More than being against it: anti-racism and anti-oppression in mental health services

Anti-oppression pedagogy in health professions: a scoping review

Health professional learners are increasingly called to learn about health inequity to reduce inequities and improve patient care and health outcomes. Anti-oppression pedagogy (AOP) addresses the need for health professional learners to understand multiple health inequities and the structures and systems that produce inequities. However, the inclusion of AOP in health professions education varies and there is a lack of clarity in its conceptualization and integration. A scoping review was conducted to address this gap and to understand how AOP is conceptualized and integrated in health professions education. Thirty-six articles met the inclusion criteria. The articles demonstrated that AOP is not commonly utilized terminology within health professions education. When AOP is integrated, it is not consistently conceptualized but is generally viewed as a broad concept that focuses on antiracism; decoloniality; intersectionality; and supporting learners to understand, critically reflect on, and act against structural and systemic forms of oppressions. In addition, there is variation in the integration of AOP in health professions education with the most common methods consisting of discussions, cases, reflection, learning through lived experiences, and the incorporation of humanities within a longitudinal curriculum. The results of this scoping review highlight the need for health professions education to develop one clear concept that educators use when teaching about anti-oppression, which may reduce working in silos and allow educators to better collaborate with each other in advancing this work. In addition, this review suggests that health professional programs should consider incorporating AOP in curricula with a broad and longitudinal approach utilizing the common methods of delivery. To better support programs in including AOP in curricula, further research is required to emphasize the benefits, provide clarity on its conceptualization, and determine the most effective methods of integration.

Racial discrimination in healthcare services among Black individuals in Canada as a major threat for public health: its association with COVID-19 vaccine mistrust and uptake, conspiracy beliefs, depression, anxiety, stress, and community resilience

OBJECTIVES

To examine the prevalence of major racial discrimination (MRD) in healthcare services and its association with COVID-19 vaccine mistrust and uptake, conspiracy theories, COVID-19-related stressors, community resilience, anxiety, depression, and stress symptoms.

STUDY DESIGN

The study used a population-based cross-sectional design.

METHODS

Data from the BlackVax dataset on COVID-19 vaccination in Black individuals in Canada was analyzed (n = 2002, 51.66% women). Logistic regression analyses were performed to examine the association between MRD and independent variables.

RESULTS

32.55% of participants declared having experienced MRD in healthcare services. Participants with MRD were less vaccinated against COVID-19, presented higher scores of vaccine mistrust, conspiracy beliefs, COVID-19 related stressors, depression, anxiety, and stress, and had lower scores of community resilience. They were more likely to experience depression (AOR = 2.13, P < 0.001), anxiety (AOR = 2.00, P < 0.001), and stress symptoms (AOR = 2.15, P < 0.001). Participants who experienced MRD were more likely to be unvaccinated (AOR = 1.35, P = 0.009).

CONCLUSIONS

Racial discrimination experienced by Black individuals in health services is a major public health concern and threat to population health in Canada. Federal, provincial, and municipal public health agencies should adapt their programs, strategies, tools, and campaigns to address the mistrust created by racial discrimination.

Applying critical leadership to advance 2SLGBTQIA+ health equity: A complex adaptive systems approach

Health inequities are increasing in Canada and across the globe. They pose a substantial threat to the health and well-being of millions of people. Organizational leadership, if it is to effectively contribute to tackling these inequities, must become more systematically infused with competencies that address power and the structural determinants of health. Health equity contexts for 2SLGBTQIA+ (Two Spirit, Lesbian, Gay, Bisexual, Trans, Queer, Intersex, Asexual, and Plus) remain a neglected area of focus in organizational leadership. The goals of this article are to provide: (1) a concise description of critical perspectives and critical leadership studies, (2) describe the urgency of theoretical and applied leadership approaches that more fulsomely integrate critical perspectives, and (3) illustrate an integration of a complex adaptive systems approach to support critical perspectives in advancing health equity for 2SLGBTQIA+ people.

