African-Caribbean interactions with mental health services in the UK: experiences and expectations of exclusion as (re)productive of health inequalities

Ethnic differences in receipt of psychological interventions in Early Intervention in Psychosis services in England - a cross-sectional study

There is some evidence of differences in psychosis care provision by ethnicity. We investigated variations in the receipt of Cognitive Behavioural Therapy for psychosis (CBTp) and family intervention across ethnic groups in Early Intervention in Psychosis (EIP) teams throughout England, where national policy mandates offering these interventions to all. We included data on 29,610 service users from the National Clinical Audit of Psychosis (NCAP), collected between 2018 and 2021. We conducted mixed effects logistic regression analyses to examine odds ratios of receiving an intervention (CBTp, family intervention, either intervention) across 17 ethnic groups while accounting for the effect of years and variance between teams and adjusting for individual- (age, gender, occupational status) and team-level covariates (care-coordinator caseload, inequalities strategies). Compared with White British people, every minoritized ethnic group, except those of mixed Asian-White and mixed Black African-White ethnicities, had significantly lower adjusted odds of receiving CBTp. People of Black African, Black Caribbean, non-African/Caribbean Black, non-British/Irish White, and of "any other" ethnicity also experienced significantly lower adjusted odds of receiving family intervention. Pervasive inequalities in receiving CBTp for first episode psychosis exist for almost all minoritized ethnic groups, and family intervention for many groups. Investigating how these inequalities arise should be a research priority.

The perceived effects of migration on the mental health of Afro-Caribbean immigrants: A narrative synthesis of qualitative studies

WHAT IS KNOWN ON THE SUBJECT?: Economic and educational opportunities are usually the principal driving forces for migration. There is a large body of quantitative research studies, mainly from the U.K., supporting the high prevalence of psychiatric disorders, mainly psychotic disorders, in Afro-Caribbean immigrants which increases across generations. The process of migration and acculturation can present significant risk factors for psychiatric disorders in immigrants. Research involving members of the Black community is generally conducted with the perception that Blacks are a homogenous group, ignoring the cultural and ethnic differences among the subgroups. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: It provides a broadened understanding of the experiences, thoughts and feelings of Afro-Caribbean immigrants, and the factors within the processes of migration and acculturation that negatively impacts their mental health. It provides context to the volume of quantitative studies indicating a high prevalence of psychiatric disorders, particularly psychotic disorders, in Afro-Caribbean immigrants and their offspring. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurses conducting mental health evaluations and assessments for members of the Black community should be culturally competent. Cultural competence entails an understanding of cultural beliefs, race, ethnicity and values. Additionally, knowledge of the effects of migration and acculturation as mental health risks is also important to improve mental health outcomes. Cultural competence will help reduce health disparities by increasing trust in the health care system and providers, not only for Afro-Caribbean immigrants, but all immigrant groups.

ABSTRACT

INTRODUCTION: There is evidence to support migration as a significant risk factor for psychiatric disorders in immigrants. Unfortunately, as an immigrant group, little is known about the mental health of Afro-Caribbean immigrants and the factors that threaten their mental health.

AIM

To explore the perceived effects of migration on the mental health of Afro-Caribbean immigrants.

METHODS

A qualitative narrative synthesis was employed to interpretively integrate 13 primary qualitative research findings. Eleven of the primary studies were conducted in the U.K., one in the U.S. and one in Canada.

RESULTS

The themes gleaned: (1) experiences of racism, (2) generational conflicts, (3) feelings of powerlessness, (4) limited socioeconomic resources, (5) unfulfilled expectations, (6) fragmented family and community and (7) ignoring cultural/ethnic identity.

DISCUSSION

The findings broadened the understanding and experiences of Afro-Caribbean immigrants and their mental health vulnerabilities as they navigate through migration and acculturation.

IMPLICATIONS FOR PRACTICE

Addressing the mental health of Afro-Caribbeans will require health care providers to: (1) be cognizant of their immigrant status; (2) understand how migration and acculturation influence the mental health of immigrants; (3) be aware of the ethnocultural differences among Black subgroups.

Ethnic minority fathers' experiences of the Neonatal Care Unit: barriers to accessing psychological support

BACKGROUND

The Neonatal Care Unit is a challenging environment for parents. Previous literature documents the need for increased and more specialised understanding of support for fathers. There remains a dearth of literature on the experiences of ethnic minority fathers in particular, who may be less likely to access psychological support available.

METHOD

This project aimed to understand the barriers ethnic minority fathers face when accessing psychology support at a Neonatal Care Unit in England. Seven fathers from ethnic minority backgrounds participated in semi-structured interviews after their babies were discharged.

RESULTS

Data were analysed using a Reflexive Thematic Analysis approach. Three main themes were identified: 'Psychology is a Threat', 'It's Not Really Talked About in our Culture', and 'A Space for Mum, Not Me'. These themes are discussed in reference to the extant literature, and recommendations are provided to improve access to support in this neonatal unit.

CONCLUSIONS

There is a need to recognise interacting influences of gender and cultural norms in supporting these fathers, including understanding the role of psychology, consideration of stigma, and knowing families in relation to their cultural context.

Views and experiences of primary care among Black communities in the United Kingdom: a qualitative systematic review

BACKGROUND

In the United Kingdom, people with non-white ethnicities are more likely to report being in worse health conditions and have poorer experiences of healthcare services than white counterparts. The voices of those of Black ethnicities are often merged in literature among other non-white ethnicities. This literature review aims to analyse studies that investigate Black participant experiences of primary care in the UK.

METHODS

We conducted a systematic literature review searching Medline, Web of Science, EMBASE, SCOPUS, Social Policy and Practice, CINAHL plus, Psych INFO and Global Health with specific search terms for appropriate studies. No publish date limit was applied.

RESULTS

40 papers (39 articles and 1 thesis) were deemed eligible for inclusion in the review. A number of major themes emerged. Patient expectations of healthcare and the health seeking behaviour impacted their interactions with health systems in the UK. Both language and finances emerged as barriers through which some Black participants interacted with primary care services. (Mis)trust of clinicians and the health system was a common theme that often negatively impacted views of UK primary care services. The social context of the primary care service and instances of a cultural disconnect also impacted views of primary care services. Some papers detail patients recognising differential treatment based on ethnicity. The review included the voices of primary care professionals where descriptions of Black patients were overwhelmingly negative.

CONCLUSION

Views and experiences of Black groups may be radically different to other ethnic minorities and thus, should be teased out of broader umbrella terms like Black and Asian Minority Ethnic (BAME) and Black Minority Ethnic (BME). To address ethnicity-based health inequalities, culturally sensitive interventions that engage with the impacted community including co-designed interventions should be considered while acknowledging the implications of being racialised as Black in the UK.

Racism against racialized migrants in healthcare in Europe: a scoping review

BACKGROUND

Racism is frequently mentioned as a social determinant of migrants' health and a barrier to health services. However, in the European context, racism and its impact on racialized migrants' access to healthcare is remarkably under-researched. This scoping review makes a first step toward filling this void by mapping the existing literature on racial and ethnic discrimination against racialized migrants in healthcare in Europe, identifying evidence gaps, and offering recommendations for future research on this topic.

METHODS

Following PRISMA guidelines, four databases were searched for empirical studies published in English between 1992 and 2022. Studies were included if they report findings on manifestations, experiences and/or impacts of racial or ethnic discrimination against racialized migrants in a healthcare setting in a European country. They were summarized by study characteristics (geographical scope, study design, research question and measures) and research findings were synthesized.

