PLoS ONE plos plosone PLOS ONE 1932-6203 Public Library of Science San Francisco, CA USA 10.1371/journal.pone.0302591 PONE-D-23-29946 Research Article People and placesGeographical locationsNorth AmericaCanada Medicine and health sciencesMental health and psychiatry People and placesGeographical locationsAfrica Biology and life sciencesNeuroscienceCognitive scienceCognitive psychologyLanguage Biology and life sciencesPsychologyCognitive psychologyLanguage Social sciencesPsychologyCognitive psychologyLanguage Earth sciencesSeasonsWinter Social sciencesSociologyEducationSchools People and placesDemographyRefugees Social sciencesSociologyCulture From struggle to strength in African and Middle Eastern newcomers’ integration stories to Canada: A participatory health equity research study African and Middle Eastern newcomers’ integration stories to Canada https://orcid.org/0000-0002-8138-6958 Fong Maggie Data curation Formal analysis Investigation Visualization Writing – original draft Writing – review & editing 1 Liu Amy Formal analysis Investigation Visualization Writing – original draft Writing – review & editing 2 https://orcid.org/0009-0007-4573-4648 Lung Bryan Formal analysis Investigation Visualization Writing – original draft Writing – review & editing 3 4 https://orcid.org/0000-0003-2687-8041 Alayche Ibrahim Formal analysis Investigation Writing – original draft Writing – review & editing 5 https://orcid.org/0000-0001-5042-0140 Sayfi Shahab Data curation Formal analysis Resources Writing – review & editing 6 Kirenga Ryan Yuhi Resources Writing – review & editing 7 Chomienne Marie Hélène Formal analysis Writing – original draft Writing – review & editing 8 9 10 Saad Ammar Formal analysis Writing – review & editing 9 Grenier Jean Formal analysis Writing – original draft Writing – review & editing 8 10 11 https://orcid.org/0000-0002-9565-1740 Kassam Azaad Formal analysis Resources Writing – review & editing 12 https://orcid.org/0000-0003-0381-4491 Ahmed Rukhsana Formal analysis Resources Writing – review & editing 13 https://orcid.org/0000-0002-1874-8346 Pottie Kevin Conceptualization Formal analysis Funding acquisition Methodology Project administration Supervision Visualization Writing – original draft Writing – review & editing 10 14 * Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada Department of Interdisciplinary Medical Sciences, Western University, London, Ontario, Canada Department of Anatomy and Cell Biology, Western University, London, Ontario, Canada Department of Biochemistry, Western University, London, Ontario, Canada Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada The Vulnerability, Trauma, Resilience and Culture Research Laboratory (V-TRaC), University of Ottawa, Ottawa, Ontario, Canada Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada Institut du Savoir Montfort, Ottawa, Ontario, Canada School of Psychology, University of Ottawa, Ottawa, Ontario, Canada Department of Psychiatry, University of Ottawa, Ottawa, Ontario, Canada Department of Communication, University at Albany, State University of New York, Albany, New York, United States of America Department of Family Medicine, Western University, London, Ontario, Canada Alamgir A. K. M. Editor Access Alliance Multicultural Health and Community Services: Access Alliance, CANADA

The authors have declared that no competing interests exist.

 * E-mail: kpottie@uwo.ca 30 4 2024 2024 19 4 e0302591 19 9 2023 8 4 2024 This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication. Background and objectives

Newcomers (immigrants, refugees, and international students) face many personal, gender, cultural, environmental and health system barriers when integrating into a new society. These struggles can affect their health and social care, reducing access to mental health care. This study explores the lived experiences of African and Middle Eastern newcomers to Ontario, Canada. An understanding of newcomer integration challenges, successes and social justice issues is needed to improve health equity and social services.

 Methods

In this qualitative study, we used a participatory research approach to collect stories reflecting participants’ integration perspectives and experiences. Beginning with our immigrant community network, we used snowball sampling to recruit newcomers, ages 18 to 30, originating from Africa or the Middle East. We used qualitative narrative analysis to interpret stories, identifying context themes, integrating related barriers and facilitators, and resolutions and learnings. We shared our findings and sought final feedback from our participants.

 Findings

A total of 18 newcomers, 78% female and approximately half post-secondary students, participated in the study. Participants described an unknown and intimidating migration context, with periods of loneliness and isolation aggravated by cold winter conditions and unfamiliar language and culture. Amidst the struggles, the support of friends and family, along with engaging in schoolwork, exploring new learning opportunities, and participating in community services, all facilitated integration and forged new resilience.

 Conclusions

Community building, friendships, and local services emerged as key elements for future immigrant service research. Utilizing a participatory health research approach allowed us to respond to the call for social justice-oriented research that helps to generate scientific knowledge for promoting culturally adaptive health care and access for marginalized populations.

 http://dx.doi.org/10.13039/100012777 Institut du savoir Montfort-Recherche 1920-HQ-000305 https://orcid.org/0000-0002-1874-8346 Pottie Kevin The study was financially supported by the Institut du Savior Montfort (1920-HQ-000305) at the Montfort Hospital, Ottawa, Onartio, Canada. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. Data Availability Data cannot be shared publicly because of ethical concerns. Minimal data set underlying the results described in our manuscript has been provided in the supporting information files. Complete data are available from the Montfort Hospital Institutional Data Access / Ethics Committee (contact Marie-Andrée Imbeault via email at marieaimbeault@montfort.on.ca) for researchers who meet the criteria for access to confidential data. Introduction

In 2021, Canada’s population had its largest proportion of immigrants in over 150 years, with the proportion of those from Africa and the Middle East steadily rising [1]. Ontario received over 40% of all immigrants to Canada [2]. Currently, in Canada, more than a tenth of newcomers (immigrants, refugees, and international students) are 18–30 years of age and it is expected that 30–49% of the total Canadian population will consist of children and youth with an immigrant background by 2036 [3]. Therefore, it is critical that Canada’s health care system be accessible and provide culturally adaptive care to help young newcomers improve both their physical and psychological well-being. Research suggests there are unmet needs to access health care specific to immigrants in Canada [4]. The likelihood of accessing mental health care among newcomers also varies depending on their world region of origin [5]. Despite a growing population of newcomer youth in Ontario, comprehensive understandings of newcomer youth experiences and their integration to Ontario are underdeveloped, especially for Ontarian newcomer youth from Africa and the Middle East [6].

Young newcomers can be particularly vulnerable to mental health issues, as they often face additional personal, gender, cultural, environmental, and socioeconomic barriers when integrating into a new society [7]. Resettlement challenges can impact the mental health of newcomers and further reduce access to appropriate resources and care [8]. There is a need to understand factors that challenge and guide young newcomers’ integration journeys in Ontario and their implication for community and mental health care resources. An understanding of the lived experiences of newcomers through their integration challenges is, therefore, needed to improve access to and uptake of mental health services [9,10].

We used a community-based participatory research approach to reduce racial and ethnic health inequities and to influence health service policy [11]. This project is part of a larger participatory health research (PHR) program with refugees and other migrants at the Canadian Collaboration for Immigrant and Refugee Health (www.ccirhken.ca). Trust is recognized as a key component to story collection [12,13], and thus we used our existing youth leaders from the CCIRH to begin the process and contribute to the research interpretation. Building on the success of narrative research approaches to study health professional integration [14], our objective was to capture stories that inform our understanding of our participants’ early integration lived experiences.

