad audience, but additional analysis is warranted to generate theoretical concepts for framework development. Further analysis will be undertaken to create a conceptual framework that illuminates how dimensions of acculturation and mental health may interact. Conceptual framework analysis (CFA) is an iterative, theoretical approach to generating concepts from heterogeneous data and synthesising ideas to create a conceptual framework [38]. This analysis occurs in eight phases: mapping data sources, reading and categorising data, identifying and naming concepts, deconstructing and categorising concepts, integrating concepts, synthesising the data, validating the conceptual framework and rethinking the conceptual framework (Fig. 1). CFA will be used during the meta-narrative synthesis phase.
The meta-narrative systematic review training materials [37] and publication standards [39] were used to design this systematic review protocol. The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) was also used to guide the development of this protocol (Additional file 1) [40]. This protocol is registered with PROSPERO, the international prospective register of systematic reviews (CRD42018089148).
Planning phase
A multidisciplinary team was assembled to undertake this systematic review. BSM conceptualised the systematic review and drafted the original review questions and systematic review protocol. GM assisted in refining and finalising the systematic review protocol. Two external researchers provided feedback on the systematic review protocol and will be consulted throughout the review if additional assistance is required.
Searching phase
Empirical studies will be accessed from the following academic databases: MEDLINE, Embase, PsycINFO, Global Health, ProQuest Social Science and Web of Science. Additional peer-reviewed articles will be accessed through King’s College London online library database, which provides access to over 500 academic databases and e-journals. This exhaustive database will provide access to relevant articles that are not included in the academic databases previously listed. Articles published from database inception up until February 2018 and written in English are eligible for inclusion. Reference lists of all eligible studies will be searched to identify articles that were undetected by electronic searches.
The search strategy will include a combination of Boolean operators and MeSH and search terms that will be formatted for each database (Additional file 2). Qualitative, quantitative and mixed methods studies will be eligible for the review if they meet the following criteria:
- 1.
Measure acculturation, biculturalism or cultural adaptation,
- 2.
Measure mental health outcomes, perceived mental health, experiences with seeking mental health care and experiences with mental health help-seeking, which includes behaviours, attitudes, intentions and/or health service use,
- 3.
Participants must be adult refugees or asylum seekers, aged 18 and older, from low- or middle-income countries.
- 4.
Research must be done in a high-income country.
- 5.
The study must be written in English.
- 6.
The study must present primary, empirical data.
Studies on adolescent refugees with participants older than 18 will be further assessed for inclusion. If studies report aggregate data including adolescent and adult refugees, then the findings will be summarised separately from the adult-only results. All studies meeting the above criteria will be included in the review, regardless of a control group.
All records will be imported and managed using the EndNote citation manager. Multiple EndNote folders will be created to track the number of records throughout each stage of the review process. Duplicate records will be deleted before the initial screening phase. The screening process will occur in two rounds: title and abstract, and full-text. Both reviewers will assess a sample of the records at the beginning of each screening round to establish screening consistency and inter-rater agreement. After reaching at least 80% agreement, the reviewers will independently screen the remaining articles. If a reviewer is unsure about the study’s relevance to the systematic review, the two reviewers will meet and reach an agreement on its inclusion during each round of the screening process. If the two reviewers are unable to reach a consensus, additional reviewers will be recruited and consulted. Reasons for elimination will be provided for each record during both stages of the screening process. The number of records and reasons for exclusion during each round will be recorded in the PRISMA diagram [40].
Mapping phase
A thorough data extraction spreadsheet will be piloted on a sample of eligible studies to ensure that all relevant data is captured. The data extraction spreadsheet adapted from Noyes [41] will record the research tradition, study setting, research questions, theoretical background, participant characteristics, data collection and analysis methods, results, methodological quality and additional information specific to review questions. After reviewers reach consensus on the utility of the data extraction spreadsheet, it will be refined and used to extract data from remaining records. Two reviewers will then independently extract data from the remaining eligible studies. At the end of data extraction, a table will be created summarising the main findings of each study.
