Written by Dr. Farhan Shahzad and Sarah Davies-Robertson
In their work, Culture, Illness, and Care: Clinical Lessons from Anthropologic and Cross-Cultural Research, Kleinman, Eisenberg and Good (1978) used the term ‘explanatory model’ that defines how patients conceptualise and construct their illness.
Conceptualising illness is an important facet of understanding the patient's point of view, i.e., what their illness means to them. It offers up opportunities to reject a wholly biomedical model and opt for a holistic and person-centred approach that considers broader cultural perspectives. People from different cultures often conceptualise their illnesses and mental health in differing ways and these explanations may be counter to common western thought, thus isolating them from a wholly western model of care.
It would be advisable to not only gain an understanding of cultural conceptualisations of distress, but to understand that ethnic communities may conceptualise their illness in many ways. In fact, ethnic communities should not be treated as a homogenous group with a one-size fits all approach. But rather, a person-centred approach that understands the broader cultural dynamics at play, however, treats the patient as an individual with their own perspective.
Studies on conceptualisations of schizophrenia among four ethnic groups have found a range of formulations, for instance. They found that Bangladeshi and African-Caribbean groups attributed schizophrenia to social causes and the supernatural and this in turn impacted on the treatment they wanted. This also meant that these communities were seen to less likely to have insight into their mental health because their conceptualisation did not fit within the biomedical framework. This in turn meant these communities were more likely to be dissatisfied with treatment.
Help Seeking Behaviours in Ethnic Minority Groups
There have been a number of studies on help seeking behaviours in ethnic minority groups (Cochrane and Stopes-Roe, 1981; Bécares and Das-Munshi, 2013; Sue et al, 1991; Sheikh and Furnham, 2000, to name a few). Because of the number of different ways ethnic minority groups conceptualise their distress, studies have shown a number of help-seeking behaviours. Help-seeking has been linked to levels of satisfaction with services and number of previous hospital admissions, as well as how communities conceptualise their mental health. However, a study in the late 1980s found that African-Caribbean people were in receipt of an inferior level of care in the UK and were less satisfied with mental health services. Further to that, Asian communities were less likely to seek help because they were more likely to seek help within their community. Families of Chinese patients with Schizophrenia either attributed the disorder to internal or external events depending on social class.
Muslims were more likely to attribute their mental illness to the supernatural and found prayer was a way of overcoming distress. Some communities such as Indian migrants were less likely to suffer distress and seek help and other studies found a correlation between an increase in mental health disorders between White Irish people with each ten percent reduction in that community’s density. Problems arise when people from BME communities live in relative isolation and it would be beneficial to have an alternative way of accessing care.
Interventions for the Hard to Reach
Studies show that barriers to accessing care are linked to stigma attached to mental health problems and that some communities do not identify with what services are offering them. Further barriers to accessing care have been previous experiences of care, whether there is a mutual understanding between professional and patient, and language and communication barriers.
Given that there are a number of reasons why people from minority groups do not access care, a more pluralistic approach would be advisable. Firstly, interventions need to be more community-centred, with a wide range of cultural knowledge used to gain a better understanding of the needs of the individual from that community. Acknowledging the diversity within these communities has also been recommended. Further, reaching isolated individuals within communities is suggested because of the paradoxical nature of being a part of a community. The community can be both a site of knowledge of services, yet the place that hinders care through narratives of stigma.
It is important to hear the voices of individuals belonging to these communities. This will ensure that the best possible interventions reach hard to reach communities, who in turn will help improve mental health services and medical care at large.
*References available upon request