A mixed methods systematic review of mental health self-care strategies for Arabic-speaking refugees and migrants

BACKGROUND

Self-care strategies can improve mental health and wellbeing, however, the evidence on preferred strategies among Arabic-speaking refugees and migrants is unclear. This mixed methods systematic review aimed to identify and synthesise the global research on mental health self-care strategies used by these populations.

METHODS

English and Arabic language studies reporting on positive mental health self-care strategies to address symptoms of posttraumatic stress disorder, generalised anxiety and depression in the target populations were identified by systematically searching eight electronic databases and grey literature. Studies were deemed eligible if they were published from 2000 onwards and included Arabic-speaking migrants, refugees or asylum seekers aged 12 years and above. A narrative synthesis of study characteristics and relevant key findings was undertaken. The review protocol was registered on PROSPERO (registration number CRD42021265456).

RESULTS

Fifty-nine records reporting 57 studies were identified, the majority appearing after 2019. There were 37 intervention studies that incorporated a self-care component and 20 observational studies that reported on self-generated self-care practices. Across both study types, four broad groups of mental health self-care were identified-social, psychological, religious/spiritual, and other (e.g., expressive arts and exercise). Psychological strategies were the most reported self-care practice overall and featured in all intervention studies. Religious/spiritual and social strategies were more common in the observational studies. Intervention studies in diverse settings reported statistical improvements on a range of outcome measures. Observational studies reported a range of individual and community benefits. Linguistic, cultural and religious considerations, inherent in the observational studies, were variably addressed in the individual and group interventions.

CONCLUSION

Overall, study participants experienced self-care as helpful although some encountered challenges in practicing their preferred strategies. Further research on mental health self-care strategies among Arabic-speaking refugees and migrants is needed in Western resettlement countries to guide mental health service delivery and primary healthcare initiatives for new arrivals and in transit countries.

"It Is Definitely a Good Program for Everyone from Every Community": A Qualitative Study of Community Partner Perspectives on the Culturally and Linguistically Diverse (CALD) Mindfulness Program

Meeting the health needs of migrant and refugee communities is crucial to successful settlement and integration. These communities are often under-served by mental health services. Previous research has demonstrated the effectiveness of a group mindfulness-based intervention tailored for Arabic and Bangla speakers living in Sydney, Australia. This study aimed to explore community partner perspectives on the program's impact, contributing factors and sustainability, and to elicit suggestions for future development. Data were collected via semi-structured telephone interviews with a purposively selected sample of 16 informants. Thematic analysis was conducted using the Rigorous and Accelerated Data Reduction (RADaR) technique. Community partners welcomed the emphasis on promoting wellbeing and reported that the community-based in-language intervention, in both face-to-face and online formats, overcame many of the barriers to timely mental health care for culturally and linguistically diverse (CALD) communities, with a beneficial impact on group participants, program providers, partner organisations and the broader community. Positive outcomes led to stronger community engagement and demand for more programs. For group mental health programs, both trust and safety are necessary. Relationships must be nurtured, diversity within CALD communities recognised, and projects adequately resourced to ensure partner organisations are not overburdened.

A Qualitative Exploration of Sources of Help for Mental Illness in Arabic-, Mandarin-, and Swahili-Speaking Communities in Sydney, Australia

Despite being disproportionately affected by poor mental health, culturally and linguistically diverse (CaLD) individuals seek help from mental health services at lower rates than others in the Australian population. The preferred sources of help for mental illness amongst CaLD individuals remain poorly understood. The aim of this study was to explore sources of help in Arabic-, Mandarin-, and Swahili-speaking communities in Sydney, Australia. Eight focus-group discussions (n = 51) and twenty-six key informant interviews were undertaken online using Zoom. Two major themes were identified: informal sources of help and formal sources of help. Under the informal sources of help theme, three sub-themes were identified: social, religious, and self-help sources. All three communities strongly recognised the role of social sources of help, with more nuanced roles held by religion and self-help activities. Formal sources of help were described by all communities, although to a lesser extent than informal sources. Our findings suggest that interventions to support help-seeking for all three communities should involve building the capacity of informal sources of help, utilising culturally appropriate environments, and the collaboration between informal and formal sources of help. We also discuss differences between the three communities and offer service providers insights into unique issues that require attention when working with these groups.

The Availability, Appropriateness, and Integration of Services to Promote Indigenous Australian Youth Wellbeing and Mental Health: Indigenous Youth and Service Provider Perspectives

Concerns about the complexity, fragmentation and inefficiency of Australia's current youth mental health service systems have led policy makers to seek improvements through a shift to community-based solutions. However, there is little evidence of how communities can make this shift. This paper examines the efforts of one Aboriginal and Torres Strait Islander (hereafter, respectfully, Indigenous) community-Yarrabah in north Queensland-to develop strategies for mental health and wellbeing service system improvements for school-aged youth (5-18 years). The research was co-designed with Yarrabah's community-controlled health service and explores the perceptions of Yarrabah youth and service providers. Iterative grounded theory methods were used to collect and analyse data from 32 youth aged 11-24 years and 24 service providers. Youth were reluctant to seek help, and did so only if they felt a sense of safety, trust, relationality and consistency with providers. Young people's four suggestions for improvement were access to (1) information and awareness about mental health; (2) youth facilities, spaces and activities; (3) safe and available points of contact; and (4) support for recovery from mental illness. Service providers highlighted an appetite for youth-guided community change and recommended five improvement strategies: (1) listening to youth, (2) linking with community members, (3) providing wellbeing promotion programs, (4) intervening early, and (5) advocating to address the determinants of youth mental health. Overall, both groups realised a disjunct between youth need and service provision, but a willingness to work together for systems change. This study demonstrates the importance of community-driven efforts that harness both youth and service providers' perspectives, and suggests a need for ongoing dialogue as the basis for co-designing and implementing improvements to wellbeing supports and mental health services for Indigenous youth.

Conceptualisations of mental illness and stigma in Congolese, Arabic-speaking and Mandarin-speaking communities: a qualitative study

BACKGROUND

Australia is an ethnically diverse nation. Research has demonstrated an elevated risk of developing a mental illness in culturally and linguistically diverse (CaLD) communities yet uptake of mental health services is low. To improve mental health treatment seeking and outcomes for CaLD individuals in Australia there is an urgent need to deeply understand barriers to treatment such as stigma. Using an exploratory qualitative approach, the aim of the study was to explore how CaLD communities' conceptualise and interpret mental illness and associated beliefs and experiences of stigma.