 Methods Ethics statement

Written informed consent was obtained by all participants and the study was approved by the Institutional Review Board at the Montfort Hospital: File ID Number: 22-23-08-022.

 Methodology

We used a community-based participatory health approach [15] together with narrative analysis [12,16] to capture the lived experiences of newly arriving youth newcomers to Ontario, Canada and how their experiences magnified or reduced social injustice during their resettlement. We purposefully sampled newcomers from Africa and the Middle East to understand participants coming from some socio-politically unstable regions. Our culturally diverse research team included several newcomer youths with immigration-related experiences, along with communication, cultural psychiatry and primary care expertise. Our research team emerged from existing Canadian Collaboration for Immigrant and Refugee Health co-design sharing circles and the intent to both work with and potentially help newcomer youth as part of the evolving PHR approach. We reflected as we worked together on our story project and decided to embark on a formal story research project. Three young community leaders (AS, SS, RYK) played a key role in recruiting participants and building trust throughout the study period and thereafter. We performed an inductive qualitative analysis of newcomer stories to investigate the challenges, lived experiences, and successes newcomers face when they first arrive in Ontario.

 Participant recruitment and eligibility

Participants were informed about our study through an infographic invitation poster shared by our colleagues from the University of Ottawa and Western University. Beginning with our community youth leaders/co-researchers, snowball sampling was used to recruit participants. To be eligible for this study, a newcomer had to be: between 18 to 30 years of age; either an immigrant, refugee, or international student; originated from Africa or the Middle East and arrived in Ontario within the last 10 years; were affiliated with an Ontario institution or non-governmental organization; able to read and write in English or French; and able to provide informed consent. For psychological safety reasons for our participants, we did not include migrants within their first year of arrival, and we selected migrants with some existing community ties to reduce risks and ensure existing support. Our newcomer youth leaders played a key role in building trustworthy relationships with potential participants, and this trust was essential to inspire and collect authentic stories from vulnerable youth.

 Research activities

For this qualitative study, our core framework consisted of a community-based participatory approach [15]. We supported our three young community leaders in recruiting participants into the project and building trust with them throughout. Co-researchers with lived experience immigrating from Africa or the Middle East were involved in each stage of the research project: design, recruitment and data collection, analysis, and writing. Study data were collected and managed using REDCap electronic data capture tools hosted at the Montfort Hospital. Participants were required to complete a questionnaire collecting information about their age, gender, country of origin, migration status, education level, French/English proficiency, and student versus employment status. Participants were provided with an e-learning module on storytelling, which outlined prompts and story examples to guide participants. Participants then shared a written story about their integration experience and journey. The written stories were anonymized by removing all identifiable information. All French stories were translated by a bilingual co-researcher (BL) and validated by another (IA) to mitigate language translation biases. We sought a range of feedback from participants as part of the research process.

 Analytical approach

Four youth researchers (MF, AL, BL, IA) were trained and supervised in narrative qualitative analysis by two researchers (RA, KP). The primary analysts were undergraduate students who were similar in age to some participants. Prior to data collection, researchers wrote stories based on experiences as second-generation immigrants and from witnessing those around them. This exercise allowed researchers to reflect on their perspectives and potential reflexivity. The researchers independently immersed, read, and reflected on the collected narratives. They used inductive analysis to identify themes within the framework of a narrative synthesis [16]: context, barriers, facilitators, and resolution. The themes were agreed on within the larger research team, and all stories were coded accordingly by each youth researcher. The analysts then extracted representative quotations for the themes. Disagreements in interpretation were resolved through discussions with the larger research team. We collected stories until new themes were no longer arising (saturation). For credibility, the summary of themes and quotations was shared with our youth leader co-investigators and our general group of participants for member checking to validate our interpretation of participant experiences. Finally, we sought feedback from participants on the impact of their story writing experience.

 Results Study participants

Eighteen youth newcomers participated in the study, sharing eighteen written stories. The characteristics of the participants are presented in Table 1. In summary, fourteen participants (77.8%) identified as females, whereas only four (22.2%) identified as males; the majority were students (55.6%) and immigrated from Africa (72.2%). Most participants completed some form of high school or higher education. English was the primary language most participants preferred for both communication and medical care (88.9%). However, most of the French-speaking participants were also proficient in English.

10.1371/journal.pone.0302591.t001 Participant characteristics.
Characteristics Frequency(n = 18) Percentage (%)
Gender Female 14 77.8
Male 4 22.2
Area of Origin African 13 72.2
Middle-Eastern 5 27.8
Immigration Status International Student 9 50.0
Economic Immigration 4 22.2
Refugee 2 11.1
Other 3 16.7
English Proficiency Level Basic 1 5.6
Proficient 15 83.3
Native Language 2 11.1
French Proficiency Level Basic 5 27.8
Intermediate 3 16.7
Proficient  7 38.9
Native Language 2 11.1
Prefer not to Answer 1 5.6
Preferred Language when Receiving or Engaging Mental Health Services English  16 88.9
French  1 5.6
Other 1 5.6
Highest Level of Education Completed Grade 10 to 12 7 38.9
College Diploma 3 16.7
Bachelor’s Degree 2 11.1
Master’s Degree or Doctorate Degree 4 22.2
Prefer not to Answer 2 11.1
Employment Status Full-time Employment 7 38.9
Unemployed 1 5.6
Student 10 55.6
Context

(i) Academic institution: Some participants felt that integrating into a new school system can be very challenging at first. Some challenges included not knowing where a newcomer belongs and feeling isolated within the large classroom sizes of the Canadian postsecondary system. However, with time and support from school resources, school became a great opportunity to feel a sense of responsibility and foster knowledge and skills towards pursuing ambitions. School was also perceived to serve as a starting point for young newcomers towards establishing meaningful relationships with other young people in Canada.

“What struck me on my first day of university was how little interest people had in talking and making new relations. Where I come from, university classes were very similar to high school classes…Classes here had more than 200 students in them, and so people just wanted to attend the class and leave. That definitely led to a sense of isolation at first, as I also had trouble knowing what to say and to whom.” -Kemi, a male from Africa

“The black community in my university was very welcomed and friendly. They showed me around campus and were there to answer any questions I had about the student experience in my university (how to get a bus pass, how to get a meal plan, etc.).” -Amna, a female from Africa

(ii) Work experiences: Being a newcomer poses unique circumstances that make it difficult to have the same work opportunities as those born in Canada. For some participants, it was important to find a stable source of income upon arrival to Canada in order to support themselves and their families. However, despite knowing English and having work experiences in their country of origin, some experienced difficulties finding opportunities in Canada due to a limited social network. No stories directly suggested discrimination as a barrier. Multiple newcomers discussed cashiering as their first source of income. Nevertheless, once newcomers found meaningful work experience in Ontario, they appreciated the cultural immersion and meeting new people.

