by Aseel Hamid
Accounting for 13% of the total global burden of disease,1 untreated mental health disorders are one of the leading causes of disability, causing lasting disruptions in mood, thinking and daily functioning. It has been predicted that by 2030, depression will be a leading cause of the global burden of disease.2 As outlined in “Access to Mental Health Care in the Middle East”, mental health is not a strong priority in the Middle East and North Africa (MENA) region and services are not widespread despite efforts made. The lack of prioritization around mental health means that the available resources are rarely translated into policy or planning for action at a population level by governments.
The purpose of this entry is to determine which factors lead to underutilization of the few existing mental health services. After all, if governments invest in services and the respective public does not utilize them then it will inevitably lead to further deprioritization: a perpetual cycle.
Where does this cycle begin?
It is highly unlikely that underutilization results from a lack of need. Prevalence rates of mental illness in MENA are similar to the prevalence rates worldwide.3 Furthermore, the MENA region has been greatly affected by conflicts, some of which are ongoing such as in Syria, Palestine and Iraq. A recent study found that countries in MENA affected by conflict tend to report a much higher rate of depression,4 and another study carried out in areas affected by conflicts show rates of 17% for post-traumatic stress disorder; 5 this is almost five times the prevalence rate of PTSD found in the US.6 Therefore it is likely that MENA has seen an increase in the prevalence of mental illness thus leading to an increased need of mental health services.
National Health Services: free healthcare for all
To begin to understand where the cycle begins and how it can be broken, it would be helpful to look at a context in which mental health services are readily available to Arabs. This allows for an examination of the social barriers, as opposed to the practical barriers to formal help seeking. It has long been established that a person’s attitudes toward seeking and using formal mental health services can significantly affect the decision to seek out professional services when the symptoms of mental health problems occur.7
The United Kingdom (UK) operates the National Health Service (NHS) where residents of the UK readily have access to free healthcare, including mental health care. There has been a large influx of Arabs settling in to the UK; the nationwide census recognized Arabs as a separate ethnic category for the first time in 2011.
Government initiatives have highlighted the mental health needs of ethnic minority groups as priority in provision of appropriate mental health services8 and numerous nationwide campaigns have attempted to increase mental health service utilization by addressing the stigma attached to mental health problems, such as Time to Change.
In order to delve deeper into the issue of underutilization, the findings of my first publication may cast some light on underutilization in an establishment where services are readily available. The study was also the first to look at Arab attitudes towards seeking professional psychological help in the UK.9 A sample of 100 Arabs living in the UK were compared with 104 British Caucasians. We tested the prediction that Arabs held a less positive attitude towards professional help seeking. More importantly, we aimed to assess factors that affected professional help seeking and their pathways, namely: causal beliefs of mental illness, shame focused attitudes and confidentiality concerns. By presenting the findings, I will cast light on the cycle of underutilization by describing potential barriers to utilization of professional mental health services, alongside suggestions for overcoming them.
It is important to note that the term ‘Arab’ denotes people living in the MENA region: a large region comprising of an amalgamation of nationalities, with inter and intra variation of diverse cultures and religions. This blog entry focuses on Arab Muslims, who compromise 91.2% of the region.10
Attitudes towards seeking professional help
The study found that Arabs showed a significantly less positive attitude to professional help seeking than their British counterparts, even after taking into account important variables such as gender, educational level and previous experience of mental illness. This is consistent with a similar study conducted on Arabs in Australia.11 Furthermore, it has been found that Arabs in MENA generally hold a negative attitude towards people with mental illness.12 It is of no surprise that the attitude held is in itself a strong predictor of seeking professional help.6
Causal beliefs of mental illness were examined and compared. As predicted, Arabs endorsed greater beliefs in supernatural causes of mental illness stemming from Islamic beliefs, such as ’a dangerous unprovoked spirit’, ‘spirit who was angry because someone did wrong’ and ‘evil eye’. British Caucasians endorsed greater beliefs in Western physiological causes of mental illness than Arabs, such as a ‘chemical imbalance in the brain’ and ‘genetics’. However, there were no significant differences in endorsement of stress-related causes.
