Newcomers’ mental health Kwame McKenzie MD

1. Newcomers’ mental healthKwame McKenzie MD

2. Think big! Fabulous initiative – thank you

3. An economically strong Toronto and Canada needs newcomers with excellent mental health Promoting mental health and preventing mental illness in immigrant groups is a vital investment for the future of Canada

4. Outline of talk Canadian research on mental health in newcomer and diverse populations An idea to discuss on one way we can improve matters

5. Canadian literature: mental health of IRER groups 5

6. Canadian research on mental health of immigrants & newcomers • Rates • Causes • Service development and use

7. Rates: newcomers health deteriorates over time (Newbold 2005) 7

8. Rates: European migrants least likely to have deterioration in health (Kim 2013)

9. Causes of illness & pathways to care (McKenzie 2004)

10. Causes: Social determinants (Hanson 2011) • More detrimental social determinants • Novel social determinants • migration, discrimination and language difficulties. • Fewer social forces that decrease risk

11. Causes: higher risk of problems with income and housing (PHAC) *

12. Causes: decreasing comparative earnings of newcomers (PHAC) 12

13. Causes: type of housing and work linked to psychological issues in refugees

14. Causes: risk of psychosis in ethnic minorities linked to social capital (Boydell) 14 14

15. Causes and mechanisms: impact of racism on health pascoe & richman 15

16. Causes: newcomers affected by other societal trends 16

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19. City1 City2 City3 1/3 of people in City 3 live under low income cut off 50% of the housing for families in City 3 is high rise More visible minorities in City 3 than City 1 Proportion of whites in City 3 is falling Poverty is color coded 19

20. Problems in services and academic sector also important

21. Barriers to care • Less likely to get care and poorer care received • Numerous barriers eg: • Awareness and stigma • Pathways unclear • Models of care and personnel not acceptable • Lack of cultural competence and sensitivity • Financial barriers • Language

22. Pathways to Care – African Group (n=25) (Anderson in press) n=1 Early Intervention Services Police & Criminal Justice (n=6) n=2 n=1 n=13 Inpatient Admission n=11 n=3 n=2 n=27 n=9 Emergency Department (n=6) n=2 n=1 n=2 n=1 n=6 n=1 n=1 General Practitioner (n=11) n=3 n=2 n=2 n=3 Outpatient Psychiatry (n=1) n=8 n=2 n=1 n=4 n=1 Other (n=1) n=1 n=1 n=1

23. % immigrant population by electoral ward

24. Things that work: facilitators of care • Acculturation • Knowledge and education • Ethno-specific health promotion • Trust in the system • Cultural competency • Co-operation between service providers • Diversity of services including alternative approaches

25. Story of resilience under strain Increased social determinants causing problems Novel social determinants because of being member of ethnic group Decreased social factors preventing problems Sector offers little focus on mental health promotion and prevention Difficulties in getting the right care Sector does not offer systematic response to needs

26. What do you do with a problem so huge?

27. Plan or plan to fail… what worksData – accountability – plan - measure

28. Decide who is responsible for what and what your place is…

29. Best treatments are linked to good diagnosis Our diagnosis is that multiple levels of actions are needed Caring immigration strategy and support Action on social determinants Specific support for newcomers and new comer communities One stop shops Health promotion Better and more diverse service sector Better linkages of services based on needs Specific evidence based services and interventions

30. Would this idea help newcomers in Toronto? If so… steal it!

32. Most important policy priority for improving mental health & disparities • Prevention of mental illness • Promotion of mental health • What level should we work at • Individual level • Group level • Societal level • What timescales • Outcomes now or build for the future?

33. Diagnosis helped by: the Government Office for Science. Advice of 400 international experts. The report takes a futures approach to strategic policy thinking.

34. Most important opportunities & challenges for the UK in the next 20yrs • Preserving the independence of the ageing population and making their knowledge available to industry • Nurturing the cognitive and emotional flexibility of the population and equipping them to deal with changing work and society • The increased expectations of the population • A movement of public services towards more choice, active citizenship and co-production • The need to harness technology and science to promote wellbeing

35. How can this be done • Our mental resources are key to meeting the challenges, individually and as a country • These resources = mental capital • (IQ, EQ and mental health) • IQ = cognitive ability, flexibility and efficiency at learning, • EQ = emotional intelligence, such as their social skills and resilience in the face of stress. • These are linked to mental health = how well an individual is able to contribute effectively to society, and also to experience a high personal quality of life.

36. Improving mental capital is the most important thing. • IQ = schools • EQ = ? • Mental health – social policy and public health • Evidence-based approaches to promotion of mental health. • But often not cross culturally validated or shown to promote equity

37. Fundamental social causes – well meaning initiatives can increase inequity (Link and Phelan) • Unless you target the reason for the inequity it is difficult to decrease inequities • Explains why the association between socio-economic status and health disparities persisted over time, despite interventions, and even after conditions previously thought to be the cause had been resolved. • Higher SES is an indicator for an array of resources including money, knowledge, power, and beneficial social connections. • Ensure that disparities continue, unless interventions specifically target the factors and mechanisms that sustain differences between population groups.

38. Improving mental capital equitably requires… • Targeting the fundamental social causes of disparities – eg power and linkages to power. • But • Modern strategies that work promote greater choice, active citizenship and co-production to deliver public services.

39. Moving towards rights and power • To promote mental capital, decrease inequalities and improve active citizenship we need more than mental health interventions and services. • We need an effective strategy to increase the access of the most marginalised in society to opportunities to influence decision makers and resource allocation.

40. Fundamental causes may need fundamental change • Rather than a single intervention, the way in which the health sector runs its business may offer a way to meet all these needs. • Move from community engagement to community marriage. • The introduction of participatory budgeting may help more equitable decisions to be made, while increasing public engagement in decision making.

41. What is participatory budgeting Participatory budgeting directly involves communities in making decisions about how to spend public money. A percentage of core budgets go to community led schemes Citizens identify, discuss and prioritise public spending and have the power to make decisions on how the money is spent.

42. How is it done Community members identify priorities and identify people from within their ranks to help work them up They then sit with experts and planners to produce actual proposals. Community members vote on which proposals to fund and the municipality implements the top proposals within the money allocated

43. Participatory budgeting Being used world wide – but not yet for health

44. Advantages of participatory budgeting • health sector demonstrate their vision of a population having shared responsibility for public health; • engage the population in discussions of public health and offer an avenue for identifying local priorities, and for consultation; • develops vertical social capital locally and directly • target fundamental causes of disparities such as power and access; • produce fairer, better-informed decisions about priorities which improve the effectiveness of existing and well known mental health interventions.

45. Participatory budgeting could unlock the potential for newcomers and communities • Harness expertise and knowledge of newcomers • Increase community voice • Demonstrate and develop self-efficacy • Develop more competent policy arena • Move power and resources from city 1 to city 3 • Increase access to power and jobs • Focus community on health promotion • Better illness prevention and services

46. An economically strong Toronto and Canada relies on us investing in the mental capital of newcomers Services are important but prevention is better than cure We need to right size our thinking on newcomer mental health

47. Think big! Newcomers are the future of Canada

48. Thank you