Appraisal phase
All studies will be assessed for quality using the Mixed Methods Appraisal Tool (MMAT) after evaluating full-text records for eligibility. This tool contains 21 items covering five methodological domains: qualitative, quantitative randomised control trials, quantitative non-randomised, quantitative descriptive and mixed methods [42]. MMAT is an efficient screening tool and commonly used to assess methodological quality for systematic review articles, and it is advisable that reviewers meet to establish a mutual understanding of MMAT’s assessment criteria to ensure consistency [43]. All reviewers will meet to discuss the MMAT’s usability and assess a sample of full-text articles. Reviewers will independently evaluate the remaining full-text articles after reaching more than 80% agreement on quality assessment. The results of each study will be assessed together with its methodological quality. If the quality of the overall paper is low, the article may be excluded from analysis as long as all reviewers have agreed to its exclusion.
Synthesis phase
The synthesis of findings will occur in two phases: constructing overarching narratives and building a conceptual framework (Fig. 2). This approach is influenced by grounded theory, whereby reviewers take an iterative approach to data analysis and extraction [38]. Like grounded theory, reviewers will use open (data categorisation), axial (identifying relationships) and selective (describing phenomenon) coding to identify units of meaning within the data [44, 45]. The analysis will commence during data extraction to apply new and emerging codes and categories to subsequent data. Through abductive analysis, reviewers will create inferences about the data by identifying emerging themes and observing the relationship between them [46]. Reviewers will use a constant comparison approach [47] to contrast emerging review findings to previous data extraction sheets, which will provide a systematic approach to identifying narratives and concepts.
We will create a preliminary codebook with deductive codes informed by the data extraction sheet and inductive codes that emerge during data analysis. Codebook revision and data analysis will occur iteratively, as the codebook will be revised to capture and describe the data. Analysis and codebook revisions will occur iteratively until an exhaustive list of codes has been created. The data extraction sheets and codebook will be imported into NVivo 11 for data management and analysis. Upon completion of data analysis, reviewers will meet to discuss emerging themes and overarching narratives. We will then identify the narratives of each research tradition and explore how these narratives have unfolded over time. These narratives will be explored further to understand the theoretical, conceptual, methodological and instrumental approaches in each research tradition. Due to the varied epistemological differences between and within the social science disciplines, we anticipate diverse conceptual approaches to understanding mental health outcomes of forced migrants. As a result, we will compare the similarities and differences between these narratives to create meta-narratives that summarise conceptual, theoretical and methodological praxis and critical debates in the literature [39]. These meta-narratives will highlight tensions and contradictory findings within the literature [35].
We will begin the CFA by re-examining the data to identify and deconstruct emerging concepts. This process includes identifying ontological, epistemological and methodological contributions to the literature [38]. Concepts will be synthesised to create a conceptual framework that is flexible and amenable to change. Berry [16] urges investigators to refrain from creating generalisations about groups of individuals, such as ‘minorities’ and ‘refugees’, experiencing acculturation. Therefore, this conceptual framework will serve as a guide for future refugee mental health research.
The last components of CFA include validating and rethinking the conceptual framework. Validation from scholars studying the same or similar phenomenon can help refine the conceptual framework, which is similar to member checking in grounded theory analysis. Therefore, the systematic review will be submitted for publication in a high-impact, multidisciplinary journal where constructive criticism will be elicited from refugee mental health scholars within varying research domains. The publication of these findings will encourage further discussions within the acculturation, mental health and refugee research communities on the application and utility of the framework.
Recommendations phase
The team will reconvene to discuss recommendations for future research, practice and policy after validating the findings. The overarching narratives will be primarily tailored for policymakers and mental health practitioners. Policy and practice recommendations will address practical ways to meet the mental health needs of growing refugee communities in high-income countries. The conceptual framework will be tailored to an academic audience because of its theoretical contributions to the literature. Research recommendations will explain how to advance the theoretical, conceptual, methodological and instrumental approaches to acculturation and refugee mental health research.