RESULTS

Out of 2365 initial hits, 1724 records were included in the title/abstract-screening, 87 records in the full text-screening, and 38 records in the data extraction. For many country and healthcare contexts, evidence on racism in healthcare is lacking. Most studies apply an explorative qualitative research design; comparability and generalizability of research results are low. Our analysis furthermore shows a near-exclusive research focus on racism on the interpersonal level as compared to institutional and structural levels. Our synthesis of study results identifies three interrelated ways in which racism manifests in and impacts migrants' healthcare: 1) general anti-migration bias, 2) health- and healthcare-related prejudice, and 3) differential medical treatment.

CONCLUSIONS

Our review underscores how racism reinforces inequities in healthcare access and quality for racialized migrants. It also highlights the need for more research on racism in Europe across a greater scope of country contexts, healthcare settings and migrant/racialized categories in order to understand specific forms of racism and capture race as a context-contingent social construct. It is critical that future research includes the consideration of individual-level racism as embedded in racism on institutional and structural levels. Methods and insights from other disciplines may help to critically examine concepts in light of underlying historical, sociopolitical and socioeconomic processes and structures, and to improve methods for researching racialization and racism in healthcare.

Double stigma in mental health service use: Experience from ethnic minorities in Hong Kong

BACKGROUND

Ethnic minorities (EMs) typically underutilise mental health services (EMs) with issues that are not shared by the local population. Understanding the underlying perceived factors could help reduce their mental health disparities.

AIMS

This is a qualitative study aiming to examine the barriers that prevent EMs from seeking mental health services in Hong Kong.

METHODS

Six semistructured focus groups with 31 EMs who resided in Hong Kong were conducted from May 31 to June 26, 2021. The outcome measures were the themes and subthemes of perspectives on mental health service use.

RESULTS

Among 31 adults (20 [64.5%] women, 11 [35.5%] men; 17 [54.8%] aged 25-39 years) who participated, most participants self-identified as Indian (13 [41.95]) or Pakistani (10 [32.3]). There were 16 individuals (51.6%) who reported severe or higher levels of anxiety or depressive symptoms, while 12 individuals (38.7%) reported moderate levels. Three emerging themes identified for the barriers to help-seeking for psychiatric intervention were (1) preexisting problems, (2) psychaitric service lacks cultural sensitivity and (3) personal or family limitation, while that for the recommendations to improve help-seeking had six themes: (1) improve cultural sensitivity, (2) make EM mental health practitioners available, (3) improve professional conduct, (4) improve on-site support, (5) improve financial support and (6) improve mental health promotion in schools.

CONCLUSION

This study found that EMs in Hong Kong experience double stigma, which keeps them away from seeking professional mental health care. There were also disparities in the use of mental health services by ethnicity. The study also made recommendations for promoting EM help-seeking at the individual, governmental and community levels.

Experiences of Non-Pharmaceutical Primary Care Interventions for Common Mental Health Disorders in Socioeconomically Disadvantaged Groups: A Systematic Review of Qualitative Studies

Common mental health disorders (CMDs) disproportionately affect people experiencing socioeconomic disadvantage. Non-pharmaceutical interventions, such as 'social prescribing' and new models of care and clinical practice, are becoming increasingly prevalent in primary care. However, little is known about how these interventions work and their impact on socioeconomic inequalities in health. Focusing on people experiencing socioeconomic disadvantage, this systematic review aims to: (1) explore the mechanisms by which non-pharmaceutical primary care interventions impact CMD-related health outcomes and inequalities; (2) identify the barriers to, and facilitators of, their implementation in primary care. This study is a systematic review of qualitative studies. Six bibliographic databases were searched (Medline, ASSIA, CINAHL, Embase, PsycInfo and Scopus) and additional grey literature sources were screened. The included studies were thematically analysed. Twenty-two studies were included, and three themes were identified: (1) agency; (2) social connections; (3) socioeconomic environment. The interventions were experienced as being positive for mental health when people felt a sense of agency and social connection. The barriers to effectiveness and engagement included socioeconomic deprivation and underfunding of community sector organisations. If non-pharmaceutical primary care interventions for CMDs are to avoid widening health inequalities, key socioeconomic barriers to their accessibility and implementation must be addressed.

Social network characteristics of Black African and Caribbean people with psychosis in the UK

Poorer social networks predict more coercive pathways to care and other adverse outcomes in people with psychosis. People from Black African and Caribbean backgrounds have more negative experiences within UK mental health care systems and family relationships often breakdown. This study aimed to examine the social network characteristics of Black African and Caribbean people experiencing psychosis and associations between network characteristics and severity of psychosis, negative symptoms, and general psychopathology. Fifty-one participants completed social network mapping interviews (a gold standard approach to assessing social network composition) and the Positive and Negative Syndrome Scale. This is the first study to explicitly measure social network size amongst Black people with psychosis living within the UK and results showed that participants' social network size (mean = 12) was comparable to that of other psychosis samples. Networks were of moderate density and comprised disproportionately more relatives than other relationship types. Poor network quality was related to more severe psychosis symptoms suggesting that social network quality may be an important factor in influencing the severity of psychosis. Findings highlight the need for community-based interventions and family therapies to mobilise sources of social support for Black people with psychosis within the UK.

Towards evidence-based and inclusive models of peer support for long covid: A hermeneutic systematic review

Since the first wave of COVID-19 in March 2020 the number of people living with post-COVID syndrome has risen rapidly at global pace, however, questions still remain as to whether there is a hidden cohort of sufferers not accessing mainstream clinics. This group are likely to be constituted by already marginalised people at the sharp end of existing health inequalities and not accessing formal clinics. The challenge of supporting such patients includes the question of how best to organise and facilitate different forms of support. As such, we aim to examine whether peer support is a potential option for hidden or hardly reached populations of long COVID sufferers with a specific focus on the UK, though not exclusively. Through a systematic hermeneutic literature review of peer support in other conditions (57 papers), we evaluate the global potential of peer support for the ongoing needs of people living with long COVID. Through our analysis, we highlight three key peer support perspectives in healthcare reflecting particular theoretical perspectives, goals, and understandings of what is 'good health', we call these: biomedical (disease control/management), relational (intersubjective mutual support) and socio-political (advocacy, campaigning & social context). Additionally, we identify three broad models for delivering peer support: service-led, community-based and social media. Attention to power relations, social and cultural capital, and a co-design approach are key when developing peer support services for disadvantaged and underserved groups. Models from other long-term conditions suggest that peer support for long COVID can and should go beyond biomedical goals and harness the power of relational support and collective advocacy. This may be particularly important when seeking to reduce health inequalities and improve access for a potentially hidden cohort of sufferers.

‘It’s been quite a poor show’ – exploring whether practitioners working for Improving Access to Psychological Therapies (IAPT) services are culturally competent to deal with the needs of Black, Asian and Minority Ethnic (BAME) communities

Cultural competency is a core clinical skill. Yet, psychological therapists may be inadequately trained to deal with the needs of service users from Black, Asian and Minority Ethnic (BAME) backgrounds. This can lead to dissatisfaction with mental health services, disengagement from therapy, and poorer treatment outcomes when compared to the White British population. The aim of this study was to explore whether practitioners working for Improving Access to Psychological Therapies (IAPT) services are culturally competent to deal with the needs of diverse communities. Semi-structured interviews were carried out with a range of practitioners, from early career psychological wellbeing practitioners (PWPs) to senior cognitive behavioural therapists (n=16). Reflexive thematic analysis (RTA) was used to analyse the data, guided by a six-phase process to produce a robust pattern-based analysis. Overall, three themes were generated: (1) encountering cultural dissonance within therapy; (2) challenges in making cultural adaptations to therapy; and (3) identifying cultural competency needs. Out of sixteen participants, only nine therapists received one-day formal training throughout their therapeutic career, whilst seven reported receiving no cultural competence training at all. Overall, it appears that there is an urgent need and desire for therapists to be offered cultural competency training so that they can better serve BAME communities. Clinical implications and future recommendations are made.