“As an immigrant, it was hard for me to find employers who were willing to hire someone with no Canadian experience or references.” -Sade, a male from Africa

“I decided to help out and get a job, but it was hard because I had no work experience in Canada”. -Youssef, a male from the Middle East

 Integration-related barriers

(i) Winter weather conditions: The frigid winters make adapting to Canada more difficult and isolating for newcomers. Oftentimes it can take a toll on newcomers physically, emotionally, and socially. The winter season in Canada felt very foreign to many participants, especially those from more tropical weather. With often gloomy weather, it was more difficult for many to take care of themselves. As the days were shorter and colder in the winter, the challenge to get out of home to exercise, get fresh air and meet new people was expressed in many of the stories. Therefore, achieving basic needs and feeling a sense of belonging during this time can seem more difficult for newcomers.

“No one prepares you for the kind of cold you experience here in Canada especially so when you’re moving from a warm country like Kenya… .The depression that winter brings is one that has been spoken about quite a lot in the form of seasonal depression. I too, was a victim to this shortly after landing. I was particularly enraged by the ’fake sun’ which is what I’d call it when the sun was out, shining despite it being -30 outside.” -Fatima, a female from Africa

"My biggest challenge while living in Canada is the cold, which is unavoidable and can really take a toll on one’s mental health." -Kofi, a male from Africa

(ii) Culture and language barriers: Cultural and language differences brought a sense of disconnect from new communities. Upon arrival in Canada, newcomers are often unfamiliar with English or French language expressions. Local idioms are common and are key to communicating effectively [17]. These disparities were perceived as challenges to communication and a source of confusion regarding expectations and norms. Thus, it was common for some participants to feel out of place or have difficulty making new connections.

"One of the first incidents I noticed was language disparities; it seemed that the way I learned English was not practical enough. Adversely, I discovered many of my classmates are bilingual. My mentality was moving on a downward slope, and I was fueled by the belief that my journey had failed." -Noura, a female from the Middle East

"When I first arrived in Canada, I felt overwhelmed by the language barrier. Although I had studied English in Nigeria, it was still hard for me to understand the Canadian accent and slang. This made it difficult for me to communicate with people around me and make new friends." -Sade, a male from Africa

(iii) Isolation, loneliness, and loss of hope: Lack of family, friends, and community fosters integration difficulties and a sense of loneliness for newcomers. Upon arrival to a new country, feelings of loneliness and isolation arose due to the distance from family and friends. Many participants expressed difficulties finding and creating new meaningful connections when they first arrived in Canada, resulting in mental health challenges.

"The other thing that hit me so hard about this country is the loneliness that is so omnipresent. You can go a whole day without people ever acknowledging your existence."—Thierry, a male from Africa

"My mentality was moving on a downward slope, and I was fueled by the belief that my journey had failed. After four months, stress, anxiety, and somehow depression overcame me. I went back to my home country. I lost considerable weight in just four months, and this made my parents feel nervous about my mentality." -Noura, a female from Middle East

(iv) Lack of resources and unknown scary migration context: For many participants, the transition to Canada was both thrilling and terrifying. Many found it scary not knowing what the future held for them in their new country. Oftentimes, this was intensified when newcomers were separated from their families and social circle. Many described not knowing where to obtain basic services when first settling down or not having the resources necessary to facilitate their integration. Some participants specifically expressed challenges with locating and accessing mental health services. Beyond the fears, many also found the transition exciting when thinking about the new opportunities that may instill them in this new country.

"There is so much about Canada that no one never really warns you about. It’s the unknown of it all that made my transition to Canada so daunting." -Thierry, a male from Africa

"Before coming to Canada, I was scared about how my experience would turn out. Moving to a whole new country can be scary and you actually never know what to expect." -Amina, a female from Africa

 Integration-related facilitators

(i) Social support: Having family and friends to support newcomers’ new journey into Canada helped ensure a smooth transition into a new society. Unfortunately, those that did not have this level of social capital found it challenging to resettle. However, one of the primary objectives of immigrating to Canada, for many, was to establish a social circle and create meaningful connections with individuals who share similar interests.

"I’ll always be thankful for having relatives in this country because they make my experience easier. When I have a problem, or miss my family, I can just call them and they’ll always be there for me." -Amina, a female from Africa

“I had a couple of friends here who supported me and gave me all the guidance I needed.” -Amara, a female from Africa

(ii) Diversity: Participants discussed their appreciation for multiculturalism, which was first experienced by many in Canada. Diversity and pluralism (an ethic of respect for diversity, viewing diversity as a strength and putting it into action) found in Canada was a major facilitator to help newcomers integrate into Canadian society. The ability to express one’s own cultural beliefs and practices in the absence of one’s own community made Canada more safe and welcoming. This might be the result of newcomers being able to find individuals who share their culture, norms, values, and hobbies, allowing these newcomers to bond with people more easily.

“At the same time, moving here can be so exhilarating, exciting even because you get to start a fresh, get to experience new things, different people and cultures” -Fatima, a female from Africa

“My positive moments were the cultural diversity I felt in Canada, work opportunities, and all the activities that I could do over here.” -Ayana, a female from Africa

(iii) New opportunities: Discovering new opportunities, whether that be for work or for higher education, helped participants grow and learn from others around them. Immigrating to Canada was perceived to advance newcomers’ career paths and facilitate providing better support for themselves or their families. Many were confident in their ability to find a balance between school or work and their personal life, which led them to explore hobbies and interests.

“Another positive moment was being able to pursue higher education opportunities in Canada that weren’t available in Nigeria. With access to quality education, I was able to further my studies and gain valuable knowledge that has helped shape my career path today.” -Sade, a male from Africa

“I have recently learned to find ways to interact with people here. I joined a boxing club and made many new friends there, friends from all over the world.” -Thierry, a male from Africa

 Resolutions and learning

(i) Hope and needing time to adapt: Newcomers’ perspectives around the accessibility and ability to ask for support, a sense of belonging, and the endless opportunities that once seemed impossible to reach, brought happiness and hope. Time, patience, and the willingness to accept change allowed many participants to embrace the new environment. In several stories, participants highlighted that their initial experiences in Canada were not always as they had hoped and that it typically required a period of adjustment. Many expressed the need to adapt and change their perspectives to improve their well-being and feel more comfortable in their new environment.

“In one year, Canada gave me a sense of belonging that I did not ever feel during my 28 years living in Lebanon. Adapting to the language, culture, and people is still something I work on every day. It is part of me growing as a person and opening up to this new side of the world."… "I hope that in a few years, I will be able to confidently say "Canada is home". -Cilia, a female from the Middle East.

“Things improved as I began to understand the dynamics and interactions of students here. I had to adapt and change to how I thought I should be.” -Kemi, a female from Africa

(iii) Developing new strategies and gaining resilience: Becoming involved in community, whether through hobbies or programs offered on campus, helped participants connect with others and feel a sense of belonging (an internal sustained psychological state). Many participants emphasized the need to connect with others to develop a sense of belonging. To achieve this, participants mentioned that involvement at community centers helped them access resources and engage further with others. Indeed, many newcomers emphasized that they had to proactively develop strategies that would enable them to integrate smoothly with their community and social circle. Additionally, participants expressed that the resolution to persevere and the ability to learn from adversity enabled them to cultivate diligence and independence, transforming them into a better, more resilient version of themselves.