Social work's opportunity and obligation to achieve population health equity

US healthcare remains a system in crisis, wherein spending outpaces other Western economies but health inequities match those of an emerging market economy. As a country founded in tenets of white supremacy, structural racism persists as evidenced by longstanding race-based disparities. Although the population health approach offers a potential framework for preventative and community-based health, without overt race-conscious design, race-based disparities will be replicated. This article outlines the current US context and healthcare policy changes that led to population health taking hold. It then articulates social work's pivotal role in population health by explicitly challenging colorblindness to reach race-based health equity. Opportunities for social work practice, leadership, and research are discussed.

Palliating in Avoidable Death: Reconciling Psychiatrists' Roles as Treaters on Death Row With Participation in a System of Overt Harm

ABSTRACT

Although nations across the globe have eliminated capital punishment, the United States remains one of the few countries in the Americas and Europe that still uses execution. There has been little discussion around the implications of psychiatry's involvement in providing care to incarcerated individuals awaiting death. The following perspective examines the United States as an example of a democratic and highly developed country where the death penalty remains an undeniable reality; the piece provides a brief discussion on psychiatry's relationship with end-of-life care to provide context for subsequent discussion on the role of the psychiatrist on death row in the United States. Medicolegal and ethical considerations are further outlined to identify specific concessions that might be made by the US criminal justice system to truly allow death row psychiatrists to practice to the highest standard of compassionate care.

A tornado in the family: fetal alcohol spectrum disorder and aggression during childhood and adolescence: a scoping review

Background

Aggression exhibited by children and youth with Fetal Alcohol Spectrum Disorder (FASD) toward family members is a major cause of stress and anxiety for caregivers, but relatively little attention has been directed toward designing interventions specific to this phenomenon. In light of the serious negative impact of this issue for families, a scoping review was undertaken to summarize the evidence available on psychosocial interventions that may mitigate the frequency and severity of aggression exhibited by children and youth with FASD toward family members.

Methods

This review was designed using PRISMA-SCR and JBI scoping review guidelines. Three databases were searched in August 2021: EMBASE, PsychINFO, and Medline.

Results

A total of 1,061 studies were imported for screening with only five studies meeting full eligibility criteria. None of the interventions were aimed at specifically targeting aggression and instead reported on broader constructs of externalizing behaviors such as hyperactivity. The interventions were limited to school-aged children. Studies reported primarily on child outcomes while only one reported on family related outcomes.

Conclusion

Following from this review of the literature, we argue that aggression is a related but separate construct from other behavioral problems most frequently targeted by parenting interventions. Given the often dire consequence of aggression displayed by children and youth with FASD and the limited number of studies, there is an urgent need for research on how to support families to manage this specific type of behavior in this population.

Anti-oppressive pedagogy in medical education: A qualitative study of trainees and faculty

PURPOSE

Despite the proliferation of interest in health equity and justice in medical education, there is limited research into the practical implementation of pedagogical approaches that align with anti-oppressive practices. This study sought to explore how to integrate anti-oppressive pedagogy into medical education.

METHODS

Using constructivist grounded theory, the authors conducted 19 semi-structured interviews with a continuum of medical education stakeholders including learners and faculty in a Canadian context between June and August 2021. Transcripts were iteratively analysed using constant comparative analysis.

RESULTS

Findings suggest that existing approaches to anti-oppressive pedagogy in medical education are misaligned with the perceived values, priorities, pace, biomedical focus and hierarchical nature of medical education, and medical practice. Although some learners are motivated to advance anti-oppressive teaching, their motivations are often related to their personal experiences of oppression. Participants suggested that transformative and structural changes are required to effectively integrate anti-oppressive pedagogy into medical education. Suggestions included a shift to community-based learning while ensuring adequate compensation for educators and addressing resistance at individual and institutional levels.

CONCLUSION

Anti-oppressive pedagogy does not presently align with existing medical education practices. Effectively integrating anti-oppressive approaches will require individual and institutional reflection on the values and assumptions that underpin the field before progress can be made in a meaningful and sustainable way.