METHODS

The study focused on three key CaLD groups: the Congolese, Arabic-speaking and Mandarin-speaking communities residing in Sydney, Australia. A series of eight focus group discussions (n = 51) and 26 key informant interviews were undertaken online using Zoom during the period of November to December 2021. Focus group discussions and key informant interviews were digitally recorded, transcribed, and analysed using NVivo software.

RESULTS

Three major themes were identified. The first theme related to mental illness terminology used in the three communities. Despite variation in the terms used to refer to 'mental illness' all three communities generally distinguished between 'mental illness', a more severe condition and 'mental health problems', considered to arise due to stressors. The second theme centred on beliefs about mental illness; with all three communities identifying migration-related stressors as contributing to mental illness. Culturally related beliefs were noted for the Congolese participants with the perception of a link between mental illness and supernatural factors, whereas Mandarin-speaking participants highlighted lack of inter and intrapersonal harmony and failure to adhere to values such as filial piety as contributing to mental illness. The final theme related to mental illness related stigma and the various ways it manifested in the three communities including presence of collectivist public stigma felt across all three groups and affiliate (family) stigma reported by the Arabic and Mandarin-speaking groups.

CONCLUSIONS

We found rich diversity in how these communities view and respond to mental illness. Our findings provide some possible insights on both service provision and the mental health system with a view to building effective engagement and pathways to care.

Barriers and enablers to Aboriginal and Torres Strait Islander careers in health: A qualitative, multisector study in western New South Wales

OBJECTIVE

Growing a strong Aboriginal and Torres Strait Islander health workforce is key to closing the gap in health outcomes between Indigenous and non-Indigenous Australians. This study sought to explore barriers and enablers to career development for Aboriginal health staff and potential strategies to enhance career pathways.

DESIGN

Qualitative study, with data collected primarily through focus group discussions (yarning circles) at different health workplaces.

SETTING

Western New South Wales.

PARTICIPANTS

Aboriginal health staff (n = 54) from Aboriginal Community Controlled Health Services, a Local Health District and a Primary Health Network, and their managers (Aboriginal and non-Aboriginal; n = 28).

MAIN OUTCOME MEASURES

Identified barriers and enablers and regional strategies for improving career pathways.

RESULTS

Aboriginal people interested in pursuing a career in health face barriers in: pre-employment, recruitment, the workplace and further education and training. Being given practical and emotional support, as well as opportunities, makes a difference at every stage. Family and community are very influential in career decisions. Within the workplace, culturally appropriate human resource systems and management structures are vital. The ability to obtain employment and access education and training locally is important to rural and remote communities.

CONCLUSION

To enhance health career pathways for Aboriginal people, strategies are needed at all levels: community, organisation, system and society. Aboriginal leadership and self-determination are crucial, as are partnerships within the health sector and between the health and the education and training sectors. Cultural safety is essential to expansion of the Aboriginal workforce, and to health care experiences and outcomes for Aboriginal community members.

Cultivating mindfulness: evaluation of a community-based mindfulness program for Arabic-speaking women in Australia

Arabic-speaking communities in Australia underutilise mental health services. Previous research with Arabic-speakers recruited individually demonstrated that an Arabic Mindfulness Compact Disc (CD) was an acceptable and useful resource for this group. Subsequently, the CD was introduced as part of a 5-week group mindfulness program for Arabic-speaking Muslim women. The intervention was delivered in a community setting by a bilingual (Arabic/English) psychologist with support from a bilingual multicultural health worker. The mixed-methods evaluation incorporated a pre–post study with a wait-list control group. An Arabic translation of the Depression Anxiety and Stress Scale (DASS21) was administered at baseline and program completion. Pre–post differences were tested using the sign test for paired samples (one-sided). Qualitative methods were used to evaluate the program’s acceptability. After five weeks, the intervention group showed statistically significant improvement on all DASS21 subscales (n = 12, p < .001 for depression and stress and p < .01 for anxiety). For the wait-list control group, only anxiety showed significant improvement (n = 8, p < .05). Qualitative analysis revealed how the women grew in their understanding of mindfulness concepts and mastered the different techniques, how they dealt with painful memories, how mindfulness practice assisted them in their daily lives, and how they related mindfulness to Islam. The in-language mindfulness intervention was shown to be culturally and spiritually relevant, and clinically effective. The group program incorporating the Arabic Mindfulness CD has potential for scaling up. Further research is required to investigate effectiveness for Arabic-speaking men with similar backgrounds.

"You Can't Work with My People If You Don't Know How to": Enhancing Transfer of Care from Hospital to Primary Care for Aboriginal Australians with Chronic Disease

Indigenous Australians experience significantly poorer health compared to other Australians, with chronic disease contributing to two-thirds of the health gap. We report on an evaluation of an innovative model that leverages mainstream and Aboriginal health resources to enable safe, supported transfer of care for Aboriginal adults with chronic conditions leaving hospital. The multisite evaluation was Aboriginal-led and underpinned by the principles of self-determination and equity and Indigenous research protocols. The qualitative study documented processes and captured service user and provider experiences. We found benefits for patients and their families, the hospital and the health system. The new model enhanced the patient journey and trust in the health service and was a source of staff satisfaction. Challenges included staff availability, patient identification and complexity and the broader issue of cultural safety. Critical success factors included strong governance with joint cultural and clinical leadership and enduring relationships and partnerships at the service delivery, organisation and system levels. A holistic model of care, bringing together cultural and clinical expertise and partnering with Indigenous community organisations, can enhance care coordination and safety across the hospital-community interface. It is important to consider context as well as specific program elements in design, implementation and evaluation.

Effectiveness of a Community-based Group Mindfulness Program tailored for Arabic and Bangla-speaking Migrants

BACKGROUND

Migrant communities are often underserved by mainstream mental health services resulting in high rates of untreated psychological distress. This collaborative study built on evidence that mindfulness-based interventions delivered in-language and culturally tailored were acceptable and clinically effective for Arabic speakers in Australia. It aimed to establish whether a group mindfulness program produced expected outcomes under normal operational conditions, and to test its scalability and its transferability to Bangla speakers.