Key learning aims

(1)

A rapid review of evidence relating to service use, experiences, and support needs of adults from minority ethnic communities along the eyecare pathway in the United Kingdom

Background

There is growing awareness of the health inequalities experienced by minority ethnic communities, who make up an increasing proportion of the United Kingdom (UK) population and have been found to be at increased risk of visual impairment (V.I.). V.I. impacts on a wide range of life domains including employment, social functioning and activities of daily living. Considering existing health inequalities, the increased risk of V.I. and its wide-ranging impact, it is important to understand the experiences of adults from minority ethnic communities living with V.I. in the UK.

Methods

A rapid evidence review of academic and gray literature published since 2005 and in English was performed. A search of AMED, CINAHL Plus and MEDLINE via EBSCOhost identified 969 articles. Articles were included in the review if they reported findings relating to the UK-context, to adults from minority ethnic communities living with V.I., and to experiences of V.I. and the eyecare pathway.

Results

A total of 11 academic articles and 4 charity reports presented findings relating to perceptions of V.I. and eye disease (n = 3), access to services and service use (n = 5), impact of interventions (n = 7), the wider impact of V.I. (n = 2), and registration status (n = 1). Much of the literature focused on primary eyecare resulting in a comprehensive list of barriers and recommendations to increase eye tests. Less research addressed experiences and use of services further along the eyecare pathway although use of services may be low. Overall, the research on the experiences of adults with V.I. from minority ethnic communities in the UK remains anecdotal, outdated or unavailable. There are substantial gaps in the evidence relating to the wider impact of V.I., the impact of perceptions of V.I., and the use of services beyond primary eyecare.

Conclusions

This review summarizes our current knowledge of the experiences of adults from minority ethnic communities living with V.I. in the UK and highlights substantial gaps in the evidence. The findings provide practical implications for practitioners and researchers committed to addressing health inequalities in the field of eyecare in the UK.

‘Not a cure, but helpful’ – exploring the suitability of evidence-based psychological interventions to the needs of Black, Asian and Minority Ethnic (BAME) communities

Individuals from Black, Asian and Minority Ethnic (BAME) groups experience profound disparities in accessing mental healthcare, show poorer treatment outcomes, and high attrition rates when compared to their White British counterparts. Despite the national rollout of Improving Access to Psychological Therapies (IAPT) services, research exploring service users’ recovery narrative has been scarce. The aim of this study was to explore whether evidence-based psychological interventions are suitable to the needs of BAME communities. Semi-structured interviews were conducted with nine BAME service users who received evidence-based psychological treatment(s) from IAPT services. Reflexive thematic analysis (RTA) was used to analyse the data which included a six-phase process to produce a robust pattern-based analysis. Overall, three themes were generated. The first theme highlighted the importance of recognising cultural dissonance within therapy, which considered patient therapeutic expectations, therapeutic guilt, and conflicting cultural identities. The second theme identified the need for therapists to develop cultural competency. This included the importance of building therapeutic trust and exploration of patient culture within therapy. The final theme considered the road to recovery and highlighted challenges with therapeutic engagement and evaluations of therapeutic effectiveness. Overall, BAME service users felt that therapy was not a cure, but found it helpful. Clinical implications and future recommendations are discussed.

Key learning aims

(1)

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.

Engagement with services in Black African and Caribbean people with psychosis: The role of social networks, illness perceptions, internalized stigma, and perceived discrimination

OBJECTIVES

Research and policies in the United Kingdom have repeatedly highlighted the need to reduce ethnic disparities and improve engagement with mental health services among Black African and Caribbean people with psychosis. The aim of this study was to examine the role of social network characteristics and psychological factors in engagement with services in Black people with psychosis.

METHODS

A cross-sectional study was conducted with 51 Black African and Caribbean adults with non-affective psychosis and currently receiving care from mental health services in England. Measures were completed to examine relationships between social networks, illness perceptions, perceived racial or ethnic discrimination in services, internalized stigma, and current engagement with services from service user and staff perspectives.

RESULTS

Social network composition (ethnic homogeneity) moderately correlated with better service user and staff reported engagement. Greater perceived personal control over problems was associated with better staff reported engagement. Lower perceived ethnic or racial discrimination in services, and specific illness perceptions (higher perceived treatment control, greater self-identification with psychosis symptoms, more concern and greater emotional response related to problems) were associated with better service user reported engagement. Internalized stigma was not associated with service engagement. Multivariate regression analyses suggested that a more ethnically homogenous social network was the strongest predictor of better service user and staff reported engagement.

CONCLUSIONS

Psychosocial interventions that target social networks, perceived ethnic and racial discrimination in services, and illness perceptions may facilitate better engagement and improve outcomes. Further longitudinal studies are required to examine causal mechanisms.

Prevalence of common mental disorders and treatment receipt for people from ethnic minority backgrounds in England: repeated cross-sectional surveys of the general population in 2007 and 2014

BACKGROUND

Concerns persist that some ethnic minority groups experience longstanding mental health inequalities in England. It is unclear if these have changed over time.

AIMS

To assess the prevalence of common mental disorders (CMDs) and treatment receipt by ethnicity, and changes over time, using data from the nationally representative probability sample in the Adult Psychiatric Morbidity Surveys.

METHOD

We used survey data from 2007 (n = 7187) and 2014 (n = 7413). A Clinical Interview Schedule - Revised score of ≥12 indicated presence of a CMD. Treatment receipt included current antidepressant use; any counselling or therapy; seeing a general practitioner about mental health; or seeing a community psychiatrist, psychologist or psychiatric nurse, in the past 12 months. Multivariable logistic regression assessed CMD prevalence and treatment receipt by ethnicity.

RESULTS

CMD prevalence was highest in the Black group; ethnic variation was explained by demographic and socioeconomic factors. After adjustment for these factors and CMDs, odds ratios for treatment receipt were lower for the Asian (0.62, 95% CI 0.39-1.00) and White Other (0.58, 95% CI 0.38-0.87) groups in 2014, compared with the White British group; for the Black group, this inequality appeared to be widening over time (2007 treatment receipt odds ratio 0.68, 95% CI 0.38-1.23; 2014 treatment receipt odds ratio 0.23, 95% CI 0.13-0.40; survey year interaction P < 0.0001).

CONCLUSIONS

Treatment receipt was lower for all ethnic minority groups compared with the White British group, and lowest among Black people, for whom inequalities appear to be widening over time. Addressing socioeconomic inequality could reduce ethnic inequalities in mental health problems, but this does not explain pronounced treatment inequalities.