The weaponization of medicine: Early psychosis in the Black community and the need for racially informed mental healthcare

There is a notable disparity between the observed prevalence of schizophrenia-spectrum disorders in racialized persons in the United States and Canada and White individuals in these same countries, with Black people being diagnosed at higher rates than other groups. The consequences thereof bring a progression of lifelong punitive societal implications, including reduced opportunities, substandard care, increased contact with the legal system, and criminalization. Other psychological conditions do not show such a wide racial gap as a schizophrenia-spectrum disorder diagnosis. New data show that the differences are not likely to be genetic, but rather societal in origin. Using real-life examples, we discuss how overdiagnoses are largely rooted in the racial biases of clinicians and compounded by higher rates of traumatizing stressors among Black people due to racism. The forgotten history of psychosis in psychology is highlighted to help explain disparities in light of the relevant historical context. We demonstrate how misunderstanding race confounds attempts to diagnose and treat schizophrenia-spectrum disorders in Black individuals. A lack of culturally informed clinicians exacerbates problems, and implicit biases prevent Black patients from receiving proper treatment from mainly White mental healthcare professionals, which can be observed as a lack of empathy. Finally, we consider the role of law enforcement as stereotypes combined with psychotic symptoms may put these patients in danger of police violence and premature mortality. Improving treatment outcomes requires an understanding of the role of psychology in perpetuating racism in healthcare and pathological stereotypes. Increased awareness and training can improve the plight of Black people with severe mental health disorders. Essential steps necessary at multiple levels to address these issues are discussed.

Health Care Use and Barriers to Care for Chronic Inflammatory Diseases (CID) among First and Second Generation South Asian Immigrant Children and Parents in Ontario Canada

Although immigrants are disproportionately impacted by growing chronic inflammatory disease (CIDs) rates, yet suffer barriers to access health care, little attention has been given to their primary healthcare or specialist healthcare access as it relates to complex, chronic diseases in Canada, a country with universal health care. This study aims to investigate CID health care use and barriers to care among first- and second-generation immigrant South Asian children and parents in the Greater Toronto Area, Ontario. Drawing on analysis of 24 in depth interviews with children and parents (14 children, 10 parents), the results reveal that although CIDs disproportionately affects South Asian immigrants, they encounter health system, geographic, interpersonal, and knowledge barriers to access requisite care. These barriers exist despite participants having a GP, and are compounded further by limited familial systems, culturally insensitive care, and structural inequities that in some instances make parents choose between health access or other basic needs. Although all participants recognized the importance of specialized care, only 11 participants regularly accessed specialized care, creating new schisms in CID management. The findings suggest that a multisectoral approach that address individual and structural level socio-structural drivers of health inequities are needed to create more equitable healthcare access.

Confronting Racism in All Forms of Pain Research: A Shared Commitment for Engagement, Diversity, and Dissemination

This third paper in the "Confronting Racism in All Forms of Pain Research" series discusses adopting an antiracism framework across all pain research disciplines and highlights the significant benefits of doing so. We build upon the previous call to action and the proposed reframing of study designs articulated in the other papers in the series and seek to confront and eradicate racism through a shared commitment to change current research practices. Specifically, we emphasize the systematic disadvantage created by racialization (ie, the Eurocentric social and political process of ascribing racialized identities to a relationship, social practice, or group) and discuss how engaging communities in partnership can increase the participation of racialized groups in research studies and enrich the knowledge gained. Alongside this critical work, we indicate why diversifying the research environment (ie, research teams, labs, departments, and culture) enriches our scientific discovery and promotes recruitment and retention of participants from racialized groups. Finally, we recommend changes in reporting and dissemination practices so that we do not stigmatize or reproduce oppressive forms of power for racialized groups. Although this shift may be challenging in some cases, the increase in equity, generalizability, and credibility of the data produced will expand our knowledge and reflect the pain experiences of all communities more accurately. PERSPECTIVE: In this third paper in our series, we advocate for a shared commitment toward an antiracism framework in pain research. We identify community partnerships, diversification of research environments, and changes to our dissemination practices as areas where oppressive forms of power can be reduced.

Diversity and Inclusion Training in Health Care: What the Evidence Suggests

On September 22, 2020, then-President Donald Trump signed Executive Order 13950, titled "Combating Race and Sex Stereotyping." This order restricted the types of diversity and inclusion (DI) training that federal agencies and contractors could offer with federal funding. In this column, the author denounces that order, uses this critique to examine DI training sessions in their current forms, and suggests evidence-based solutions for organizations that are committed to dismantling racism. Mental health organizations must move beyond single, standalone DI training sessions that target individual providers and initiate institution-wide activities that embrace antiracism and structural competence.

