Background
Methods
Study design: systematic map
Research questions and objectives
Definitions
Mental health inequalities and inequities
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the prevention of mental ill health;
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access to and experience of mental health care; and
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outcomes associated with mental ill health.
The population, intervention, outcomes and study designs
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anxiety
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bipolar disorder
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antisocial behaviour and conduct disorders (in children and young people)
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depression
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eating disorders
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mental health problems in the pregnancy and postnatal period
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personality disorders
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psychosis and schizophrenia
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self-harm.
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F20-29: Schizophrenia, schizotypal and delusional disorders
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F30-39: Mood (affective) disorders
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F40-48: Neurotic, stress-related and somatoform disorders
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F60-69: Disorders of personality and behaviour in adult persons
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F91: Conduct disorders (in: Behavioural and emotional disorders with onset usually occurring in childhood and adolescence)
Characteristics | Populations |
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Protected characteristics (Equality Act 2010) | |
Age | Children and young peoplea |
Older adultsa | |
Disability | People with intellectual/learning disability and/or autism |
People with physical or sensory impairment | |
Race | Cultural and ethnic minority groups |
Religion or belief | Religious communities |
Pregnancy and maternity | New or expectant mothersa |
Sex | Men or womena People who are intersexb |
Gender reassignmente | People who are transsexual or transgender |
Sexual orientation | People with a minority sexual orientation |
Other characteristics (from the NICE equality impact assessment) | |
Socioeconomic status | People with a low socioeconomic statusc |
Other categories | Other groups in the population who experience poor health because of circumstances often affected by, but going beyond, sharing a protected characteristic or socioeconomic status. The following are examples of groups covered in the NICE guidance [26]: • refugees and asylum seekers • migrant workers • looked after children • homeless people • prisoners and young offendersd |
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Research question 1: any primary study evaluating effectiveness
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Research question 2: any economic evaluation
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Research question 3: any primary study evaluating barriers and/or facilitators to intervention uptake.
Search strategy
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MEDLINE and MEDLINE In-Process via Ovid
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Health Management Information Consortium (HMIC) via Ovid
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Applied Social Sciences Index Abstracts (ASSIA) via ProQuest
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Social Policy & Practice via Ovid
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Sociological Abstracts via ProQuest
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Social Services Abstracts via ProQuest
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PsycINFO via Ovid.
Study selection
Inclusion criteria
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Focus on a population with:a.Mental health disorders, conditions or problems that meet the definition for population in this review, andb.Focus on a population group with protected or other characteristics identified as at risk of experiencing mental health inequalities (see Table 1), and
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Address an intervention, as defined by this review, focused on addressing or reducing mental health inequalities, and
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Meet the following criteria for one or more of the research questions:
Data extraction
Study quality (risk of bias)
Results
Study ID | Study intervention details | Intervention type(s) | Intervention strategies employed | Target population(s) |
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Bhui et al. [149] | Therapeutic communication interventions | Access, intervention | Engaging the community (EC), other—culturally adapted interventions (OCA), other—technology (OT) | Minority ethnicities |
