Social Support and Mental Well-Being of Newcomer Women and Children Living in Canada: A Scoping Review

: Newcomer women and children are less likely to access and utilize mental health support services as compared to the general Canadian population, despite reporting experiences of mental health issues. This review aimed to map out the social support interventions that are available for promoting the mental well-being of newcomer women and children living in Canada. A search using Medline, Cumulative Index for Nursing and Allied Health Literature, PsycINFO, and the Cochrane library was conducted to identify published studies. Studies were screened, extracted, and synthesized by two independent reviewers in line with the methodological approach for scoping reviews. Fourteen articles published in English between 2012–2023 were reviewed. Results identified five types of interventions: art and sand play interventions, support groups and workshops, assessment of existing support services, social media interventions, and short-term cognitive behavioral therapy. Our results suggest that culturally appropriate social support interventions increase mental well-being outcomes, such as self-esteem and social support, and reduce peri-migratory traumas for newcomer women and children in Canada. However, findings from this review underscore the need for more quantitative and participatory research approaches so that newcomer women’s and children’s needs are adequately explored and addressed.


Introduction
Mental well-being is fundamental to positive human functioning and overall wellbeing.The phenomenon of mental well-being is multifaceted and non-unidirectional, meaning that it is not merely a responsibility of individuals, but also an obligation of the society in which we live and work.Women's mental well-being plays a critical role in the development of strong families and productive communities, due to its positive and direct intergenerational association with their children's physical, behavioral, social, cognitive, and emotional functioning [1,2].Evidence from a meta-analysis of 193 studies suggests that an intergenerational association of maternal psychological issues with a child's functioning was found more commonly among families with minority ethnic backgrounds [3].
Among various socioeconomic determinants that influence mental well-being, migration has been viewed as a factor that could impact mental well-being and lead to negative psychosocial consequences [4,5].Between 2016-2021, Canada recorded a historically significant surge in immigration, with more than 1.3 million new immigrants choosing to settle in the country [6].In 2021, women accounted for 50.9% of the Canadian population and in the same year, 27% of women were immigrants [7].According to projections made by Statistics Canada, newcomer women will represent more than approximately 27% of Canada's total female population by 2031 [8].If the current composition of immigrants continues, by 2031, 31% of the female population will represent visible minority groups [9] defined by the Employment Equity Act as "persons, other than Aboriginal peoples, who are non-Caucasian in race or non-white in color" [10].
Migration to Canada has been seen as more challenging and different for newcomer women due to various factors, such as male dependency, lack of awareness about policies, less exposure to opportunities, negative experiences of adversity prior to migration, and responsibilities for children [11].A literature review exploring women's experiences of immigration in Canada identified that language and culture differences, employment barriers, discrimination, marginalization, social isolation, and loss of social support are major influences on the mental well-being of immigrant women [5].These findings also maintained that women who had strong support systems were able to experience autonomy and a better quality of life.Evidence from a longitudinal survey of 7700 immigrants in Canada indicated a positive association of low income with emotional problems; additionally, immigrants from South and Central America, Asia, and the Pacific were more likely to experience emotional challenges than immigrants from other geographic areas [12].It is also reported that newcomer women are more likely to suffer from perinatal mental health challenges, such as anxiety and depression, as compared to other women in Canada [6,7].
There is substantial evidence available that establishes a strong correlation between social support and mental health outcomes [13].Social support has been defined as the provision of help or resources (ranging from tangible to emotional) to others, particularly through social networks and connections [14].In responding to immigration-related challenges, there have been many efforts; support has been initiated at various levels by government and non-government organizations in the form of resettlement services, employment facilities, training programs, peer-support programs, and other health and social services [15][16][17].However, despite the availability of several interventions and support services, psychosocial challenges, including high rates of anxiety and depression among newcomer women living in Canada, still exist, especially among those who belong to racialized groups and migrate from socioeconomically disadvantaged countries [18][19][20].When newcomer parents face socio-economic challenges and struggle to manage their needs, the health of their children may be overlooked as a prime concern [21].In addition to the high prevalence of mental health issues, access to, and utilization of, mental health and social services remain concerns for this population, among which women and children are the most vulnerable [22,23].It is well-documented that many newcomers suffer from peri-and pre-migratory traumas and report lower mental health than their Canadian counterparts [24,25].Killian and Lehr [20] found that low levels of social support were associated with high rates of anxiety and depression among newcomer women residing in the Greater Toronto Area.
The Mental Health Commission of Canada notes that immigrants are much less likely to utilize mental health care services as compared to the general Canadian population [24].Among newcomer groups, Asian immigrants are the least likely to utilize services, even though they make up the majority of the immigrant population [7,26].For newcomers, access to mental health services is often mediated by factors such as awareness of available programs, language proficiency, and financial capacity, to name a few [23,24].Housing and financial instability especially impact participants' ability to attend mental health care appointments [25].In particular, for women, access is further restricted by family dynamics, such as childcare responsibilities, that make it difficult to seek and attend programs, and joint-living arrangements that leave little room for privacy [27].Mental health services are consistently being underutilized by newcomers; therefore, examining the implementation and outcomes of interventions can lead to tailoring and designing better programs for the future.There is a pressing need for mental health research, particularly focused on newcomer communities and specific subgroups like immigrants and refugees.Although efforts have been invested in designing various social support initiatives for newcomer individuals and families in Canada, no review was identified that has synthesized evidencebased social support interventions for newcomer women and children in the Canadian context.As the Canadian population continues to diversify and increase, it is crucial for policymakers and service providers to gain a deeper insight into the mental health outcomes and utilization of services among newcomers, given the stresses associated with the process of re-settlement.
This review aimed to look at social support interventions for newcomer women and children across Canada and to learn which types of interventions related to mental health and well-being have been implemented, as well as their outcomes.Mental health and wellbeing outcomes have been defined as positive outcomes including resilience, self-efficacy, coping, self-esteem, social connections, quality of life, or improvements in mental health issues and challenges such as depression or anxiety.