Stress-Related Mental Health Disorders and Inflammation in Pregnancy: The Current Landscape and the Need for Further Investigation

Many studies have focused on psychoimmunological mechanisms of risk for stress-related mental health disorders. However, significantly fewer studies have focused on understanding mechanisms of risk for stress-related disorders during pregnancy, a period characterized by dramatic changes in both the innate and adaptive immune systems. The current review summarizes and synthesizes the extant literature on the immune system during pregnancy, as well as the sparse existing evidence highlighting the associations between inflammation and mood, anxiety, and fear-related disorders in pregnancy. In general, pregnant persons demonstrate lower baseline levels of systemic inflammation, but respond strongly when presented with an immune challenge. Stress and trauma exposure may therefore result in strong inflammatory responses in pregnant persons that increases risk for adverse behavioral health outcomes. Overall, the existing literature suggests that stress, trauma exposure, and stress-related psychopathology are associated with higher levels of systemic inflammation in pregnant persons, but highlight the need for further investigation as the existing data are equivocal and vary based on which specific immune markers are impacted. Better understanding of the psychoimmunology of pregnancy is necessary to reduce burden of prenatal mental illness, increase the likelihood of a successful pregnancy, and reduce the intergenerational impacts of prenatal stress-related mental health disorders.

Breaking Borders: How Barriers to Global Mobility Hinder International Partnerships in Academic Medicine

This article describes the authors' personal experiences of collaborating across international borders in academic research. International collaboration in academic medicine is one of the most important ways by which research and innovation develop globally. However, the intersections among colonialism, academic medicine, and global health research have created a neocolonial narrative that perpetuates inequalities in global health partnerships. The authors critically examine the visa process as an example of a racist practice to show how the challenges of blocked mobility increase inequality and thwart research endeavors. Visas are used to limit mobility across certain borders, and this limitation hinders international collaborations in academic medicine. The authors discuss the concept of social closure and how limits to global mobility for scholars from low- and middle-income countries perpetuate a cycle of dependence on scholars who have virtually barrier-free global mobility-these scholars being mainly from high-income countries. Given the current sociopolitical milieu of increasing border controls and fears of illegal immigration, the authors' experiences expose what is at stake for academic medicine when the political sphere, focused on tightening border security, and the medical realm, striving to build international research collaborations, intersect. Creating more equitable global partnerships in research requires a shift from the current paradigm that dominates most international partnerships and causes injury to African scholars.

"We're Working in a Trauma Avoidant Culture": A Qualitative Study Exploring Assertive Community Treatment Providers' Perspectives on Working with Trauma and PTSD in People with Severe Mental Illness

Assertive Community Treatment (ACT) is the most widely used evidence-based community mental health intervention for people with severe mental illness (SMI). Despite research showing that the vast majority of those with SMI have traumatic histories, the ACT service model does not have consistent guidelines on how to address trauma in their client population. This study employed thematic-analysis through interviewing ACT providers to better understand their perspectives on working with trauma in clients. Five overarching themes with 21 sub-themes emerged: the role and scope of ACT teams and model regarding trauma, discussions of trauma with clients, current treatment of trauma, barriers to working with trauma, and recommendations for enabling trauma discussions and treatment. Some examples for recommendations were: a need for more training regarding trauma, increasing resources like including a psychologist and trauma specialized professionals on the team, more support from leadership, and a cultural change from medicalization. Implications of the barriers and suggestions are discussed.

Program staff perspectives on implementing youth-initiated mentoring with systems-involved youth

Youth-initiated mentoring (YIM) is an approach to mentor recruitment that represents a significant departure from how formal mentoring typically has been conceptualized and carried out, most notably by having youth identify their own mentors. Despite enthusiasm for YIM, implementation can require significant shifts in program practices. Given the limited resources with which most mentoring programs have to work, it is important to discern staff investment in YIM and what it takes for programs to implement this approach. This study explored YIM implementation at the organizational level through interviews with mentoring program staff (n = 11) and addressed motivations of mentoring program staff to implement YIM, how their programs implemented this approach, and their perceptions of the facilitators and barriers to successful YIM implementation.

