Black and minority mental health in the UK: Challenges and solutions.

The current Covid-19 pandemic has brought into sharp focus the differential rates of morbidity and mortality in Black, Asian and Minority Ethnic (BAME) groups particularly in the United Kingdom (UK). Furthermore, the multiple deaths, shootings and murders of Black individuals in the United States of America (USA) have brought greater public attention onto this issue. These events, as well as the subsequent campaign around the world on Black Lives Matter, have once again highlighted a number of differences across racial and ethnic divides (Devakumar et al., 2020; E: Covid-19 understandi, 2020). These have been further exacerbated by structural and institutional racism which in turn has been activated by politicians in many countries such as the USA, the UK, Hungary, Brazil and elsewhere (Gravlee, 2020; Krieger, 2020; Oliveira et al., 2020). In many countries around the globe, minorities in general have faced and continue to experience tremendous discrimination in a number of fields, including education, employment and health including access to healthcare (Pager & Shepherd, 2008). High death rates among ethnic minorities due to Covid-19 in the UK have been attributed to a number of factors such as occupation, income inequality, poverty, overcrowding, high ethnic density, pre-existing chronic physical co-morbid conditions (such as obesity, diabetes, hypertension, chronic lung disease etc) and other behavioural factors such as smoking (E: Covid-19 understandi, 2020).

A majority (86%) of the population in England and Wales identify themselves as white and the remaining are Black, Asian and Minority Ethnic (BAME) according to the 2011 census. Among the minority ethnic groups, 7.5% are of Asian heritage and 3.3% are Black, 2.2% mixed ethnicity and 1% are other minorities (S: Population of Englan, 2018). In the first decade of the 21st Century, the numbers of the Other White group and Black Africans increased (S: Comparability over t, 2012). Another notable statistic concerns the prison population, where it has been observed that Black, Asian and minority groups are over-represented, 24% compared with 14% of the White population (Coid et al., 2002). It is obvious that the effects of incarceration will be experienced far beyond prison and jail walls and impact upon the physical and mental health of not only of prisoners but also that of their families and dependents (Bhugra, 2020). Furthermore, prisoners face double jeopardy as they also show higher than expected rates of various psychiatric disorders, especially psychoses and certain physical illnesses such as hypertension and diabetes. In addition, after release from prisons, their needs for housing, employment, and educational opportunities are very often not met (Enggist et al., 2014). Thus, in order to deliver equity, there must be joined-up thinking and planning between health, education, employment, justice and other ministerial departments.

Some minority ethnic groups in the UK show consistently higher than expected rates of schizophrenia (between 3 and 7 times) (Pinto et al., 2008) whereas others show high rates of depression and self-harm (2–3 times higher) (S: Common mental disord, 2017) than the white population. Similarly, prevalence of type-2 diabetes is substantially higher among many ethnic minority groups such as Bangladeshi, Pakistani, Indian, Indo-Caribbean, Black African, Black Caribbean and Chinese (Diabetes, 2020). Pakistani men at all ages show higher rates of angina and Pakistani men and women (55 years and older) show a higher prevalence of heart attacks (Diabetes, 2020). Rate of hypertension is highest in Black Caribbean groups (George et al., 2017). Sexually transmitted infections, including HIV, are reported to be highest amongst Black ethnic groups (Mohammed et al., 2018). The rates of chronic illnesses also varies across different ethnic groups (Mohammed et al., 2018). Some groups such as those of Chinese origin have shown better health outcomes than their white counterparts (: Briefing paper Qual, 2017). These variations in incidence, prevalence and outcomes highlight the importance of their recognition and appropriate interventions.