Study Selection
In total, 1163 records were identified in the search.Of this number, 170 duplicates were removed, leaving 933 papers to be screened.Of these, 69 met the inclusion criteria and were included for full-text screening.Finally, 14 studies were identified for inclusion in the review.Table 1 provides details of the studies included in the review.Women found support group meetings to be a valuable source of emotional support and advice for addressing challenges such as language barriers, parenting, healthcare, and maintaining cultural traditions.
Del-Pino-Brunet [35] To analyze intervention programs that aim at promoting social integration and preventing the radicalization of migrants in Canada.
--18 papers published before January 2019 Systematic review Despite limitations, programs targeting migrant women and children yielded positive outcomes, e.g., increased social support, reduced loneliness and depression, improved quality of life, integration, enhanced knowledge, self-esteem, and coping abilities.
Stewart [36] To design and evaluate an accessible and culturally appropriate social support intervention that meets the support needs and preferences identified by Zimbabwean and Sudanese refugee parents.

months
Alberta and Ontario 5 new parents; new to Canada; had a preschool child between the ages of 4 months and 5 years born in Canada

Pilot intervention
Culturally sensitive interventions created a space for participants to share information on relevant resources, learn how to improve spousal/familial relationships and cope with parenting stress.Meetings decreased loneliness and isolation and enhanced coping strategies for refugee parents.
Stewart [17] To design and pilot a culturally congruent intervention that meets the support needs and preferences of two ethnocultural distinct refugee groups.

Types of Interventions
The interventions were categorized into five categories, as follows: art-based interventions, support groups and workshops, assessment of existing support services, social media interventions, and short-term cognitive behavioral therapy.

Group Art-Based Interventions
A total of six studies [28][29][30][31][32][33] evaluated the effectiveness of using art/sand-based interventions to improve the mental well-being of newcomer women and children.Out of these six studies, one study focused on women [31] and five on children [28][29][30]32,33], and were facilitated by a therapist and trained teachers, respectively.We identified three creative interventions that entailed sand play, which provided a safe space for preschool immigrants and refugee children to express their identities, emotions, experiences and ability to cope with violence [29]; group art therapy for children was found to be effective in reducing psychological distress and improving their quality of life [30]; and traditional Syrian embroidery techniques promoted feelings of community and home, social support, gratitude, hope, and improvements in feelings of loneliness among Syrian refugee women [31].
We also included two literature reviews that evaluated the benefits of group arts-based interventions on the mental health of immigrant children and youths.A narrative literature review concluded that arts classes at school or in communities can have the potential to improve immigrant children's peer support, emotional well-being, self-esteem, and confidence [28].A scoping review of such interventions endorsed the effectiveness of creative programs, including drama-based programs, sand play, storytelling, and other play-based programs in improving coping skills and supporting the mental health needs of immigrants, and refugee children and youths [33].
Although not a direct interventional study, we included a qualitative study [32] that evaluated the implementation of creative workshops using a series of focus groups with facilitators who provided the intervention to asylum-seeking refugees and migrant youths and children living in shelters.The study suggested that these creative interventions, including imagery, music, yoga, games, and arts, have contributed to promoting emotional safety and social connection among children and their parents.