METHODS

A 5-week mindfulness program was delivered to 15 Arabic-speaking and 8 Bangla-speaking groups in community settings. The mixed-methods evaluation incorporated a pre-post study. Descriptive statistics were used to summarise the socio-demographic data, group attendance and home practice. Differences in DASS 21 and K10 scores from pre to post-intervention were tested using the nonparametric sign test for paired samples (two-sided). Multiple linear regression analysis was performed to determine the effects of selected sociodemographic variables, group attendance and home practice on clinical outcomes, based on intention to treat. Content analysis was used to examine the qualitative data.

RESULTS

The program attracted 168 Arabic speakers and 103 Bangla speakers aged 16 years and over, mostly women. Cultural acceptability was evident in the overall 80% completion rate, with 78% of Arabic speakers and 84% of Bangla speakers retained. Both language groups showed clinically and statistically significant improvements in mental health outcomes on the DASS21 and K10. Thirty new referrals were made to mental health services. Participant feedback emphasised the benefits for their everyday lives. All but one participant reported sharing the mindfulness skills with others.

CONCLUSIONS

Across multiple and diverse groups of Arabic and Bangla speakers in Sydney, the community-based group mindfulness program was shown to have high levels of cultural acceptability and relevance. It resulted in clinically and statistically significant improvements in mental health outcomes, facilitated access to mental health care and boosted mental health literacy. This innovative, low-intensity, in-language mental health intervention that was originally developed for Arabic speakers is scalable. It is also transferable-with cultural tailoring-to Bangla speakers.

A framework for preferred practices in conducting culturally competent health research in a multicultural society

Background

Improving the health and well-being of the whole population requires that health inequities be addressed. In an era of unprecedented international migration, meeting the health care needs of growing multicultural or multiethnic societies presents major challenges for health care systems and for health researchers. Considerable literature exists on the methodological and ethical difficulties of conducting research in a cross-cultural context; however, there is a need for a framework to guide health research in multicultural societies.

Methods

The framework was informed by “research on research” that we have undertaken in community and primary health care settings in Sydney, Australia. Case studies are presented as illustrative examples.

Results

We present a framework for preferred practices in conducting health research that is culturally informed, high-quality, safe, and actionable.

Conclusions

The framework is not intended to be universal, however many of its aspects will have relevance for health research generally. Application of the framework for preferred practices could potentially make health research more culturally competent, thus enabling enhanced policies, programmes and practices to better meet population health needs. The framework needs to be further tested and refined in different contexts.

Systems integration to promote the mental health of Aboriginal and Torres Strait Islander children: protocol for a community-driven continuous quality improvement approach

BACKGROUND

Systems integration to promote the mental health of Aboriginal and Torres Strait Islander children works towards developing a spectrum of effective, community-based services and supports. These services and supports are organised into a coordinated network, build meaningful partnerships with families and address their cultural and linguistic needs, to help children to function better at home, in school, in the community, and throughout life. This study is conducted in partnership with primary healthcare (PHC) and other services in three diverse Indigenous Australian communities. It entails conceptualising, co-designing, implementing, and evaluating the effectiveness of systems integration to promote the mental health and wellbeing of Indigenous school-aged children (4-17 years). This paper outlines a protocol for implementing such complex community-driven research.

METHODS/DESIGN

Using continuous quality improvement processes, community co-designed strategies for improved systems integration will be informed by narratives from yarning circles with Indigenous children and service providers, and quantitative data from surveys of service providers and audits of PHC client records and intersectoral systems. Agreed strategies to improve the integration of community-based services and supports will be modelled using microsimulation software, with a preferred model implemented in each community. The evaluation will investigate changes in the: 1) availability of services that are community-driven, youth-informed and culturally competent; 2) extent of collaborative service networks; 3) identification by PHC services of children's social and emotional wellbeing concerns; and 4) ratio of children receiving services to identified need. Costs and benefits of improvements to systems integration will also be calculated.

DISCUSSION

The study will provide evidence-informed, community-driven, and tested models that can be used for implementing systems integration to promote the mental health and wellbeing of Indigenous children. It will identify the situational enablers and barriers that impact systems integration and determine the extent to which systems integration improves service availability, systems and child outcomes. Evidence for the cost effectiveness of systems-level integration will contribute to national mental health policy reform.

Understanding the needs of local youth to inform drug and alcohol prevention and harm reduction services: A qualitative study

ISSUE ADDRESSED

Reducing drug and alcohol harm is a public health priority and the Australian government has adopted a harm minimisation approach to policy. Understanding the needs of local youth is necessary for the design of relevant prevention and harm reduction services.

METHODS

Using 5 unstructured focus groups and 10 interviews involving 30 participants recruited from different settings, this study explored youth perspectives around alcohol and other drugs and the psychosocial factors that influence their substance use.

RESULTS

Three main themes were identified. First, young people perceived that drugs fell into a hierarchy related to the harm they cause and the stigma associated with use. Second, the importance of validating a young person's experience with using drugs (regardless of where they were placed on their substance-use trajectory) as a measure to increase the credibility of drug education programs. Third, the significant influence of peers on young people's drug attitudes and behaviours.

CONCLUSIONS

Drug and alcohol education strategies must be more explicit regarding harm across all drug types, regardless of legal status or perceived social acceptability. Prevention services would benefit from including lived realities from young people's varied and changing experiences with using substances. Peer involvement in the design of preventive strategies (and involvement in participatory research to identify felt needs) is paramount to ensure teachings are grounded in a young person's social context and lived realities. SO WHAT?: This study provides information to guide the development of appropriate and authentic drug and alcohol prevention and harm reduction services for young people.

Integration of traditional and western treatment approaches in mental health care in Pacific Island Countries

OBJECTIVE

To explore the extent of integration of traditional and western approaches in mental health care in Pacific Island Countries (PICs).

METHOD

Examination of national mental health policies and literature review.

RESULTS

Traditional healers were included as resources for mental health in four of the seven policies that we were able to access. While their role in mental health care is widely acknowledged in the literature, there are few empirical studies exploring integration.

CONCLUSION

Local research on integrative mental health care is needed to guide mental health policy and service development in PICs. Any research must include the full range of formal and informal service providers as well as patients and families.

