1. Mental health of ethnic groups & cultural competence Kwame McKenzie MD

2. 2 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

3. Demographics

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

5. 5 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

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. Canadian Literature

12. 12 Canadian literature tagcloud

13. 13 Clusters of research Rates Why different rates – ie social determinants Differences in use of services

14. 14 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

15. 15 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

16. Health of immigrants to Canada in first 4 years

17. 17

18. 18 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

19. Causes

20. 20 Canadian literature Social 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

21. 21 Ratio of earnings of recent immigrants to Canadian people is decreasing over time

22. 22 Households currently in housing that is inadequate, unsuitable or unaffordable. *

23. 23 Example causes of psychological problems in refugees

24. 24 Pascoe and Richman

25. Added secular changes

26. 26

27. 27

28. 28 The problem is not just Bay Street

29. 29 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

30. Getting care and improving outcomes

31. 31 Pathways to care

32. 32 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

33. 33 % immigrant population by electoral ward In Toronto and Vancouver moving from city centre to suburbs

34. 34 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

35. 35 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

36. 36 How do we move forward?

37. 37 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

38. 38 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

39. 39 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

40. 40 Promoting equity is the responsibility of the organization Someone does need to be responsible so that they can be called to account

41. 41 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

42. 42 Model for improved service response

43. 43 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…

44. 44 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

45. Thank you