"I do believe that all those experiences, for better or worse, shaped me into the person I am today. I learned a lot about myself over the last few years, and so despite the challenges and the difficulties, I wouldn’t change much. It taught me resilience and endurance, and that it was fine to be on your own for a while. It also taught me that I am much stronger than I believed I was, and those lessons I will carry with me wherever I go." -Kemi, a female from Africa

"Overall, I’m very grateful for all the struggle I went through cause it taught me hard work and not depending on others." -Youssef, a male from Middle East

 Discussion

This study has engaged and explored the lived experience of young people immigrating to Ontario from Africa and the Middle East. The findings of this study shine a light on key challenges and adaptive processes that play out in the lives of newcomers. We identified common struggles with isolation and loneliness related to Canadian winter, large and impersonal classrooms, and cultural, language and employment barriers. We identified transitional experiences that included finding and developing social connections and family support. Finally, the stories highlight the discovery of opportunities that may be associated with social health and engagement within a pluralistic society. Our participatory approach to story sharing allowed participants to reflect on their own challenges and adaptive means to overcome barriers in collaboration with sharing story themes with other participants. Sharing written stories required literacy, trust, resilience, and self-confidence, which are also key attributes that enable emerging leaders.

The most common barriers leading to a feeling of isolation in this study were winter weather conditions, cultural and language barriers, and a feeling of having limited integration resources. Feeling unprepared for weather and immigration transition challenges was a common lived experience for newcomers integrating into the Canadian context. The severe Canadian winter led to isolation and was identified as an imposing barrier to developing social connections, a challenge that is not always spoken about in settlement information. This can lead to feelings of loneliness and prevent newcomers from establishing a sense of belonging and home in their new environment. Winter weather as a prominent Canadian integration barrier is often not discussed in the literature. It would be important to place consideration on this barrier in the development of culturally competent services for newcomer youth. Ensuring that newcomer youth are equipped with the knowledge and resources to help them adjust to the Canadian winters prior to arrival may also mitigate fears and stresses that were commonly associated with the unknowns of moving to Canada.

Similar to our findings, various Canadian studies discuss getting accustomed to new languages, social isolation, and cultural identity confusion as common post-migration barriers for newcomer youth [7]. Young newcomers often discussed challenges in establishing social networks and meaningful connections in school [6]. Newcomer students often felt like outsiders due to the large size and lecture-style classes.

Newcomers who were able to develop supportive social networks in Canada often reported more positive academic experiences compared to those who reported feeling isolated. Our findings highlight the need for community social resources in the academic setting to support newcomers not only academically, but also socially and psychologically to ensure better productivity and well-being [9,18]. School and work environments made an early impact on newcomers’ integration journeys. Student resources and clubs catering to newcomers and international students facilitated transition into their academic setting. Cultural diversity and pluralism in the workplace and school environment can also help improve integration experiences of newcomers and make it seem less intimidating. Therefore, many newcomers described their experiences as students, employees, or both as a prominent part of their identity and integration story in Canada. Programs that provide opportunities for youth to form peer relationships or connect with other newcomers to exchange information on support and integration would be beneficial [19].

Newcomer participants often referred to seeking new opportunities as positive situations that facilitated their integration into Canadian society. Newcomers who focused on opportunities appeared better able to address their anxiety in a new country. This interpretation may be justified by a qualitative study on social support for immigrants and refugees in Canada, in which newcomers valued social health and support since it fosters a sense of empowerment, community, social integration, building networks, sharing experiences/problems, reducing stress, and physical/mental distress [20]. Furthermore, another common theme among newcomer-written stories is the seeking of new opportunities in Canada. Based on a study on immigrant and refugee youth in Montreal, Canada, these individuals have encountered opportunities and successes that helped them adapt to living conditions when first settling down in Canada [8]. Accordingly, The Resilience Framework [21] also suggests that finding new opportunities also helps newcomers plan out their future, allowing them to achieve their final goal. Therefore, discovering new opportunities proves to be a strong facilitator that helps Canadian newcomers integrate into a new society.

Some stories discussed the challenges of focusing on other aspects of life, such as careers, ambitions, or education when basic living necessities are a concern. These findings support ideas of The Resilience Framework, which emphasizes the importance of prioritizing basic needs when trying to build resiliency within vulnerable populations [21]. Our findings highlighted the challenges many newcomers face with finding job opportunities when first arriving in Canada. Multiple newcomers discussed the frustration of not having their past work and academic experiences validated in Canada. This finding possibly suggests that limited employment among young newcomers were confounded by language barriers and limited validation of academic credentials [6,9].

Our findings strongly support previous recommendations for embedding more mental health support and other social services at the community level rather than clinically for newcomers [22]. This strategy helps to increase accessibility as well as reduces potential cultural stigma and mistrust in health professionals. More importantly, these resources and services should be newcomer-focused and newcomer-led. Ensuring newcomers within the communities are integrated into the decision-making and leadership processes is pivotal to both service users and the community as a whole [22]. Being able to meet other newcomers who have shared similar experiences helped facilitate participants to find a sense of belonging in their new work, school, and home communities. Recommendations by the Mental Health Commission of Canada have also emphasized, “a central part of each provincial and regional plan to improve the mental health of [immigrant, refugee, ethno-cultural, and racialized, or IRER] groups must include the involvement of IRER communities, consumers, and families in planning, decision-making, implementation, and evaluation” [22]. Similarly, organizations, including Canadian post-secondary institutions, that aim to better support young newcomers to Canada should ensure that youth have a voice and leadership role in the organizing and delivering of such resources. This also allows for greater job opportunities for newcomers, which as many participants indicated, can often be a challenge especially for young newcomers.

One of the main strengths of our study was that our participant recruitment and engagement strategy allowed us to engage youth leaders more deeply within our research team. These youth leaders played a critical role in recruiting participants from Africa and the Middle East, a challenge that previous research have documented [23]. We believe our openness to a range of stories was important to ensure participant autonomy. Based on the participants’ feedback regarding experience with our study, there was some indication that giving them a voice and an opportunity to help others had a positive impact on participants. Sharing their stories may have also helped them better understand and adapt to a new world and left them in a better position to be supportive to other newcomers; i.e., peer support and future equity researchers.

The major limitation to our narrative method was the inability to enter in a dynamic ongoing two-way dialogue with participants to better understand their stories. For example, having the ability to fully contextualize experiences in the words of the participants may have added additional depth to the interpretations. Furthermore, our study did not include enough participants to allow for analysis of subgroups such as gender, country of origin, and immigration status. We also received more female than male participants, limiting our understanding of the male perspective. Finally, our participants needed to speak English or French, have access to the internet and have the ability to write a story, as well as already have connections with a local institution, which would have limited the breadth of perspectives. For example, most of our participants were students, and we recognized this link was an essential support for our participants. Broadening the scope of community leaders and affiliated local institutions for recruitment may help address these limitations in future studies. However, as ensuring a sense of community and security among participants is crucial in participatory research, incorporating in-person data collection methodologies may be more beneficial when working with larger groups of participants and to achieve a greater depth of understanding newcomers’ stories. In this study, we have addressed the need for research based on social justice principles through the application of PHR. Our approach has allowed us to generate scientific knowledge aimed at advancing health equity and accessibility for marginalized populations. We found that winter weather conditions, language and cultural barriers, and perceived limited resources negatively impacts the integration and well-being of Canadian newcomers. In contrast, community building, social networks, and access to local resources facilitated the integration process. Further investigation of how immigration status, pre-settlement contexts, and gender can impact the integration journeys of newcomers in Canada could help to provide a more comprehensive understanding of their experiences. Future immigrant and refugee mental health research, as well as the development of culturally adaptive resources, should prioritize these key elements.