Realisation of a joint consumer engagement strategy in the Nepean Blue Mountains region

Ensuring consumer engagement at different levels of the health system - direct care, organisational design and governance and policy - has become a strategic priority. This case study explored, through interviews with six purposively selected 'insiders' and document review, how one Medicare Local (now a Primary Health Network, PHN) and Local Health District worked together with consumers, to establish a common consumer engagement structure and mechanisms to support locally responsive, integrated and consumer-centred services. The two healthcare organisations worked as partners across the health system, sharing ownership and responsibility. Critical success factors included a consumer champion working with other highly motivated consumers concerned with improving the health system, a budget, and ongoing commitment from the Medicare Local or PHN and the Local Health District at executive and board level. Shared boundaries were an enormous advantage. Activities were jointly planned and executed, with consumer participation paramount. Training and mentoring enhanced consumer capacity and confidence. Bringing everyone on board and building on existing structures required time, effort and resources. The initiative produced immediate and lasting benefits, with consumer engagement now embedded in organisational governance and practice.

Evaluation of the acceptability and clinical utility of an Arabic-language mindfulness CD in an Australian community setting

The cultural, linguistic, and religious diversity of Australia's population presents challenges for mental health service delivery. Arabic-speaking communities in Australia underutilise mental health services despite high levels of trauma and psychological distress. Clinicians who work with this population lack linguistically and culturally appropriate clinical resources. The aim of this study was to explore the acceptability and clinical utility of a Mindfulness Skills CD translated into formal Arabic. The 70 participants were Arabic-speaking adults, mostly Lebanese-born Muslim women, who enrolled in a 5-week mindfulness program using the CD and agreed to follow-up at 12 weeks. Both recruitment and data collection were undertaken by a female project officer who is a widely respected member of the Arabic community in south-east Sydney. Compliance with the program protocol was high and all but 4 participants continued to use the CD beyond the 5 weeks. Overall, participants reported that mindfulness techniques fitted well with their way of life and were compatible with their cultural and religious practices. Most found mindfulness complementary to their regular reflective prayer. Using the Mindfulness Skills CD was associated with statistically significant reductions in psychological distress as measured by the Kessler Scale (K10) and the Depression, Anxiety, and Stress Scale (DASS21) postprogram (K10; DASS21 Depression and Stress subscales) and at follow-up (all measures). The evaluation showed that the Arabic Mindfulness Skills CD is an effective and culturally appropriate mental health resource for this population group. This low-cost, easily distributed resource is suitable for use in individual self-management and as an adjunct to primary and specialist mental health care.

Integration of Indigenous healing practices with western biomedicine in Australia, Canada, New Zealand and the United States of America: a scoping review protocol

REVIEW QUESTIONS

This scoping review aims to explore the following questions.

Interventions to improve access to cataract surgical services and their impact on equity in low- and middle-income countries

BACKGROUND

Cataract is the leading cause of blindness in low- and middle-income countries (LMICs), and the prevalence is inequitably distributed between and within countries. Interventions have been undertaken to improve cataract surgical services, however, the effectiveness of these interventions on promoting equity is not known.

OBJECTIVES

To assess the effects on equity of interventions to improve access to cataract services for populations with cataract blindness (and visual impairment) in LMICs.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2017, Issue 3), MEDLINE Ovid (1946 to 12 April 2017), Embase Ovid (1980 to 12 April 2017), LILACS (Latin American and Caribbean Health Sciences Literature Database) (1982 to 12 April 2017), the ISRCTN registry (www.isrctn.com/editAdvancedSearch); searched 12 April 2017, ClinicalTrials.gov (www.clinicaltrials.gov); searched 12 April 2017 and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en); searched 12 April 2017. We did not use any date or language restrictions in the electronic searches for trials.

SELECTION CRITERIA

We included studies that reported on strategies to improve access to cataract services in LMICs using the following study designs: randomised and quasi-randomised controlled trials (RCTs), controlled before-and-after studies, and interrupted time series studies. Included studies were conducted in LMICs, and were targeted at disadvantaged populations, or disaggregated outcome data by 'PROGRESS-Plus' factors (Place of residence; Race/ethnicity/ culture/ language; Occupation; Gender/sex; Religion; Education; Socio-economic status; Social capital/networks. The 'Plus' component includes disability, sexual orientation and age).

DATA COLLECTION AND ANALYSIS

Two authors (JR and JP) independently selected studies, extracted data and assessed them for risk of bias. Meta-analysis was not possible, so included studies were synthesised in table and text.

MAIN RESULTS

From a total of 2865 studies identified in the search, two met our eligibility criteria, both of which were cluster-RCTs conducted in rural China. The way in which the trials were conducted means that the risk of bias is unclear. In both studies, villages were randomised to be either an intervention or control group. Adults identified with vision-impairing cataract, following village-based vision and eye health assessment, either received an intervention to increase uptake of cataract surgery (if their village was an intervention group), or to receive 'standard care' (if their village was a control group).One study (n = 434), randomly allocated 26 villages or townships to the intervention, which involved watching an informational video and receiving counselling about cataract and cataract surgery, while the control group were advised that they had decreased vision due to cataract and it could be treated, without being shown the video or receiving counselling. There was low-certainty evidence that providing information and counselling had no effect on uptake of referral to the hospital (OR 1.03, 95% CI 0.63 to 1.67, 1 RCT, 434 participants) and little or no effect on the uptake of surgery (OR 1.11, 95% CI 0.67 to 1.84, 1 RCT, 434 participants). We assessed the level of evidence to be of low-certainty for both outcomes, due to indirectness of evidence and imprecision of results.The other study (n = 355, 24 towns randomised) included three intervention arms: free surgery; free surgery plus reimbursement of transport costs; and free surgery plus free transport to and from the hospital. These were compared to the control group, which was reminded to use the "low-cost" (˜USD 38) surgical service. There was low-certainty evidence that surgical fee waiver with/without transport provision or reimbursement increased uptake of surgery (RR 1.94, 95% CI 1.14 to 3.31, 1 RCT, 355 participants). We assessed the level of evidence to be of low-certainty due to indirectness of evidence and imprecision of results.Neither of the studies reported our primary outcome of change in prevalence of cataract blindness, or other outcomes such as cataract surgical coverage, surgical outcome, or adverse effects. Neither study disaggregated outcomes by social subgroups to enable further assessment of equity effects. We sought data from both studies and obtained data from one; the information video and counselling intervention did not have a differential effect across the PROGRESS-Plus categories with available data (place of residence, gender, education level, socioeconomic status and social capital).