These findings have interesting implications, particularly as there has been criticism of the use of therapies based on Western theories of mental illness, carried out by Western researchers and whose evidence base consists predominantly of a Western sample.13 Arguably, this criticism is justified. Psychological intervention in the UK is informed by a strong evidence base carried out in accordance with regulatory guidelines set out by the National Institute for Health and Clinical Excellence (NICE), which has strong roots in the medical model of mental illness. This is problematic for Arabs who tend to endorse stronger supernatural causal beliefs of mental illness arising from Islam, as this in turn leads to differential treatment preferences. This is in line with a systematic review outlining barriers to accessing mental health services in MENA, with a strong barrier being a preference for traditional healing over Westernized, scientific methods.14
In the UK, guidelines set by the British Psychological Society (BPS) strongly encourage a consideration of the context in which people live, particularly their culture.15 An integrative approach may bridge the gap between ‘alternative pathways’ of traditional healing and Western-based therapies. An open discourse could be encouraged between religious authorities and mental health professionals. As suggested in a UK study looking at jinn possession and mental illness, mental health professionals can teach Imams to recognize mental illness and Islamic religious professionals can in turn educate health professionals about the importance of religious factors in mental illness.16 Indeed a great strength of the services provided in the UK stems from the multi-disciplinary nature of teams that are necessary for providing optimum care.
Shame focused attitudes and confidentiality
It is established that Arabs generally hold stigmatizing beliefs towards seeking professional mental health services, both within the MENA region17, 18 and in the United States19. We assessed whether shame-focused attitudes and confidentiality concerns predicted attitude towards seeking professional psychological help. We found that confidentiality concerns, but not shame focused attitudes, significantly predicted attitudes for both Arabs and British Caucasians. An interesting pathway was found for the Arab sample (see Figure 1). The pathway suggests that stronger endorsement of supernatural causal beliefs of mental illness leads to greater shame focused attitudes which leads to stronger confidentiality concerns, finally leading to more negative professional help seeking attitudes.
Targeting awareness with the aim of reducing stigmatizing attitudes and promoting understanding is undoubtedly beneficial to the progress of prioritizing mental health needs in MENA. However these findings imply that it may be more helpful to target specific concerns regarding confidentiality. It is imperative that potential service users are assured of the confidentiality of the services they seek. This is especially the case when it involves Islamic causal beliefs that may lead to exclusion and isolation, such as punishment for one’s sins or jinn possession. Concerns are likely to be heightened in close communities. If confidentiality was an important factor for Arabs migrating to the UK, who would have likely left their extended family and strong sense of community behind, then it would likely be a strong concern within the MENA region and therefore something that cannot be ignored.
Looking at Arab help seeking attitudes in a context where services are readily available can shed light on mental health service provision and utilization in the MENA region. It is important, however, to be careful when extrapolating findings, not only because Arabs living in the UK have potentially differing attitudes from Arabs in MENA, but also due to the terminology of ‘Arab’, as previously mentioned. While there are many similarities amongst Arab nations and cultures, cultural and religious variation would likely lead to differences in attitudes, causal beliefs and treatment preferences.
Keeping in mind these limitations, the findings are helpful in illuminating potential barriers, particularly when there is a paucity of underutilization research in the region itself. A strong determinant of utilization is a negative attitude towards professional help seeking. Concern over confidentiality is a known direct predictor of this and should be taken into account in the development, planning and publicization of mental health services. Furthermore, services in the West that have implemented and integrated culturally and religiously sensitive practice using multidisciplinary teams and open communication between various providers can act as good examples and a potential way forward for services in MENA; leading to greater uptake of services and ultimately greater prioritization of the vital mental health needs in the region.
For a detailed discussion of the limitations and further implications of the paper discussed, click here.
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