These variations in outcomes may be related to differences in cultural and personal behaviours across different ethnic groups (Beacres, 1991–2013). For example, smoking rates of tobacco use remain high in some Black, Asian and other minority ethnic groups (igital: Statistics o, 2019). Pakistani and Bangladeshi groups report low levels of physical activity (Williams et al., 2010). This latter study notably found that physical activity levels remains low even when socio-economic factors have been accounted for, and that factors such as urbanisation, psychological distress, and degree of acculturation may partially account for some of the differences noted. Patterns of alcohol consumption (and hence rates of associated complications) also vary across ethnic groups (F: Ethnicity and alcoho, 2010) and some of these differences are attributable to religious affiliations. Dietary differences and the use of salt in cooking (which is high amongst some ethnic groups) may well contribute to higher rates of hypertension (Leung & Stanner, 2011). These dietary differences combined with a lack of exercise and/or physical activity may lead to overweight or obesity (S: Overweight adults. 2, 2020) in some ethnic and socio-economic groups which puts them at greater risk of ill health as higher BMI levels which have been shown to be contributory to higher levels of mortality due to Covid-19 (E: Covid-19 understandi, 2020; Caussy et al., et al.). This must also be considered in the context of intersectionality of ethnicity, culture and socio-economic disadvantage.

It is well recognised that various social determinants play a major role in physical and mental health. Differential access and attainment in education (aS: Ethnicity pay gaps, 2018) may lead to differential employment and consequently may lead to inadequate or insecure housing which will influence health and ageing including longevity (Gruer et al., 2016). Social and generational inequalities directly or indirectly related to institutional, structural or personal discrimination as a result of racism and prejudice stopping people from seeking help leading to chronicity of their conditions and consequently poorer outcomes (Paxman, 2017).

In many countries and many settings, healthcare services are not culturally sensitive or competent thereby preventing ready access to and acceptance of healthcare services (Betancourt et al., 2005). The Covid-19 pandemic is not confined to a single country and just when there is an urgent need for global co-operation and collaboration, countries appear to be fighting to grab resources, medications and vaccines.

There is an increasing interest in geopolitical factors which tend to affect population health (Persaud et al., 2019, 2020, p. pp19). Examples include global trade imbalances, climate change, violent extremism, and armed conflict. Some of these factors work at global levels whereas others occur at local or even individual levels. Healthcare policies are often focused on health not taking education, employment, housing and other factors into account. In order to deliver the most appropriate and accessible services, the quality of data has to be excellent (Khunti et al., 2020) and continually captured so as to understand temporal relationships and keep policy makers informed of dynamic changes. This needs to be carried out in a joined-up manner: from better data capture to accountability at ministerial level. Establishing an Office for Minority Health, or something similar, with appropriate levels of responsibility, would help with the collection of this data to recognise the actual extent of the problem. Indeed, there is a precedent for such a move when the USA created a federal agency ‘Office of Minority Health’ in 1986 after the landmark Heckler report (Heckler, 1985). Given the risk that policies (and consequently services) may continue to exacerbate the differential outcomes for minority and vulnerable groups, an essential approach that offers a mechanism for identifying and addressing these issues in both policy and healthcare institutions is needed. Such a solution is potentially an effective option for identifying these institutional issues in nations with diverse populations.

Given that discrimination is direct and indirect as well as institutional, there is a need for this to be tackled at both policy and practical levels. Therefore, such a body has to be responsible for keeping the elimination of ethnic inequalities across all organisations under review. Developing research questions in conjunction with patient and community partnerships, rapid research strategy development, and application of such research to service development and outcome measurements is a must. For example, developing cultural competency training and service delivery with ongoing evaluation of improvement in service users' experiences and outcomes. Recognition and delivery of the resources to support health equity through setting up the repository of data, reports and sharing examples of good clinical practice and working with researchers, policymakers, patients, their carers and families, and other healthcare professionals has to be at the heart of such an institution.

Such an organisation must have a clear role to play at various levels in meeting the health and social care needs of BAME mentally ill offenders as well as prisoners. And thus, in turn, have a positive socioeconomic effect on society as a whole by decreasing the likelihood of ending up in prisons where those needs cannot be met. Improved access to health care and improved health status will lead to improved opportunities for employment, housing, and family support especially if cultural variations are embedded in such a rehabilitation process. Different countries will need to modify their functions according to their needs and should set tailored standards for hospitals, training institutions and regulatory bodies. As a minimum, they should meet the requisite standards as set out by bodies such the World Health Organisation. Making progress against these major problems of inequalities will require dedicated work for a long time, perhaps over a generation.

Declaration of competing interest

The authors have no competing interests to declare.