Quality of life

This quality of life section addresses issues relating to cultural and language diversity in the care and provision of services to people who have a mental illness. It aims to:

encourage an appreciation of the value of understanding cultural and language diversity in mental health care;

inform people about what they might reasonably expect in the care and services available to them;

give an overview of the current problems; and

assist the mental health workforce to provide services that are easily accessible and sensitive to cultural needs.

Culture in health care
'In Australia …the mental health care system (including the education system that produces health professionals) is essentially monolingual and monocultural. The structures, priorities and programs of the system do not reflect the diversity of the population that it has a responsibility to serve.'
Minas 1990, p.250

Definition of Culture
"an abstract concept that refers to learned and shared patterns of perceiving and adapting to the world. Culture is reflected in its products: the learned shared beliefs, values, attitudes and behaviours that are characteristic of a society or population. Culture is not a static phenomenon; it is dynamic and ever-changing, but it maintains a sense of coherence."
Fitzgerald et al. 1997a, p.3

People in all cultures create shared 'models' (Bonvillain 1993). These cultural models, different in each culture, allow people to express their views about the way their particular society is structured and functions, and the ways people should live out their lives and behave towards each other. They are not usually expressed openly, but serve as a background for behaviour. In any health care interaction at least three cultures are involved.

Cultures in health care
The culture of the person seeking health care: Individuals with a mental illness and their carers/ families are likely to perceive their condition from the perspective of a recipient of a particular service. Their expectations as the receiver of a service are influenced by their particular cultural backgrounds, the personal values and beliefs they hold about mental health and the treatment of mental illness.

The culture of the health practitioner: Health care practitioners often see themselves, their co-workers and the recipients of their services who share their cultural background as 'acultural'. Sometimes it is only when they interact with individuals from another cultural background that culture becomes a consideration. This kind of thinking can result in a lack of awareness of the influence their own culture has on their interactions.

The culture of the health care system in which the interaction takes place: As part of their education, health practitioners learn to view health related practices from a perspective that is generally consistent with the wider view of health in the particular society. They develop ways of thinking that support their professional roles and the services they provide. They also develop expectations about behaviours that are 'appropriate' in health care settings. These expectations may be very different from those of the people they treat.

(Fitzgerald 1992; based on Kleinman 1978)

In NSW, mental health workers may come into contact with a diverse range of people from different cultures, so they cannot automatically be expected to know all these people's perceptions of mental illness. Hence, by recognising the different cultures in health care the mental health worker can ask questions which encourage the client or family member to provide their own valid perspective.

Risk factors
People from culturally and linguistically diverse backgrounds face particular risk factors related to their experiences prior to and after entering the country of settlement. Factors which may particularly impact the mental health of migrants, refugees and international students include:

Social and economic disadvantage

Insecurity of employment

Difficulty accessing medical and social services

Subjection to degrees of racism

And lack of recognition of qualifications obtained in their country of origin.
(Minas 1990, Jayasuriya et al. 1992)

Government principles and requirements
There has been much effort in NSW in directing health workers to address cultural and language diversity in their provision of services to people with a mental illness. The very fact that these directions have been included in government documents indicates the seriousness of the potential problems that can arise in this area.

Section 6 of the NSW Mental Health Act 1990 requires that the religious, cultural and language needs of persons with a mental illness be taken into account in all aspects of service provision. Numerous government reports and policy documents support this requirement (for example, Caring for Mental Health in a Multicultural Society 1998; Mental Health for Multicultural Australia: A National Strategy, (Minas et al. 1993); Western Sydney Area Health Service Migrant Health Strategic Plan, 1995-2000, 1995; and Burdekin et al. 1993).

