The Barriers and Promoters of Seeking Mental Healthcare: A Mixed Methods Study of Bangladeshi Populations in Toronto S A M I BACKGROUND PopulationBackground • 100,000 Bangladeshis currently reside in Canada • Most immigrated after S ▫ 1967 changing of immigration policy ▫ 1971 war A • Nearly 4,000 Bangladeshis immigrated to M Canada as Permanent Residents in 2013 I South Asian Mental Health • South Asian populations underutilize mental health services (Tiwari & Wang, 2008) S • Report unmet mental healthcare need (Gadalla, 2010) A • Face barriers in seeking treatment (Surood & Lai, 2010; Li & Brown, 2000) M I Objectives ❶ To identify attitudes towards seeking mental health care for Bangladeshi immigrant S populations A ❷ To identify barriers and facilitators of M seeking mental healthcare I METHODS Quantitative Phase • 47 participants • Data collection: June – September 2013 S • Survey instruments ▫ Inventory of Attitudes Toward Seeking Mental Health A Services (Mackenzie et al., 2004) M ▫ Sociodemographic questionnaire • $20 gift card I • Descriptive and bivariate-level statistics Qualitative Phase ▫ One-on-one interviews S ▫ 20 participants: • 19 in Bengali; 1 in English A ▫ Semi-structured interview protocol M ▫ Audio recorded ▫ $20 gift card I ▫ Thematic analysis (Braune & Clark, 2006) RESULTS Illness models • Holistic and Social Determinants of Health S perspective ▫ Only one participant spoke of biological causes of A mental illness ▫ Few spoke of spiritual causes M I “Mental health…. it is society, community, all together can run all of this all together, children, and S family - have whole A environment/society run smoothly and adjust to all of these – this is a M person I would understand as I being mentally healthy. ” - Female immigrant, 3 years in Canada Knowledge of Mental Health Resources • GENERAL HEALTH SERVICES: ▫ Telehealth Ontario ▫ Toronto Distress Centres S • YOUTH SERVICES: ▫ Naseeha — Muslim Youth Helpline ▫ Kids Help Phone A • WOMEN’S SERVICES: ▫ Women’s Resource Centre Helpline • GENERAL MENTAL HEALTH M SERVICES: ▫ Centre of Addictions and Mental I Health (CAMH) ▫ ConnexOntario Mental Health Helpline ▫ Canadian Mental Health Association (CMHA) Mental Health Table 1 - Health factors for East Danforth/Crescent Town Bangladeshi participants by length of stay in Canada Newcomers Longer-term immigrants Pearson chi- LifetimeS mental n(%) n(%) square test health issues 23(48.9%) 24(51.1%) p-value Table 2 A Health factors for East Danforth/Crescent Town Bangladeshi participants by Depression length of stay in Canada6(28.6%) 10(41.7%) 0.360 StressM 14(66.7%) 17(70.8%) 0.763 Anxiety 5(23.8%) 12(50.0%) 0.071 HeadachesI 10(47.6%) 9(37.5%) 0.493 Worry/miss 12(57.1%) 8(33.3%) 0.109 family Mental Health Consultation Table 1 - Health factors for East Danforth/Crescent Town Bangladeshi participants by length of stay in Canada Newcomers Longer-term immigrants Pearson chi- Lifetime mental health n(%) n(%) square test consultationsS 23(48.9%) 24(51.1%) p-value A Mental health 10 (43.5%) 11 (45.8%) 0.871 services in Canada TraditionalM or omitted omitted 0.975 spiritual mental healthI resources Family/friends 15(71.4%) 17(70.8%) 0.965 Mental Health Consultation • 44% of participants reported past-year mental health consultation S • National average is 10% (Lesage et al., 2006) • Majority spoke to their family doctor (36.2%) A • Report inadequacy in care M I Positive Attitudes Towards Seeking Mental Health Services S Promoters Quantitative Phase Findings: A - Employment in one’s field of work or M study - Male gender I - Attending school in Canada Qualitative Phase Findings PROMOTERS BARRIERS -Open discussion S -Migration and -Community resources -Internet resettlement -Family doctor A -Lack of mental health -Education literacy -Translation/interpreter -System-level barriers services M -Policy-level barriers -Social support -Appropriately disseminated -Mental health stigma mental health service info I -Female gender -Well-trained professionals -Lack of employment -Emphasis on confidentiality of services DISCUSSION AND CONCLUSIONS Merging findings ● Overarching factor related to barriers and promoters identified in both legs of the S study: A - Relative cultural and social isolation of the Bangladeshi immigrant community M - Lack of economic integration was the I most pressing concern for this community BAD JOBS ARE NOT S LETTING US EVEN A CONSIDER OUR M MENTAL HEALTH. I Access Alliance, 2013 “…it is not easy to get a job…Can’t find the opportunity…On top of that, for women and children…This S country is totally different…children don’t listen to them…Taking all of A this together, depression starts. I know someone that committed M suicide from stress. Wasn’t able to I tolerate all of this, and mentally they became sick.” – Female Bangladeshi immigrant, 6 years in Canada Summary • Holistic view of mental health • Majority of participants did not have knowledge of available mental health resources S • Financial difficulty upon arrival was the greatest stressor of mental health A • Cultural and social isolation of the Bangladeshi immigrant community is a major barrier to M seeking mental health services • Participants developed a four-pronged strategy to increase the level of mental health service I access for the community Four-Pronged Action Plan ❷ Health System-Level ❶ Government-Level -Culturally safe mental healthcare -financial support models -job and skills matching -Translators (+/-) programs for newcomers -Matching programs S -information about mental -Expand mental healthcare role of GP health services provided to -Appropriately translated and immigrants upon arrival disseminated mental health info A -Fostering community champions ❹ Individual-Level M ❸ Community-Level -individual from community who -community awareness can share their personal experience I campaigns using mental health system -educational programs Bottom Line • Mental health is a concern for Bangladeshi immigrant populations S • Lack of economic support and integration makes it difficult to prioritize mental health A • The community lacks information on resources available as well as awareness on the M importance of the issue I Next Steps • Policy change to increase economic supports for newcomers S • Effective jobs-matching, skills–bridging programs A • Mental health awareness workshops • Bengali-translated advertisements on mental M health I Next Steps • Mental health training for family doctors • Models of mental healthcare grounded in S cultural safety • Community education around parenting and A difficulties newcomers experience • Research into family doctors’ role in mental M health consultation I Acknowledgments • Dr. Hala Tamim, School of Kinesiology and Health Science, York University S • Dr. Nazilla Khanlou, School of Nursing, York University A • La Barge Graduate Scholarship in Multiculturalism, York University M • LaMarsh Research Award, York University I Thank you! S Email: [email protected] CIHR Postdoctoral Fellow A Social Aetiology of Mental Illness (SAMI) Centre for Addiction and Mental Health (CAMH) M University of Toronto I S A EXTRA SLIDES M I Recommendations from Participants ● multi-pronged, culturally-appropriate, targeted mental health outreach campaign S ● appropriate mental health resource information dissemination and community awareness and education in the immigrant Bangladeshi community of East A Danforth/Crescent Town ● four-pronged comprehensive strategy Government-level M Health system-level Community-level I Individual-level Table 1 Sample demographics of quantitative phase participants (n = 47) by length of stay in Canada Newcomers Longer-term immigrants Pearson chi-square n(%) n(%) test 23(48.9%) 24(51.1%) p-value Age range 20-40 19(82.6%) 16(66.7%) 0.210 41-60 4(17.4%) 8(33.3%) Gender Male 6(26.1%) 5(20.8%) 0.671 Female 17(73.9%) 19(79.2%) Marital status Married omitted omitted 0.975 S 22(95.7%) 23(95.8%) Religion Islam 17(73.9%) 21(87.5%) 0.237 Hinduism 6(26.1%) 3(12.5%) A English proficiency Not at all-a little bit 2(8.7%) 3(12.5%) 0.596 Moderate 12(52.2%) 9(37.5%) Quite a bit- extremely well 9(39.1%) 12(50.0%) MEducation level in Bangladesh < university degree University degree or higher 2(8.7%) 3(13.0%) 0.636 21(91.3%) 20(87.0%) EducationI in Canada Attend school 6(26.1%) 5(22.7%) 0.534 Not attend 17(73.9%) 17(77.3%) Note. # Low Income Measure for four-person household (average household size in this sample) is $39,860 (income after taxes) (Statistics Canada, 2013). Note. Some cells were omitted due to low sample size. # of household members 2-3 11(47.8%) 7(29.2%) 0.188 4-5 12(52.2%) 17(70.8%) # relatives in city None 10(43.5%) 13(54.2%) 0.040* 1-4 10(43.5%) 3(12.5%) 5 or more 3(13.0%) 8(33.3%) S Annual household income < $29,999 17(77.3%) 8(36.4%) 0.022* A$30, 000-49,999 3(13.6%) 10(45.5%) $50,000+ 2(9.1%) 4(18.2%) Working status MYes 5(21.7%) 9(37.5%) 0.238 No 18(78.3%) 15(62.5%) Employed in field of Istudy/work Yes omitted 2(8.3%) 0.398 No 20(87.0%) 17(70.8%) n/a 2(8.7%) 5(20.8%) Opinions of Access Alliance “I think after new immigrants come, they go to various neighbourhoods, Access S Alliance, these types of social services for different information, this is where they go first regarding what to do, what not to A do. They provide various trainings and courses. At that time, this information M could be included as part of those courses. Or have advertisements at the I hospital or at the Family physician’s office or some sort of mental health service can be available there.” – Female newcomer “No, this information [about mental health] has not come. The ones that I know, or what I know about mental health is because of tv ads I saw on tv.