Toward a moral commitment: Exposing the covert mechanisms of racism in the nursing discipline

Recent Canadian and international events have sparked dialogue and action to address racism within the nursing discipline. While the urgency to seek and implement antiracist solutions demands the attention of nurses, we contend that a contemporary analysis of the mechanisms that continue to perpetuate racism within nursing's theoretical foundation is required first. This study reconsiders the perceived functions of racism within the current state of nursing concepts and theories. In particular, we expose the role that covert racism plays by inadvertently sustaining racism through nursing's theoretical foundation, and how this process strengthens white supremacy. We argue that, in the absence of exposing these covert mechanisms, the development of solutions will be futile in dismantling racism. By making visible the covert mechanisms of racism within nursing's theoretical foundation, we attempt to establish an opportunity for the nursing discipline to dismantle its racist foundation and engage in sustained antiracist action. Lastly, this study demonstrates the need to equip the discipline with a moral commitment to antiracism in an effort to emancipate nursing from its racist legacies.

"We Die 25 Years Sooner:" Addressing Physical Health Among Persons with Serious Mental Illness in Supportive Housing

People diagnosed with serious mental illness (SMI) experience significant health disparities, including high rates of premature mortality. Supportive housing may serve as a critical service setting for addressing physical health, but comprehensive health-related services within these programs remain an exception. This study sought to identify barriers, and potential solutions, to addressing the physical health needs of people with SMI within supportive housing. Semi-structured interviews and focus groups were conducted with multiple stakeholders (clients, peer specialists, non-peer staff, leadership) across three supportive housing agencies. There was general consensus regarding multiple barriers at the individual, organizational, policy/system, and community levels. Nevertheless, stakeholders also identified strategies in domains such as staffing, organizational culture, partnerships, communication, and infrastructure for addressing barriers. These findings can inform planning for implementation of health initiatives within supportive housing while also highlighting the need for broader community, systems, and policy change.Trial Registration Number: NCT02175641.

Decolonizing Care at Diagnosis: Culture, History, and Family at an Urban Inter-tribal Clinic

The decolonization framework in medical anthropology is slowly reframing tropes of cultural competency toward decolonizing health care. For decolonization of health care to occur, both colonial histories and continuing postcolonial inequities must be recognized from the first diagnostic moment. We report on qualitative research into the role of culture, history, and family experience in person-specific reactions to receipt of a diagnosis. A collaborative approach at an urban inter-tribal clinic was used to interview patients with a recent (within six months) diagnosis of diabetes or related condition. Interviews revealed ways that the Relocation Act eventuated in isolation, poverty, and diabetes among now-urban Native Americans. We discuss how patients may or may not have the ability to (re)connect with their heritage and may simultaneously perceive only recent family contexts as influential in their diabetes. We conclude by acknowledging how postcolonial harms are not captured in diagnoses but should not be left out of diagnostic discussions.

Classism and Everyday Racism as Experienced by Racialized Health Care Users: A Concept Mapping Study

In Toronto, Canada, 51.5 % of the population are members of racialized groups. Systemic labor market racism has resulted in an overrepresentation of racialized groups in low-income and precarious jobs, a racialization of poverty, and poor health. Yet, the health care system is structured around a model of service delivery and policies that fail to consider unequal power social relations or racism. This study examines how racialized health care users experience classism and everyday racism in the health care setting and whether these experiences differ within stratifications such as social class, gender, and immigration status. A concept mapping design was used to identify mechanisms of classism and everyday racism. For the rating activity, 41 participants identified as racialized health care users. The data analysis was completed using concept systems software. Racialized health care users reported “race”/ethnic-based discrimination as moderate to high and socioeconomic position-/social class-based discrimination as moderate in importance for the challenges experienced when receiving health care; differences within stratifications were also identified. To improve access to services and quality of care, antiracist policies that focus on unequal power social relations and a broader systems thinking are needed to address institutional racism within the health care system.

Experiences of everyday racism in Toronto's health care system: a concept mapping study

BACKGROUND

In Canada, there is longstanding evidence of health inequities for racialized groups. The purpose of this study is to understand the effect of current health care policies and practices on racial/ethnic groups and in particular racialized groups at the level of the individual in Toronto's health care system.

METHODS

This study used a semi-qualitative study design: concept mapping. A purposive sampling strategy was used to recruit participants. Health care users and health care providers from Toronto and the Greater Toronto Area participated in all four concept mapping activities. The sample sizes varied according to the activity. For the rating activity, 41 racialized health care users, 23 non-racialized health care users and 11 health care providers completed this activity. The data analysis was completed using the concept systems software.