Problems relating to cultural and language diversity
Currently there appear to be many problems faced by both people from non-English speaking backgrounds and their mental health service providers. There is little research-based evidence concerning cultural and language diversity in the field of schizophrenia, but evidence in literature from a broader but related base identifies problems such as:

lack of access to adequate mental health care;

low level of awareness about mental health services;

lack of access to health promotion and prevention information;

people not coming into contact with the health system until their illness has reached an acute stage;

people receiving culturally inappropriate mental health treatments and services (including lack of family involvement); and

inadequate education for mental health professionals regarding cultural and language diversity.
(Minas et al. 1993)

Access to culturally appropriate services
People from culturally and linguistically diverse backgrounds are less likely to use mental health services and are more likely to access mental health services at a later stage in their illness and as an involuntary patient (NSW Department of Health 1998). Migrants with schizophrenia and related disorders use community mental health services at a rate 47% lower than the overall community (McDonald & Steel 1997).

Reasons cited for the reduced utilisation of mental health services by people from culturally and linguistically diverse backgrounds include:

Insufficient coordination between existing services;

Language barriers to access;

Lack of cultural awareness and sensitivity by service providers;

Stigma and shame associated with mental illness;

Delay in diagnosis and detection of psychiatric symptoms accurately;

Use of indigenous healers;

General Practitioners' lack of resources and skills in providing mental health care and in timely referral of the patient to appropriate mental health services;

Lack of information about mental illness, mental health issues and available services; and

Exposure to trauma in the past.
(NSW Department of Health 1998)

The provision of culturally and linguistically matched mental health services to migrant and refugee communities has been identified as a key strategy for addressing the low utilisation of mental health services by members of ethnic minority groups (Mitchell et al. 1996). Regular consultation with community leaders; active involvement of mental health service staff in partnership with community members; provision of culturally relevant mental health education; and the support of non government community led organisations have all been recommended to address this issue.

Communication difficulties
In addition to being unfamiliar with the mental health system, people from culturally and linguistically diverse backgrounds experience communication difficulties due to their lack of knowledge of the English language, making communication the overriding problem in multicultural interactions (Wong 1996; Minas et al. 1994; French 1994; Hough 1992; Parsons 1990; Quinn & Drousiotou 1985). To be able to effectively communicate a person needs to have an understanding not only of the language, with its rules and structures, but also of the social and cultural meanings conveyed (Fitzgerald et al. 1997a; Bonvillain, 1993).

While research shows that the use of bilingual health workers increases service use and improves the chances of people from the ethnic community maintaining contact with a service (Takeuchi et al. 1995; Flaskerud & Liu 1991), bilingual health workers remain under-utilised by mental health services (NSW Department of Health, 1998).

It is unlikely that any single strategy will address all of the cultural or linguistics barriers that may prevent some people from culturally and linguistically diverse backgrounds from accessing and effectively using services. Despite this, there is wide consensus amongst international experts that the provision of culturally competent and compatible mental health services is a key ingredient for maximizing the effectiveness of mental health services to these communities. Flaskerud (1986) identifies nine major components of culture compatible services. These are:

providers share the culture of the person with a mental illness;

providers who share the language or language style of the person;

location of the agencies in the person's community;

flexible hours and appointments;

provision of or referral to services for social, economic, legal and medical problems;

use of family members in the therapy process;

use of a treatment approach that is focused on solution of practical problems as understood by the person;

use of or referral to clergy and or traditional healers; and

involvement of people with mental illness in determining, evaluating and publicising services.

Government strategies
NSW Department of Health (1998) has outlined strategies for the mental health care of people from culturally and linguistically diverse backgrounds in the document Caring for Mental Health in a Multicultural Society. The eight strategies adopted by the NSW Department of Health are summarised as:

Providing information on mental health and services to people of culturally and linguistically diverse backgrounds in a manner which is sensitive to their cultural values, practices and language.

Facilitating better co-ordination between mental health services and multicultural services to improve access and care to mental health services by people from culturally and linguistically diverse backgrounds.

Increasing the quality and effectiveness of mental health care in the primary care setting by enhancing and supporting the role of the General Practitioners and primary mental health carers.

