Access to health care for undocumented migrant children and pregnant women confronts human rights and professional values with political and institutional regulations that limit services. In order to understand how health care professionals deal with these diverging mandates, we assessed their attitudes toward providing care to this population. Clinicians, administrators, and support staff (n = 1,048) in hospitals and primary care centers of a large multiethnic city responded to an online survey about attitudes toward access to health care services. Analysis examined the role of personal and institutional correlates of these attitudes. Foreign-born respondents and those in primary care centers were more likely to assess the present access to care as a serious problem, and to endorse broad or full access to services, primarily based on human rights reasons. Clinicians were more likely than support staff to endorse full or broad access to health care services. Respondents who approved of restricted or no access also endorsed health as a basic human right (61.1%) and child development as a priority (68.6%). A wide gap separates attitudes toward entitlement to health care and the endorsement of principles stemming from human rights and the best interest of the child. Case-based discussions with professionals facing value dilemmas and training on children's rights are needed to promote equitable practices and advocacy against regulations limiting services.
Youth mental health is of paramount significance to society globally. Given early onset of mental disorders and the inadequate access to appropriate services, a meaningful service transformation, based on globally recognized principles, is necessary. The aim of this paper is to describe a national Canadian project designed to achieve transformation of mental health services and to evaluate the impact of such transformation on individual and system related outcomes.
We describe a model for transformation of services for youth with mental health and substance abuse problems across 14 geographically, linguistically and culturally diverse sites, including large and small urban, rural, First Nations and Inuit communities as well as homeless youth and a post-secondary educational setting. The principles guiding service transformation and objectives are identical across all sites but the method to achieve them varies depending on prevailing resources, culture, geography and the population to be served and how each community can best utilize the extra resources for transformation.
Each site is engaged in community mapping of services followed by training, active stakeholder engagement with youth and families, early case identification initiatives, providing rapid access (within 72 hours) to an assessment of the presenting problems, facilitating connection to an appropriate service within 30 days (if required) with no transition based on age within the 11 to 25 age group and a structured evaluation to track outcomes over the period of the study.
Service transformation that is likely to achieve substantial change involves very detailed and carefully orchestrated processes guided by a set of values, principles, clear objectives, training and evaluation. The evidence gathered from this project can form the basis for scaling up youth mental health services in Canada across a variety of environments.
This evaluative study assesses the effects of a school drama therapy program for immigrant and refugee adolescents designed to prevent emotional and behavioral problems and to enhance school performance. The 9-week program involved 136 newcomers, aged 12 to 18, attending integration classes in a multiethnic school. Pretest and posttest data were collected from the students and their teachers. The self-report and teacher's forms of the Strengths and Difficulties Questionnaire were used to assess emotional and behavioral symptoms. At the end of the program, although there were no reported improvement in self-esteem or emotional and behavioral symptoms, the adolescents in the experimental group reported lower mean levels of impairment by symptoms than those in the control group, when baseline data were controlled for. Their performance in mathematics also increased significantly compared to that of their control peers. The findings suggest that the workshops may have an impact on social adjustment of recently arrived immigrants and refugees. This drama therapy program appears to be a promising way of working preventively and in a nonstigmatizing manner with adolescents who have been exposed to diverse forms of adversity, among which are war and violence.
Recognizing and appropriately treating mental health problems among new immigrants and refugees in primary care poses a challenge because of differences in language and culture and because of specific stressors associated with migration and resettlement. We aimed to identify risk factors and strategies in the approach to mental health assessment and to prevention and treatment of common mental health problems for immigrants in primary care.
We searched and compiled literature on prevalence and risk factors for common mental health problems related to migration, the effect of cultural influences on health and illness, and clinical strategies to improve mental health care for immigrants and refugees. Publications were selected on the basis of relevance, use of recent data and quality in consultation with experts in immigrant and refugee mental health.
The migration trajectory can be divided into three components: premigration, migration and postmigration resettlement. Each phase is associated with specific risks and exposures. The prevalence of specific types of mental health problems is influenced by the nature of the migration experience, in terms of adversity experienced before, during and after resettlement. Specific challenges in migrant mental health include communication difficulties because of language and cultural differences; the effect of cultural shaping of symptoms and illness behaviour on diagnosis, coping and treatment; differences in family structure and process affecting adaptation, acculturation and intergenerational conflict; and aspects of acceptance by the receiving society that affect employment, social status and integration. These issues can be addressed through specific inquiry, the use of trained interpreters and culture brokers, meetings with families, and consultation with community organizations.
Systematic inquiry into patients' migration trajectory and subsequent follow-up on culturally appropriate indicators of social, vocational and family functioning over time will allow clinicians to recognize problems in adaptation and undertake mental health promotion, disease prevention or treatment interventions in a timely way.