Loneliness in older people and COVID-19: Applying the social identity approach to digital intervention design

The COVID-19 pandemic is worsening loneliness for many older people through the challenges it poses in engaging with their social worlds. Digital technology has been offered as a potential aid, however, many popular digital tools have not been designed to address the needs of older adults during times of limited contact. We propose that the Social Identity Model of Identity Change (SIMIC) could be a foundation for digital loneliness interventions. While SIMIC is a well-established approach for maintaining wellbeing during life transitions, it has not been rigorously applied to digital interventions. There are known challenges to integrating psychological theory in the design of digital technology to enable efficacy, technology acceptance, and continued use. The interdisciplinary field of Human Computer Interaction has a history of drawing on models originating from psychology to improve the design of digital technology and to design technologies in an appropriate manner. Drawing on key lessons from this literature, we consolidate research and design guidelines for multidisciplinary research applying psychological theory such as SIMIC to digital social interventions for loneliness.

Which Non-Pharmaceutical Primary Care Interventions Reduce Inequalities in Common Mental Health Disorders? A Protocol for a Systematic Review of Quantitative and Qualitative Studies

Common mental health disorders (CMDs) represent a major public health concern and are particularly prevalent in people experiencing disadvantage or marginalisation. Primary care is the first point of contact for people with CMDs. Pharmaceutical interventions, such as antidepressants, are commonly used in the treatment of CMDs; however, there is concern that these treatments are over-prescribed and ineffective for treating mental distress related to social conditions. Non-pharmaceutical primary care interventions, such as psychological therapies and "social prescribing", provide alternatives for CMDs. Little is known, however, about which such interventions reduce social inequalities in CMD-related outcomes, and which may, unintentionally, increase them. The aim of this protocol (PROSPERO registration number CRD42021281166) is to describe how we will undertake a systematic review to assess the effects of non-pharmaceutical primary care interventions on CMD-related outcomes and social inequalities. A systematic review of quantitative, qualitative and mixed-methods primary studies will be undertaken and reported according to the PRISMA-Equity guidance. The following databases will be searched: Assia, CINAHL, Embase, Medline, PsycInfo and Scopus. Retrieved records will be screened according to pre-defined eligibility criteria and synthesised using a narrative approach, with meta-analysis if feasible. The findings of this review will guide efforts to commission more equitable mental health services.

Mental Health in Ethnic Minority Populations in the UK: Developmental Trajectories from Early Childhood to Mid Adolescence

A large body of literature has demonstrated that there are developmental differences in mental health problems. However, less is known about the development of mental health problems in ethnic minority children, particularly at the population level. Using a detailed ethnic classification and nationally representative data from the UK Millennium Cohort Study (n = 18, 521, 49% female, 18% ethnic minority), this study examines ethnic differences in children's mental health problems and trajectories of mental health from ages 3 to 14 years. Growth curve modeling revealed that ethnic minority children followed different developmental trajectories of internalizing and externalizing problems than white children, either in terms of the mean-level and/or rate of change across age. These differences were not explained by child sex, socioeconomic status, maternal depressive symptoms, and maternal immigrant status, highlighting the need for further research exploring the factors that underpin ethnic inequalities in child mental health.

The perspectives of health professionals and patients on racism in healthcare: A qualitative systematic review

OBJECTIVE

To understand racial bias in clinical settings from the perspectives of minority patients and healthcare providers to inspire changes in the way healthcare providers interact with their patients.

METHODS

Articles on racial bias were searched on Medline, CINAHL, PsycINFO, Web of Science. Full text review and quality appraisal was conducted, before data was synthesized and analytically themed using the Thomas and Harden methodology.

RESULTS

23 articles were included, involving 1,006 participants. From minority patients' perspectives, two themes were generated: 1) alienation of minorities due to racial supremacism and lack of empathy, resulting in inadequate medical treatment; 2) labelling of minority patients who were stereotyped as belonging to a lower socio-economic class and having negative behaviors. From providers' perspectives, one theme recurred: the perpetuation of racial fault lines by providers. However, some patients and providers denied racism in the healthcare setting.

CONCLUSION

Implicit racial bias is pervasive and manifests in patient-provider interactions, exacerbating health disparities in minorities. Beyond targeted anti-racism measures in healthcare settings, wider national measures to reduce housing, education and income inequality may mitigate racism in healthcare and improve minority patient care.

Mental Health in Ethnic Minority Populations in the UK: Developmental Trajectories from Early Childhood to Mid Adolescence

A large body of literature has demonstrated that there are developmental differences in mental health problems. However, less is known about the development of mental health problems in ethnic minority children, particularly at the population level. Using a detailed ethnic classification and nationally representative data from the UK Millennium Cohort Study (n = 18, 521, 49% female, 18% ethnic minority), this study examines ethnic differences in children’s mental health problems and trajectories of mental health from ages 3 to 14 years. Growth curve modeling revealed that ethnic minority children followed different developmental trajectories of internalizing and externalizing problems than white children, either in terms of the mean-level and/or rate of change across age. These differences were not explained by child sex, socioeconomic status, maternal depressive symptoms, and maternal immigrant status, highlighting the need for further research exploring the factors that underpin ethnic inequalities in child mental health.

Social Capital and Mental Health Among Black and Minority Ethnic Groups in the UK

Black and minority ethnic communities are at higher risk of mental health problems. We explore differences in mental health and the influence of social capital among ethnic minority groups in Great Britain. Cross-sectional linear and logistic regression analysis of data from Wave 6 (2014–2016) of the Understanding Society databases. In unadjusted models testing the likelihood of reporting psychological distress (i) comparing against a white (British) reference population Indian, Pakistani, Bangladeshi and mixed ethnic minority groups recorded excess levels of distress; and (ii) increasing levels of social capital recorded a strong protective effect (OR = 0.94: 95% CI 0.935, 0.946). In a subsequent series of gender-specific incremental logistic models-after adjustment for sociodemographic and socioeconomic factors Pakistani (males and females) and Indian females recorded higher likelihoods of psychological distress, and the further inclusion of social capital in these models did not materially alter these results. More research on the definition, measurement and distribution of social capital as applies to ethnic minority groups in Great Britain, and how it influences mental wellbeing is needed.

Psychosocial Responses to Healthcare: A Study on Asylum-Seeking Families' Experiences in Denmark

Much work has gone into unpacking the range of individual, interpersonal and structural barriers that prevent asylum-seekers from accessing healthcare. In this Brief Communication, we disentangle asylum-seeking families' psychosocial responses when accessing healthcare as crucial dimensions of the access experience. Drawing on semi-structured interviews with 11 asylum-seeking families in Denmark, we present examples from three specific healthcare encounters between families and healthcare professionals in the Danish asylum system. We demonstrate how unfamiliarity with the healthcare system, interpersonal miscommunication and cultural insensitivity among professionals evoke specific emotions that undermine participants' trust in the healthcare system and affect their future motivation for healthcare seeking and ultimately also their healthcare seeking behavior. We argue for an urgent need to recognize the pivotal role of such psychosocial responses in shaping healthcare access for asylum-seeking families. Focusing on these responses is an important next step in overcoming barriers in access to healthcare, which have been described in literature for years.

Accessing Mental Health Services: a Systematic Review and Meta-ethnography of the Experiences of South Asian Service Users in the UK

Background

Despite calls to address ethnic inequalities to accessing mental health services in the UK, governmental initiatives have had limited impact. Studies indicate that South Asian communities underutilise mental health services. Previous reviews have identified cultural and institutional factors that may influence service use, but these are mostly narrative and limited in their scope.

Method

A systematic literature search resulted in fifteen studies exploring the experiences of seeking help and barriers to accessing and using services from the perspective of British South Asian service users.

