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Supporting race equality in mental healthcare
South Asian communities > Background
The South Asian community is the largest ethnic minority group living in Britain, representing just over 4% of the population (2001 Census). It consists of four main groups of people - Indian (1.8%), Pakistani (1.3%), Bangladeshi (0.5%) and other Asian (0.4%). South Asian culture is very diverse, encompassing hundreds of languages and dialects, many religions, beliefs, people of different classes, histories and countries.
South Asian communities > Key mental health issues
- General: racism, stigma, language barriers, cultural beliefs and practices
- Social risk factors: poverty unemployment low levels of education; (Bangladeshi); loneliness and isolation (women)
- Health: alcohol misuse (men); high suicide rates and self harm (women);low reported rates of depression/affective disorders (Bangladeshi)
- Service issues: lack of knowledge of services (elderly) delay seeking help
South Asian communities > Family: myths and stereotypes
The traditional stereotype of South Asian families is one of an extended family where individual members offer support and respect to one another. In this setting, it is believed that people do not need the support of external services or institutions, and would rather 'look after their own'. While the extended family structure still exists, some families can experience violence and pressure in marriage and relationships. Anecdotal evidence suggests a high rate of depression among the South Asian community, often linked to marital and family pressures, and issues such as housing, employment, low economic status and racism. Studies show that distressed individuals have few outlets, and feel they can no longer look to their families for help.
South Asian communities > Women
The rate of deliberate self-harm among young Asian women is higher than the national average. It has been suggested that this may be due to 'culture conflict', whereby young women disagree with their parents' or husband's views around subjects such as divorce, religion, widowhood, inter-cultural marriage and family honour.
South Asian communities > Domestic Violence
In a survey, the mental health charity Rethink revealed that 55% of South Asian women respondents had suffered some form of domestic abuse. The majority of the women (73%) stated that shame (or 'sharam') prevented them from getting help. The study revealed that common adverse health effects resulting from domestic violence include depression and emotional pain, as well as difficulty sleeping, anxiety and mood swings.
South Asian communities > Faith
A Mental Health Foundation research project3 suggested that there was a positive link between better mental health and practices such as attending mosque. The mosque plays a major part in community life, and people may turn to it for informal psychological support, often visiting and consulting religious leaders on health issues. However, mental health problems may often go undetected, as medical practitioners may not be seen as appropriate people to contact.
South Asian communities > Spotlight on: language barriers
Where English is a second language, accessing mental health services can be very difficult. Language is a key contributing factor to incidences of mis-diagnosis, as well as low referral for psychotherapy and counselling.
There are ways in which people whose first language is not English can make themselves understood and receive appropriate treatment - usually through the use of family members as interpreters. However, this can be inappropriate, especially if children are interpreting for parents.
Service providers have a statutory duty to provide information to patients about available services, consent to treatment, detention, rights of appeal and other legal matters. Such information should be explained, as far as possible, in a way that patients understand. This includes the use of appropriate language and translated materials.
South Asian communities > Hints and tips: delivering inclusive and effective mental health care
- Arrange twice-yearly meetings with local Asian faith leaders
- Local faith leaders could help promote inter-cultural understanding in pursuit of race equality in mental health. Ask whatever questions you feel are necessary to help you deliver inclusive and effective health care for South Asian people in your area. Share information with your staff on the specific faith, health and communications needs of this BME community.
- Learn about significant religious dates in the faith calendar of your service-user communities
- This will help inform your cultural understanding of those you are seeking to help, and will help ensure your service offerings, groups and initiatives do not clash with key dates for religious observance.
- To find out more about the religions most frequently practiced in Britain, key beliefs and religious festivals, visit the Resources section
- Use specially trained bilingual mental health care interpreters
- This is particularly important in emergencies. Consider any issues that may arise relating to the age, sex and class of your chosen interpreter, or any religious or political differences that may exist between interpreter and patient. And remember: although a patient may speak English, stress or distress can impede language skills.
African Caribbean communities > Background
According to the 2001 Census, the number of people of Black Caribbean descent living in the UK is around 1.0% and people of Black African descent is 0.8%. Those defining themselves as Black Other make up 0.2% of the population. In the main the community lives within the inner cities, and over half are British born. They tend to experience poorer health, have reduced life expectancy and have greater problems accessing health services than the majority white population. For mental health, major concerns include disparities and inequalities in terms of rates of mental ill health, service experience and service outcome.