AUTHORS' CONCLUSIONS

Current evidence on the effect on equity of interventions to improve access to cataract services in LMICs is limited. We identified only two studies, both conducted in rural China. Assessment of equity effects will be improved if future studies disaggregate outcomes by relevant social subgroups. To assist with assessing generalisability of findings to other settings, robust data on contextual factors are also needed.

Beyond diagnosis and survivorship: findings from a mixed-methods study of a community-based cancer support service

This consumer-led research investigated the client experiences and the individual and community benefits of a community-based cancer support service operating in a regional setting. The study included cross-sectional surveys, focus group discussions and key-informant interviews. In total, 114 clients, 28 carers and 20 therapists were surveyed; three client focus groups were conducted and five directors and staff were interviewed. For many clients and carers, the warm welcome experienced at first contact sets the tone for a long-term association with the organisation. The feeling of being cared for extends to the broader community and living with cancer becomes more than survivorship. Integral to the organisational model are opportunity (second-hand) shops that enable subsidised complementary therapies and other services, offer a way of giving back and assist disadvantaged community members. The organisational model has benefits, not only for people living with cancer and their families, but also for the wider community.

Inequality in cataract blindness and services: moving beyond unidimensional analyses of social position

OBJECTIVE

Inequalities in cataract blindness are well known, but data are rarely disaggregated to explore the combined effects of a range of axes describing social disadvantage. We examined inequalities in cataract blindness and services at the intersection of three social axes.

METHODS

Three dichotomous social variables (sex (male/female); place of residence (urban/rural); literacy (literate/illiterate)) from cross-sectional national blindness surveys in Pakistan (2001-2004; n=16 507) and Nigeria (2005-2007; n=13 591) were used to construct eight subgroups, with disadvantaged subgroups selected a priori (ie, women, rural dwellers, illiterate). In each data set, the social distribution of cataract blindness, cataract surgical coverage (CSC) and effective cataract surgical coverage (eCSC) were examined. Inequalities were assessed comparing the best-off and worst-off subgroups using rate differences and rate ratios (RRs). Logistic regression was used to assess cumulative effects of multiple disadvantage.

RESULTS

Disadvantaged subgroups experienced higher prevalence of cataract blindness, lower CSC and lower eCSC in both countries. A social gradient was present for CSC and eCSC, with coverage increasing as social position improved. Relative inequality in eCSC was approximately twice as high as CSC (Pakistan: eCSC RR 2.7 vs CSC RR 1.3; Nigeria: eCSC RR 8.7 vs CSC RR 4.1). Cumulative disadvantage was observed for all outcomes, deteriorating further with each additional axis along which disadvantage was experienced.

CONCLUSIONS

Each outcome tended to be worse with the addition of each layer of social disadvantage. Illiterate, rural women fared worst in both settings. Moving beyond unidimensional analyses of social position identified subgroups in most need; this permits a more nuanced response to addressing the inequitable distribution of cataract blindness.

A national survey of telehealth activity in Australian hospitals

We conducted a national survey of Australian hospitals to assess their use of telehealth. Information was sought from the 814 hospitals with 10 or more beds, excluding the small number that provided only day surgery and seven for which we could not identify a contact person. A total of 564 replies were received (a 69% response rate). Nationally, nearly half (49%) reported that they were engaged in some telehealth activity. However, there was a significant difference across jurisdictions. Hospitals in the public sector were significantly more likely to report the use of telehealth than those in the private sector (62% vs 14%). Hospital remoteness was measured according to the Accessibility/Remoteness Index of Australia (ARIA). The highest levels of use were reported by hospitals in 'very remote' and 'remote' areas (90% and 88%, respectively), with moderate levels of use in 'moderately accessible' and 'accessible' areas (67% and 52%, respectively) and the lowest level of use in 'highly accessible' areas (35%). This trend was significant.

The Graniators support group program

Aboriginal grandmothers (grannies) in many communities throughout Australia are considered the backbone of the social structure. This is the case for the Murri Granies in a town in regional eastern Australia. Many of these women are also their grandchildren's primary caregivers and disciplinarians, and sometimes this role is detrimental to their own care and well-being. As a response to this stress, the local Aboriginal Medical Service (AMS), which includes a comprehensive primary health care facility, began promoting the program `Relax to the Max' to the Grannies as part of the holistic care they offer. Since these humble beginnings some three years ago, the group has grown to become the Graniators support group. In addition to their initial work of supporting each other, the group extended their field of action to the entire community to address social issues, particularly those around youth and children. To complement and strengthen their initiative, the Graniators partnered with other organizations in the community including the police, the municipal council, the state government's department of housing, the local primary school and a special youth service group. The program's evaluation has proved to be extremely positive in providing others in the community a clear and positive formula for driving change at a grass roots level. ( Promotion & Education, 2007, (2): pp 80-81)

Love stories: understanding the caring journeys of aged Greek-Australian carers

This article documents the findings of a short-term longitudinal study that explored the caring journeys of aged Greek carers providing in-home care for their spouse. Through a deeper understanding of carers' decisions and decision-making and insights from service providers and community leaders, we aimed to inform policy makers, service managers and providers about how to develop and promote culturally appropriate support services, and negotiate them with carers and care recipients in a timely way. Initially, we conducted three focus groups and one follow-up forum with service providers and Greek community leaders. Then, over a 6-month period, we conducted two in-home interviews and two telephone interviews with 12 older Greek carers. We sought to understand factors influencing carers' decision-making regarding service uptake, and we provided information about services as required. Through our thematic analysis, we found that most carers wanted to remain as independent as possible and to avoid forced separation from the one they loved, through institutionalisation. They placed great value on their caring role which, while a struggle at times, gave them a sense of meaning, purpose and belonging. We also found that carers had great resourcefulness, strength and competence. They were all in long-term relationships, had negotiated coming to a foreign country and establishing themselves and were now in the process of negotiating old age and increasing frailty while at the same time providing care and support to family and friends. Our findings suggest that services need to be communicated in ways which support what carers value, not on outdated assumptions about cultural groups, otherwise providers will perpetuate exclusion. We propose an outreach in-home service model with an emphasis on ageing well and staying at home. This model of service provision is a model of care which emphasises relationships and community, and seeks to build social and cultural capital.

