Mental health of ethnic groups & cultural competence

Kwame McKenzie MD

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Outline of talk

What is the issue?• Demographics• Canadian focused research

– Rates– Risks– Service use

Improving service response and the place of cultural competence in Canada

Demographics

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Globalisation leads to diversity20 cities with over a million foreign born

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In Canada, 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

Canadian Literature

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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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IRER groups Different rates of mental illness

Low rates of mental illness increase over time Rates vary in IRER groups in Canada Little information on racialised groups Little information on non-visible minorities

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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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Health of immigrants to Canada in first 4 years

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Hansson et al 2012

Rates of depression vary by age groups and ethnic

group

Refugee youth high rates of mental health problems

Suicide rates low for immigrant groups but trajectories differ

Causes

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Canadian literatureSocial determinants important

Social factors problems for all but..

Minority ethnic groups• more detrimental social determinants • novel social determinants

– migration, discrimination and language difficulties.

• fewer 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

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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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Example causes of psychological problems in refugees

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Pascoe and Richman

Added secular changes

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The problem is not just Bay Street

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City1 City2 City3

Most children in Toronto live in City 3

1/3 of people in City 3 live under low income cut off

50% of the housing for families in City 3 is high rise

Poverty is color coded

Getting care and 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

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Conclusion

In Canada, as elsewhere… Different groups have different rates of illness, risks

and needs Improving outcomes will be complex because of the

complex reasons for these differences One size may not fit all - may include general

initiatives and specific targeted services

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How do we move forward?

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Cultural competence and health equity

Health inequities = differences in access, use or outcome because of an interaction between community need and service response

To be culturally competent need to promote equity at population, system and practice levels

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Integrated improvement strategy

Rates:• Health promotion• Illness prevention• Social equity• Resilient communities

Service response• Equitable access to medical services• Equitable outcomes of medical services • Equitable access to social support services

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The perfect parent problem

All parts of the service are responsible. Health systems reorganize when they are challenged If that fails they suggest training staff Staff believe it is their fault because they want to be

perfect parents They take training but it does not work because the

problem is more systemic True equity needs more than cultural competence

training

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Promoting equity is the responsibility of the organization

Someone does need to be responsible so that they can be called to account

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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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Model for improved service response

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Things we can locally

Hiring (at all levels including docs) Internal structures that promote diversity Develop organizational cultural competence eg pathways to

care and 360 appraisal Link with local organizations Train in individual cultural competence – dealing with difference Know the Kleinman questions + drug differences Offer diversity of treatment and patient centred outcomes Stay humble…

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Moving forward…

No comprehensive plans in Canada

Plan or plan to fail? Plan requires multi-

year commitment Cultural competence

has its place but it is not a replacement for a health equity plan

Thank you