Promoting positive mental health attitudes and developing strategies for the prevention of mental health problems and disorders and providing early intervention to culturally and linguistically diverse communities.

Enhancing the skills and capacity of mental health professionals to enable them to provide timely, appropriate and effective mental health services to a culturally diverse community.

Promoting and developing mental health services which recognise and incorporate diverse linguistic and cultural needs including culturally appropriate assessments, diagnosis and treatment.

Promoting and facilitating appropriate and effective partnerships between mental health services, consumers, carers and non-government organisations.
Supporting ongoing research and evaluation on the mental health and service needs of people from culturally and linguistically diverse backgrounds.

Culture affects all interactions, both monocultural and multicultural. Different cultural perspectives are often cited as the reason for problems in health care settings, especially in multicultural interactions. Though the Government directs health care workers to address these issues and offers strategies to deal with them, it is important to be vigilant in watching for problems that may arise. These can be placed into two broad categories:

problems of the lack of awareness of and access to adequate mental health care for people with a mental illness; and

problems of culturally inappropriate and inadequate treatment because of poor communication and lack of cultural knowledge, on the part of the health care worker.

There is a need for continuing provision of information and resources, and education for:

people with a mental illness and their families and carers on information about mental health and services; and

mental health care workers in understanding the effects of language and cultural diversity on their services and being assisted in the implementation of the government provided strategies.

References

For a list of references for this quality of life section on cultural and language diversity, click here.

To ensure the information presented here is in line with current research and best practice, this section will be updated regularly, so make sure you bookmark this page and return often. If you would like to be alerted to updates automatically, join our free mailing list. We also encourage you to email us with your views on the 'quality of life' content, whether you are a consumer, carer or mental health professional. The Guidelines were developed using a collaborative approach and we would like to ensure that any updates to this section are also carried out in a collaborative manner, so your views are very important to us.

This section on 'quality of life' proudly sponsored by:

SFNSW Inc...Locked Bag 5014 Gladesville NSW 1675...ph: 02 9879 2600...fax: 02 9879 2699...Email: admin@sfnsw.org.au