 Supporting information <p>(PDF)</p> </caption> </supplementary-material> </sec> </body> <back> <ack> <p>We would like to acknowledge our participants for giving their time and sharing their stories.</p> </ack> <ref-list> <title>References The Daily—Immigrants make up the largest share of the population in over 150 years and continue to shape who we are as Canadians. In: Statistics Canada [Internet]. 26 Oct 2022 [cited 30 Aug 2023]. Available: https://www150.statcan.gc.ca/n1/daily-quotidien/221026/dq221026a-eng.htm. Ontario Demographic Quarterly: Highlights of first quarter | ontario.ca. [cited 30 Aug 2023]. Available: http://www.ontario.ca/page/ontario-demographic-quarterly-highlights-first-quarter. Census in Brief: Children with an immigrant background: Bridging cultures. In: Statistics Canada [Internet]. 25 Oct 2017 [cited 30 Aug 2023]. Available: https://www12.statcan.gc.ca/census-recensement/2016/as-sa/98-200-x/2016015/98-200-x2016015-eng.cfm. Kalich A, Heinemann L, Ghahari S. A Scoping Review of Immigrant Experience of Health Care Access Barriers in Canada. J Immigr Minor Health. 2016;18: 697–709. doi: 10.1007/s10903-015-0237-6 26093784 Durbin A, Moineddin R, Lin E, Steele LS, Glazier RH. Mental health service use by recent immigrants from different world regions and by non-immigrants in Ontario, Canada: a cross-sectional study. BMC Health Serv Res. 2015;15: 336. doi: 10.1186/s12913-015-0995-9 26290068 Woodgate RL, Busolo DS. Above chaos, quest, and restitution: narrative experiences of African immigrant youth’s settlement in Canada. BMC Public Health. 2018;18: 333. doi: 10.1186/s12889-018-5239-6 29514615 Kirmayer LJ, Narasiah L, Munoz M, Rashid M, Ryder AG, Guzder J, et al. Common mental health problems in immigrants and refugees: general approach in primary care. CMAJ. 2011;183: E959–E967. doi: 10.1503/cmaj.090292 20603342 Gyan C, Chowdhury F, Yeboah AS. Adapting to a new home: resettlement and mental health service experiences of immigrant and refugee youth in Montreal. Humanit Soc Sci Commun. 2023;10: 86. doi: 10.1057/s41599-023-01572-7 36909256 Kalchos LF, Kassan A, Ford L. Access to Support Services for Newcomer Youth Through the Process of School Integration: A Critical Narrative Literature Review. Can J Sch Psychol. 2022;37: 307–327. doi: 10.1177/08295735221130442 36312206 Ng E, Zhang H. Access to mental health consultations by immigrants and refugees in Canada. In: Statistics Canada [Internet]. 16 Jun 2021 [cited 30 Aug 2023]. Available: https://www150.statcan.gc.ca/n1/pub/82-003-x/2021006/article/00001-eng.htm. doi: 10.25318/82-003-x202100600001-eng 34142786 Cacari-Stone L, Wallerstein N, Garcia AP, Minkler M. The Promise of Community-Based Participatory Research for Health Equity: A Conceptual Model for Bridging Evidence with Policy. Am J Public Health. 2014;104: 1615–1623. doi: 10.2105/AJPH.2014.301961 25033119 Greenhalgh T, Wengraf T. Collecting stories: is it research? Is it good research? Preliminary guidance based on a Delphi study. Med Educ. 2008;42: 242–247. doi: 10.1111/j.1365-2923.2007.02956.x 18275411 Dahal G, Qayyum A, Ferreyra M, Kassim H, Pottie K. Immigrant Community Leaders Identify Four Dimensions of Trust for Culturally Appropriate Diabetes Education and Care. J Immigr Minor Health. 2014;16: 978–984. doi: 10.1007/s10903-013-9805-9 23471673 Pottie K, Haydt S, Farrell B, Kennie N, Sellors C, Martin C, et al. Pharmacist’s identity development within multidisciplinary primary health care teams in Ontario; qualitative results from the IMPACT (†) project. Res Soc Adm Pharm. 2009;5: 319–326. doi: 10.1016/j.sapharm.2008.12.002 19962675 Wallerstein N, Duran B. Community-Based Participatory Research Contributions to Intervention Research: The Intersection of Science and Practice to Improve Health Equity. Am J Public Health. 2010;100: S40–S46. doi: 10.2105/AJPH.2009.184036 20147663 Andrews M, Squire C, Tamboukou M. Doing Narrative Research. SAGE Publications, Ltd; 2013. doi: 10.4135/9781526402271 Pottie K, Kassam A, Gruner D. Community-based mental health care and narrative exposure therapy. In: Bhugra D, Ayonrinde O, Tolentino EJ, Valsraj K, Ventriglio A, Bhugra D, editors. Oxford Textbook of Migrant Psychiatry. Oxford University Press; 2021. pp. 305–310. doi: 10.1093/med/9780198833741.003.0035 Pottie K, Dahal G, Georgiades K, Premji K, Hassan G. Do First Generation Immigrant Adolescents Face Higher Rates of Bullying, Violence and Suicidal Behaviours Than Do Third Generation and Native Born? J Immigr Minor Health. 2015;17: 1557–1566. doi: 10.1007/s10903-014-0108-6 25248622 Kanu Y. Educational Needs and Barriers for African Refugee Students in Manitoba. Can J Educ. 2008;31: 915–940. Simich L, Beiser M, Stewart M, Mwakarimba E. Providing Social Support for Immigrants and Refugees in Canada: Challenges and Directions. J Immigr Minor Health. 2005;7: 259–268. doi: 10.1007/s10903-005-5123-1 19813292 What is the Resilience Framework? In: Boingboing [Internet]. [cited 31 Aug 2023]. Available: https://www.boingboing.org.uk/resilience/resilient-therapy-resilience-framework/ Hansson E., Tuck A., Lurie S. & McKenzie K., for the Task Group of the Services Systems Advisory Committee, Mental Health Commission of Canada (2010). Improving mental health services for immigrant, refugee, ethno-cultural and racialized groups: Issues and options for service improvement. Fête M, Aho J, Benoit M, Cloos P, Ridde V. Barriers and recruitment strategies for precarious status migrants in Montreal, Canada. BMC Medical Research Methodology. 2019;19: 41. doi: 10.1186/s12874-019-0683-2 30808301 10.1371/journal.pone.0302591.r001 Decision Letter 0 Alamgir AKM Academic Editor 2024 AKM Alamgir This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Submission Version 0

23 Oct 2023

PONE-D-23-29946From struggle to strength in African and Middle Eastern newcomers’ integration stories to Canada: A participatory health research studyPLOS ONE

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Reviewer #1: Thank you for the opportunity to review the manuscript. The research is important and provides an important contribution to young adult immigrant and refugee experiences in Canada. What is less clear is the attention to mental health and health considerations and why they are not discussed in or referred back to in the discussion sections. It will be helpful to get some policy recommondations given the attention or the need for adaptive and culturally responsive health care access in the introduction. This needs to be followed through in the findings and discussion and then recommendations.

