‘How can we help when she won't tell us what's wrong?’ Professionals working with South Asian women who have experienced sexual abuse

Understanding ethnic inequalities in mental healthcare in the UK: A meta-ethnography

BACKGROUND

Evidence regarding the presence and persistence of ethnic inequalities in mental healthcare is well established. The reasons for these inequalities and lack of progress in diminishing them are less understood. This meta-ethnography aims to provide a new conceptual understanding of how ethnic inequalities are created and sustained; this is essential to develop effective interventions. Specifically, we sought to understand why people from ethnic minority groups are underrepresented in primary care mental health service provision and overrepresented in crisis pathways and detention.

METHODS AND FINDINGS

Following eMERGe guidelines for meta-ethnographies, we searched OpenGrey, Kings Fund, CINAHL, Medline, PsycINFO, and Social Care Online databases for qualitative articles published from database inception until October 2, 2022, using broad categories of search terms relating to "ethnicity AND (mental illness/mental health/emotional distress) AND (help-seeking/service utilisation/experience/perception/view)." We included all conceptually rich articles that used qualitative methods of data collection and analysis and excluded non-UK studies and those that focused solely on causation of mental illness. Our patient, public, and practitioner lived experience advisory group provided feedback and input on key stages of the project including search terms, research questions, data analysis, and dissemination. A total of 14,142 articles were identified; 66 met the inclusion criteria. We used reciprocal, refutational, and line of argument analytical approaches to identify convergence and divergence between studies. The synthesis showed that current models of statutory mental healthcare are experienced as a major barrier to the delivery of person-centred care to those in ethnic minority groups due to the perceived dominance of monocultural and reductionist frameworks of assessment and treatment (described as "medical" and "Eurocentric") and direct experiences of racist practice. The lack of socially oriented and holistic frameworks of knowledge and understanding in medical training and services is experienced as epistemic injustice, particularly among those who attribute their mental illness to experiences of migration, systemic racism, and complex trauma. Fear of harm, concerns about treatment suitability, and negative experiences with health providers such as racist care and medical neglect/injury contribute to avoidance of, and disengagement from, mainstream healthcare. The lack of progress in tackling ethnic inequalities is attributed to failures in coproduction and insufficient adoption of existing recommendations within services. Study limitations include insufficient recording of participant characteristics relating to generational status and social class in primary studies, which prevented exploration of these intersections.

CONCLUSIONS

In this study, we found that the delivery of safe and equitable person-centred care requires a model of mental health that is responsive to the lived experiences of people in ethnic minority groups. For the people considered in this review, this requires better alignment of mental health services with social and anti-racist models of care. Our findings suggest that intersections related to experiences of racism, migration, religion, and complex trauma might be more relevant than crude ethnic group classifications. Strategies to tackle ethnic inequalities in mental healthcare require an evaluation of individual, systemic, and structural obstacles to authentic and meaningful coproduction and implementation of existing community recommendations in services.

Help seeking and mental health outcomes among South Asian young adult survivors of sexual violence in the New York State Region

BACKGROUND

Sexual violence is a growing issue faced across diverse South Asian American communities under the backdrop of a distinct religious and cultural environment that intersects with the ability to prevent and manage this public health crisis. There is also growing attention on sexual violence experienced by younger or second-generation South Asian Americans, although little is known on the prevalence of this violence and its impact on health outcomes. Using data from a community-driven sexual violence survey, this study describes the experience of sexual violence and related help seeking behaviors and mental health outcomes among 18-34-year-old South Asian Americans living near the New York (NY) State region.

METHODS

Participants were recruited via social media to participate in an anonymous survey developed in partnership with an advisory board of South Asian young adult representatives. Data was analyzed descriptively and through adjusted logistic regression models.

RESULTS

Overall, responses from 335 sexual assault survivors were analyzed. Types of assault experienced included no-contact (97.6%), contact (75.2%), rape attempts (50.2%), rape (44.6%), and multiple rape (19.6%). Many reported perpetrators were South Asian (65.1%) or family members (25.1%). Only 27.6% indicated they had reported assaults to authorities or received services. In adjusted analyses, odds of help seeking were higher among participants who were older (AOR:1.10, 95%CI:1.02-1.20), were a sexual minority (lesbian, gay, bisexual) (1.98, 1.05-3.71), had a family member as the perpetrator (1.85, 1.01-3.40), had lower disclosure stigma (1.66, 1.16-2.44), and experienced depression (2.16, 1.10-4.47). Odds of depression were higher among sexual minority participants and lower among those with higher sexual assault disclosure stigma (3.27, 1.61-7.16; 0.68, 0.50-0.93).

CONCLUSIONS

Findings call for greater targeted policy interventions to address the prevention of sexual violence among young South Asian Americans and greater focus on improving help seeking behaviors and improving mental health outcomes among survivors.