			Cultural and language diversity This quality of life section addresses issues relating to cultural and language diversity in the care and provision of services to people who have a mental illness. It aims to: encourage an appreciation of the value of understanding cultural and language diversity in mental health care; inform people about what they might reasonably expect in the care and services available to them; give an overview of the current problems; and assist the mental health workforce to provide services that are easily accessible and sensitive to cultural needs. Culture in health care 'In Australia …the mental health care system (including the education system that produces health professionals) is essentially monolingual and monocultural. The structures, priorities and programs of the system do not reflect the diversity of the population that it has a responsibility to serve.' Minas 1990, p.250 Definition of Culture "an abstract concept that refers to learned and shared patterns of perceiving and adapting to the world. Culture is reflected in its products: the learned shared beliefs, values, attitudes and behaviours that are characteristic of a society or population. Culture is not a static phenomenon; it is dynamic and ever-changing, but it maintains a sense of coherence." Fitzgerald et al. 1997a, p.3 People in all cultures create shared 'models' (Bonvillain 1993). These cultural models, different in each culture, allow people to express their views about the way their particular society is structured and functions, and the ways people should live out their lives and behave towards each other. They are not usually expressed openly, but serve as a background for behaviour. In any health care interaction at least three cultures are involved. Cultures in health care The culture of the person seeking health care: Individuals with a mental illness and their carers/ families are likely to perceive their condition from the perspective of a recipient of a particular service. Their expectations as the receiver of a service are influenced by their particular cultural backgrounds, the personal values and beliefs they hold about mental health and the treatment of mental illness. The culture of the health practitioner: Health care practitioners often see themselves, their co-workers and the recipients of their services who share their cultural background as 'acultural'. Sometimes it is only when they interact with individuals from another cultural background that culture becomes a consideration. This kind of thinking can result in a lack of awareness of the influence their own culture has on their interactions. The culture of the health care system in which the interaction takes place: As part of their education, health practitioners learn to view health related practices from a perspective that is generally consistent with the wider view of health in the particular society. They develop ways of thinking that support their professional roles and the services they provide. They also develop expectations about behaviours that are 'appropriate' in health care settings. These expectations may be very different from those of the people they treat. (Fitzgerald 1992; based on Kleinman 1978) In NSW, mental health workers may come into contact with a diverse range of people from different cultures, so they cannot automatically be expected to know all these people's perceptions of mental illness. Hence, by recognising the different cultures in health care the mental health worker can ask questions which encourage the client or family member to provide their own valid perspective. Risk factors People from culturally and linguistically diverse backgrounds face particular risk factors related to their experiences prior to and after entering the country of settlement. Factors which may particularly impact the mental health of migrants, refugees and international students include: Social and economic disadvantage Insecurity of employment Difficulty accessing medical and social services Subjection to degrees of racism Insecure housing And lack of recognition of qualifications obtained in their country of origin. (Minas 1990, Jayasuriya et al. 1992) Government principles and requirements There has been much effort in NSW in directing health workers to address cultural and language diversity in their provision of services to people with a mental illness. The very fact that these directions have been included in government documents indicates the seriousness of the potential problems that can arise in this area. Section 6 of the NSW Mental Health Act 1990 requires that the religious, cultural and language needs of persons with a mental illness be taken into account in all aspects of service provision. Numerous government reports and policy documents support this requirement (for example, Caring for Mental Health in a Multicultural Society 1998; Mental Health for Multicultural Australia: A National Strategy, (Minas et al. 1993); Western Sydney Area Health Service Migrant Health Strategic Plan, 1995-2000, 1995; and Burdekin et al. 1993). Problems relating to cultural and language diversity Currently there appear to be many problems faced by both people from non-English speaking backgrounds and their mental health service providers. There is little research-based evidence concerning cultural and language diversity in the field of schizophrenia, but evidence in literature from a broader but related base identifies problems such as: lack of access to adequate mental health care; low level of awareness about mental health services; lack of access to health promotion and prevention information; people not coming into contact with the health system until their illness has reached an acute stage; people receiving culturally inappropriate mental health treatments and services (including lack of family involvement); and inadequate education for mental health professionals regarding cultural and language diversity. (Minas et al. 1993) Access to culturally appropriate services People from culturally and linguistically diverse backgrounds are less likely to use mental health services and are more likely to access mental health services at a later stage in their illness and as an involuntary patient (NSW Department of Health 1998). Migrants with schizophrenia and related disorders use community mental health services at a rate 47% lower than the overall community (McDonald & Steel 1997). Reasons cited for the reduced utilisation of mental health services by people from culturally and linguistically diverse backgrounds include: Insufficient coordination between existing services; Language barriers to access; Inadequate income; Lack of cultural awareness and sensitivity by service providers; Stigma and shame associated with mental illness; Delay in diagnosis