A decade of peace: Mental health issues and service developments in the Solomon Islands since 2003

OBJECTIVE

To describe the impact on mental health and psychosocial wellbeing of the armed conflict that occurred in the Solomon Islands from 1998-2003 and the subsequent political unrest and natural disasters, and the developments in mental health services since 2003.

METHOD

A literature and document review was conducted, supplemented by the written reflections of senior staff in the Solomon Islands Mental Health Service.

RESULTS

Conflict and natural disaster have had a significant impact on the mental health and functioning of individuals, families and communities. National health system reform has been accompanied by the reorientation of the mental health services from custodial care to care in the community and greater emphasis on mental health promotion and prevention. The dedication of the small group of Solomon Islands mental health professionals, supported by local health service managers and external donors, has been a major strength. However, they face significant challenges.

CONCLUSIONS

Continued investment in mental health, including the treatment and prevention of mental and substance use disorders, is essential for mental health and development outcomes. All development stakeholders, including civil society, government, academic and research institutions, and development partners, have a role to play.

The value of partnerships: lessons from a multi-site evaluation of a national social and emotional wellbeing program for Indigenous youth

OBJECTIVE

To evaluate the first three years of a national program to improve the social and emotional wellbeing of Indigenous youth in remote and regional Australia.

METHODS

Combination of open inquiry and audit review involving investigation of process and outcomes, with a broad national overview supplemented by five in-depth case studies in diverse settings.

RESULTS

Community development principles were applied at all 14 sites. There were many examples of collaborative, community-driven health promotion initiatives, with most progress observed where there were strong local partnerships. Within the range of activities, education sessions on alcohol and other drugs, mental health and violence were facilitated by program staff. There was a tension between community development and specific program delivery, with the balance reflecting the needs and capacity of individual sites, program staff expertise and contractual requirements.

CONCLUSIONS AND IMPLICATIONS

The main lessons concern program design and resourcing and ways of working. Program staff at each site learned to be not too ambitious, but to work consistently with the community, establishing partnerships and engaging and training community members. Community and stakeholder capacity enhancement should be regarded as core, and evaluation built in. Activities directed at youth must be engaging and effective, and integrated with other programs and services.

Developing a culturally appropriate mental health care service for Samoa

Mental Health Care Services are part of the National Health Services for Samoa. Their function is to provide mental health care services to the population of Samoa, which numbers 180,000 people. However, like many other countries in the Pacific region, mental health is considered a low priority. The mental health budget allocation barely covers the operation of mental health care services. More broadly, there is a lack of political awareness about mental health care services and mental health rarely becomes an issue of deliberation in the political arena. This article outlines the recent development of mental health care services in Samoa, including the Mental Health Policy 2006 and Mental Health Act 2007. It tells the story of the successful integration of aiga (family) as an active partner in the provision of care, and the development of the Aiga model utilizing Samoan cultural values to promote culturally appropriate family-focused community mental health care for Samoa. Mental Health Care Services today encompass both clinical and family-focused community mental health care services. The work is largely nurse-led. Much has been achieved over the past 25 years. Increased recognition by government and increased resourcing are necessary to meet the future health care needs of the Samoan people.

Improving access to eye health services in rural Timor-Leste

CONTEXT

Delivering eye health services to people in rural areas, especially in fragile, post-conflict countries, is a major challenge. This article reports on the implementation and evaluation of an innovative district-based outreach service. The main project partners were the Timor-Leste Ministry of Health and an international non-government organization, with assistance from a local non-government organization.

ISSUE

An eye care nurse in Covalima District, a remote location 178 km from Timor-Leste's capital, Dili, was provided with a motor-bike for transport and regular support for outreach eye services to sub-district facilities. Data collected over the first year of operation were examined and included: services provided, spectacles dispensed, health promotion activities conducted and the cost of providing these. The project was also evaluated for its relevance, effectiveness, efficiency, impact and sustainability.

LESSONS LEARNED

In the first 12 months, 55 outreach visits were conducted across the district's seven sub-districts during which 1405 people received vision screening, and 777 spectacles were dispensed. In addition to meeting the five evaluation criteria, compared with the hospital-based eye clinic the outreach service resulted in significantly greater gender equity among eye health service beneficiaries. This pilot project demonstrates what can be achieved when a Ministry of Health (central and district level) and non-government organizations (international and local) work in partnership to support a dedicated health care provider.

Mental health services in the Solomon Islands

The Solomon Islands comprise an archipelago of nearly 1,000 islands and coral atolls and have an estimated population of 549,574 people. Formal mental health services date back to 1950 when an asylum was established. Since then the process of mental health service development has been largely one of incremental change, with a major boost to community services in the last two decades. During the 1990s a mental health outpatient clinic was established in Honiara, together with attempts to recruit nursing staff as psychiatric coordinators in the provinces. In 1996, the Ministry commenced sending registered nurses for psychiatric training in Papua New Guinea. By 2010, there were 13 psychiatric nurses and one psychiatrist, with a second psychiatrist in training. A National Mental Health Policy was drafted in 2009 but is yet to be endorsed by Cabinet. A significant portion of the population still turns to traditional healers or church leaders for purposes of healing, seeking help from Western medicine only after all other alternatives in the community have been exhausted. There is still a long way to go before mental health services are available, affordable and accessible to the whole population, including people living in geographically remote areas. Realization of this vision requires increased resourcing for mental health services; improved communication and collaboration between the centrally-based, national mental health services and the provincial health services; and closer, ongoing relationships between all stakeholders and partners, both locally and internationally.

Building capacity in identification and management of mood disorders: an Australia-Sri Lanka collaboration

OBJECTIVE

This paper describes a collaborative capacity-building project in the identification and management of mood disorders, involving the Black Dog Institute in Sydney, Australia, and several organizations in Sri Lanka, and presents the qualitative evaluation findings.

METHOD

The two-year project comprised an initial intensive educational program delivered at the Institute with follow-up via email and an online forum (Phase 1), and continuing collaboration with the eight Sri Lankan clinicians and their respective organizations to build awareness of mood disorders and train others in Sri Lanka (Phase 2).

RESULTS

The eight trainees planned and executed several joint and separate activities during Phase 2, with an emphasis on raising awareness of mood disorders and health professional training. Evaluations of the local training activities were very positive.