Findings

Qualitative data was synthesised through meta-ethnography, and three themes emerged: Distanced from Services, Dilemma of Trust and Threat to Cultural Identity. South Asian service users were positioned at a distance from being able to access services and stuck in a dilemma of mistrusting White and Asian professionals. They constructed their cultural identity through a set of important values which were neglected by mental health services. Service users, therefore, appeared to engage in an ongoing evaluation of the potential benefits of accessing services against the risks of threat to their personal and cultural identities. The findings are discussed in relation to Eurocentric models of care and community engagement approaches.

Conclusion

The review argues that institutional racism and cultural dissonance marginalise South Asian service users from access to quality and effective mental healthcare. It is recommended that services acknowledge the impact of alienation and powerlessness and advance their practices to establish trust and cultural safety for South Asian service users in the UK.

Exploring service user and family perspectives of a Culturally adapted Family Intervention (CaFI) for African-Caribbean people with psychosis: A qualitative study

OBJECTIVES

In the UK, people of African-Caribbean background have the highest rates of psychosis and greatest inequity in mental health services of all ethnicities. National policies have highlighted the lack of evidence-based psychological interventions for this group. The aim of this study was to examine the acceptability of a novel Culturally adapted Family Intervention (CaFI) for African-Caribbean individuals diagnosed with non-affective psychosis and their relatives.

DESIGN

A qualitative design.

METHODS

Semi-structured interviews conducted with 22 service users and 12 family members following participation in CaFI. The interview topic guide included perceptions of the needs and benefits of CaFI; usefulness, cultural specificity and accessibility of CaFI therapy and supporting materials; content and delivering of CaFI sessions; views and experiences of working with CaFI therapists; and perceived barriers and facilitators to implementation.

RESULTS

Deductive framework analysis identified three main themes for service users: perceived benefits, barriers and limitations, and delivery of the therapy. Four themes were identified for family members: perceived benefits, perceptions of therapists, delivery of therapy, and accessibility of therapy content, supporting materials, and cultural appropriateness.

CONCLUSIONS

CaFI was found to be an acceptable intervention for African-Caribbean service users with psychosis and their relatives. Family interventions considering the needs of ethnic and cultural groups have the potential to improve the mental health care and experiences of service users and their families.

PRACTITIONER POINTS

The Culturally adapted Family Intervention (CaFI) was viewed as acceptable to African-Caribbean service users with psychosis and their families. Through adapting interventions to be more culturally sensitive, it is possible to enhance the care of those who typically have poor engagement with mental health services. In-keeping with their ethos of individualized care delivery, mental health services should place more emphasis on being able to offer appropriate, culturally adapted interventions to their service users.

Inequalities in referral pathways for young people accessing secondary mental health services in south east London

Differences in health service use between ethnic groups have been well documented, but little research has been conducted on inequalities in access to mental health services among young people. This study examines inequalities in pathways into care by ethnicity and migration status in 12-29 years old accessing health services in south east London. This study analyses anonymized electronic patient record data for patients aged 12-29 referred to a south east London mental health trust between 2008 and 2016 for an anxiety or non-psychotic depressive disorder (n = 18,931). Multinomial regression was used to examine associations between ethnicity, migration status, and both referral source and destination, stratified by age group. Young people in the Black African ethnic group were more likely to be referred from secondary health or social/criminal justice services compared to those in the White British ethnic group; the effect was most pronounced for those aged 16-17 years. Young people in the Black African ethnic group were also significantly more likely to be referred to inpatient and emergency services compared to those in the White British ethnic group. Black individuals living in south east London, particularly those who identify as Black African, are referred to mental health services via more adverse pathways than White individuals. Our findings suggest that inequalities in referral destination may be perpetuated by inequalities generated at the point of access.

Toward an Intersectional Approach to Health Justice

Despite unprecedented global wealth creation, health inequity-the unjust health inequality between classes and groups among and within countries-persists, reviving the relevance of social justice as a lens to understand and as an instrument to intervene in these issues. However, the theoretical aspects and polysemous character of social justice as applied in the field of public health are often assumed rather than explicitly explained. An intersectional justice approach to understanding health inequality, inequity, and injustice might be useful. It argues that preexisting class-, race/ethnicity-, and gender-based health injustice and the socially differentiated impacts of the COVID-19 pandemic are shaped, interconnectedly, by economic maldistribution, cultural misrecognition, and political misrepresentation. Pursuing health justice requires analyses, strategies, and interventions that integrate the economic, cultural, and political spheres of redistribution, recognition, and representation, respectively. Such an intersectional approach to health justice is even more relevant and compelling in light of the COVID-19 pandemic. This article is broadly about class, race/ethnicity, and gender political economy of public health-but with a narrower focus on maldistribution, misrecognition, and misrepresentation, shaping social and health injustices.

"Crazy person is crazy person. It doesn't differentiate": an exploration into Somali views of mental health and access to healthcare in an established UK Somali community

Background

Mental health conditions have been shown to disproportionately affect those from Black, Asian and Minority Ethnic (BAME) communities. Somali communities globally have relatively high levels of mental illness, but low levels of mental health service use, with numerous barriers to care identified.

This study was conducted in an established UK Somali community in the South West of England and aimed to explore community beliefs and views about the causes of mental illness, treatment for mental illness, and access to medical services in general. Participants were asked about how mental health and illness are understood and conceptualised, along with the cultural meaning of mental illness and its manifestations in relation to men, women and young people.

Design

Using a community-based participatory research design, in partnership with local Somali community organisations, the research team conducted four focus groups with a total of 23 participants aged over 18. Open-ended questions were used to facilitate discussion. Transcripts were analysed thematically.

Results

The participants discussed the role of migration and associated stress from the civil war and how that could contribute to mental illness.

Participants tended to view the symptoms of mental illness as physical manifestations such as headaches and to describe a strong community stigma where those with mental health conditions were viewed as “crazy” by others. Barriers to accessing healthcare included language barriers, waiting times and a mistrust of doctors. Various ideas for improvements were discussed, including ideas to reduce stigma and ideas for community initiatives.

Conclusion

Cultural considerations and reducing stigma are vital in improving understanding of mental illness and improving access to mental health services, along with building relationships and trust between the Somali community and health care workers.

"Crazy person is crazy person. It doesn't differentiate": an exploration into Somali views of mental health and access to healthcare in an established UK Somali community

BACKGROUND

Mental health conditions have been shown to disproportionately affect those from Black, Asian and Minority Ethnic (BAME) communities. Somali communities globally have relatively high levels of mental illness, but low levels of mental health service use, with numerous barriers to care identified. This study was conducted in an established UK Somali community in the South West of England and aimed to explore community beliefs and views about the causes of mental illness, treatment for mental illness, and access to medical services in general. Participants were asked about how mental health and illness are understood and conceptualised, along with the cultural meaning of mental illness and its manifestations in relation to men, women and young people.

DESIGN

Using a community-based participatory research design, in partnership with local Somali community organisations, the research team conducted four focus groups with a total of 23 participants aged over 18. Open-ended questions were used to facilitate discussion. Transcripts were analysed thematically.

RESULTS

The participants discussed the role of migration and associated stress from the civil war and how that could contribute to mental illness. Participants tended to view the symptoms of mental illness as physical manifestations such as headaches and to describe a strong community stigma where those with mental health conditions were viewed as "crazy" by others. Barriers to accessing healthcare included language barriers, waiting times and a mistrust of doctors. Various ideas for improvements were discussed, including ideas to reduce stigma and ideas for community initiatives.

