Co-designing the 'Empower Community Health' programme: A capacity-building initiative to support community health workers' non-communicable disease health promotion in Ethiopia.

In 2024, the number of forcibly displaced people reached an unprecedented 123 million worldwide; this included 43 million refugees, of whom a quarter resettle in high-income countries. Refugees are at high risk of mental disorders, particularly post-traumatic stress disorder (PTSD) and depression, with prevalence estimates of around 30%. Although evidence-based psychosocial treatments for PTSD can be effective for refugees in high-income settings, treatment response is heterogeneous, and a substantial proportion of individuals show limited improvement. A key explanation is the impact of social determinants of mental health after resettlement, often described in the refugee literature as post-migration stressors. These include unemployment, poverty, insecure legal status, family separation and social isolation, all of which can maintain or exacerbate symptoms of mental disorders. In Denmark, refugees granted residence have access to the labour market and, when unemployed, are generally affiliated with municipal employment services as part of the employment and benefit system. Employment, social and healthcare services are organised across separate sectors with differing mandates and priorities.; this may hinder coordination and leave people with multifaceted health and social needs to navigate multiple agencies. In combination, post-migration stressors and fragmented services may limit the effectiveness of mental health treatment for refugees. Integrated care models have been developed in other psychiatric populations to bridge health and welfare systems, reduce fragmentation and address social determinants that impede recovery, and these are now widely promoted in mental healthcare. However, refugees undergoing mental health treatment have remained largely absent from this research base. Despite recognition that social determinants may undermine treatment, no randomised controlled trials (RCTs) have tested integrated care models that simultaneously address mental health and post-migration stressors among refugees in high-income settings. Such trials in real-world settings are needed to determine whether adapting standard PTSD treatment to incorporate targeted support for post-migration stressors can improve outcomes. To address this gap, we developed an integrated care intervention that embedded systematic collaboration with employment services into specialised mental health treatment for unemployed refugees with PTSD. As many post-migration stressors influencing recovery extend beyond the scope of specialised mental health services, the intervention was designed to facilitate coordinated action across sectors. It was expected that addressing these stressors would support improvements in both mental health and functioning. The aim of the present RCT was to evaluate the effects of an add-on integrated care intervention compared with treatment as usual (TAU) for unemployed refugees with PTSD, with respect to measures of functioning, mental health symptoms, quality of life and post-migration stressors. We hypothesised that participants receiving the add-on integrated care intervention would have superior outcomes across all measures compared with those receiving TAU. The study was a pragmatic, parallel-group, two-arm superiority trial with a 1:1 allocation ratio to either TAU or TAU with an add-on integrated care intervention. The trial formed part of a larger mixed-methods research programme, which also included a separate qualitative study exploring patient and provider experiences, a health economic evaluation, and a follow-up study using clinical and registry data. The setting was a highly specialised mental health out-patient clinic for refugees and migrants, the Competence Centre for Transcultural Psychiatry (CTP), in the Capital Region of Denmark. This clinic serves a catchment area of nearly two million people, and culturally sensitive care, including use of interpreters and attention to patients’ cultural and social context, is an integral part of routine clinical practice. The intersectoral collaboration involved five municipalities, representing about half of the catchment area. Participants were randomised electronically, stratified by municipality, using a sequence generated by an independent researcher.