CONCLUSIONS

The collaborative, systematic and systemic approach, and the train-the-trainer model adopted, has worked well. This project has built capacity in mood disorders among mental health clinicians in Sri Lanka, including those working in primary care. It has contributed to the implementation of national mental health policy, strengthened local networks and established new connections with Australian institutions. 'North-south' collaborations such as this would make good investments for international bodies and development agencies.

Decision-makers, donors and data: factors influencing the development of mental health and psychosocial policy in the Solomon Islands

Mental disorders and psychosocial problems are common, and present a significant public health burden globally. Increasingly, attention has been devoted to these issues in the aftermath of violent conflict. The Solomon Islands, a small Pacific island nation, has in recent years experienced periods of internal conflict. This article examines how policy decisions regarding mental health and wellbeing were incorporated into the national agenda in the years which followed. The study reveals the policy shifts, contextual influences and players responsible. The Solomon Islands' experience reflects incremental change, built upon longstanding but modest concern with mental health and social welfare issues, reinforced by advocacy from the small mental health team. Armed conflict and ethnic tensions from 1998 to 2003 promoted wider recognition of unmet mental health needs and psychosocial problems. Additional impetus was garnered through the positioning of key health leaders, some of whom were trained in public health. Working together, with an understanding of culture and politics, and drawing on external support, they drove the agenda. Contextual factors, notably further violence and the ongoing risk of instability, a growing youth population, and emerging international and local evidence, also played a part.

Fear and shame: using theatre to destigmatise mental illness in an Australian Macedonian community

ISSUES ADDRESSED

Previous research has revealed low levels of mental health service utilisation and widespread discrimination towards people with mental illness in Sydney's Macedonian community. As an extension to a multifaceted community intervention to improve mental health literacy and reduce stigma, a Macedonian-language play was produced.

METHODS

Qualitative data from earlier studies and professional experience were used to craft a script that was performed by actors from the Macedonian community. Eight performances at three venues were attended by approximately 1,600 people. Telephone interviews with 236 audience members (including 76 with personal or family experience of mental illness) and 25 key informants were conducted 1-10 months later. Data were analysed and compared with data collected pre-intervention.

RESULTS

Compared with the earlier data, the audience sample was significantly more likely to report positive community attitudes toward people with mental illness and their families, and to favour disclosure to extended family and friends. They also indicated greater willingness to seek help from health services. Key informants reported greater service utilisation since the play was staged.

CONCLUSIONS

Building on previous work, theatre was an effective means of disseminating information and reducing stigma around mental illness in the target community.

Beliefs, barriers, social support, and environmental influences related to diabetes risk behaviours among women with a history of gestational diabetes

ISSUE ADDRESSED

Women with previous gestational diabetes mellitus (GDM) are at increased risk of developing type 2 diabetes; this risk is higher in non-Caucasian women. This study explored the beliefs, attitudes, social support, environmental influences and other factors related to diabetes risk behaviours among Arabic, Cantonese/Mandarin, and English speaking women with recent GDM.

METHODS

Women living in the Sydney metropolitan area (Australia) who had GDM 6-36 months previously were included. In-depth semi-structured telephone interviews on women's experiences and perceptions of GDM and the lifestyle risk factors for developing type 2 diabetes were conducted in the language participants spoke at home (n=20 Arabic, 20 Cantonese/Mandarin, 17 English). Data were analysed for underlying themes using NVivo software.

RESULTS

Mental distress, role perceptions, social support and cultural expectations were major issues related to women's struggles to find the right balance between the large proportion of household and child care responsibilities and leading a healthy lifestyle.

CONCLUSION

Women's ability to follow a healthy lifestyle is embedded in their psychological wellbeing and the social and cultural context of their lives. The study highlights the need for a holistic approach that ensures personal support and access to services as well as lifestyle specific programs.

Description and evaluation of a project to improve the identification and management of mood disorders in developing countries

OBJECTIVE

This paper describes a training program in mood disorders for senior mental health clinicians in the Pacific region and presents the qualitative evaluation findings.

METHOD

The program, which incorporated a 2-week intensive course in Sydney and follow-up in-country, was undertaken by 13 clinicians from the Ministries of Health in seven Pacific Island countries. Evaluation data were gathered throughout the program. Participating individuals and their respective Ministries also completed an activity completion report.

RESULTS

The evaluation was very positive. Individual and organizational reports documented immediate and expected ongoing benefits and expressed a desire for continuing collaboration.

CONCLUSIONS

The program has resulted in a major boost to regional expertise and leadership in mood disorders. Furthermore, it has made an important contribution to the implementation of individual country mental health policies, one which strengthens the regional mental health network and builds new connections with Australian institutions. Success was based on a collaborative approach, high levels of institutional and individual commitment, and careful attention to both content and process issues. Sustainability will be enhanced through ongoing collaborative in-country and regional activities.

Using a multifaceted community intervention to reduce stigma about mental illness in an Australian Macedonian community

ISSUES ADDRESSED

Mental health services are under-utilised by the Macedonian community in south-east Sydney. This project investigated attitudes and beliefs towards mental illness in this community and used the findings to inform a multifaceted community intervention to reduce stigma and improve mental health literacy.

METHODS

The study was conducted in two phases. In Phase 1, 100 people from the Macedonian community - 24 clients of the mental health service, 23 carers and 53 community members - participated in a telephone interview about mental illness. These results were used in Phase 2 to deliver targeted education programs to key individuals and groups within the community.

RESULTS

In Phase 1, participants cited negative views about mental illness, negative attitudes and discrimination towards people with mental illness, and concerns about confidentiality as the main reasons for failing to seek care early. In Phase 2, more than 90% of those who provided written feedback indicated that the community and workplace education sessions had given them a better understanding of mental illness and its impact.

CONCLUSIONS

Considerable progress was made towards the long-term aims of raising awareness, positively changing attitudes and behaviours and encouraging the utilisation of mental health services in the target community.

