1. Improving mental health and illness in IRER groups in Canada Kwame McKenzie MD

2. 2 Outline of talk  Demographics  International and Canadian literature  Views of communities  Models of improving outcomes

3. Demographics

4. 4 Globalisation leads to diversity 20 cities with over a million foreign born

5. 5 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

6. 6 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 10

7. 7 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”

8. 8 Percentage change in visible minorities 2001 to 2006 37.7 20.6 22.9 25.2 27.531.4 Canadian Average Increase 27.2% 48.6 100.0 19.6 46.9 41.6 9.1 55.1

9. 9 Region of birth of people who have immigrated to Canada in last 5 years

10. 10 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 10

11. Mental health and mental illness in IRER groups

12. 12 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.

13. 13 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. “

14. 14 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

15. International and Canadian Literature

16. 16 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

17. 17 Canadian literature tagcloud

18. 18 Clusters of research  Rates  Why different rates – ie social determinants  Differences in use of services

19. 19 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

20. 20 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 16

21. 21 Effect size 0.41 – refugees worse mental health Porter and Haslam - JAMA

22. 22 Migrants risk of schizophrenia Selten & Cantor Graae Am J Psychiatry. 2005 Jan;162(1):12-24. Migrant groupRelative risk95% CI first generation2.72.3-3.2 second generation4.71.5-13.1 “black” migrants4.83.7-6.2 “white” migrants2.31.7-2.9

23. Why the problem?

24. 24 Canadian literature Social 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

25. 25 Ratio of earnings of recent immigrants to Canadian people is decreasing over time

26. 26 Households currently in housing that is inadequate, unsuitable or unaffordable. *

27. 27 Recent Immigrants Reporting Emotional Problems, by Income Quartile Figure 1: Source: Statistics Canada. Longitudinal Survey of Immigrants to Canada, 2005.

28. 28 * 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.

29. 29 Example causes of psychological problems in refugees

30. What do people with lived experience from diverse communities say? Kwame McKenzie

31. 31 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?

32. How do you feel about the mental health services you are receiving now?

33. 33  “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”

34. What do you think the most important issues are for preventing mental health problems in your community?

35. 35  “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”.

36. 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?

37. 37  “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.”

38. 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?

39. 39  “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).”

40. 40  “…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.”

41. Are there other issues that you think are important for improving the health service response to ethno-racial groups?

42. 42 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

43. Improving outcomes

44. 44 Pathways to care

45. 45 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

46. 46 % immigrant population by electoral ward In Toronto and Vancouver moving from city centre to suburbs

47. 47 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

48. From inequality to inequity

49. 49 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

50. 50 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 OrganisationXX Service systemXXXX Societal / legislative XXXX

51. 51 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

52. 52 Model of services

53. Thanks