The Working with Culture seminar is offered as a course during the month long Annual McGill Summer Program for Social and Transcultural Psychiatry, attended by local and international participants each May since 1994. The article outlines some of the premises and pedagogical approaches of this clinically oriented biweekly seminar series with discussions and didactic teaching on cultural dimensions of mental health care. The course readings, seminar topics and invited speakers focus mainly on therapist client encounters constructed by the multiple voices with dimensions of psychiatric, social, historical, legal, ethical, political, systemic and intra-psychic domains. The dual leadership emphasizes the gaps and complementarity amongst voices, and it invites and supports a destabilizing decentering process and the creation of solidarities amongst participants. Applying a bio-psychosocial case study method, each 3-h seminar engages the participants in a critical dialogue on apprehending the enmeshment of social suffering with psychiatric disorders whilst examining the usefulness and the limits of cultural formulation models. The seminar working group and teaching approach acknowledges cultural hybridity as a dynamic process marked by continuous therapist attunement to uncertainty or 'not knowing' which implies a dethroning of an expert position.
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Comment In: Cult Med Psychiatry. 2013 Jun;37(2):390-723564248
This study analyses the roles of collective self-esteem and religiosity in the relationship between discrimination and psychological distress among a sample of 432 recent immigrants from Haiti and Arab countries living in Montreal, Quebec. Collective self-esteem (CSE), religiosity, discriminatory experiences, and psychological symptoms of depression and anxiety were assessed. Regression analyses revealed direct negative effects of discrimination, CSE, and religiosity on psychological distress for the entire sample. CSE, however, also appeared to moderate the effects of discrimination on psychological distress. Participants with higher CSE reported lower levels of anxiety and depression as a result of discrimination compared to those who expressed lower CSE levels. The results suggest that the relationship between CSE, discrimination, and psychological distress must be reexamined in light of recent sociopolitical changes and the upsurge in ethnic and religious tensions following the war on terror.
This evaluative study assessed the effect of a creative expression program designed to prevent emotional and behavioral problems and to enhance self-esteem in immigrant and refugee children attending multiethnic schools.
The 12-week program involved 138 children, aged 7 to 13, registered in both integration classes designed for immigrant children and regular classes at two elementary schools. Pretest and posttest data were collected from the children themselves and from their teacher. Teachers used Achenbach's Teacher's Report Form to assess the emotional and behavioral symptoms of their pupils whereas children self-reported their symptoms with the Dominic, a computerized questionnaire. Self-esteem was measured with the Piers-Harris Self-Concept Scale administered by interviewers to the children.
At the end of the program, the children in the experimental groups reported lower mean levels of internalizing and externalizing symptoms and higher mean levels of feelings of popularity and satisfaction than the children in the control groups, when controlling for baseline data. In integration classes, the effect on self-esteem was especially notable in boys. The intervention's effect on internalizing and externalizing symptoms was not modified by gender, age or fluency in the mainstream language.
The study provides some evidence that creative workshops in the classroom can have a beneficial effect on the self-esteem and symptomatology of immigrant and refugee children from various cultures and backgrounds. These quantitative results support previous qualitative analysis showing that the workshops participate in the reconstruction of a meaningful personal world while simultaneously strengthening the link of the child to the group. They also transform the teachers' perceptions of newcomers by placing an emphasis on their strength and their resilience, while not negating their vulnerabilities.
Douglas Mental Health University Institute, Division of Social and Transcultural Psychiatry, McGill University, Montreal, Quebec, Canada. robert.whitley@mcgill.ca
In this article we explore the discourse and practice of evidence-based medicine (EBM) in the context of social and cultural diversity. The article consists of 2 parts. First, we begin by defining EBM, describing its historical development and current ascendance in medical practice. We then note its importance in contemporary psychiatry, comparing dynamics between the United States and Canada. Secondly, we offer a constructive critique of the application of EBM and evidence-based practices in the context of ethnocultural diversity, as one consistent reflection on the EBM literature is that it is does not adequately address issues of diversity. In doing so, we use the situation here in Canada as an extended case study, though our observations will likely be applicable in other diverse nations, such as the United States, the United Kingdom, and Australia. We critically examine the following 6 issues related to the practice of EBM in a diverse society: generalizability and transferability of evidence-based interventions; diversifying standards of evidence in EBM; strategies to address diversity in EBM research; cultural adaptations of evidence-based interventions; integrating idiographic knowledge; and, training and health service delivery. Concurrent with our critique, we offer research and practice suggestions that may address outstanding challenges vis-à-vis the practice of EBM in a diverse society. These include a need for more effectiveness research, more openness to diverse sources of knowledge, better integration of idiographic and nomothetic knowledge, and a critical approach to extrapolation and transfer of knowledge.
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Comment In: Can J Psychiatry. 2011 Sep;56(9):511-321959025
Migration flux is being transformed by globalization, and the number of people with either undocumented or with a precarious status is growing in Canada. There are no epidemiological data on the health and social consequences of this situation, but clinicians working in primary care with migrants and refugees are increasingly worried about the associated morbidity. This commentary summarizes findings from a pilot study with health professionals in the Montreal area and suggests that the uninsured population predicament is a national problem. Although ethical and legal issues associated with data collection by clinicians, institutions and governments need to be examined, estimating the public health consequences and long-term cost associated with problems in access to health care due to migratory status should be a priority. Current regulations and administrative policies appear to be at odds with the principles of equal rights set out by the Canadian Charter of Rights and Freedoms and the UN Convention on the Rights of the Child. Beyond the commitment of individual clinicians, Canadian medical associations should take an advocacy role and scrutinize the ethical and medical implications of the present system.
