Improving mental health and illness in IRER groups in

CanadaKwame McKenzie MD

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Outline of talk

Demographics International and Canadian literature Views of communities Models of improving outcomes

Demographics

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Globalisation leads to diversity20 cities with over a million foreign born

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Immigration

Main driver of population growth• Responsible for more than two-thirds of growth between

2001 and 2006

Nearly 20% of Canadian population foreign-born

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Number of Permanent Residents, by Category, Canada, 1984-2008

Source: Citizenship and Immigration Canada. Facts and Figures 2008: Immigration Overview--Permanent and Temporary Residents. 2009, p. 6.10

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Immigrant population

Diverse groups with different realities and needs Diversity between and within provinces and

communities All provinces have changing demographics 64% belong to three Statistics Canada groupings:

“South Asian”, “Chinese”, and “Black”

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Percentage change in visible minorities 2001 to 2006

37.720.6

22.9

25.2

27.5 31.4

Canadian Average Increase 27.2%

48.6

100.0

19.6

46.9

41.6 9.1

55.1

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Region of birth of people who have immigrated to Canada in last 5 years

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Where are people coming to?

Figure 3: Destination of Permanent Residents and Temporary Foreign Workers, 2008

                                                                                                                                                                                                                                                                              

Notes: Percentages are rounded for clarity of presentation.Provinces at 1% or below (NS, NB, PEI, NL and the Territories) are not shown.Source: Citizenship and Immigration Canada. Facts and Figures 2008: Immigration Overview--Permanent and Temporary Residents. 2009, p. 26, 62.10

Mental health and mental illness in IRER groups

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What is mental health

“a state of wellbeing in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community”

World Health Organization.

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Mental illness

“clinically significant patterns of behavior or emotions, associated with some level of distress, suffering, or impairment in one or more areas such as school, work, social and family interactions, or the ability to live independently. “

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Linking mental health and mental illness

you can have a mental illness and have mental health

but

poor mental health increases your chance of mental illness

International and Canadian Literature

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Mental health services in 5 selected countries: Kirby Commission

Inattention to mental health needs of ethnic minorities is unethical.

It leads to: • Poorer access to care• Poorer outcomes• Increased use of crisis and emergency care• Increased use of police and prison justice system

• And is expensive

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Canadian literature tagcloud

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Clusters of research

Rates

Why different rates – ie social determinants

Differences in use of services

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Diverse cultural groups Different rates of mental illness

Low rates of mental illness in immigrant groups when they arrive in Canada but may increase over time

Local studies in Canada report high rates of mental health problems and illnesses in some IRER groups

Rates vary in IRER groups in Canada Little information on racialised groups or Caribbean

origin groups

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Canadian-Born Population and Immigrants Reporting "Fair" or "Poor"

Health,

Source: Newbold KB. Self-rated health within the Canadian immigrant population: Risk and the healthy immigrant effect. Social Science and Medicine, 2005.16

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Effect size 0.41 – refugees worse mental health

Porter and Haslam - JAMA

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Migrants risk of schizophreniaSelten & Cantor Graae Am J Psychiatry. 2005 Jan;162(1):12-24.

Migrant group Relative risk 95% CI

first generation 2.7 2.3-3.2

second generation 4.7 1.5-13.1

“black” migrants 4.8 3.7-6.2

“white” migrants 2.3 1.7-2.9

Why the problem?

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Canadian literatureSocial determinants important

Social factors linked to mental health problems for all More detrimental usual social determinants Cultural groups also exposed to novel social

determinants• migration, discrimination and language difficulties.

less availability of social forces that decrease risk

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Ratio of earnings of recent immigrants to Canadian people is decreasing over time

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

1980 1990 2000 2005

Males w Univ. Deg Females w Univ. Deg Males w/o Univ. Deg Females w/o Univ. Deg

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Households currently in housing that is inadequate, unsuitable or unaffordable.

*

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Recent Immigrants Reporting Emotional Problems, by Income Quartile

Figure 1:

Source: Statistics Canada. Longitudinal Survey of Immigrants to Canada, 2005.