The participants were purposefully sampled but you note they were "intentionally found" I would recommend purposefully sampled as that is related to qualitative methods of recruitment.

Was it intentional to say that particpants were from Africa and the Middle East? these are continents and not countries for example; and this may reinforce a homogenous reading of the diversity of your participants. If this was done to protect your participants please explain.

Was informed consent obtained verbally as well as in writing and was it continous? you may want to see resources on rights of people in context of forced migration by "your rights in research by Canadian Council of Refugees"

In qualitative research member checking is not or should not be a form of validation only, this is because the process was reflexive related to the fact that you had youth/peers working with you and writing with you. How do you know people feel the same when you go back? it is process and so a few sentences about researcher reflexivity may help.

Similarly, data saturation is troubled as being 'a gold standard' for determining sample size of event the end of thematic analysis; consider concepts such as informational power.

What are policy recommendations moving forward that could included a gender based + analysis related to newcomer youth/resiliency? e.g. you mention local geography as being a contributor to loneliness and isolation but there were multiple factors. I appreciate the nod to a resiliency framework but what are the policy recommendations related to supporting the mental health and wellbeing of these newcomers?

Line 143-144 did you collect sociodemographic data related to Canadian Bench Marks for Language proficiency?

11% of your sample were refugees (people forced to migrate) do you know which streams does it matter for your overall findings and analysis? e.g. are the challenges uniquely different?

Finally, as the research is taking a participatory approach at what stages was consent received and how long did you engage with the participants and peer researchers? what were the impacts to hearing the stories and their mental health and wellbeing , e.g. potentially being triggered. Where there some limitations?

Line 352 you cite Canadian studies but only list one.

Overall the findings are important and relevant, greater attention to the above mentioned details and policy recommendations would be helpful. The most important being international students and how they might require support for their mental health and wellbeing in academic institutions.

Thank you for the opportunity to review

Reviewer #2: The study examined the experiences of African and Middle Eastern newcomers (immigrants, refugees, and international students) in Ontario, Canada, to better understand their integration challenges, successes, and social justice issues, aiming to enhance health and social services. Using a participatory research method, the authors collected stories from 18 newcomers (78% female, about half post-secondary students) aged 18-30 from Africa and the Middle East through snowball sampling within the immigrant community network. Qualitative narrative analysis was employed to interpret the stories, uncovering context themes, barriers, and facilitators. The authors found support from family, friends, education, and community services. The study highlights the significance of community building, friendships, and local services in immigrant service research. The paper addresses an intriguing subject of significant importance.

Overall, the paper was interesting and a nice addition to existing qualitative research on

newcomer integration. It’s an important topic and presenting this research using thematic content was a unique way to shed light on what newcomers find useful or lacking throughout the integration process. The discussion section was solid and well-written, however, the background and methods/results seemed a big vague in some areas. Please see below for specific comments:

Background (Lines 65-67): Why are newcomers particularly vulnerable? Could this be elaborated on? I also wondered what makes younger newcomers susceptible in comparison to older newcomers. This seems counterintuitive, as I expect it to be the reverse. Research has shown that younger newcomers are generally more flexible and adaptable. Is it context-specific?

Line 144: the percentage reported in brackets (88.9%) reads oddly and should perhaps be

moved slightly after the word “language.”

Methods/Results:

- What was the average range of ages of the participants?

- How long had the participants been in Ontario?

- It would be helpful if the authors gave more information about what was communicated with the participants regarding sharing a written story about their integration experience and journey. Were there any prompts that they were given? What were they instructed?

- Only two refugees were sampled for the study. Were their stories captured in the themes that originated from students and immigrants?

- The authors mentioned that they agreed on the overall themes but didn’t mention

how they went about/agreed on coding the stories. Also, they mention having four categorical themes, but it appears as though each category has subthemes, however, there is no mention of this in the methods section.

- Although immigrants, refugees, and international students are all newcomers, they are distinct groups with experiences and challenges. Whereas refugees are forced to leave their home countries due to circumstances beyond their control, immigrants choose to move for various reasons. On the other hand, international students come to study in a foreign country with the primary intention of pursuing education, often with the expectation of returning to their home country once their studies are completed. In Canada, international students are not considered immigrants, as their status is temporarily tied to their educational pursuits. It would be important to clearly distinguish between the three groups and to discuss if different themes emerged within each category.

- The authors may want to consider including a frequency table as it would be useful in providing a breakdown of which themes/subthemes populated often/less often between participant stories (unless all themes applied to every story, but this should be commented on either way for better clarification.)

Line 232 onwards: (iv) is coded as lack of resources and unknown scary migration context. The

former is not elaborated much in this section; it felt vague until I read the next section, making

me wonder if the sections should be combined.

Future Direction: The authors mention some important limitations, such as language and the

fact that all participants were students (though having a study on students’ experiences

is interesting.) Since the participants arrived from different countries, I did wonder about pre-

settlement contexts and differences between where an individual comes from and how this

might impact their settlement experience in Canada. I think this is beyond the scope of the

paper but would be maybe something they’d want to consider including under

conclusions/future direction.

**********

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Reviewer #1: No

Reviewer #2: No

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 10.1371/journal.pone.0302591.r002 Author response to Decision Letter 0 Submission Version 1

7 Jan 2024

Dear reviewers,

Many thanks for the constructive feedback you provided. We integrated the comments in the new submitted manuscript.

Thanks for your kind consideration,

Corresponding author,

Dr. Kevin Pottie

Thank you for the opportunity to review the manuscript. The research is important and provides an important contribution to young adult immigrant and refugee experiences in Canada. What is less clear is the attention to mental health and health considerations and why they are not discussed in or referred back to in the discussion sections. It will be helpful to get some policy recommendations given the attention or the need for adaptive and culturally responsive health care access in the introduction. This needs to be followed through in the findings and discussion and then recommendations.

Response: Thank you for your helpful review. We have revised to add more discussion on mental health implications and health considerations. Specifically, we discussed our results in relation to the provision of mental health resources for newcomers and policy recommendations regarding the structure of mental health and community organizations.

The participants were purposefully sampled but you note they were "intentionally found" I would recommend purposefully sampled as that is related to qualitative methods of recruitment.

Response: Thank you for the recommendation, edits have been made to the manuscript.

Was it intentional to say that particpants were from Africa and the Middle East? these are continents and not countries for example; and this may reinforce a homogenous reading of the diversity of your participants. If this was done to protect your participants please explain.

Response: Thanks. The use of “Africa and the Middle East” was intentional in the reporting of results. Information on the country of origin of participants was collected. Responses ranged throughout both continents; however, many participants originated from similar regions. Therefore, such information was removed from the manuscript and stories to protect the participants' identity as many conflict-affected regions have a small close-knit relationship and would risk being identified through some of the chosen quotes. Similarly, because snowball sampling was used the likelihood of participants knowing one another was higher, and thus also the risk of participant identification. Within our CBPR approach, we prioritized trust and safety for our participants to support safe story sharing.

Was informed consent obtained verbally as well as in writing and was it continuous? you may want to see resources on rights of people in context of forced migration by "your rights in research by Canadian Council of Refugees"

Response: Informed consent was obtained in writing at the start of the survey and story collection process. Participants were also aware that their consent could be withdrawn at any point throughout the study process. Participants who completed and submitted the online survey, which contained their written story, were provided with an honorarium for their time. We have edited our methods to make these points clear.