Revealing the wood and the trees: reporting qualitative research

Qualitative research methodologies, which are oriented to better understanding of the context, meaning and experiences of people's lives, have much to contribute to health promotion. For researchers trained in quantitative methods, writing up qualitative research for a peer-reviewed journal can be a challenge, especially keeping within the prescribed word limits. How well you explain and disseminate your research will influence how others evaluate its quality; this has implications not only for what you write and the terminology you use but for how you structure your article. This paper provides a general guide to presenting qualitative research for publication in a way that has meaning for authors and readers, is acceptable to editors and reviewers, and meets criteria for high standards of qualitative research reporting across the board. We discuss the writing of all sections of an article, placing particular emphasis on how you might best present your findings, illustrating our points with examples drawn from previous issues of this Journal. Overall, we emphasise that reporting qualitative research involves sharing both the process and the findings, that is, revealing both the wood and the trees.

Community perceptions of mental health needs: a qualitative study in the Solomon Islands

Background

Psychosocial and mental health needs in the aftermath of conflict and disaster have attracted substantial attention. In the Solomon Islands, the conceptualisation of mental health, for several decades regarded by policy makers as primarily a health issue, has broadened and been incorporated into the national development and social policy agendas, reflecting recognition of the impact of conflict and rapid social change on the psychosocial wellbeing of the community as a whole. We sought to understand how mental health and psychosocial wellbeing were seen at the community level, the extent to which these issues were identified as being associated with periods of 'tension', violence and instability, and the availability of traditional approaches and Ministry of Health services to address these problems.

Methods

This article reports the findings of qualitative research conducted in a rural district on the island of Guadalcanal in the Solomon Islands. Key informant interviews were conducted with community leaders, and focus groups were held with women, men and young people. Wellbeing was defined broadly.

Results

Problems of common concern included excessive alcohol and marijuana use, interpersonal violence and abuse, teenage pregnancy, and lack of respect and cooperation. Troubled individuals and their families sought help for mental problems from various sources including chiefs, church leaders and traditional healers and, less often, trauma support workers, health clinic staff and police. Substance-related problems presented special challenges, as there were no traditional solutions at the individual or community level. Severe mental illness was also a challenge, with few aware that a community mental health service existed. Contrary to our expectations, conflict-related trauma was not identified as a major problem by the community who were more concerned about the economic and social sequelae of the conflict.

Conclusion

Communities identify and are responding to a wide range of mental health challenges; the health system generally can do more to learn about how this is being done, and build more comprehensive services and policy on this foundation. The findings underscore the need to promote awareness of those services which are available, to extend mental health care beyond urban centres to rural villages where the majority of the population live, and to promote community input to policy so as to ensure that it 'fits' the context.

A qualitative study of barriers to mental health services utilisation among migrants from mainland China in south-east Sydney

BACKGROUND

Chinese-language speakers comprise the largest non-English speaking population in Australia but they have among the lowest rates of mental health services utilisation.

MATERIAL

A bilingual (Mandarin/English) researcher conducted in-depth interviews with China-born mental health patients and members of the general community, and mental health service providers.

DISCUSSION

Participants identified several factors that limit access to mental healthcare as well as the quality of care received: mental health literacy, communication difficulties, stigma, confidentiality concerns, service constraints and discrimination. Cross-cultural communication was not just a matter of hearing individual words but also appreciating idioms and cultural and social references.

CONCLUSION

Findings have implications for the prevention and treatment of mental disorders among migrants from China, and caution against assuming heterogeneity within ethnic groups. Mental health services must become more culturally competent in their attempts to engage the target group and to deliver both acute and continuing care.

Telemedicine as a means of delivering cognitive-behavioural therapy to rural and remote mental health clients

We explored the feasibility and acceptability of delivering cognitive-behavioural therapy (CBT) via videoconference to clients with depression and/or anxiety living in rural north Queensland. The study involved 15 mental health clients and their five case managers. First, each case manager was instructed in the use of telemedicine for clinical consultation, and given training in CBT. This was done via videoconference. Then the clients were introduced to telemedicine. Following six to eight intensive weekly sessions of CBT, there was improvement in certain clinical outcome measures (i.e. the Mental Health Inventory and the Health of the Nation Outcome Scale). There was a significant improvement (P<0.05 using a t-test) in the client Mental Health Inventory scores before (mean = 109) and after treatment (mean = 148). However, in the absence of a control condition, it was not possible to conclude that the treatment had a specific effect on the disorders studied. Both clients and case managers found telemedicine consultations acceptable. Clients' ratings ranged from 3 to 4.5, while case mangers' ratings ranged from 3 to 5 ('average' to 'much better than average').

Identification of Australians from culturally and linguistically diverse backgrounds in national health data collections

In multicultural Australia, comprehensive and up-to-date information on ethnicity and health is essential to guide policy and service development in the health sector. Data collected for purposes other than research are a potentially important source of information. This study explored the extent to which indicators of cultural and linguistic diversity are currently included in national health and welfare service data collections, and the data standards employed. We identified and reviewed 44 relevant bodies of work: 7 national data dictionaries, 15 national data sets, 10 national health data collections and 12 national surveys. Each of the large data dictionaries (health, community services and housing assistance) contained several ethnicity-related variables. Immigrant Australians were identified (usually by country of birth, sometimes by language, and occasionally by period of residence or year of arrival) in all the major national health and community data sets, health data collections and surveys. Australian Bureau of Statistics standards and classifications relating to cultural and linguistic diversity were widely used. Researchers, health policy makers and planners should fully exploit these secondary data sources, as well as undertaking or commissioning primary research.

Abstinence and alcohol use among urban Aborigines in Western Australia

Aboriginal males and females aged 15 years and over were recruited from patients attending community-controlled health services in Perth and Carnarvon, Western Australia. Questions were asked about present and past use of alcohol. Rates of abstinence and drinking cessation were greater than in the general population. Both samples contained sizeable numbers of people whose weekly consumption of alcohol was within recommended limits. These are encouraging findings for Aboriginal health workers and others concerned to help those who continue to drink at hazardous and harmful levels.

Taking telehealth to the bush: lessons from north Queensland

Networking North Queensland (NNQ) was a two-year project to improve access to health services in rural and remote communities. The project involved email and Internet access in 61 communities, in a region almost three times the size of the UK. Videoconferencing equipment was also installed at 21 sites and a total of 197 h of videoconferencing was recorded at 10 of the remote sites over 12 months. As a result of the project, health consumers enjoyed improved access to medical, specialist, allied health and primary health services. In addition, health service providers had better access to reliable, up-to-date health-care information via intranet and Internet services. Consideration of local issues--local needs and existing resources--was vital to the achievements of the project. Community involvement and community access were also important factors in its success.