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Q. Why consider culture in MH?
· ethical reasons
· affects world view
· treatment appropriateness
· holistic
· relating (humanistic/transpersonal perspective)
· safety
· focus on individual’s norms & values
· Represent 18% of NZ total population
· Needs not met by existing monocultural/bicultural health services
· Includes sub-groups more at risk of PUSH/PULL factors e.g. migrants & refugees
· Adult immigrants have HIGHER rates of MH problems than if they’d remained in their homelands
Establishing a new life for 1st & 2nd Generation migrants is a stressful process
· loss of family * afraid & vulnerable
· loss of identity (ethnic, religious, sexual etc) * intimidated
· loss of belonging * anxious
· loss of rituals * lonely & isolated
· loss of culture
· loss of language * positive & hopeful
· loss of support networks/structures
· loss of home & possessions
Negative:
· stressful & leads to problems in mental, emotional & physical health
· dual tasks of resolving GRIEF over losses & mastering resettlement conditions
· Eisenbrook speaks of “cultural bereavement” for country, culture & subculture
· Sense of dislocation & displacement also common (not belonging & not fitting in)
Positive:
· opportunity for exploration & personal growth
· psychosocial transition
· excitement & liberation of aloneness/anonymity & new choices
· some losses mediated by equal opportunities
eg. Safety, easier educational access & ability to earn higher income
· belief about origin of illness
· way signs & symptoms are experienced & described
· belief about alternative & complementary forms of treatment & support
· willingness to seek treatment & support
Migrants wait a long time before getting help because:
· language issues
· don’t know what services are available
· don’t know how to access services
· failure to provide services to NESB communities which are equal in quality and effectiveness to those which are available to the community at large constitutes an infringement on the rights of those NESB communities
· attitudes toward mental illness are diverse & may be associated with religious or quasi-religious beliefs
Problems for NESB communities:
· lack of equitable access to INFORMATION essential to maintain health & early treatment of illness
· paucity of information available to NESB communities concerning services, what they offer & how to access them
Barriers to NESB using Services:
· resistance to access due to STIGMA
· shame
· greater role/involvement of family
· communication/language barriers
· lack of bilingual health workers
· difficulties accessing language services/interpreters etc
· common presentation of psychological distress in form of SOMATIC complaints
· migrants perception that their experience & situation is not understood
· lack of CULTURALLY APPROPRIATE services
· mental health system’s “blanket “ approach to diagnosis & treatment
· health workers insensitivity to cultural issues
· mistrust of government services & agencies
· socio-economic :finances, transport, geography
KLEINMAN: Tool to elicit health beliefs in clinical encounters
Taken from “Patients & Health in the Context of Culture (1981)
Role of naïve inquirer to find out what people think.
Shifts focus off health professional
· what do you call your problem/what name does it have?
· what do you think has caused your problem?
· Why do you think it started when it did?
· What does your sickness do to you?/how does it work?
· How severe is it? Will it have a short or long course?
· What do you fear most about the sickness?
· What are the chief problems your sickness has caused you?
· What kind of treatment do you think you should receive?
· What are the most important results you hope to receive from this treatment?
E.g. Schizophrenia: spiritual expression
Different explanations
Problems in Diagnosis:
· lack of reliability with cross-cultural diagnosis – either OVER-diagnosed or UNDER-diagnosed
· NESB clients are poor users of services therefore little comparative data
· An increased indirect cost to the community as a result of misdiagnosis & inadequate treatment of illness
· Family disruption & breakdown, increase in domestic conflict & violence
ATTENTION to cultural ideas opens up treatment options
It depends on the Psychiatrist & multidisciplinary team to consider a wider perspective & range of help
OTTOWA CHARTER = guideline for health & to ensure basic human rights & needs
Unique issues for NESB:
· less likely to be involved in decision making regarding treatment
· more likely to be passive recipients of treatment
· for cultural & linguistic reasons treatment may be inappropriate
· lack of involvement of NESB communities in the design & evaluation of health services & policies, which results in the development of service structures & practices which are frequently inappropriate to the needs of NESB communities
· stigma
· fear
· delaying treatment
· lack of understanding about confidentiality
NESB are OVER-REPRESENTED in crisis presentations & in forensic populations
NESB spend between 20-40% longer as an inpatient than other members of the community and are more likely to be admitted as an INVOLUNTARY patient (Travier 1995)
Predictors of Potential Need for MHServices by Migrants:
· separation from family
· separation from community
· inability to communicate in english
· limited access to suitable accommodation & employment (professional qualifications not recognised in nz)
· limited access to social supports/welfare
· hostile reception by host community
EFFECTS:
· more suffering in addition to the illness
· more costly due to misdiagnosis
· more stress due to unnecessary investigation
· development of avoidable chronicity