African Caribbean communities > Key mental health issues
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General: racism, stigma, language barriers
Social risk factors: poverty, unemployment (men), exclusion from school, loneliness and isolation, homelessness, contact with the criminal justice system
Service issues: delay seeking help, high use of physical/drug treatments, low use of psychological/talking treatments, compulsory admission under Mental Health Act, high rates of admission/re-admission, families/carers have difficulties accessing help
African Caribbean communities > Spotlight on: fear
The Sainsbury Centre for Mental Health believes there are 'circles of fear that prevent black people from engaging with mainstream services. This means that black people may come to services too late, when they are already in crisis.
"If you combine [the] different layers of fear of black people, fear of mental illness and fear of mental health services, you arrive at a pernicious circle of fear. A circle that impacts negatively on the engagement of black people with services and vice versa."
The Sainsbury Centre for Mental Health
Violence and black patients: the myth
Mental health care staff are often concerned about violence, and it appears that racial bias in perceptions of danger influence patient management. However, in a study comparing black and white patients, black patients were perceived as being more dangerous despite exhibiting lower levels of aggressive behaviour.
African Caribbean communities > Hints and tips: delivering inclusive effective mental health care
1. Involve African-Caribbean communities (amongst other communities) in the planning and implementation of services from the outset. If more relevant individuals and organisations are directly involved in the planning and delivery of mental health services, it would help avoid problems relating to language barriers, myths and cultural mis-interpretations
2. Use advocates for first-time patient interviews
Entering mental health services can be unknown and frightening for all patients. But for patients from African-Caribbean communities, fear of services can be particularly acute. Having an advocate (with expertise in translation where necessary) on hand during the first interview can help to settle and ease a patient into care.
3. Develop culturally effective outreach and cultural engagement programmes
Many people from African-Caribbean communities are reluctant to present to mental health services, so you may need to get 'out there' and spread the word about your service offering. In this way you can raise awareness about the benefits of early intervention, and help dispel community fears.
4. Recruit service users from African-Caribbean communities to help break the 'circles of fear'
On the wards, in inpatient units, or out in the community, willing current or former service users who've been through the system could really help your cause. This will be of particular benefit to community outreach work.
Mental health and the Irish community > Background
Because of the practice of including the Irish in the overall White "ethnic" category, and the assumption that ethnicity is related to skin colour, it is often forgotten that the Irish community is the UK's largest immigrant ethnic minority. There is widespread evidence that the experience of Irish people in Britain is more akin to other, more visible, minority ethnic populations than the White majority. As with other minority ethnic communities, the Irish are more likely to live in London and the South East and other major urban centres.
Like any minority ethnic community, the Irish are not a homogeneous group. Many people who identify as Irish were born in Britain. Significant numbers have mixed parentage and take pride in expressing their dual cultural heritage. Irish Travellers have a distinct cultural heritage with language, customs and traditions which often set them apart from other Irish people. The age profile of the Irish community is an older one, with large numbers in the post-pension age group. For a range of different reasons associated with migratory patterns, occupational history, marriage, divorce and premature death, Irish people are more likely to live alone. As such Irish people and in particular those who are older can experience social isolation and have limited support networks in times of illness.
Despite significant evidence of success and affluence among Irish people, social, economic and housing disadvantage follows a broadly similar pattern to other minority groups. Although not as overt as in the past, anti-Irish racism still persists in the form of "Irish jokes" and stereotypes around alcoholism. This impacts at individual level, making people angry, uncomfortable, rejected and even feeling inferior. A lack of understanding of Irish culture on the part of healthcare practitioners, can affect diagnosis, treatment and recovery from mental illness.
Research has shown repeatedly that Irish people in Britain have excessive rates of admission for all diagnostic categories of mental illness, (Walls 2004) and consistently and significantly higher rates of psychological ill-health (Erens et al 2001), particularly depression and anxiety (Sproston and Nazroo 2002, O' Connor and Nazroo 2002).
The Count Me In Census 2005 demonstrated that the profile of Irish inpatients was different to other groups in that Irish admissions were more likely to be aged 50 and over and less likely to be under 24. The 2006 census shows lower rates of GP referral, higher rates of self-referral, admissions via A&E and significantly elevated rates of referral through the criminal justice system. The 2006 census demonstrated double than average rates of seclusion and higher levels of admission to medium and high secure wards.
Mental health and the Irish community > Key mental health issues for the Irish community
- General: invisibility and exclusion, anti-Irish racism, stigma, negative stereotypes.
- Social risk factors: poverty, unemployment, loneliness and isolation, homelessness, poor living and working conditions, discrimination within the criminal justice system, low levels of social support
- Health: high rates of depression and anxiety, higher risk of psychiatric morbidity, high levels of consultation with psychological problems, high incidence of childhood trauma, perceived alcohol misuse, misdiagnosis and potential dual diagnosis, high suicide rates.