Support Group and Workshop Participation
We found four studies that implemented support groups and workshops for newcomer women in Canada [17,[34][35][36].Three of these studies [17,34,36] focused on providing emotional support to Somali, southern Sudanese and Zimbabwean parents and their children.The interventions were facilitated by peer facilitators matched by ethnicity and gender and revealed several insights into the post-migratory experiences of African refugees.These studies found that most newcomers had a minimum amount of information on support resources and services; in fact, African refugees from refugee camps took many years to learn how to navigate service systems [17].Support groups helped bridge this gap by providing women with information and resources and a safe space where they could share their problems, feelings, and obtain advice from their peers.
These support groups were found to be effective for newcomer women, with several positive outcomes.The group setting proved to be an effective space for teaching mothers about proper infant-feeding practices, soothing their children, and awareness and solutions for bullying at school [17].Support groups were perceived as a helpful source for learning to resolve family conflicts, adopting positive coping mechanisms and skills (such as family budgeting and anger management), improving communication with spouses and children, enhancing self-worth, and developing social connections with others outside their homes [34,36].The support groups also played a role in assessing newcomers' children's needs.The study conducted by Stewart and colleagues reported that support group participants identified that refugee children required special support at school in order for them to adjust to the Canadian education system, especially when their parents could not dedicate extra time to them due to multiple low-paying jobs and an overall lack of resources [17].As a result, refugee parents expressed a need for after-school groups that could help children with school work and diminish exposure to maladaptive habits such as drugs and gangs [17].
We included a systematic review of 18 studies that assessed the social integration interventions for migrants in Canada [35].The findings of this review were promising, as they had increased women's knowledge of support resources and their quality of life.Interventions geared towards physical health also had positive mental health outcomes, e.g., aerobic and strength training workshops offered to newcomer women boosted selfesteem and were associated with decreased loneliness and an increase in perceived social support and integration [35].

Assessment of Existing Social Support Services and Programs
We found two articles that assessed the existing services and programs for newcomer women's and children's mental health.One study was a piloted intervention designed to offer psychoeducation to new mothers who were struggling with their infants [37], while the other assessed services provided by various community health centers using a case study approach and an assessment of social networks available to newcomer women [38].
It was reported that health care providers are aware that newcomer women in Canada are at an increased risk of peripartum depression [37].Using culturally sensitive, clientcentered approaches involving in-depth interviews to understand clients' problems was key for successful social services.Psychoeducational information under a trained therapist was found to be effective in making mental health interventions more understandable and accessible for parents from diverse cultural backgrounds, and provided newcomer mothers with resources and information about peripartum depression, child development concerns, and resources they could seek out for support regarding these issues [37].
Similarly, another study that examined strategies to engage newcomers and marginalized populations in Ontario community health centers revealed the importance of community development processes by addressing the layers of barriers that marginalized populations experience in accessing healthcare [38].The community participation strategies included formal partnerships of health centers with other agencies and the use of informal social support strategies such as peer leaders, café meeting tables, and storytelling.These strategies were acknowledged by the study participants and were found to be effective in improving their self-esteem and confidence for participating in their healthcare [38].

Social Media Intervention
We found only one study that explored the use of social media for newcomer women [39].There was a significant positive association reported between the use of Facebook and Twitter platforms for emotional support.Participants described social media as a positive tool for venting their frustrations, expressing their feelings, and taking a stand against racism and discrimination.They also used social media for relaxation and finding funny and joyful content as a distraction from loneliness.However, some participants reported fear of cyber harassment and bullying, especially in regard to their religion.They believed that social media provided a space for xenophobia and avoided political content and debates to protect themselves from distress and harm [39].

Short-Term Cognitive Behavioral Therapy
One article described a case study using cognitive behavioral therapy to help a 29-year-old single newcomer mother (who had a history of anxiety, depression and abusive relationships) to overcome her negative migratory experiences [40].Therapy activities included a thought journal to track negative and distressing thoughts and an activity calendar to monitor tasks and behaviors.It was found that 10 weekly individual sessions were effective in improving her scores from "extremely severe" to "mild" on a depression and anxiety scale.The woman also learned new skills to address depression and anxiety symptoms and planned to access a local women's resource center referred to her by the therapist [40].

Materials and Methods
This scoping review utilized the methods laid out by Arksey and O'Malley [41].The Arksey and O'Malley framework has five stages, as follows: (i) identifying the research question; (ii) searching relevant studies; (iii) selecting studies and inclusion; (iv) extracting data; and (v) summarizing and organizing findings [41].