In qualitative research member checking is not or should not be a form of validation only, this is because the process was reflexive related to the fact that you had youth/peers working with you and writing with you. How do you know people feel the same when you go back? it is process and so a few sentences about researcher reflexivity may help.

Response: Our team consisted of a diverse group of authors who often played different roles throughout our study process. In that, youth who wrote for the project played less of a role in the analysis procedure until after all analyses had been completed. As well, participant names and identifying information were removed from stories prior to thematic analyses to ensure confidentiality, but also help minimize researcher reflexivity. We have added a section regarding details of our co-researchers and reflexivity in our methods section.

Similarly, data saturation is troubled as being 'a gold standard' for determining sample size of event the end of thematic analysis; consider concepts such as informational power.

Response: Thank you for this reference to information power. Authors coded and analyzed all stories individually. Themes that were prevalent in the majority of participants’ stories and that were coded by almost all authors for a story were represented in the results. A supplementary document including our study’s minimal underlying data has since been included for additional reference to mitigate harmful information power.

What are policy recommendations moving forward that could included a gender based + analysis related to newcomer youth/resiliency? e.g. you mention local geography as being a contributor to loneliness and isolation but there were multiple factors. I appreciate the nod to a resiliency framework but what are the policy recommendations related to supporting the mental health and wellbeing of these newcomers?

Response: This has been addressed in our previous response to comment #1. Specifically, we discuss the recommendation of providing young newcomers with leadership opportunities and roles in community-based support and organizations for other newcomers. This not only allows newcomers to feel more connected and less isolated, but also provides them with more job opportunities to ensure their basic needs are met. According to the resiliency framework, it is only once basic needs can be met, that newcomers are able to build and sustain resiliency.

Line 143-144 did you collect sociodemographic data related to Canadian Bench Marks for Language proficiency?

Response: Participants were asked to score their English and French proficiencies as “basic”, “intermediate”, “proficient”, “Not applicable (if it is their first language)” or they “preferred not to answer”. Most participants were more proficient in English compared to French. Participants were also asked to indicate the language they prefer communicating in when it comes to receiving or engaging in mental health services? The options included “English” , “French” , “Other” and “prefer not to answer”, and most participants responded “English” as well.

11% of your sample were refugees (people forced to migrate) do you know which streams does it matter for your overall findings and analysis? e.g. are the challenges uniquely different?

Response: Stories were deidentified prior to researchers analyzing and coding them. This was done to respect participant confidentiality as well as to minimize researchers’ confirmation bias when coding and interpreting them. Matching the results retrospectively, participants expressed similar challenges despite belonging to different categories of immigrant. The context of the challenges sometimes differed slightly, but not extensively. For example, those who are immigrant or refugee discussed loneliness and isolation more commonly in the context of work and community whereas international students discussed the challenge more in the context of academic environments. Our project was not large enough to conduct matrix analysis, for example in regard to refugee status, we have added 'refugees’ as a future research topic.

Finally, as the research is taking a participatory approach at what stages was consent received and how long did you engage with the participants and peer researchers? what were the impacts to hearing the stories and their mental health and wellbeing , e.g. potentially being triggered. Where there some limitations?

Response: Please refer to the response of comment #4 regarding consent. Participants and peer researchers were engaged with this project for a year; however, some played a more consistent role than others. As well, participants were able to discontinue the project at any point they felt uncomfortable or were no longer able to contribute. Only selective quotes and findings that were relevant to our results were shared with the majority of participants to avoid potential triggers and negative impacts on mental health. Like participants, researchers were also offered resources and support as needed. However, most researchers were familiar with this area of work and topic, so there were minimal disturbances. Instead, some participants and researchers actually expressed a feeling of empowerment after reading the stories.

Line 352 you cite Canadian studies but only list one.

Response: The Canadian study cited is a literature review that “aimed to identify risk factors and strategies in the approach to mental health assessment and to prevention and treatment of common mental health problems for immigrants in primary care”. Their results include and discuss the findings of 113 Canadian studies, 10 of which are systematic reviews and 3 that are meta-analyses.

Background (Lines 65-67) :Why are newcomers particularly vulnerable? Could this be elaborated on? I also wondered what makes younger newcomers susceptible in comparison to older newcomers. This seems counterintuitive, as I expect it to be the reverse. Research has shown that younger newcomers are generally more flexible and adaptable. Is it context-specific?

Response: A key factor contributing to the vulnerability (or precarity) of younger newcomers is the lack of tailored resources for youth. Many existing resources for immigrants and refugees are designed with families or middle-aged adults in mind, overlooking the unique needs and challenges faced by younger individuals. Furthermore, our results emphasize the pressing need for better resources, as evidenced by the numerous accounts from youth expressing their struggles and the necessity for more targeted support.

Line 144: the percentage reported in brackets (88.9%) reads oddly and should perhaps be moved slightly after the word “language.”

Response: Thank you for the recommendation, revisions have been made to the manuscript.

What was the average range of ages of the participants?

Response: The range of ages of the participants was 18-30.

How long had the participants been in Ontario?

Response: “Newcomers were defined as those who have been here between 1-10 years.”

It would be helpful if the authors gave more information about what was communicated with the participants regarding sharing a written story about their integration experience and journey. Were there any prompts that they were given? What were they instructed?

Response: Participants were provided with an e-learning module on storytelling, which outlined prompts and story examples to guide participants. We have included this e-learning module in our supporting information.

Only two refugees were sampled for the study. Were their stories captured in the themes that originated from students and immigrants?

Response: See our response of comment #9- also on refugees>

“Response: Stories were deidentified prior to researchers analyzing and coding them. This was done to respect participant confidentiality as well as to minimize researchers’ confirmation bias when coding and interpreting them. Matching the results retrospectively, participants expressed similar challenges despite belonging to different categories of immigrant. The context of the challenges sometimes differed slightly, but not extensively. For example, those who are immigrant or refugee discussed loneliness and isolation more commonly in the context of work and community whereas international students discussed the challenge more in the context of academic environments. Our project was not large enough to conduct matrix analysis, for example in regard to refugee status, we have added 'refugees’ as a future research topic.”

The authors mentioned that they agreed on the overall themes but didn’t mention how they went about/agreed on coding the stories. Also, they mention having four categorical themes, but it appears as though each category has subthemes, however, there is no mention of this in the methods section.

Response: Thank you. We have clarified this in our methods section. Each author independently read and annotated the stories. Common themes were then discussed and collaboratively agreed upon, and these were subsequently categorized under the four overarching themes. Disagreements in interpretation were resolved through extensive discussions within the larger research team. Revisions have been made to the manuscript to provide a more comprehensive understanding of our approach.

Although immigrants, refugees, and international students are all newcomers, they are distinct groups with experiences and challenges. Whereas refugees are forced to leave their home countries due to circumstances beyond their control, immigrants choose to move for various reasons. On the other hand, international students come to study in a foreign country with the primary intention of pursuing education, often with the expectation of returning to their home country once their studies are completed. In Canada, international students are not considered immigrants, as their status is temporarily tied to their educational pursuits. It would be important to clearly distinguish between the three groups and to discuss if different themes emerged within each category.