RESULTS

Participants generated 35 unique statements of ways in which patients feel disrespect or mistreatment when receiving health care. These statements were grouped into five clusters: 'Racial/ethnic and class discrimination', 'Dehumanizing the patient', 'Negligent communication', 'Professional misconduct', and 'Unequal access to health and health services'. Two distinct conceptual regions were identified: 'Viewed as inferior' and 'Unequal medical access'. From the rating activity, racialized health care users reported 'race'/ethnic based discrimination or everyday racism as largely contributing to the challenges experienced when receiving health care; statements rated high for action/change include 'when the health care provider does not complete a proper assessment', 'when the patient's symptoms are ignored or not taken seriously', 'and 'when the health care provider belittles or talks down to the patient'.

CONCLUSIONS

Our study identifies how racialized health care users experience everyday racism when receiving health care and this is important to consider in the development of future research and interventions aimed at addressing institutional racism in the health care setting. To support the elimination of institutional racism, anti-racist policies are needed to move beyond cultural competence polices and towards addressing the centrality of unequal power social relations and everyday racism in the health care system.

The Detrimental Influence of Racial Discrimination on Child Health in the United States

BACKGROUND

The current literature describing the largely damaging effect of racial discrimination on child health is weakened by several confounding factors. We aimed to: 1) describe the relation between racial discrimination and child health and 2) evaluate the potential mediating role of mental health relating racial discrimination to child health, using methods that mitigate confounding.

METHODS

Using the 2011-2012 National Survey of Children's Health (N = 95,677), we performed: 1) propensity score analysis, matching and comparing discrimination-exposed to non-exposed children and 2) structural equation modeling, examining mental health as a mediator of the pathway between discrimination and child health.

RESULTS

In the first approach, the proportion of children with excellent health was 5.4% (95% Confidence Interval (CI), 3.6,7.2%) lower with exposure to racial discrimination. Among minority children, those with low income had the greatest decrements in general health associated with racial discrimination. Among white children, those with high income had the greatest decrements. In the structural equation model, minority children had higher odds of experiencing racial discrimination (Odds ratios (ORs) ≥ 5.47, [95% CIs, 4.92,10.6]); meanwhile, children who experienced discrimination were more likely to have anxiety and depression (ORs ≥ 3.58, [95% CIs, 2.87,4.58]), which were linked to lower odds of excellent health (ORs ≤ 0.44, [95% CIs, 0.41.52]).

CONCLUSION

The negative health association of racial discrimination may be mediated by mental health and vary by racial, ethnic, or socioeconomic group. This work may stimulate the formation of targeted interventions to address these disparities.

From Learning Psychiatry to Becoming Psychiatrists: A Qualitative Study of Co-constructive Patient Simulation

Objectives: Co-constructive patient simulation (CCPS) is a novel medical education approach that provides a participatory and emotionally supportive alternative to traditional supervision and training. CCPS can adapt iteratively and in real time to emergent vicissitudes and challenges faced by clinicians. We describe the first implementation of CCPS in psychiatry. Methods: We co-developed clinical scripts together with child and adolescent psychiatry senior fellows and professional actors with experience performing as simulated patients (SPs). We conducted the simulation sessions with interviewers blind to the content of case scenarios enacted by the SPs. Each hour-long simulation was followed by an hour-long debriefing session with all participants. We recorded and transcribed case preparation, simulation interactions, and debriefing sessions, and analyzed anonymized transcripts through qualitative analysis within a constructivist framework, aided by NVivo software. Results: Each of six CCPS sessions was attended by a median of 13 participants (range, 11-14). The first three sessions were conducted in person; the last three, which took place during the COVID-19 pandemic, via synchronized videoconferencing. Each of the sessions centered on clinically challenging and affectively charged situations informed by trainees' prior experiences. Through iterative thematic analysis we derived an alliterating "9R" model centered on three types of Reflection: (a) in action/"while doing" (Regulate, Relate, and Reason); (b) on action/"having done" (Realities, Restraints, and Relationships); and (c) for action/"will be doing" (with opportunities for Repair and Reaffirmation). Conclusions: CCPS is an experiential approach that fosters autonomous, meaningful, and individually tailored learning opportunities. CCPS and the 9R model for reflective practice can be effectively applied to psychiatry and have the potential to contribute uniquely to the educational needs of its trainees and practitioners.