Garcia et al. [151] | Collaborative care model for people with limited English proficiency | Access | Restructuring the care team (RSCT), enhancing language, literacy and communication (ELLS), other—culturally adapted interventions (OCA) | People with depression and limited English-speaking proficiency |
Gardner et al. [152] | Incredible Years parenting programme | Early intervention, intervention | Delivering education and training (DET), providing psychological support (PPS) | Children aged 2–10 years from socially disadvantaged families (included differential effects for ethnic minorities) |
Lucas et al. [154] | Unconditional monetary or financial benefits interventions | Prevention, access | Providing financial incentives or removing financial barriers (PFIP) | Pregnant women and families with children with low socioeconomic status |
Pega et al. [155] | Unconditional monetary or financial benefits interventions | Prevention, access | Providing financial incentives or removing financial barriers (PFIP) | Children and adults with low socioeconomic status from low- and middle-income countries |
Rojas-Garcia et al. [156] | Psycho-educational interventions for depression | Early intervention, intervention | Delivering education and training (DET), providing psychological support (PPS), other—culturally adapted interventions (OCA) | Minority ethnic mothers with low socioeconomic status |
Vallury et al. [157] | Computerised CBT | Access, intervention | Providing psychological support (PPS), other—technology (OT) | People living in rural or remote communities |
van der Waerden et al. [158] | Psycho-educational interventions for depression | Early intervention, intervention | Delivering education and training (DET), providing psychological support (PPS), other—culturally adapted interventions (OCA) | Women with low-socioeconomic status |
Weaver and Lapidos [159] | Community health workers interventions | Access | Engaging the community (EC), other—culturally adapted interventions (OCA) | Disadvantaged communities including ethnic minorities and immigrants, people of low socioeconomic status, gender (both male and female), pregnancy and location |
Intervention strategy as defined by Clarke et al. [161] | Modification(s) |
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Enhancing language and literacy services (ELLS) | Broadened to include ‘communication’ as follows: enhancing language, literacy and communication i.e. non-verbal languages (sign language and braille) and accessibility devices such as hearing aids and loops, in addition using interpreters and health literacy screening |
Other: - home-based care - increased referrals - patient/provider racial/ethnic concordance - adjust therapy regimen | Broadened to include the following additional strategies in the ‘other’ category: - technology (OT) - community revitalisation (OCR) - culturally adapted interventions (OCA) - not otherwise specified (NOS) |
Additional intervention strategies not defined by Clarke et al (2013) [161] | |
Improving access to support, care and treatment for mental health problems (IASCT) | New category used in this study to sort strategies that address logistical barriers to accessing mental health support, care and treatment aimed at reaching wider populations or decreasing waitlists. It was added to capture intervention strategies that go beyond the provision of solely psychological therapies. It includes new service models or programmes such as the IAPT programme in the UK. |
Intervention strategy | Brief description | Population or inequalities targeted | Number of studies includeda |
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Delivering education and training (DET) | Delivering skills-based training/teaching or providing information or tools for self-learning. May be delivered to a person who has, or is at risk of, a mental health problem (e.g. training to aid self-management of symptoms), to the person’s family or teachers (e.g. training in parenting techniques or behaviour management) or to the health professionals who work with individuals with mental health problems (e.g. competence training). | • Minority ethnic or immigrant communities, indigenous communities, LGBTQ+ communities, people who have a sensory or physical impairment, people who have a learning disability, females young people, older adults • Pregnancy and maternity, socioeconomic factors, rural or remote localities, urban localities | 29 |
Providing reminders and feedback (PRF) | Providing prompts to promote adherence to the intervention or care programme. Typically delivered as telephone or text reminders to encourage the participant. | • Minority ethnic or immigrant communities, young people • Pregnancy and maternity, socioeconomic factors | 3 |