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* Significantly different from estimate for Canadian-born (p <0.01).Note: All explanatory variables are based on the situation in 1994/95. Because of rounding, some confidence intervals with 1.0 as upper/lower limit are significant.Data source: 1994/95 to 2002/03 National Population Health Survey, longitudinal file.

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Example causes of psychological problems in refugees

What do people with lived experience from diverse

communities say?Kwame McKenzie

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5 questions

Current service satisfaction Most important issues for prevention Who most risk / should be targeted Would more racially diverse workforce change use

mental health services? Are there other important issues?

How do you feel about the mental health services you are receiving

now?

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“I live the life of a single person even though I have family around me (client breaks down and cries), I appreciate the fact that my worker is available to me 24/7, she is there for me in terms of alternating her schedule and she calls to ask me if I am doing okay and she treats me like a daughter. She always calls me on Monday morning to ask me how I am doing and I appreciate that so much. I do not know if I could go on without her assistance. Speaking of assistance I find housing problems a significant barrier in my ability to live my life. I hope this issue is brought to light”

What do you think the most important issues are for preventing

mental health problems in your community?

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“While using the mental health services such going to a psychiatrist, participating in a mental health awareness workshop or attending a group, usually we are labelled as mad or crazy”.

Are there particular people in your community who you think are most

at risk of mental health problems and should be the first targeted for

help?

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“If youth are not targeted, there is a big risk of addiction to drugs and joining the gangs …”

“…if our children are healthy and fine, we are happy and relieved, but if they are suffering from mental health problems then the whole family are affected and our symptoms are worsened.”

“Youths are suffering from the cultural conflict, from one side they are forced by parents to stick to their culture and traditions while from the other side, they are exposed to different cultural norms, therefore it is important focus on youth and adolescents groups.”

Would a more racially diverse workforce, or someone who speaks

your language in mainstream services make any difference to whether or how you use mental

health services?

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“I have the ability to speak with an individual in Tamil and English, which is nice. I definitely think the language barrier is a key component in many people in our community not being able to take advantage of the services that are offered. I had switched from having a doctor at (Hospital A) to (a Tamil doctor at Hospital B) because I felt there was a spiritual/cultural component/link to understanding my health problems.I did not receive this respect for culture in using the services at (Hospital A).”

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“…language and culture play an important role in mental health service delivery. For example if I go to a service provider who doesn’t know my language and is not familiar with my culture, first of all I will not be able to explain my problem to him/her as I want to say it, secondly, even if he/she gets me, will still not be able to provide me with a culturally appropriate treatment which is very important.”

Are there other issues that you think are important for improving

the health service response to ethno-racial groups?

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More can be done

Afghan• Employment, support groups, English language and computer

classes Somali

• Services at places of worship, Imams taught, decrease stigma, choice to use ethno-specific or culturally competent mainstream

Tamil• Housing, befriending, education, programming, day care, work

Improving outcomes

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Pathways to care

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Diverse populations: Barriers to care

Less likely to get care and poorer care received Numerous barriers eg:

• Awareness and stigma• Pathways unclear• Models of care and personnel not acceptable• Lack of cultural competence and sensitivity• Financial barriers• Language

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% immigrant population by electoral wardIn Toronto and Vancouver moving from city centre to

suburbs

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Diverse populations: facilitators of care

length of stay in Canada / acculturation knowledge and education ethno-specific health promotion trust in the system cultural competency co-operation between service providers diversity of services including alternative approaches

From inequality to inequity

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Service inequity

Inequality Different groups may have different needs

Inequity Issue is service response to differential need

Equity lens targets remedial differences in service need, access, use, quality or outcomes

Aim to identify things we can do something about and who should be doing it

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Who can offer interventions for what type of need

Differential need

Inequitable service response

Context in which need & service response occur

Clinicians and teams

X

Organisation X X

Service system XX X X

Societal / legislative

XX X X

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Mental Health Strategy Framework

The MHCC framework for a transformed mental health service

A major issue will be a move towards an increased focus on the prevention of mental illness and the promotion of mental health

Another will be on improving services for Canada’s diverse populations

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Model of services

Thanks