- Service issues: lack of knowledge of services (especially men), delay in seeking help, low or late uptake of services, prevalence of stereotyping
- Spotlight on suicide: High rates of suicide have been recorded among Irish people in England for several decades (Harding and Maxwell 1997, Neeleman et al 1997). During 1999-2003 suicide and undetermined deaths among Irish men and women were 39% and 40% higher than average (De Ponte 2005). The pattern is replicated in figures for parasuicide especially among Irish women. There are particular concerns among Irish community organisations about high suicides in prison, especially among Irish Traveller men.
- Spotlight on alcohol: Alcohol is a sensitive issue in the Irish community. The stereotype of the drunken Irish is inappropriate and offensive but is a factor in low or late uptake of health services, dissatisfaction with care, misdiagnosis and ineffective poor treatment. However, despite some of the highest levels of abstention in Europe, alcohol problems do exist in sections of the Irish community and need to be handled sensitively. Socio-economic, cultural and structural factors all play a part in alcohol misuse among Irish people in Britain (Tilki 2006). Poor physical health, social exclusion, homelessness and discrimination are all linked to alcohol related ill-health. There is community evidence that Irish people use alcohol as a form of medication to deal with the symptoms of underlying mental illness and there is also a suggestion that an alcohol related diagnosis may be more acceptable than a mental illness one (Walls 2004). The potential link between alcohol and suicide for Irish people living in the UK should not be under-estimated.
- Spotlight on faith: It is invariably assumed that Irish people are all Catholics and deeply religious. While the majority of people from the Republic of Ireland are born and raised as Catholics and many practice their faith, others are nominal in relation to church attendance and some have actively rejected their faith. People from Northern Ireland are more likely to be Protestant although like other religious groups they vary in the extent to which faith is personally important or practised. Many Irish people who were abused in institutions by clerics have actively rejected their religion. There is a tendency to assume that the mental health problems of Irish people arise from a state of "Irish Catholic guilt". While this may be true for some, such assumptions neglect the importance of faith in coping with distress and mental illness. Older people and especially women tend to be more religious but many who have lapsed from their faith often return to it when they are distressed. Prayer, rituals and devotions to different saints provide a source of support to Irish people when they are ill.
Mental health and the Irish community > Hints and tips: Delivering inclusive and effective mental health care for the Irish community in Britain.
- Identify whether there is an Irish community organisation in your locality, consult them and involve them in assessing need, planning, delivery and evaluation of mental health services.
- Locate your Community Development Worker or one of the specific Irish Community Development Workers to advise on assessing need, planning, delivery and evaluation of mental health services.
- Develop culturally appropriate outreach strategies to target hard to reach Irish people with mental health problems.
- Proactively involve Irish service users in consultations and recruit members of the Irish community to trust boards, local tribunal bodies etc
- Seek the advice of the Federation of Irish Societies on training for cultural competence
- Explore partnerships with Irish voluntary sector organisation, commissioning culturally appropriate services where possible.
- Erens B., Primatesta P., Prior G. (2001) The Health Survey for England 1999. London. The Stationery Office.
- Harding S., Maxwell R. (1997) Differences in mortality of migrants. In F. Drever and M. Whitehead. Health Inequalities. Decennial supplement, No 15, pp 108-21.London. The Stationery Office.
- Nazroo J, King M ( 2002) Psychosis - symptoms and estimated rates in Sproston K., Nazroo J. (2002) Ethnic Minority Psychiatric Illness Rates in the Community (EMPIRIC). Quantitative Report. London. The Stationery Office
- De Ponte p (2005) Deaths from suicide and undetermined injury in London. London Development Centre for Mental Health and London Health Observatory.
- O' Connor W., Nazroo J. (2002) Ethnic differences in the context and experience of mental illness: A qualitative study London. The Stationery Office
- Tilki M (2006) The social contexts of drinking among Irish men in London. Drugs: Education, Prevention and Policy 13 (3) pp247-261
- Tilki M., (2003) A study of the Health of the Irish-born people in London : The relevance of social and socio-economic factors, health beliefs and behaviour. Unpublished PhD Thesis Middlesex University.
- Walls P (2004) Irish mental health in England: The evidence. Appendix 1 and 2, in Consulting the Irish community on Inside Outside : Improving mental health services for Black and Ethnic Minority Communities in England - the community response and its evaluation. Report commissioned by the Federation of Irish Societies and funded by the Department of Health