Providing psychological support (PPS) | Delivery of psychological therapies that promote well-being, such as CBT or interpersonal therapy. May be aimed at a person who has an existing mental health problem (intervention) or is at risk of a mental health problem (prevention), such as during pregnancy. | • Minority ethnic or immigrant communities, indigenous communities, religious communities, LGBTQ+ communities, people who have a sensory or physical impairment, males, young people, older adults, people experiencing homelessness, refugees • Pregnancy and maternity, socioeconomic factors, rural or remote localities, urban localities | 45 |
Restructuring the care team (RSCT) | The addition of new members to an existing care team, the introduction of a new role to the team or the shifting of duties among the team. Directed at care teams. Changes may occur at a local level (e.g. within a single service or region) or at a national level as a result of change in policy. | • Minority ethnic or immigrant communities, indigenous communities, females, young people, older adults • Pregnancy and maternity, socioeconomic factors | 13 |
Engaging the community (EC) | Involving community members or organisations in mental health support or education, to improve engagement. This is best done outside of the health care setting. May include outreach, co-production, education campaigns or the delivery of care in a community. | • Minority ethnic or immigrant communities, indigenous communities, religious communities, LGBTQ+ communities, females, young people, older adults, refugees • Pregnancy and maternity, socioeconomic factors, rural or remote localities, urban localities | 26 |
Providing financial incentives or removing financial barriers (PFIP) | Offering free provisions or money, subsidised services or removing financial barriers to accessing care or treatment. May be delivered via policy change (e.g. national change in health insurance policies) or may be targeted at disadvantaged groups (e.g. renewal or regeneration of deprived housing areas). | • Minority ethnic or immigrant communities, indigenous communities, females, males, young people • Socioeconomic factors, rural or remote localities, urban localities | 7 |
Improving access to testing and screening (IATS) | Improves the accessibility of testing or screening by addressing logistical, social or financial barriers. May introduce more routine mental health assessments for specific populations or address issues which can impede access to testing, such as diagnostic overshadowing (e.g. with a comorbid physical condition or learning disability). | • Minority ethnic or immigrant communities • Socioeconomic factors, urban localities | 2 |
Improving access to support, care and treatment for mental health problems (IASCT) | Addresses logistical barriers to accessing psychological therapies in order to reach a wider population or decrease wait-list durations. May be national programmes addressing logistical barriers (e.g. lengthy waiting lists and lack of resources) or engagement programmes aimed at reaching underserved communities. | • Minority ethnic or immigrant communities, indigenous communities, religious communities, females, males, young people, older adults, socioeconomic factors, rural or remote localities, urban localities | 8 |
Enhancing language, literacy and communication (ELLS) | Improving language or communication skills in order to improve engagement or adherence to care. May be delivered to the individual with a mental health problem to improve accessibility of care (e.g. for those with limited proficiency in the local language or those who have a sensory impairment) or to the health professional to improve therapeutic communication with specific communities. | • Minority ethnic or immigrant communities, people who have a sensory or physical impairment, older adults • Pregnancy and maternity, socioeconomic factors | 3 |
Other—home-based care (OHBC) | Delivery of healthcare or support in the participant’s home. Typically involves outreach visits from a healthcare professional or peer support worker to the individual with a mental health problem. | • Minority ethnic or immigrant communities, young people • Pregnancy and maternity, socioeconomic factors | 5 |
Other—culturally adapted interventions (OCA) | Tailored interventions which work within the cultural context of the recipient and take greater account of their cultural background and experiences. May include culturally modified versions of well-evidenced therapies (e.g. cognitive behavioural therapy) or interventions developed specifically for the community of interest. | • Minority ethnic or immigrant communities, indigenous communities, religious communities, LGBTQ+ communities, people who have a sensory or physical impairment, females, males, young people, older adults, refugees • Pregnancy and maternity, socioeconomic factors, rural or remote localities, urban localities | 26 |
Other—technology (OT) | Providing information, skills-based training or therapeutic regimens delivered through the Internet, typically via mobile devices. Often targeted at communities who face logistical barriers to accessing care, but may also be implemented in healthcare settings to improve information exchange between members of a care team. | • Minority ethnic or immigrant communities, indigenous communities, young people, older adults • Pregnancy and maternity, socioeconomic factors, rural or remote localities | 6 |