The coin model of privilege and critical allyship: implications for health

Health inequities are widespread and persistent, and the root causes are social, political and economic as opposed to exclusively behavioural or genetic. A barrier to transformative change is the tendency to frame these inequities as unfair consequences of social structures that result in disadvantage, without also considering how these same structures give unearned advantage, or privilege, to others. Eclipsing privilege in discussions of health equity is a crucial shortcoming, because how one frames the problem sets the range of possible solutions that will follow. If inequity is framed exclusively as a problem facing people who are disadvantaged, then responses will only ever target the needs of these groups without redressing the social structures causing disadvantages. Furthermore, responses will ignore the complicity of the corollary groups who receive unearned and unfair advantage from these same structures. In other words, we are missing the bigger picture. In this conceptualization of health inequity, we have limited the potential for disruptive action to end these enduring patterns.

The goal of this article is to advance understanding and action on health inequities and the social determinants of health by introducing a framework for transformative change: the Coin Model of Privilege and Critical Allyship. First, I introduce the model, which explains how social structures produce both unearned advantage and disadvantage. The model embraces an intersectional approach to understand how systems of inequality, such as sexism, racism and ableism, interact with each other to produce complex patterns of privilege and oppression. Second, I describe principles for practicing critical allyship to guide the actions of people in positions of privilege for resisting the unjust structures that produce health inequities. The article is a call to action for all working in health to (1) recognize their positions of privilege, and (2) use this understanding to reorient their approach from saving unfortunate people to working in solidarity and collective action on systems of inequality.

Mental health care among blacks in America: Confronting racism and constructing solutions

OBJECTIVES

To describe reasons for unmet need for mental health care among blacks, identify factors associated with causes of unmet need, examine racism as a context of unmet need, and construct ways to improve service use.

DATA SOURCES

Data from the 2011-2015 National Survey on Drug Use and Health were pooled to create an analytic sample of black adults with unmet mental health need (N = 1237). Qualitative data came from focus groups (N = 30) recruited through purposive sampling.

STUDY DESIGN

Using sequential mixed methods, reasons for unmet need were regressed on sociodemographic, economic, and health characteristics of respondents. Findings were further explored in focus groups.

PRINCIPAL FINDINGS

Higher education was associated with greater odds of reporting stigma and minimization of symptoms as reasons for unmet need. The fear of discrimination based on race and on mental illness was exacerbated among college-educated blacks. Racism causes mistrust in mental health service systems. Participants expressed the importance of anti-racism education and community-driven practice in reducing unmet need.

CONCLUSION

Mental health systems should confront racism and engage the historical and contemporary racial contexts within which black people experience mental health problems. Critical self-reflection at the individual level and racial equity analysis at the organizational level are critical.

Racism and Its Harmful Effects on Nondominant Racial-Ethnic Youth and Youth-Serving Providers: A Call to Action for Organizational Change: The Society for Adolescent Health and Medicine

Racism can exert negative effects on the self-concepts, health and well-being, and life trajectories of both nondominant racial-ethnic (NDRE) youth and youth-serving providers. In the face of growing nationalism, ethnocentrism, xenophobia, and overt expressions of racism, the Society for Adolescent Health and Medicine recognizes the critically important need to address the issue of racism and its impact on both NDRE youth and youth-serving providers. Organizations involved in clinical care delivery and health professions training and education must recognize the deleterious effects of racism on health and well-being, take strong positions against discriminatory policies, practices, and events, and take action to promote safe and affirming environments. The positions presented in this paper provide a comprehensive set of recommendations to promote routine clinical assessment of youth experiences of racism and its potential impact on self-concept, health and well-being, and for effective interventions when affected youth are identified. The positions also reflect the concerns of NDRE providers, trainees, and students potentially impacted by racism, chronic minority stress, and vicarious trauma and the imperative to create safe and affirming work and learning environments across all levels of practice, training, and education in the health professions. In this position paper, Society for Adolescent Health and Medicine affirms its commitment to foundational moral and ethical principles of justice, equity, and respect for humanity; acknowledges racism in its myriad forms; defines strategies to best promote resiliency and support the health and well-being of NDRE youth, providers, trainees, and students; and provides recommendations on the ways to best effect systemic change.