CONCLUSION

Cultural considerations and reducing stigma are vital in improving understanding of mental illness and improving access to mental health services, along with building relationships and trust between the Somali community and health care workers.

Managing a moral identity in debt advice conversations

Previous research has found that stigma can be a barrier to service use but there has been little work examining actual service encounters involving members of stigmatized groups. One such group are those with problematic or unmanageable debts. Providing advice to members of this group is likely to be particularly difficult due to the stigma associated with being in debt. Using conversation analysis and discursive psychology, this study examines 12 telephone advice conversations between debt advisors and individuals in debt. Both clients and advisors oriented to the negative moral implications of indebtedness and typically worked collaboratively to manage these issues. Clients often claimed a moral disposition as a way to disclaim any unwanted associations with debt, but could find it difficult to reconcile this with an insolvency agreement. Moreover, the institutional requirements of the interaction could disrupt the collaborative management of stigma and advisors could manage the subsequent resistance from clients in either client‐centred or institution‐centred ways. The findings suggest that the products offered by debt advice agencies, as well as the manner in which they are offered to clients, can either help or hinder debtors negotiate the stigma‐related barriers to service engagement.

Substance use and use disorders and treatment receipt among adults in families receiving Temporary Assistance for Needy Families (TANF), 2003-2014

BACKGROUND/PURPOSE

Legalization of marijuana for medical and/or recreational use in some U.S. states has increased attention to substance use and related problems. However, little attention has been paid to these phenomena among adults in families receiving Temporary Assistance for Needy Families (TANF) whose adverse life experiences may put them at elevated risk of substance use disorders (SUDs).

METHODS

Data from the 2003-2014 National Survey on Drug Use and Health (NSDUH) were used to test trends in past-month binge drinking and past-year marijuana, other illicit drug, and any illicit drug use and to examine SUD prevalence and treatment correlates among adults in TANF families.

RESULTS

While rates of binge drinking and any illicit drug use remained steady, marijuana use increased from 15.8% in 2003/2004 to 21.6% in 2013/2014, a 36.7% increase. Increased marijuana use was strongly related to changes in marijuana risk perception. Among adults in TANF families, 19.5% of men and 10.8% of women had a past-year SUD, but only one in five received treatment. Those aged 18-25, Black or Hispanic women, and those who had children at home when surveyed were less likely to have received treatment.

DISCUSSION

Preventive efforts to address substance use, especially marijuana use, among adults in TANF families are needed. Moreover, given greater odds of unmet SUD treatment need among these economically disadvantaged adults, particularly racial/ethnic minority women and those who are in emerging adulthood, uninsured, and have children at home, measures to provide more inclusive services such as integrated behavioral health care are needed.

Culturally adapted Family Intervention (CaFI) for African-Caribbean people diagnosed with schizophrenia and their families: a mixed-methods feasibility study of development, implementation and acceptability

Background

African-Caribbean people in the UK experience the highest incidence of schizophrenia and the greatest inequity in mental health care. There is an urgent need to improve their access to evidence-based care and outcomes. Family intervention (FI) is a National Institute for Health and Care Excellence-approved psychosocial intervention. Although clinically effective and cost-effective for schizophrenia, it is rarely offered. Evidence for any research into FI is lacking for ethnic minority people generally and for African-Caribbean people specifically.

Aims

(1) To assess the feasibility of delivering a novel, culturally appropriate psychosocial intervention within a ‘high-risk’ population to improve engagement and access to evidence-based care. (2) To test the feasibility and acceptability of delivering FI via ‘proxy families’.

Design

A mixed-methods, feasibility cohort study, incorporating focus groups and an expert consensus conference.

Setting

Two mental health trusts in north-west England.

Participants

We recruited a convenience sample of 31 African-Caribbean service users. Twenty-six family units [service users, relatives/family support members (FSMs) or both] commenced therapy. Half of the service users (n = 13, 50%), who did not have access to their biological families, participated by working with FSMs.

Interventions

An extant FI model was culturally adapted with key stakeholders using a literature-derived framework [Culturally adapted Family Intervention (CaFI)]. Ten CaFI sessions were offered to each service user and associated family.

Main outcome measures

Recruitment (number approached vs. number consented), attendance (number of sessions attended), attrition (number of dropouts at each time point), retention (proportion of participants who completed therapy sessions), and completeness of outcome measurement.

Results

Of 74 eligible service users, 31 (42%) consented to take part in the feasibility trial. The majority (n = 21, 67.7%) were recruited from community settings, seven (22.6%) were recruited from rehabilitation settings and three (9.7%) were recruited from acute wards. Twenty-four family units (92%) completed all 10 therapy sessions. The proportion who completed treatment was 77.42% (24/31). The mean number of sessions attended was 7.90 (standard deviation 3.96 sessions) out of 10. It proved feasible to collect a range of outcome data at baseline, post intervention and at the 3-month follow-up. The rating of sessions and the qualitative findings indicated that CaFI was acceptable to service users, families, FSMs and health-care professionals.

Limitations

The lack of a control group and the limited sample size mean that there is insufficient power to assess efficacy. The findings are not generalisable beyond this population.

Conclusions

It proved feasible to culturally adapt and test FI with a sample of African-Caribbean service users and their families. Our study yielded high rates of recruitment, attendance, retention and data completion. We delivered CaFI via FSMs in the absence of biological families. This novel aspect of the study has implications for other groups who do not have access to their biological families. We also demonstrated the feasibility of collecting a range of outcomes to inform future trials and confirmed CaFI’s acceptability to key stakeholders. These are important findings. If CaFI can be delivered to the group of service users with the most serious and persistent disparities in schizophrenia care, it has the potential to be modified for and delivered to other underserved groups.

Future work

A fully powered, multicentre trial, comparing CaFI with usual care, is planned.

Trial registration

Current Controlled Trials ISRCTN94393315.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 6, No. 32. See the NIHR Journals Library website for further project information.

Immigrant-based Disparities in Mental Health Care Utilization

Studies of immigrant-based disparities in mental health care have been limited by small sample sizes and a lack of measures of different dimensions of acculturation. This study draws on the National Epidemiological Survey on Alcohol and Related Conditions to address these limitations. Results indicate first-generation immigrants have lower rates of utilization for both mood and anxiety disorders. Nativity-based disparities in treatment are particularly notable among people from African and Hispanic origins, while there is little evidence of disparities among people from European origins. Of three dimensions of acculturation, only the identity dimension has a positive association with mental health care utilization.

Perceived barriers to accessing mental health services among black and minority ethnic (BME) communities: a qualitative study in Southeast England

OBJECTIVE

In most developed countries, substantial disparities exist in access to mental health services for black and minority ethnic (BME) populations. We sought to determine perceived barriers to accessing mental health services among people from these backgrounds to inform the development of effective and culturally acceptable services to improve equity in healthcare.

DESIGN AND SETTING

Qualitative study in Southeast England.

PARTICIPANTS

26 adults from BME backgrounds (13 men, 13 women; aged >18 years) were recruited to 2 focus groups. Participants were identified through the registers of the Black and Minority Ethnic Community Partnership centre and by visits to local community gatherings and were invited to take part by community development workers. Thematic analysis was conducted to identify key themes about perceived barriers to accessing mental health services.