Other—community revitalisation (OCR) | Regeneration or renewal of deprived community areas or poorer socioeconomic localities. Typically provided through government initiatives, investment or policy change. | • Minority ethnic or immigrant communities, young people • Socioeconomic factors, urban localities | 6 |
Other—not otherwise specified (O-NOS) | Alternative strategies not otherwise specified. This included moving people to less deprived or distressed localities. | • Socioeconomic factors, rural or remote localities | 1 |
Characteristic | Number of studies | Characteristic sub-type | Number of studies |
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1. Race | 49 | a) Minority ethnic and immigrants | 47 |
b) Indigenous communities | 6 | ||
2. Religion | 2 | a) Religion | 2 |
3. Sexual orientation and gender identity | 4 | a) LGBTQ+ | 4 |
4. Disability | 7 | a) Physical or sensory impairment | 4 |
b) Learning disability | 5 | ||
5. Sex | 12 | a) Female | 9 |
b) Male | 4 | ||
6. Age | 56 | a) Young people | 49 |
b) Older adult | 8 | ||
7. Pregnancy and maternity | 21 | a) Pregnancy and maternity (including perinatal and postnatal periods) | 21 |
8. Socioeconomic factors | 80 | a) Socioeconomic factors | 80 |
9. Location | 24 | a) Rural/remote | 16 |
b) Urban | 9 | ||
10. Specific intersectional groups | 10 | a) Homeless people | 3 |
b) Youth offenders | 1 | ||
c) Refugees | 7 | ||
11. Other | 10 | a) Any other | 10 |
Country | Number of studies |
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Research question 1—Effectiveness of interventions to address inequalities in mental health care | |
USA | 34 |
UK | 17 |
Australia | 7 |
Ireland | 6 |
The Netherlands | 4 |
Iran | 3 |
India | 2 |
Austria, Belgium, Canada, China, Colombia, France, Germany, Israel, Norway, Pakistan, Portugal, Spain | 1 study per country |
Research question 2—Economic evaluations of interventions to address mental health inequalities | |
Ireland | 2 |
USA | 2 |
UK | 1 |
Research question 2—Barriers and facilitators to interventions to address mental health inequalities | |
UK | 10 |
USA | 8 |
Australia | 7 |
Canada | 2 |
Chile and Colombia, Ethiopia, Ireland, Kenya, Sweden | 1 study per country |
Study ID | Intervention details | Intervention strategies employed |
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Gardner et al [152] | Incredible Years parenting programme | Providing psychological support (PPS), delivering education and training (DET) |
Grote et al. [79] | MOMCare intervention | Providing reminders and feedback (PRF), providing psychological support (PPS), pestructuring the care team (RSCT), other—culturally adapted interventions (OCA) |
McGilloway et al. [100] | Incredible Years parenting programme | Providing psychological support (PPS), delivering education and training (DET) |
O’Neil et al. [108] | Incredible Years parenting programme | Providing psychological support (PPS), delivering education and training (DET) |
Rhodes et al. [119] | Chronic Care Initiative | Improving access to testing and screening (IATS), improving access to support, care and treatment for mental health problems (IASCT), restructuring the care team (RSCT) |
Romeo et al. [121] | Health check intervention | Improving access to testing and screening (IATS) |
Types of barriers | Populations at risk of experiencing barrier type | Barriers identified in the literature | Facilitators identified in the literaturea |
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Limited treatment options and service limitations | Homeless people, pregnant women with low socioeconomic status | • Inexperienced or unhelpful staff [50] • Lack of provision of home treatment [50] • Lack of service coordination [34] • Limited treatment options [147] • Lack of adequate discharge planning [56] • The use of specialist services as the ‘default’ [57] • Perceived or actual availability of resources [57] • Inappropriate or limited booking systems [66] • Appointments scheduled during working hours [38] • Perceived difficulties in administering treatment [141] | • Diversity of treatment options (e.g. outreach, home-based care, help over the phone, street clinics) [147] • Collaborative agency approach [32] |
Perceived or real discrimination (from staff, family or the community) | Aboriginal communities, ethnic minorities | • Clinician bias [49] • Discrimination towards patients from staff [50] • Racism [33] • Failure to acknowledge non-mainstream concepts of health [33] • Sociocultural barriers that may reduce motivation for treatment [147] • Fear of harassment [147] • Attitudinal factors [57] • Cultural naivety, insensitivity and discrimination [103] • Existing social and cultural values or norms concerning gender and traditional family structure [109] | • Staff trained in providing culturally appropriate alternatives to mainstream care [33] |