International Medical Graduates in Psychiatry: Cultural Issues in Training and Continuing Professional Development

A position paper developed by the Canadian Psychiatric Association's Education Committee and approved by the CPA's Board of Directors on August 15, 2016.

The effectiveness of a Housing First adaptation for ethnic minority groups: findings of a pragmatic randomized controlled trial

BACKGROUND

Little is known about the effectiveness of Housing First (HF) among ethnic minority groups, despite its growing popularity for homeless adults experiencing mental illness. This randomized controlled trial tests the effectiveness of a HF program using rent supplements and intensive case management, enhanced by anti-racism and anti-oppression practices for homeless adults with mental illness from diverse ethnic minority backgrounds.

METHODS

This unblinded pragmatic field trial was carried out in community settings in Toronto, Canada. Participants were 237 adults from ethnic minority groups experiencing mental illness and homelessness, who met study criteria for moderate needs for mental health services. Participants were randomized to either adapted HF (n = 135) or usual care (n = 102) and followed every 3 months for 24 months. The primary study outcome was housing stability; secondary outcomes included physical and mental health, social functioning, quality of life, arrests and health service use. Intention to treat statistical analyses examined the effectiveness of the intervention compared to usual care.

RESULTS

During the 24-month study period, HF participants were stably housed a significantly greater proportion of time compared to usual care participants, 75 % (95 % CI 70 to 81) vs. 41 % (95 % CI 35 to 48), respectively, for a difference of 34 %, 95 % CI 25 to 43. HF also led to improvements in community integration over the course of the study: the change in the mean difference between treatment groups from baseline to 24-months was significantly greater among HF participants compared to those in usual care (change in mean difference = 2.2, 95 % CI 0.06 to 4.3). Baseline diagnosis of psychosis was associated with reduced likelihood of being housed ≥ 50 % of the study period (OR = 0.37, 95 % CI 0.18 to 0.72).

CONCLUSION

Housing First enhanced with anti-racism and anti-oppression practices can improve housing stability and community functioning among ethnically diverse homeless adults with mental illness.

TRIAL REGISTRATION

International Standard Randomized Control Trial Number Register Identifier: ISRCTN42520374 , assigned August 18, 2009.

Moving from rhetoric to reality: adapting Housing First for homeless individuals with mental illness from ethno-racial groups

BACKGROUND

The literature on interventions addressing the intersection of homelessness, mental illness and race is scant. The At Home/Chez Soi research demonstration project is a pragmatic field trial investigating a Housing First intervention for homeless individuals with mental illness in five cities across Canada. A unique focus at the Toronto site has been the development and implementation of a Housing First Ethno-Racial Intensive Case Management (HF ER-ICM) arm of the trial serving 100 homeless individuals with mental illness from ethno-racial groups. The HF ER-ICM program combines the Housing First approach with an anti-racism/anti-oppression framework of practice. This paper presents the findings of an early implementation and fidelity evaluation of the HF ER-ICM program, supplemented by participant narrative interviews to inform our understanding of the HF ER-ICM program theory.

METHODS

Descriptive statistics are used to describe HF ER-ICM participant characteristics. Focus group interviews, key informant interviews and fidelity assessments were conducted between November 2010 and January 2011, as part of the program implementation evaluation. In-depth qualitative interviews with HF ER-ICM participants and control group members were conducted between March 2010 and June 2011. All qualitative data were analysed using grounded theory methodology.

RESULTS

The target population had complex health and social service needs. The HF ER-ICM program enjoyed a high degree of fidelity to principles of both anti-racism/anti-oppression practice and Housing First and comprehensively addressed the housing, health and sociocultural needs of participants. Program providers reported congruence of these philosophies of practice, and program participants valued the program and its components.

CONCLUSIONS

Adapting Housing First with anti-racism/anti-oppression principles offers a promising approach to serving the diverse needs of homeless people from ethno-racial groups and strengthening the service systems developed to support them. The use of fidelity and implementation evaluations can be helpful in supporting successful adaptations of programs and services.