Lessons for mental health service design in Scotland — how can we ensure equal access?

Dr Paulina Trevena reflects on the barriers to equal access in mental healthcare for migrant and minority populations in Scotland.

The COVID-19 global pandemic had a major impact on people’s mental health, exacerbating issues of accessing mental health support in Scotland. Long waiting lists and appointments offered within work hours only (sometimes far from home or work) form serious barriers to accessing such support.

Migrant and minority populations face additional challenges to accessing mental health support, such as the language barrier, cultural barriers, lack of knowledge and understanding of pathways to support, and (perceived) inability to take time off work. During the pandemic, mental health support services were temporarily suspended or moved online, which created additional barriers for those lacking digital skills.

Particular pressures

Simultaneously, these populations face particular pressures resulting from their migrant and/or minority ethnic status, such as social isolation (living far from family with limited support networks locally), precarious employment, and institutional discrimination.

Minority populations were disproportionately experiencing poorer mental health during the pandemic. The most vulnerable groups, such as asylum seekers, refugees, and Roma communities, were hit especially hard, as were migrant essential workers. Mental health support was identified as one of the key needs during the pandemic yet remained largely unmet. There are three key reasons behind this: inadequate provision, stigma and discrimination.

Currently, the Scottish mental health care system does not cater to the needs of migrant and minority ethnic populations, language being the key barrier to accessing support. Support in native languages is not available. While translation is, there is little awareness of this option. Moreover, in a therapeutic context, where we speak about highly private and emotional issues, using a translator proves problematic. Hence, some of our study participants have sought mental health support privately from their home countries. Others mentioned this opportunity was not available to them due to financial or practical reasons.

Self-stigma

Notably, there is also considerable self-stigma around mental health among minority ethnic communities. This may be due to cultural differences in attitudes: in some communities, mental health remains a taboo subject and individuals are reluctant to discuss it regardless of their circumstances.

Labour market discrimination also plays strongly into not seeking mental health support, with some people fearing this may impact on their current employment or future opportunities. People from migrant and minority ethnic communities often work in low-skilled or precarious jobs where they are discriminated against. Taking time off work to receive mental health support is not seen as possible. Conversely, some in higher skilled positions, e.g. in healthcare, spoke about the perceived stigma around using mental health support, even if it was available to them.

This is why addressing stigma and discrimination more broadly is important for creating the key conditions for service delivery. Migrant and minority ethnic populations clearly need mental health support yet the inaccessibility of services on the one hand, and facing stigma and discrimination on the other are not commensurate to receiving such support.

Useful lessons

The pandemic brought useful lessons in this respect. Our research demonstrated some key points for improving mainstream mental health service provision:

• communities need to be involved in service design in order for it to be successful,
• such engagement should be consistent as communities’ needs change over time,
• to be able to identify specific needs, relevant statistical data should be disaggregated by ethnicity and nationality (and not just race),
• accessibility needs to be improved, e.g. via cultural awareness training for staff; routine translation of information materials and providing these in accessible formats; providing support in native languages.

The pandemic also provided opportunities for expanding mental health support through charities. Some were able to source qualified therapists who spoke their clients’ native languages. These initiatives proved highly successful, as did online well-being activities, such as exercise classes and creative workshops.

Moving forward, mainstream mental health services should build on these valuable lessons to ensure equal access for all residents of Scotland.

Dr Paulina Trevena

This guest blog summarises the findings from an expert review for the Scottish Government Coronavirus (COVID-19) Learning and Evaluation Oversight Group. The study was led by Dr Paulina Trevena, with Dr Anna Gawlewicz and Professor Sharon Wright of the University of Glasgow in collaboration with the charities Feniks, Black and Ethnic Minority Infrastructure in Scotland (BEMIS) and the Scottish Refugee Council (SRC). This rapid-response research was based on a review of academic and grey literature, secondary analysis of data from the Migrant Essential Workers project, and new interviews with stakeholders, mainly from the third sector. The study was funded by the Scottish Government Coronavirus (COVID-19): Learning and Evaluation Oversight Group. The full report is available here.