Access to care (including physical access, such as transportation) | People with disabilities (learning or physical), homeless people, people with co-occurring substance use problems, people with low socioeconomic status, people living in rural or remote locations, young people with low socioeconomic status | • Difficulties getting an appointment and contacting health providers [50] • Inappropriate referrals and referral rejections [57] • Need for registration at GP practice in order to be treated [66] • Inappropriate or limited booking systems [66] | • Integration of different services [34] • Reducing transportation barriers through use of mobile health interventions [35] • Provision of services within geographical reach [36] • Services provided in close proximity to where people live [37] • Support for people’s ability to access treatment considering their working conditions [38] • Involvement of family in the person’s care [38] • GP as the first point of contact and with a link to external agencies, collaboration between GPs and other healthcare workers [39] • Convenient location and provision of outreach [32] • Internet-based interventions, as these offer flexibility regarding time and location, low effort, accessibility and (sometimes) anonymity [40] • Widened programme/intervention eligibility (e.g. allowing women who already have a child to participate in the programme) [41] |
Financial constraints | Homeless people, people with low socioeconomic status, ethnic minorities | • Inadequate income support [56] • Affordability of technological/digital means as requirements for some treatments (e.g. mobile phones, mobile data 3G/4G) [35, 43] • Lack of health insurance [148] • Lack of childcare provisions [66] • Reduction in spending on health and social care [110] • Housing insecurity [41] | • Removal of financial barriers to prescription medication [42] • Reduce the financial costs associated with data usage by consolidating content onto health apps and minimising the need for online linkages [43] • Provision of free health services and treatment [44] • Provision of affordable services within reach of, and financial support for, families with low socioeconomic status [36] • Subsidies for treatment-related expenses [38] |
Communication issues | Ethnic minorities, immigrants and migrants, people with disabilities (learning or physical) | • Difficulty contacting practitioners [50] • Perceived ineligibility for treatment based on communication difficulties [57] | • Define and provide specific staff training on communication strategies focused on health needs of the identified population (e.g. migrants) [148] • Meeting the needs of people with low literacy using health apps that provide audio recordings, audio-visual displays and diagrams as well as written information [43] |
Awareness of available services | Older people, ethnic minorities | • Ignorance about services [57] • Lack of understanding from staff about types of care available and who these are designed for [57] • Lack of knowledge about the healthcare system and about informal networks of healthcare professionals [148] | • Making campaigns more relevant and effective, use of simpler, more positive language, use of less individualistic language (e.g. ‘me’), respecting different beliefs [45] • Community engagement [46] • Primary care professionals to map community activities [46] • Engaging the local targeted community (including members of the religious community, e.g. the local rabbi )[47] |
Trust in services or ‘the system’ | People living in rural or remote locations, aboriginal communities, ethnic minorities | • Patient cultural views and/or perceptions of the clinician’s culture [49] • Anxiety and/or lack of confidence in asking for help [50] • Negative past experiences with services [147] • Past experience of punitive or forced mental health care making patients unwilling to take up treatment [57] • Concerns about privacy [66] • Decision to seek help from a traditional or religious healer [36] • Fear of ‘asylums’ [45] | • Facilitation of opportunities for disclosure through tele-mental health methods [48] • Building trusting relationships [37] |
Appropriateness of available services | Aboriginal communities, ethnic minorities, immigrants, children and young people | • Patient cultural views [49] • Diagnostic overshadowing [57] • Complex comorbidity [62] • Technical ability [43] • Inconsistent methods and application of treatment (e.g. for trans-identifying patients) [65] • Lack of GP training in mental health and/or substance use issues [39] • Failure to provide age-appropriate environments [32] | • Provision of culturally appropriate alternatives to mainstream care [33] • Cultural and linguistic competence of staff; cultural reference points [34] • Developing services that are acceptable to people at risk of disadvantage, such as older people and those from ethnic minorities [35] • Making services ‘holistic’ and ensuring ‘cultural safety’ of primary healthcare services [37] • Providing access to male and female therapists, provision of choice in care and maintaining confidentiality [47] |