RESULTS

Participants identified 2 broad themes that influenced access to mental health services. First, personal and environmental factors included inability to recognise and accept mental health problems, positive impact of social networks, reluctance to discuss psychological distress and seek help among men, cultural identity, negative perception of and social stigma against mental health and financial factors. Second, factors affecting the relationship between service user and healthcare provider included the impact of long waiting times for initial assessment, language barriers, poor communication between service users and providers, inadequate recognition or response to mental health needs, imbalance of power and authority between service users and providers, cultural naivety, insensitivity and discrimination towards the needs of BME service users and lack of awareness of different services among service users and providers.

CONCLUSIONS

People from BME backgrounds require considerable mental health literacy and practical support to raise awareness of mental health conditions and combat stigma. There is a need for improving information about services and access pathways. Healthcare providers need relevant training and support in developing effective communication strategies to deliver individually tailored and culturally sensitive care. Improved engagement with people from BME backgrounds in the development and delivery of culturally appropriate mental health services could facilitate better understanding of mental health conditions and improve access.

Ubiquitous Yet Unique

This exploratory study was grounded in a qualitative framework and used a focus group method to examine the meanings that individuals with disabilities (e.g., permanent mobility impairments, sensory impairments) attach to their experiences of stress, as well as major sources or causes of stress in these individuals' lives. Overall, the data showed that stress is an inherent and central part of everyday life for individuals with disabilities. The meanings attached to stress emphasized the personal anxiety and discomfort that affected, most often in negative ways, the participants' physical, psychological, emotional, and social functioning. Counterbalancing this negative focus, most of the participants agreed that stress could be a positive and constructive motivator for stimulating personal action and growth, bringing about positive life changes, enhancing personal awareness, and aiding in solving problems. Interpretation of the sources or causes of stress data produced two theme clusters. The individual theme cluster comprises (a) disability (i.e., added demands in daily living and the complications of disability and aging), (b) health, (c) interpersonal relationships, and (d) the inability to meet expectations. The systemic/ environmental cluster incorporates four sources of stress: (a) exclusionary social systems/ structures, (b) physical accessibility, (c) employment accessibility, and (d) economic marginality. In an effort to integrate these distinct yet interrelated themes, an emergent model is proposed in which social exclusion is used as the overarching conceptual framework for understanding the findings specific to sources or causes of stress. Implications of the findings for rehabilitation counseling for individuals with disabilities also are discussed.

How doctors' communication style and race concordance influence African-Caribbean patients when disclosing depression

OBJECTIVE

To determine the impact of doctors' communication style and doctor-patient race concordance on UK African-Caribbeans' comfort in disclosing depression.

METHODS

160 African-Caribbean and 160 white British subjects, stratified by gender and history of depression, participated in simulated depression consultations with video-recorded doctors. Doctors were stratified by black or white race, gender and a high (HPC) or low patient-centred (LPC) communication style, giving a full 2×2×2 factorial design. Afterwards, participants rated aspects of doctors' communication style, their comfort in disclosing depression and treatment preferences

RESULTS

Race concordance had no impact on African-Caribbeans' comfort in disclosing depression. However a HPC versus LPC communication style made them significantly more positive about their interactions with doctors (p=0.000), their overall comfort (p=0.003), their comfort in disclosing their emotional state (p=0.001), and about considering talking therapy (p=0.01); but less positive about considering antidepressant medication (p=0.01).

CONCLUSION

Doctors' communication style was shown to be more important than patient race or race concordance in influencing African Caribbeans' depression consultation experiences. Changing doctors' communication style may help reduce disparities in depression care.

PRACTICE IMPLICATIONS

Practitioners should cultivate a HPC style to make African-Caribbeans more comfortable when disclosing depression, so that it is less likely to be missed.

Mental health in-reach in an urban UK remand prison

Purpose

– Prison mental health in-reach teams (MHITs) have developed in England and Wales over the last decade. Services have been nationally reviewed, but detailed descriptions of their work have been scarce. The purpose of this paper is to describe the functions of one MHIT in a busy, ethnically diverse, male remand prison in London, UK.

Design/methodology/approach

– Clinical and demographic data were collected for prisoners referred to the MHIT using a retrospective design over an 18-week period in 2008/2009 (n=111).

Findings

– Foreign national prisoners and sentenced prisoners were significantly under-referred. Most referrals were already known to community mental health services, although around a quarter accessed services for the first time in prison. Around a third presented with self-harm/suicide risks. Substance misuse problems were common. Although the MHIT had evolved systems to promote service access, prisoner self-referrals were limited.

Practical implications

– Foreign national prisoners require enhanced investment to improve service access. MHITs identify people with mental disorders for the first time in prisons, but better screening arrangements are needed across systems. An evaluation of multiple MHIT models could inform a wider delivery template.

Originality/value

– One of the first ground-level evaluations of MHITs in England and Wales.

Black African asylum seekers’ experiences of health care access in an eastern German state

Purpose

– The purpose of this paper is to examine how access to health care for (rejected) asylum seekers in an eastern German state is structured and experienced and to consider the implications for their human rights.

Design/methodology/approach

– The paper is based on 12 in-depth interviews with rejected black African asylum seekers and also draws on ethnographic research undertaken at a grassroots refugee organisation and asylum homes. The analysis of the interview data are framed by theorisations of “everyday practices” as “tactics” of resistance to an imposed order.

Findings

– Accomplishing health care access involved a range of structural barriers and humiliating interactions with administrative and health care staff, which had adverse consequences for their health status and were injurious to their human rights and dignity. The study participants used a range of oppositional and discursive tactics in an effort to secure certain (health) outcomes, mediate social relations and resist their domination as asylum seekers.

Research limitations/implications

– Further research should focus on the cumulative micro-level effects of asylum policies on health care access and how they create health inequities and violate asylum seekers’ rights and dignity.

Practical implications

– Policy priorities should include the provision of human rights education as well as training and support for administrative and health staff.

Originality/value

– There is limited qualitative research on the health care experiences of asylum seekers in Germany. This paper makes policy recommendations and identifies areas for further research and human rights advocacy.

Barriers to health care access faced by black immigrants in the US: theoretical considerations and recommendations

Although 54 % of the total black immigrant population is from the Caribbean and 34 % is from Africa, we know relatively little about barriers to healthcare access faced by black immigrants. This paper reviews literature on the barriers that black immigrants face as they traverse the healthcare system and develops a conceptual framework to address barriers to healthcare access experienced by this population. Our contribution is twofold: (1) we synthesize the literature on barriers that may lead to inequitable healthcare access for black immigrants, and (2) we offer a theoretical perspective on how to address these barriers. Overall, the literature indicates that structural barriers can be overcome by providing interpreters, cultural competency training for healthcare professionals, and community-based care. Our model reflects individual and structural factors that may promote these initiatives.

Comparisons of Costs between Black Caribbean and White British Patients with Advanced Multiple Sclerosis in the UK

Background. Multiple sclerosis (MS) is now more common among black and minority ethnic groups in the UK but little is known about the costs of care amongst different ethnic groups. Objective. This study examined and compared service use and costs for people severely affected with MS from Black Caribbean (BC) and White British (WB) backgrounds in the UK and identified predictors of cost for both groups. Method. Population-based cross-sectional study of 43 BC and 43 WB patients with MS (EDSS ≥ 6) and their informal caregivers recruited from an MS service in southeast London. Interviews collected data on health and social service use and informal care support. Costs were calculated using UK unit cost data. Using regression analyses we compared costs between the ethnic groups and identified possible predictors of cost. Results. The mean (SD) costs for the WB and BC groups were £ 25,778 ( £ 39,387) and £ 23,186 ( £ 30,433), respectively. Results identified no significant difference in total cost between the two ethnic groups. The EDSS score alone was a significant predictor of cost. Conclusion. Similar costs between ethnic groups indicate that with regard to this MS service and geographical area, access to care was not affected by ethnicity.