and detection of psychiatric symptoms accurately; Use of indigenous healers; General Practitioners' lack of resources and skills in providing mental health care and in timely referral of the patient to appropriate mental health services; Lack of information about mental illness, mental health issues and available services; and Exposure to trauma in the past. (NSW Department of Health 1998) The provision of culturally and linguistically matched mental health services to migrant and refugee communities has been identified as a key strategy for addressing the low utilisation of mental health services by members of ethnic minority groups (Mitchell et al. 1996). Regular consultation with community leaders; active involvement of mental health service staff in partnership with community members; provision of culturally relevant mental health education; and the support of non government community led organisations have all been recommended to address this issue. Communication difficulties In addition to being unfamiliar with the mental health system, people from culturally and linguistically diverse backgrounds experience communication difficulties due to their lack of knowledge of the English language, making communication the overriding problem in multicultural interactions (Wong 1996; Minas et al. 1994; French 1994; Hough 1992; Parsons 1990; Quinn & Drousiotou 1985). To be able to effectively communicate a person needs to have an understanding not only of the language, with its rules and structures, but also of the social and cultural meanings conveyed (Fitzgerald et al. 1997a; Bonvillain, 1993). While research shows that the use of bilingual health workers increases service use and improves the chances of people from the ethnic community maintaining contact with a service (Takeuchi et al. 1995; Flaskerud & Liu 1991), bilingual health workers remain under-utilised by mental health services (NSW Department of Health, 1998). It is unlikely that any single strategy will address all of the cultural or linguistics barriers that may prevent some people from culturally and linguistically diverse backgrounds from accessing and effectively using services. Despite this, there is wide consensus amongst international experts that the provision of culturally competent and compatible mental health services is a key ingredient for maximizing the effectiveness of mental health services to these communities. Flaskerud (1986) identifies nine major components of culture compatible services. These are: providers share the culture of the person with a mental illness; providers who share the language or language style of the person; location of the agencies in the person's community; flexible hours and appointments; provision of or referral to services for social, economic, legal and medical problems; use of family members in the therapy process; use of a treatment approach that is focused on solution of practical problems as understood by the person; use of or referral to clergy and or traditional healers; and involvement of people with mental illness in determining, evaluating and publicising services. Government strategies NSW Department of Health (1998) has outlined strategies for the mental health care of people from culturally and linguistically diverse backgrounds in the document Caring for Mental Health in a Multicultural Society. The eight strategies adopted by the NSW Department of Health are summarised as: Providing information on mental health and services to people of culturally and linguistically diverse backgrounds in a manner which is sensitive to their cultural values, practices and language. Facilitating better co-ordination between mental health services and multicultural services to improve access and care to mental health services by people from culturally and linguistically diverse backgrounds. Increasing the quality and effectiveness of mental health care in the primary care setting by enhancing and supporting the role of the General Practitioners and primary mental health carers. Promoting positive mental health attitudes and developing strategies for the prevention of mental health problems and disorders and providing early intervention to culturally and linguistically diverse communities. Enhancing the skills and capacity of mental health professionals to enable them to provide timely, appropriate and effective mental health services to a culturally diverse community. Promoting and developing mental health services which recognise and incorporate diverse linguistic and cultural needs including culturally appropriate assessments, diagnosis and treatment. Promoting and facilitating appropriate and effective partnerships between mental health services, consumers, carers and non-government organisations. Supporting ongoing research and evaluation on the mental health and service needs of people from culturally and linguistically diverse backgrounds. Culture affects all interactions, both monocultural and multicultural. Different cultural perspectives are often cited as the reason for problems in health care settings, especially in multicultural interactions. Though the Government directs health care workers to address these issues and offers strategies to deal with them, it is important to be vigilant in watching for problems that may arise. These can be placed into two broad categories: problems of the lack of awareness of and access to adequate mental health care for people with a mental illness; and problems of culturally inappropriate and inadequate treatment because of poor communication and lack of cultural knowledge, on the part of the health care worker. There is a need for continuing provision of information and resources, and education for: people with a mental illness and their families and carers on information about mental health and services; and mental health care workers in understanding the effects of language and cultural diversity on their services and being assisted in the implementation of the government provided strategies. References For a list of references for this quality of life section on cultural and language diversity, click here. To ensure the information presented here is in line with current research and best practice, this section will be updated regularly, so make sure you bookmark this page and return often. If you would like to be alerted to updates automatically, join our free mailing list. We also encourage you to email us with your views on the 'quality of life' content, whether you are a consumer, carer or mental health professional. The Guidelines were developed using a collaborative approach and we would like to ensure that any updates to this section are also carried out in a collaborative manner, so your views are very important to us. This section on 'quality of life' proudly sponsored by: