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Many studies suggest that immigrants to Canada, especially those from non-European countries, tend to under use health services, particularly mental health services, compared with Canadian-born people (1–4). Debate as to whether this is owing to reduced levels of need (a reflection of the healthy-immigrant effect) or to immigrants’ reluctance to use services because of unidentified barriers is ongoing (5). Establishing greater knowledge in this area is a key research priority of various commentators and agencies concerned with immigrant health in Canada (6–8). Further research will undoubtedly help inform interventions that could reduce health disparities among immigrants, which is also a key government priority (7,9). The study of immigrant inequalities in health brings a set of specific conceptual and methodological challenges. Social, cultural, religious, linguistic, geographic, and economic variables are hypothesized as important in determining health service use (10–12). Unpacking the impact and interaction of these variables is difficult, and they may apply to immigrant subgroups with differential weight (13). The present study aims to address some of these issues through the qualitative study of West Indian immigrants in Montreal not currently using mental health services, despite the presence of significant somatic symptoms and (or) emotional distress. We use the term “West Indian” to refer to people from the islands and territories in the Commonwealth Caribbean (including Guyana). Community groups in Montreal frequently employ this term; we believe it is preferable to the term “Caribbean,” as the latter term, by definition, includes peoples from other islands (for example Cuba and Haiti) with different histories, languages, and cultures, not included in the present study. The aim of the study is to document and explore West Indian immigrants’ given reasons for not consulting mental health services. This is of interest, as relatively little research has been conducted regarding health and illness among West Indians in Canada, despite significant communities in major metropoles such as Toronto and Montreal (14,15). The study further aims to create a framework of barriers to mental health care grounded in empirical data that can be used to guide interventions as well as future research with similar groups. MethodWe conducted 15 in-depth interviews with West Indian immigrants in Montreal who were not currently using mental health services, despite a significant level of somatic symptoms and (or) emotional distress as indicated by a somatic symptom index and responses to the 12-item General Health Questionnaire. Participants were sampled from a larger cross-sectional community survey (n = 2241) investigating mental health care use among different ethnocultural groups in an inner city neighbourhood in Montreal (4). Of participants in this community survey, 268 were West Indian. Approximately 60% agreed to a follow-up telephone interview. Respondents who reported 4 or more somatic, emotional, or medically unexplained symptoms and who were not currently using mental health services were invited to take part in a third-stage, face-to-face interview. Sixty-three percent agreed to participate (n = 20). Of these, 15 people completed the interview, providing useable transcripts. This group comprised 11 women and 4 men. The interviews followed the McGill Illness Narrative Interview (16) that includes a series of open questions regarding health beliefs and health service use. Interviews lasted between 1 and 2 hours and were held at a local hospital. They were recorded onto audiocassette and transcribed. Transcriptions, unpublished in their entirety to protect confidentiality, were imported into the Ethnograph software package, where data were systematically examined to discover common explanations given for nonuse of mental health services. Validity of the findings is strengthened by the fact that, although playing complementary roles in the research process, the authors agreed on the principal results of the study on the basis of their close connection with the raw data. The hospital institutional review board granted ethical approval, and all research participants gave informed consent. ResultsThree significant factors that assist understanding participants’ reluctance to use mental health services emerged strongly from participants’ narratives. The 3 common themes explaining participants’ reluctance to use health services, in order of importance, are as follows: 1. A perceived overwillingness on the part of doctors to prescribe pharmaceutical medications, which most participants deemed negative. First, the overwhelming majority of participants had a negative attitude toward medication. From previous doctor– patient interactions, they felt that physicians far too quickly and easily dispensed medication, which most participants did not think could solve the real root of their problems. This led to a general reluctance to use any health service (including psychiatry) that relied on pharmaceutical medication as a primary intervention. The following quotes, from the 15 useable transcripts of the recorded interviews, summarize common attitudes: “I don’t like taking medication, like pills and so on and so forth. But they are quick to give you a prescription which I don’t like.” (Int 02) “They always giving you pills. I don’t believe in taking a lot of pills like that. You know, you go and every time you go they give you a lot of pills.” (Int 07) “Sometimes I know what to take and I doesn’t take it, sometimes I don’t like take too much pills. Just taking pills all the while, I don’t like it. It’s too much.” (Int 09) “What he [the Doctor] going to do for me? He going to find me a nice husband, going to pay my rent? What’s he can do? He can’t do that, so he’s going to make me happy taking pill! No!” (Int 08) 2. A perceived lack of time and dismissive attitude of physicians during previous doctor–patient interactions deterring current use of mental health services. The second factor that emerged strongly from the data was the perceived lack of time and dismissive attitude of physicians during previous doctor–patient interactions, which deterred current use of mental health services. Many participants lamented this lack of time, as it did not allow them to ask questions regarding the efficacy and side effects of prescribed medication. Others thought it indicated an uncaring and hostile attitude. The following examples are quoted from the interviews: “You’re supposed to question pills and most of the time you go to them, you don’t have time to question them what is this for, what is that for, which I do. What is this for, the side effect, because some of them don’t even tell you.” (Int 07) “Every time I go to my doctor, is a prescription for this, a prescription for that and I’m not a drug person, I don’t like medication, thank the Lord. I’d rather be looked after, check me out and tell me, okay there is nothing . . . I would like to be looked after but not with a prescription. . . . explain to me, take time, listen to me, talk to me, you know . . . if I’m just ignored and that you’ll give me 5 minutes of your time by the time I reach home, it has me feeling that, what did I go to the doctor for? You know? But if I get a good 15 minutes and sit down, ‘Okay, I’ll look at you, I’ll check you out, this is what is causing this= then I’ll be able to stay better. But not ‘take this prescription 3 times a day.’” (Int 10) “I was going to see another [Doctor] and every time I asked him questions he’d never want to talk to me, won’t listen to me. And then at one point after I used to ask him a lot of questions, when I phone up, the secretary told me that, ‘Well, um, just continue taking pills, but the doctor haven’t set you up for another appointment.’ So in other words he want me to quit going to see him. Because this is my body, I’m asking questions, which I have a right to. I pay you. My government is paying you to, you know. You spend 5 minutes with me and you’re getting me through the door. So anyway, I quit.” (Int 13) “What I feel can be done is if the doctors are a little more like concerned. ‘Cause I feel like they come and they check you, ‘how are you feeling today?’ and they are very - so fast, they are so fast, like, ‘how are you feeling today,’ and, ‘you have pain?’ And they give you some medicine and that’s it.” (Int 15) 3. A belief in the curative power of nonmedical interventions, most notably God and, to a lesser extent, traditional folk medicine and healers. The final theme to emerge from the data is a belief in the curative power of nonmedical interventions, most notably God and, to a lesser extent, traditional folk medicine and healers. This was the least consistent of the 3 themes, with a wider degree of heterogeneity in participants’ responses than the other 2 factors. Most participants were devout Christians and felt that divine intervention was an important aspect of healing: “I didn’t know how to explain it to someone, how to ask for help, how to tell anyone . . . but I don’t know where that cure came from…because I had a lot of faith, a lot of hope and I prayed all day long, all night long. Any hour of the day I just had to say, ‘Lord, help me. You see, I’m breaking down. Pull me back.’ You know, I never gave up . . . and I feel that has a lot to do with it.” (INT02) “A friend—we knew each other from home, she came up a year before me . . . we’d meet in church . . . she’ll try to comfort me by telling me put my trust in Him, you know? Because this is what she’s doing and it works . . . it will help.”(Int 10) Some participants preferred the use of folk-medicine and traditional healers to the conventional health care system, while many others deemed them to lack efficacy. The following quotes summarize these opposing views: “The people from here just love them [pills]. But you don’t want to because in our country we use a lot of herbs, a lot of bush . . . and then they are much better than the medicines than the pills sometimes.” (Int 07) “No, no, I don’t believe in all that healer stuff. Only God can heal you. I wouldn’t take nothing else . . . they have places all around that you could go to—ba, ba, ba, ba, ba, come to this place and we’ll fix it, but I never believe it.” (Int 08) It is also worth mentioning themes, which other studies suggest could be important, that did not emerge from the data. First, participants rarely brought up economic issues, which are prominent features in US studies of immigrant health (for example, 17,18). This probably reflects the fact that, unlike the US, Canada has a universal health care system free at the point of use. Second, despite being anglophones in a francophone province, participants rarely raised linguistic issues as a problem. Finally, participants hardly mentioned racism, a theme prominent in the British literature (19,20), as a barrier to health care. It is unlikely that this reflects a real belief among participants that racism is absent from the Canadian health care system; it may simply indicate a reluctance to raise the issue with white interviewers. DiscussionTo our knowledge, this is the first in-depth qualitative study exploring why West Indian immigrants may be reluctant to use mental health care services in Canada. As this is a case study of a homogenous population in a specific setting, inferences drawn from the study that can be applied to other groups elsewhere may be limited. That said, we have produced a framework, grounded in the empirical data, that can be used to guide interventions as well as research in other populations. This framework highlights the role of 3 factors consonant with previous work on immigrant and minority group health, most notably, a negative orientation toward medication in the immigrant group compounded by a perceived lack of understanding and time for discussion from doctors (10,12). Some of this may be amenable to simple interventions, for example giving (and appropriately advertising) the opportunity for longer appointments or greater use of “talking therapies.” Of interest, numerous studies in the UK have indicated that black people are less likely to be offered “talking therapies” and more likely to be offered (higher dosages of) pharmaceutical medication (19,20). Participants definitely felt that doctors were unsympathetic to “talk” and more interested in dispensing medication. Whether or not this is a racial issue needs further exploration in Canada. One other point worthy of note is that participants= negative attitudes toward mental health services were derived largely from previous experience with other (nonpsychiatric) health services. Psychiatry is generally a downstream service as patients often have numerous encounters with other physicians before psychiatric consultation. Thus attitudes toward psychiatry and psychiatrists are partly shaped by health care experiences outside the discipline, which has ramifications for interventions as well as everyday practice. We acknowledge 2 limitations of this study. First, the sample size was small; however, considering the very specific inclusion criteria, this was, in our opinion, unavoidable. Second, all 3 interviewers in this study were white, Canadian professionals. It has been noted that black people in Canada are usually careful in choosing what to reveal and what not to reveal to white people (21,22). The use of black interviewers might have yielded different results with regard to certain factors, for example, the effect of racism. All the interviewers, however, were experienced and highly trained, and respondents did raise other sensitive issues related to their social world, for example, sexual and relationship issues. Nevertheless, future research exploring the issue of immigrant disparities in mental health care use may need to account for these issues at the design stage in an effort to reduce potential response bias. Funding and SupportThe research was supported by grants from the Canadian Institutes of Health Research, grant number MSS-55123 and the fonds de récherche en santé du Québec, grant number 941080–104. The paper was written while Rob Whitley was a Research Fellow in the Division of Social and Transcultural Psychiatry, McGill University, Montreal, Quebec. References1. Laroche M. Health status and health services utilisation of Canada's immigrant and nonimmigrant populations. Can Public Policy 2000;26:51–73. 2. Hyman I. Immigration and health. Health policy working paper series. Working paper 01-05. Ottawa (ON): Health Canada; 2001. 3. Kirmayer LJ, Galbaud Du Fort G, Lasry JC, Weinfield M, Young A. [Utilisation of mental health services for psychological distress by immigrants. In: A Lesage, editor. Annual meeting of the Canadian Academy for Psychiatric Epidemiology; 1996 Oct 1; Quebec City (QC)] Located at (Canadian Academy for Psychiatric Epidemiology). 4. Kirmayer LJ, Young A, Galbaud du fort G, Weinfeld M, and Lasry JC. Pathways and barriers to mental health care: a community survey and ethnographic study. Jewish General Hospital; Montreal (QC): Report 6. Culture and Mental Health Research Unit, Institute of Community and Family Psychiatry; 1996. 5. DesMeules M, Gold J, Kazanjian A, Manuel D, Payne J, Vissandee B, McDermott S, and others. New approaches to immigrant health assessment. Can J Public Health 2004;95(3):I22–I26. 6. Gold J, DesMeules M. National symposium on immigrant health in Canada. Can J Public Health 2004;95(3):I–3. 7. Health Canada. Towards a healthy future: second report on the health of Canadians. Ottawa (ON): Health Canada; 1999. 8. Kinnon D. Canadian research on immigration and health: an overview. Ottawa (ON): Health Canada; 1999. 9. Romanow RJ. Building on values: the future of health care in Canada. Ottawa (ON): Commission on the future of health care in Canada; 2002. 10. Horne R, Graupner L, Frost S, Weinman J, Wright SM, Hankins, M. Medicine in a multicultural society: the effect of cultural background on beliefs about medication. Soc Sci Med 2004;59:1307–13. 11. Tugwell P, Kristjansson B. Moving from description to action; challenges in researching socio-economic inequalities in health. Can J Public Health 2004;95:85–7. 12. Schnittker J. Misgivings of medicine? African Americans= scepticism of psychiatric medication. J Health Soc Behaviour 2003;44:506–24. 13. Ali JS, McDermott S, Gravel RG. Recent research on immigrant health from statistics Canada=s population surveys. Can J Public Health 2004;95(3):I9–I13. 14. Lashley M. The unrecognised social stressors of migration and reunification in Caribbean families. Transcult Psychiatry 2000,37:201–16. 15. Torczyner JL and Springer S. The evolution of the Black community of Montreal: change and challenge. Montrel (QC): McGill Consortium for ethnicity and social planning; 2001. 16. Groleau D, Kirmayer L J. Sociosomatic theory in Vietnamese immigrants= narratives of distress. Anthropology and Medicine 2004,11:117–33. 17. Brown ER, Ojeda VD, Wyn R, Levan R. Racial and ethnic disparities in access to health insurance and health care. UCLA centre for health policy research. Los Angeles (CA): The Henry J Kaiser Foundation; 2000. 18. Institute of Medicine. Unequal treatment: confronting racial and ethnic disparities in health care. Washington (DC): Institute of Medicine; 2002. 19. Fernando S. Cultural diversity, mental health and psychiatry: the struggle against racism. New York (NY): Brunner-Routledge; 2003. 20. Bhui K. Racism and mental health. London (UK): Jessica Kingsley; 2002. 21. Kelly J. Under the gaze; learning to be black in a white society. Halifax (NS): Fernwood; 1998. 22. Henry F. The Caribbean diaspora in Toronto: learning to live with racism. Toronto (ON): University of Toronto Press; 1994. Author(s)Manuscript received July 2005, revised, and accepted November 2005. 1. Assistant Professor, New Hampshire-Dartmouth Psychiatric Research Center, Lebanon, New Hampshire. 2. Professor, Division of Social and Transcultural Psychiatry, Department of Psychiatry, McGill University, Montreal, Quebec 3. Assistant Professor, Division of Social and Transcultural Psychiatry, Department of Psychiatry, McGill University, Montreal, Quebec. Address for correspondence: Dr Rob Whitley, New Hampshire-Dartmouth Psychiatric Research Centre, 2 Whipple Place, Suite 202, Lebanon, NH 03766 e-mail: rob.whitley@dartmouth.edu
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