Service Organisations’ Cultural Competency When Working with Ethnic Minority Victims/Survivors of Child Sexual Abuse: Results from a Program Evaluation Study in Australia

Founded in the results of a systematic literature review, a professional development program was developed about the needs of ethnic minority victims/survivors of child sexual abuse, with one component on the role of organisations. The objective was to address the misperception that frontline workers are more responsible for cultural competency. The program was delivered across Australia in 2019 (T1 n = 112, T2 n = 44). Data collection for the program evaluation was conducted over six months using a mixed-methods design. The results show that: (a) a sizeable portion of organisations (16%) do not have any ethnic minority staff, and very few are in management positions (6–13%); (b) ethnic minority staff, and staff in organisations specialised for ethnic minority communities, offer choice to clients about ethnically-matched service providers more often; (c) there is evidence supporting the usefulness of ongoing training; (d) the use of a multicultural framework was rated higher ‘in principle’ than ‘in practice’, and ratings increased after the program; (e) the proportion of organisations collecting ethnicity-related data did not increase over time; (f) all organisations specialised for ethnic minority communities had visually inclusive websites but was only 54% for mainstream organisations; and (g) organisations specialised for ethnic minority communities have stronger links with other local ethnic minority community organisations. Overall, the program is seen as useful for promoting cultural competency at the organisational level; clearly identifying key mandatory and ideal elements, which support good practice with this highly vulnerable and marginalised client group.

"His body is human, but he has a tiracchāna heart": An ethnographic study of the epigenesis of child abuse in Cambodia

In Cambodia, more than half of all children experience physical, emotional, or sexual abuse. This article examines how Cambodians view the causes and effects of child abuse and analyses its underlying cultural forces. Adopting a conceptual framework originally developed for the cultural context of violence against women, 110 cases of child abuse were ethnographically studied, comprising 61 cases of sexual abuse (50 girls and 11 boys), 26 cases of physical abuse (13 girls and 13 boys), and 23 cases of emotional abuse or neglect (13 girls and 10 boys). The perpetrators included fathers and other close relatives, lay Buddhist officiants and monks, and neighbors. Most informants viewed the sexual or physical abuse of children as stemming from "cultural attractors," including blighted endowment caused by deeds in a previous life, a bad character starting early in life, astrological vulnerability to abuse, preordained entanglement between the child and the abuser (they are "fated" to meet), sexual craving, "entering the road to ruin," and a moral blindness that portrays the abuser as blameless. Although these traits are similar to those identified in the explanations of violence against women, there were notable differences such as the role of the tiracchāna in explaining sexual abuse, including incest. Using these findings, this article identifies a cultural epigenesis of child sexual abuse, and provides a blueprint for developing a culturally responsive plan to prevent child abuse.

Bread, milk and a Tattslotto ticket: the interpretive repertoires of young adult gambling in Australia

The discourse of Australian young adults who gamble regularly was analysed to explore key dilemmas and challenges of a generation who grew up with the positive and negative impacts of gambling advertisements. Qualitative interviews of seven young recreational gamblers who regularly frequent gaming machine venues were conducted. The discourse that they used to describe their gambling involvement, motivation, development and subjective views were analysed and three central repertoires: 'Culture not self,' 'If it makes you happy,' and 'No problem here!' were identified. The current findings demonstrate the participants' attempts to understand and legitimise their gambling. Further, it was suggested that young adults face a series of dilemmas when deciding whether to gamble and to what extent they gamble. Their discourse highlights the tension between individual agency, societal expectations and familial influence. The respondents primarily gambled for social reasons in a manner which they perceived as culturally acceptable. The importance of harm minimization and public awareness campaigns directed at young adults was also discussed.

'They're more than animals': refugees' accounts of racially motivated violence

Previous discursive research has found that minority group members may deny or downplay the existence of discrimination. However, to date, little research has addressed the issue of violence against minority group members. This study therefore draws on interviews with asylum seekers and refugees in a Scottish city to analyse their reports of violence committed against them. One form of reporting violence was by way of a complaint available to any speaker, in making no reference to attributes of attackers or victim. When racism was alleged, it was presented as a tentative, reluctant or 'last resort' explanation. The descriptions offered by interviewees reflected the contributions made by the interviewer, highlighting the ways in which these reports are interactional co-productions. The results suggest that accounts from victims of seemingly racially motivated violence may function in similar ways to 'new racism' in making racism seem to 'disappear'. These findings point to the potential difficulties that arise in identifying and looking to challenge instances of 'new racism'.

Talking therapy services for adult survivors of childhood sexual abuse (CSA) in Scotland: perspectives of service users and professionals

This study aimed to elicit perceptions and experiences of talking therapy services for CSA survivors and professionals utilizing qualitative interviews and analyzing transcripts using Interpretative Phenomenological Analysis. Participants included 13 adult survivors and 31 professionals in statutory and voluntary services in Scotland. Main themes were benefits from and challenges of the therapeutic process. Benefits included a trusting therapeutic relationship, feeling safe to disclose, breaking isolation, enhancing self-esteem and self-worth, contextualizing the abuse, and moving toward recovery. Challenges included trauma-focused work, supportive contact, continuity and consistency of services, accessibility during acute episodes, hearing and managing disclosures, child protection issues, and availability and accessibility of services. The findings support a greater emphasis on relational models, supervision, and training.