What was the project about?
The aims of the project were to:
- Improve access to health care services for Chinese people with mental health needs
- Improve the experiences of Chinese people with mental health needs using health care services
The objectives of the project were to:
- Enable the voice of the Chinese patient to be heard, through providing language and cultural support, and thus ensure that patients receive appropriate and responsive services
- Build a two-way bridge between Chinese patients and mental health professionals, providing explanations of Chinese cultural background to professionals and relaying information from professionals to patients to reduce the stigma of mental illness among the community
- Provide continuity and stability in the support received by Chinese patients that would not be available with the conventional use of interpreters
- Provide emotional and practical support to Chinese patients and their families, recognising that social welfare is crucial to mental well-being
Why was the project needed?
Language, culture, poor symptom recognition and stigma are often cited as barriers to access leading to low uptake of health services. The NHS Executive Mental Health Task Force report (Department of Health, 1994) observed that the Chinese and Vietnamese communities were largely 'invisible' to mainstream purchasers and providers. The main areas of difficulty for Chinese families were:
- lack of English
- lack of knowledge of their rights
- cultural differences, including lack of understanding by the statutory sector
- scattered settlement
- long and unsociable working hours
These issues continue to be relevant today.
In Chinese Mental Health Issues in Britain (1997), Blackwell describes three areas where Western psychiatrists occasionally fall in error when treating Chinese patients:
- 'Normalising' behaviour which is the result of mental illness – misconstruing signs and symptoms of mental illness as being normal behaviours within the Chinese 'culture', with the result of patients not receiving treatment or receiving inappropriate treatment
- Misinterpreting normal culturally determined behaviour as evidence of mental illness
- Mismanagement – using treatment styles and regimens that are unsuited to Chinese patients, for example, underestimating the importance of the family in treatment decisions
These were the project research questions:
- What issue does the client want to tackle?
- Does the advocate support the client in discussing illness with the family or community?
- What is the kind of cultural explanation done by the advocate in meetings with the health professional?
Key learning points
The provision of a community-based advocacy service is essential to meeting the mental health needs of the Chinese community in London. The community advocacy model used in this project was successful in:
- improving access to health and social care services among settled Chinese residents
- improving engagement with mental health services for patients with severe mental illness, especially among new migrants
- improving communication and understanding between health professionals and across all client groups and in all settings, including general practice, community mental health services and inpatient units
- improving communication and understanding between other services, such as housing and legal services, across all client groups, and assisting in issues that were key factors in determining health and mental health and in promoting recovery
The CNHLC's counselling service is an important resource that provides culturally and linguistically sensitive support to the Chinese community in London. Current statutory provision of psychological therapies does not meet the cultural or language needs of Chinese people.
New migrants are a particularly vulnerable group who require practical assistance to meet their basic welfare needs. Across all client groups, advocacy support in this area was highly valued by both service providers and clients. The advocate worked in partnership with social workers and community psychiatric nurses to ensure that the basic needs of clients were met. Social isolation was also prevalent across all groups but was perhaps experienced more intensely by new migrants, who were also isolated from their family and for whom there is a lack of Chinese community resources.
- A pan-London Chinese mental health advocacy service should be commissioned to provide advocacy in community settings and under the statutory provisions of the Mental Health Act 2007.
- Chinese advocates with Cantonese, Mandarin and English language skills should be trained under the new national independent advocacy qualifications for IMHAs and IMCAs.
- Mechanisms should be put in place to make the CNHLC’s counselling service available to a wider population and to make the service available to Chinese people through the NHS. This will also help to ensure viability and sustainability of the service.
- A pan-London Chinese mental health advocacy service should provide advocacy support in the community to ensure that vulnerable groups, such as new migrants, receive basic welfare support. This should be achieved by advocates working in partnership with care providers.
- A culturally and linguistically responsive befriending service should be set up to tackle social isolation among Chinese people with mental illness. This should meet the needs of a diverse population and be provided in the two main spoken dialects: Cantonese and Mandarin.
How was the service evaluated?
While the project was available to any persons of Chinese ethnic origin living in London, the evaluation focused on three broad groups within this heterogeneous population:
- first-generation settlers
- new migrants
- students in higher or post-18 education.
It was postulated that a) the issues giving rise to mental or psychological distress; b) the pathways to the project, and c) the type of support provided by the project might be different for each group.
For example, among first-generation settlers, inter-generational conflict might be a prevalent issue compared to social isolation among new migrants or peer pressure among students.
Using realistic evaluation, the evaluation sought to identify and elucidate the mechanisms of access and advocacy.
The project evaluation comprised of two components:
- A quantitative, descriptive component derived from the case notes kept by the advocate: number of clients; client demographics; referral routes
- A qualitative case-study component consisting of interviews with clients, clients’ relatives and care providers to address the research questions posed by the process evaluation
Between the start of the project in December 2006 and July 2009 when data were collated, a total of 40 clients accessed the project. For the realistic evaluation, eight client cases were selected and a total of 14 transcripts were analysed with the data set consisting of a mixture of interviews with clients, their family members, care providers and an advocate account.