Research Question
What social support interventions are available for promoting mental health of newcomer women and children living in Canada?

Searching Relevant Studies
A search strategy was developed with the assistance of an experienced university librarian (Table 2).The search was conducted using Medline, Cumulative Index for Nursing and Allied Health Literature (CINAHL), PsycINFO, and the Cochrane library, and was limited to Canada, including studies from all provinces and territories.

Types of Studies
We included all evidence-based studies with quantitative, qualitative, and mixedmethods designs, and reviews.Studies published in English between 2012 and 2023 were included for this review.Studies were excluded if they did not report support interventions, mental health outcomes, and newcomer women (immigrants or refugees) and children living in Canada.

Interventions and Comparators
Studies that focused on social support interventions and their impact on mental health outcomes of newcomer women and their children in Canada were included in the review.The included interventions differed in nature, content, duration, format (e.g., individual and group), and delivery mode (e.g., face-to-face, e-learning, and blended).

Outcomes
This review focused on mental health outcomes.Mental health is a broad construct and is represented through various outcomes and their combination.This review included all positive mental health variables, such as resilience, self-efficacy, coping, self-esteem, social connections, quality of life etc., and improvements in mental health issues such as depression and anxiety etc.

Participants
This review included studies that focused on women >18 years and children <18 years of age, who have migrated to Canada as immigrants and/or refugees from any part of the world.Studies that included other gender identities as target populations were only considered in the review if they presented separate findings on women.

Context
This review included studies that were conducted with newcomer women and children in the Canadian context.Newcomer women were defined as women who have moved to Canada, for a period of usually less than five years, irrespective of the reason for migration or legal status.The search was not restricted to any cultural, gender or socioeconomic characteristics of participants.

Study Selection
All identified papers were imported into Covidence [42], a web-based software platform that supports citation review, duplicates, resolution of discrepancies between independent reviewers, and agreement on final consensus data.Two independent reviewers screened the titles and abstracts of identified studies and additional resources for inclusion based on our inclusion criteria.They also reviewed the selected full-text papers and determined their eligibility for inclusion in the review and recorded the reasons for exclusion.At each stage of screening, disagreements between the reviewers were resolved by a third reviewer.In the case where a full-text paper was not available through the database or university library services, we manually conducted a search through Google Scholar and ResearchGate and requested corresponding authors through email to share full-text papers.A visual representation of these steps is presented in Figure 1 using the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews (PRISMA-ScR) flow chart.

Study Selection
All identified papers were imported into Covidence [42], a web-based software platform that supports citation review, duplicates, resolution of discrepancies between independent reviewers, and agreement on final consensus data.Two independent reviewers screened the titles and abstracts of identified studies and additional resources for inclusion based on our inclusion criteria.They also reviewed the selected full-text papers and determined their eligibility for inclusion in the review and recorded the reasons for exclusion.At each stage of screening, disagreements between the reviewers were resolved by a third reviewer.In the case where a full-text paper was not available through the database or university library services, we manually conducted a search through Google Scholar and ResearchGate and requested corresponding authors through email to share full-text papers.A visual representation of these steps is presented in Figure 1

Data Extraction
Two independent reviewers extracted data for all the selected studies using Covidence.In order to minimize bias, two independent reviewers extracted the data using a data extraction form and verified the data together from the direct sources.The data extraction categories included authors, title, journal, year, country, design, participants, intervention (type and duration), comparator, and outcome elements.The third reviewer reviewed any disparities between the two independent reviewers and resolved them together through discussion.Once the data extraction was complete, data were organized in a synopsis table for easy reference and relevant comparison.

Data Synthesis
Our data were summarized using the type, format and duration of interventions, participants, study design, research setting and outcomes.