Response: Thank you. While we understand there are different groups of newcomers, our intention was to focus on the age-related lived experiences of youth. Incidentally in Canada, it is well recognized that most international students will have a direct line for immigration. It is also possible that an international student may be fleeing conflict in a different way. Participants were not categorized based on these distinctions, as many participants in our study belonged to multiple groups (i.e. despite being a refugee, they spent the majority of their life in Canada as a student; therefore, also experiencing the struggles and facilitators of the Canadian education system). Authors were also blinded to participants' details to prevent bias, recognizing that preconceived expectations could influence the focus on particular challenges in the stories of each newcomer population.

The authors may want to consider including a frequency table as it would be useful in providing a breakdown of which themes/subthemes populated often/less often between participant stories (unless all themes applied to every story, but this should be commented on either way for better clarification.)

Response: Thank you for the recommendation. We have included a table of the populated themes and quotes that was coded for in our supporting documents.

Line 232 onwards: (iv) is coded as lack of resources and unknown scary migration context. The former is not elaborated much in this section; it felt vague until I read the next section, making me wonder if the sections should be combined.

Response: Integrated in the manuscript.

Future Direction: The authors mention some important limitations, such as language and the fact that all participants were students (though having a study on students’ experiences is interesting.) Since the participants arrived from different countries, I did wonder about pre- settlement contexts and differences between where an individual comes from and how this might impact their settlement experience in Canada. I think this is beyond the scope of the paper but would be maybe something they’d want to consider including under conclusions/future direction.

Response: We have integrated this point in the manuscript. Overall this is out of the scope our research, but we agree it is important for future research.

Submitted filename: NSP_ Response letter.pdf

 10.1371/journal.pone.0302591.r003 Decision Letter 1 Alamgir AKM Academic Editor 2024 AKM Alamgir This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Submission Version 1

6 Feb 2024

PONE-D-23-29946R1From struggle to strength in African and Middle Eastern newcomers’ integration stories to Canada: A participatory health equity research studyPLOS ONE

Dear Dr. Pottie,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process by Mar 22 2024 11:59PM..

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We look forward to receiving your revised manuscript.

Kind regards,

AKM Alamgir, PhD

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

Reviewer #3: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

Reviewer #3: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: N/A

Reviewer #3: N/A

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

Reviewer #3: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

Reviewer #3: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: (No Response)

Reviewer #3: It is with interest that I have read this manuscript in its revised version. This research adds important understanding to the challenges that face newcomers from Africa and the Middle East and points out opportunities to facilitate their integration and support building their resilience. The results set a foundation for future research and initiatives to improve health equity and social services tailored to this marginalized population.

The authors utilized appropriate relevant literature to support their approach, including those that justify their predetermined age range of recruits between 18-30. Moreover, the need to run such research and its implication for improving the welfare of such communities was properly described, which made the objective clear. The selected type of research was also properly justified based on previous literature.

The authors clearly described their methodology as well as their strategic involvement of newcomer researchers to help build the “trust” needed for the input of the participants. However, in response to the first reviewer inquiry regarding any prompts or instructions given to the participants, the authors explained that “Participants were provided with an e-learning module on storytelling, which outlined prompts and story examples to guide participants. We have included this e-learning module in our supporting information.” I would suggest mentioning this in the methodology as it gives valuable information on how the stories were collected from the participants, which would guide future research.

In line [115], the statement is an exact repetition of the opening statement in line [86]. If the authors find the need to mention the approach again in that section, I suggest rephrasing it to avoid redundance.

In the Results section, the added table was useful. I would suggest replacing “Count” by “Frequency (n=18)” and replace “Frequency” with “Percentage”. Also, in the table section (Highest Level of Education Completed), the total is 19 which suggests an error to be corrected.

In lines [342-344] of the Discussion section, I found the statement a bit unclear. I had to read it several times to understand that the authors found that the amount of literacy, trust, resilience, and self-confidence were attributes that could enable emerging leaders. I suggest a simple rephrasing to avoid the unclarity of an important statement.

In lines [426-435], the authors discuss the limitations of their research, including the recruitment process. It might be useful if they can suggest recommendations to overcome this limitation in future research based on their experience, which would be beneficial for future researchers building on their methodology.

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Reviewer #2: No

Reviewer #3: No

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 10.1371/journal.pone.0302591.r004 Author response to Decision Letter 1 Submission Version 2

24 Mar 2024

It is with interest that I have read this manuscript in its revised version. This research adds important understanding to the challenges that face newcomers from Africa and the Middle East and points out opportunities to facilitate their integration and support building their resilience. The results set a foundation for future research and initiatives to improve health equity and social services tailored to this marginalized population.

The authors utilized appropriate relevant literature to support their approach, including those that justify their predetermined age range of recruits between 18-30. Moreover, the need to run such research and its implication for improving the welfare of such communities was properly described, which made the objective clear. The selected type of research was also properly justified based on previous literature.

The authors clearly described their methodology as well as their strategic involvement of newcomer researchers to help build the “trust” needed for the input of the participants. However, in response to the first reviewer inquiry regarding any prompts or instructions given to the participants, the authors explained that “Participants were provided with an e-learning module on storytelling, which outlined prompts and story examples to guide participants. We have included this e-learning module in our supporting information” I would suggest mentioning this in the methodology as it gives valuable information on how the stories were collected from the participants, which would guide future research.

Response: Thank you for your helpful review. We have incorporated your suggestion in the methodology of our revised manuscript.

In line [115], the statement is an exact repetition of the opening statement in line [86]. If the authors find the need to mention the approach again in that section, I suggest rephrasing it to avoid redundance.

Response: Integrated in the manuscript.

In the Results section, the added table was useful. I would suggest replacing “Count” by “Frequency (n=18)” and replace “Frequency” with “Percentage”. Also, in the table section (Highest Level of Education Completed), the total is 19 which suggests an error to be corrected.

Response: Thank you for your recommendation and for bringing this error to our attention. Revisions have been made to the manuscript.

In lines [342-344] of the Discussion section, I found the statement a bit unclear. I had to read it several times to understand that the authors found that the amount of literacy, trust, resilience, and self-confidence were attributes that could enable emerging leaders. I suggest a simple rephrasing to avoid the unclarity of an important statement.

Response: Integrated in the manuscript.

In lines [426-435], the authors discuss the limitations of their research, including the recruitment process. It might be useful if they can suggest recommendations to overcome this limitation in future research based on their experience, which would be beneficial for future researchers building on their methodology.

Response: Thank you for your recommendation. We have integrated this point in the manuscript.

Submitted filename: Response_Letter.pdf

 10.1371/journal.pone.0302591.r005 Decision Letter 2 Alamgir AKM Academic Editor 2024 AKM Alamgir This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Submission Version 2

9 Apr 2024

From struggle to strength in African and Middle Eastern newcomers’ integration stories to Canada: A participatory health equity research study

PONE-D-23-29946R2

Dear Dr. Kevin Pottie,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

AKM Alamgir, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #3: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #3: It was interesting to see the final version of the manuscript with the final amendments. The authors ensured a smooth integration of the modifications and addressed the recommended suggestions.

We look forward to have future research built on this one to advance newcomer's health equity.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #3: Yes: Madona Yahia

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