At the crossroads of anthropology and epidemiology: current research in cultural psychiatry in the UK

Cultural psychiatry research in the UK comprises a broad range of diverse methodologies, academic disciplines, and subject areas. Methodologies range from epidemiological to anthropological/ethnographic to health services research; mixed methods research is becoming increasingly popular, as are public health and health promotional topics. After briefly outlining the history of cultural psychiatry in the UK we will discuss contemporary research. Prominent themes include: the epidemiology of schizophrenia among Africans/Afro-Caribbeans, migration and mental health, racism and mental health, cultural identity, pathways to care, explanatory models of mental illness, cultural competence, and the subjective experiences of healthcare provision among specific ethnic groups such as Bangladeshis and Pakistanis. Another strand of research that is attracting increasing academic attention focuses upon the relationship between religion, spirituality, and mental health, in particular, the phenomenology of religious experience and its mental health ramifications, as well as recent work examining the complex links between theology and psychiatry. The paper ends by appraising the contributions of British cultural psychiatrists to the discipline of cultural psychiatry and suggesting promising areas for future research.

The role of schools in promoting inclusive communities in contexts of diversity

Against the background of evidence for links between ill-health and prejudice, in this article we discuss how to promote inclusive communities in contexts of diversity. A brief critical overview of dominant psychological approaches to prejudice reduction reveals the apolitical nature of these approaches, and thus, we argue for a more contextual and political model on how to promote inclusive communities. Drawing on examples of different school practices on cultural diversity from across England, we argue that we need to develop a perspective that connects local contexts of everyday practice, resistance and agency to the institutional and structural realities of prejudice.

'Our community is the worst': the influence of cultural beliefs on stigma, relationships with family and help-seeking in three ethnic communities in London

BACKGROUND

Existing knowledge about the cultural beliefs of black and minority ethnic (BME) communities in the UK regarding stigma and mental illness is limited.

MATERIAL

Data were collected in 10 focus groups, five with service users and five with laypersons, from BME communities in London.

DISCUSSION

Thematic analysis identified that cultural beliefs regarding mental illness reflect four different voices present within the BME communities.

CONCLUSION

The study revealed that cultural beliefs influencing both relationships with family and, consequently, help-seeking for individuals with mental illness must be considered in the development of anti-stigma interventions and when engaging communities around mental health.

Panic disorder among African Americans, Caribbean blacks and non-Hispanic whites

INTRODUCTION

This study investigated co-morbidities, level of disability, service utilization and demographic correlates of panic disorder (PD) among African Americans, Caribbean blacks and non-Hispanic white Americans.

METHODS

Data are from the National Survey of American Life (NSAL) and the National Comorbidity Survey-Replication (NCS-R).

RESULTS

Non-Hispanic whites are the most likely to develop PD across the lifespan compared to the black subgroups. Caribbean blacks were found to experience higher levels of functional impairment. There were no gender differences found in prevalence of PD in Caribbean blacks, indicating that existing knowledge about who is at risk for developing PD (generally more prevalent in women) may not be true among this subpopulation. Furthermore, Caribbean blacks with PD were least likely to use mental health services compared to African Americans and non-Hispanic whites.

CONCLUSION

This study demonstrates that PD may affect black ethnic subgroups differently, which has important implications for understanding the nature and etiology of the disorder.

Stigma, discrimination, or symptomatology differences in self-reported mental health between US-born and Somalia-born Black Americans

OBJECTIVES

We examined differences in self-reported mental health (SRMH) between US-born and Somalia-born Black Americans compared with White Americans. We tested how SRMH was affected by stigma toward seeing a mental health provider, discrimination in the health care setting, or symptoms of depression.

METHODS

Data were from a 2008 survey of adults in Minnesota and were limited to US-born and Somalia-born Black and White Americans (n = 938).

RESULTS

Somalia-born adults were more likely to report better SRMH than either US-born Black or White Americans. They also reported lower levels of discrimination (18.6%) than US-born Black Americans (33.4%), higher levels of stigma (23.6% vs 4.7%), and lower levels of depressive symptoms (9.1% vs 31.6%). Controlling for stigma, discrimination, and symptomatology, Somalia-born Black Americans reported better SRMH than White and Black Americans (odds ratio = 4.76).

CONCLUSIONS

Mental health programming and health care providers who focus on Black Americans' mental health might be missing important sources of heterogeneity. It is essential to consider the role of race and ethnicity, but also of nativity, in mental health policy and programming.

'We are doing our best': African and African-Caribbean fatherhood, health and preventive primary care services, in England

Recent policy pronouncements emphasise the importance of engaging fathers with preventive primary care services. However, in England, there is a paucity of literature which examines African and African-Caribbean fathers' experiences of service provision. This paper reports a study that investigated African and African-Caribbean fathers' beliefs about fatherhood, health and preventive primary care services, with the aim of addressing the deficit in the literature. Nine focus groups involving 46 African and African-Caribbean fathers, recruited using purposive sampling, were undertaken between October 2008-January 2009. Fatherhood was seen as a core aspect of the participants' identities. The fathers enacted these identities in a number of ways, such as caring for and protecting children, which were influenced by spirituality, relationships with women, paid work and racism. The fathers had concerns about their bodies, medical conditions, physical activity and forms of consumption. However, their primary focus was on maintaining and improving the well-being of their children. This resulted in them neglecting their own health needs as they had to meet the obligations of family life and paid work. The fathers reported limited contact with preventive primary care services and were unaware of their purpose, function and availability. They identified ethnicity as a positive asset, and felt their families and communities had particular strengths. However they acknowledged that structural constraints, including racism, influenced their perceptions of and access to local health services. The engagement of African and African-Caribbean fathers needs to be addressed more specifically in policy as part of a broader programme of action to tackle health inequalities. In addition, child health services could build on fathers' commitment to children's well-being through practice that addresses fathers' as well as mothers' needs in families.

Satisfaction with inpatient treatment for first-episode psychosis among different ethnic groups: a report from the UK AeSOP study

BACKGROUND

There is concern about the level of satisfaction with mental healthcare among minority ethnic patients in the UK, particularly as black patients have more compulsory admissions to hospital.

AIMS

To determine and compare levels of satisfaction with mental healthcare between patients from different ethnic groups in a three-centre study of first-onset psychosis.

METHOD

Data were collected from 216 patients with first-episode psychosis and 101 caregivers from South London, Nottingham and Bristol, using the Acute Services Study Questionnaire (Patient and Relative Version) and measures of sociodemographic variables and insight.

RESULTS

No differences were found between ethnic groups in most domains of satisfaction tested individually, including items relating to treatment by ward staff and number of domains rated as satisfactory. However, logistic regression modelling (adjusting for age, gender, social class, diagnostic category and compulsion) showed that black Caribbean patients did not believe that they were receiving the right treatment and were less satisfied with medication than white patients. Black African patients were less satisfied with non-pharmacological treatments than white patients. These findings were not explained by lack of insight or compulsory treatment.

CONCLUSIONS

The study found that black patients were less satisfied with specific aspects of treatment, particularly medication, but were equally satisfied with nursing and social care. Understanding the reasons behind this may improve the acceptability of psychiatric care to black minority ethnic groups.