Discussion
This scoping review aimed to investigate what is known about the types of mental health interventions available to newcomer women and children in Canada and the successes and drawbacks of these interventions.Our results suggest that there are limited social support interventions reported in the Canadian context targeted for newcomer women's and children's mental well-being, each with its own unique benefits and outcomes.These interventions have shown to be beneficial in reducing reduce peri-migratory traumas for women and children, especially those who have fled from violence in their home countries.However, there is a limited availability of mental health services specifically for newcomer children [43].Most of the interventions focused on children make use of art or sand play, or target parents instead, in order to improve parenting techniques or improve child-parent relationships [17,34,36,37].
We also found studies that focus on assessing social support services for newcomer women, who seem to experience several systemic challenges; logistic and practical problems, including language barriers, lack of cultural understanding and inaccessibility for participants are at the forefront of these issues [35,38].Language barriers are one of the most reported obstacles for participants when seeking support [28,[30][31][32].
This review acknowledges several strategies that were reported to be effective for newcomer women and children.Culturally appropriate support groups based on ethnicity, gender, and preferences can serve as safe spaces for newcomer women to share problems, feelings, and seek and offer advice.Informal meetings and storytelling groups can influence community participation by increasing self-worth and confidence among women [44], and may lead to improvements in spousal communications and decision-making for healthcare.Similarly, group fitness can also have added benefits for mental health, e.g., increased self-esteem and social support [45].We also found that accessing social support services through the phone seems to be a potential option for newcomer women; these services are cost effective and can have the potential to reduce loneliness and improve social integration among women.They can also aid newcomers in navigating the Canadian healthcare system, which is integral, given that newcomers and refugees often struggle with reaching out to, and making sense of, support services.
Although a plethora of studies in the literature exists regarding the prevalence of periand post-partum depression among new immigrants [46], our review identified one study of short CBT aimed at reducing symptoms of peripartum depression in newcomer women in Canada between 2012-2023 [41].However, further research is needed to explore the feasibility of accessing and utilizing therapeutic services for newcomer families in Canada.
For children, after-school programs can be effective in helping newcomer children with school work, family support and protection against exposure to drugs and gangs [17].We emphasize the use of multilevel care involving families, schools, and communities in delivering relevant and effective social support interventions for promoting the mental health of newcomer children and youths.This involves creating support programs in schools that cater to the specific needs of newcomer families by including language support and cultural understanding.Eliminating language barriers alone may encourage women to reach out to mental support services and resources [47].Successful art-based techniques identified in this review, such as sand play and embroidery, illustrate the use of non-verbal forms of expression that allow women and children to express themselves without needing to verbally recall traumatic experiences or have English fluency [28,29,[31][32][33].Although our review found a variety of art and sand-based interventions for children, the Syrian embroidery workshop was the only arts-based program identified for women [31].This intervention had several positive mental health outcomes such as increased feelings of community and friendship, and decreased feelings of loneliness among the participants [31].The results indicate that incorporating traditional cultural activities may help newcomers come to terms with their migratory experiences by creating a sense of belonging and fostering a community.Furthermore, activity-based interventions elicit a sense of accomplishment and achievement in both children and adults and can be used to improve self-esteem and create positive feelings [28,31].
The use of social media, specifically platforms such as Facebook and Twitter, which have been found to provide emotional support [48], should be further explored, as remote interventions can target a larger population and make it easier for women who have commuting and geographical challenges to benefit from these.However, Internet-based interventions also raise concerns for cyber safety and confidentiality, and efforts to protect participants from cyber harassment must be practiced before exploring this option.
Despite the limited evidence reporting social support and mental health interventions for newcomer women and children living in Canada, this review highlights an overarching theme of social connection and community engagement that has been consistent throughout the studies and appreciated by women for contributing to their positive mental health outcomes.One of the gaps that we identified was the lack of quantitative and interventional studies that examine the effectiveness of social support interventions for this population.Future research that focuses on the development and testing of interventions that are culturally appropriate and contextually rooted in newcomers' needs will have the potential to provide rigorous evidence that can be used by service providers.A major recommendation for service providers would be to allocate adequate resources to address cultural and language barriers so that newcomer families feel safe and able to navigate resources that meet their needs.

Limitations
While this review presents an important body of evidence supporting the mental health needs of newcomer women and children, it is important to acknowledge some notable limitations.Specifically, inherent to the design of a scoping review, we did not conduct a quality assessment.Therefore, studies with varying quality were included in this review.Additionally, the articles included in this review are limited to a few, but relevant, databases.Hence, articles that are available outside of these databases were not included in this review.However, we included studies that are relevant to the objective of this scoping review.

Conclusions
This scoping review highlights a variety of programs and initiatives that aim to support newcomer women and children in the Canadian context.These programs, while diverse, remain limited in availability, accessibility, and utility for newcomer women and children, especially for those who belong to ethnic minorities.Future interventions and programs should be designed using a participatory approach, allowing for a meaningful engagement with newcomer women, so that their diverse needs can be heard and effective interventions can be developed and implemented.Moving forward, systematic reviews are needed in order to identify the quality evidence for improving the mental health of newcomer women and children in Canada and beyond.
using the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews (PRISMA-ScR) flow chart.

Table 1 .
Study design characteristics and outcomes.

Table 2 .
Terms Used in the Literature Search.
* indicates multiple character searches starting with the same word.