Navigating Stigma and Support: Realist Evaluation of Support for Migrant Informal Caregivers of Loved Ones with Mental Illness

Abstract ‘They Are Not Mental?!’ (TANM) is a peer educational intervention aimed at supporting migrant informal caregivers of people with mental illness. In the short term, the intervention focuses on promoting openness about mental health, increasing understanding of mental illness and caregiver support, and fostering trust with the healthcare sector. This study examined whether stakeholders perceived changes in these short-term outcomes and which intervention elements contributed to these changes. A realist evaluation was conducted to refine our initial program theory, through 27 interviews with ambassadors, program staff and participants, 10 observations of peer educational sessions and 76 post-questionnaires completed by participants. Findings were synthesized into context–mechanism–outcome configurations forming a refined program theory, which was validated in a focus group with four representatives of the coordinating organizations. Across groups, those involved in TANM perceived progress towards its short-term outcomes, but levels of openness and subsequent help-seeking varied. These differences reflected variation in contextual factors, namely the presence of shared cultural frames, prior acquaintance between ambassadors and participants, shared language and continued availability of ambassadors and the Family-Experience-Expert beyond the formal implementation period. Trust was fostered through these factors and enabled more transformative processes such as peer education and sharing of personal experiences, which normalized mental health discussions and help-seeking behaviours. Ambassadors as trusted peers are central to achieve TANM’s aims of encouraging openness, knowledge exchange, and help-seeking. To sustain its impact, future implementations should ensure ambassadors are peers and are structurally supported. Moreover, these types of interventions need complementary, system-level actions - including investments in culturally sensitive care practices.