“Maybe once I find a good job, I will be better”: Seeking Mental Healthcare in Little Bangladesh, Toronto, Canada

Objective: In order to inform the development of culturally safe models of mental healthcare and promotion, this concurrent mixed methods study explored the following research questions: 1) What are the characteristics of community members with positive attitudes toward seeking mental health services and 2) What are the barriers and promoters of mental health service access for Bangladeshi immigrants living in the “Little Bangladesh” locale in Toronto, Canada which has one of the highest rates of people seeking mental health care in the city. Method: Participants were surveyed in the quantitative phase (n = 47) using a sociodemographic questionnaire and the Inventory of Attitudes Toward Seeking Mental Health Services (IASMHS) and interviewed during the qualitative phase (n = 20). Results: The quantitative phase found that male gender, Journal of Concurrent Disorders Volume (TBD), Issue (TBD), 2020 (pp. (TBD) attending school in Canada, and being employed in one’s field of study/work were associated with more positive attitudes toward seeking mental healthcare. Lack of economic integration, mental health awareness and education, mental health literacy, and the presence of community mental health stigma were identified as the major barriers toward seeking care in the qualitative phase. Conclusion and Implication: After merging phases, the common factor that emerged from both legs of the study was the stressor of economic insecurity during the migration and resettlement process and how that acts as a barrier to seeking mental healthcare. Participants recommended a multi-pronged, targeted mental health outreach campaign to facilitate economic integration for new immigrants, address mental health stigma, promote available mental health resources, and develop new models of care.

It is estimated that one in five Canadians will experience a mental illness or addiction during their lifetime (Smetanin et al., 2011). Evidence suggests that immigrant mental health deteriorates after arrival in Canada (Ali, 2002;Bergeron, Auger & Hamel, 2009;Islam, 2013;Lou & Beaujot, 2005;Ng & Omariba, 2010). Moreover, mental health is a highly stigmatized issue within South Asian diasporic populations (those reporting origins in India, Pakistan, Bangladesh, Sri Lanka, and other countries) living in Canada (Cader, 2017;Islam, 2012).
South Asian populations make up the largest visible minority group in Canada (Statistics Canada, 2008) and is projected to increase to over a quarter (28%) of the population by 2031 (Statistics Canada, 2016). Although sharing certain characteristics, South Asian populations come from vast and varying countries of origin, speak hundreds of different languages and dialects, are affiliated with different religions, and have diverse migration histories in Canada (Statistics Canada, 2007;Tran, Kaddatz & Allard, 2005). While studies on the Bangladeshi diaspora in London, UK have been used to inform culturally-safe mental healthcare practice (Dein, Alexander & Napier, 2008;Dein & Littlewood, 2016) Canada (Gadalla, 2010).
Only 5.7% of South Asian immigrants sought mental healthcare services (Tiwari & Wang, 2008) compared to the 10% national average (Lesage et al., 2006). Moreover, amongst those with a mental health disorder, only 37.5% of South Asians sought professional help (Tiwari & Wang, 2008 Cultural safety (Ramsden, 1991;1992) in mental healthcare provision acknowledges power imbalances and racism present in healthcare and recognizes the dynamism of culture. Static representations of culture, lack of acknowledgment of power dynamics, and lack of thoughtful review of effective service delivery practices have been identified as the major mental health system access barriers (Williams, 2002;Williams, 2006;Williams, 2010

Qualitative Phase
A subset of twenty participants was chosen from the forty-seven quantitative phase participants (4 men; 16 women).
Depending upon the participants' preferences, the interviews were offered in Bengali (n = 19) and English (n = 1). A semistructured interview protocol was followed.
Interview participants were given a $20 gift card upon agreeing to partake in the study.
The 30-minute interviews were audiorecorded. The mp3 files were transcribed and translated into English from Bengali by the lead researcher.

Sample Profile
Analysis of the sociodemographic and

Qualitative Phase
The sample profile and demographics for the qualitative phase participants are summarized in Table 2   This proactive approach helps to waylay health system costs down the road.

Limitations
This study had a number of

Conflict of Interest
Author FI, Author HT and Author NK declare that they have no conflict of interest.

BARRIERS PROMOTERS
-Lack of financial support for new immigrants -Failure to provide information about mental health resources to immigrants upon arrival in Canada -Increasing financial aid and supports for new immigrants -Job and skills matching programs -Government concern for immigrant mental health and wellbeing

❷ MENTAL HEALTH SYSTEM-LEVEL
-Education -Mental health awareness

BARRIERS PROMOTERS
-Perception of difficulty in using mental health services -Lack of culturally-safe mental health services and professionals -Lack of dissemination of culturally-safe mental health information -Lack of targeted dissemination of information to this population -Emphasis on confidentiality of services -Family doctor -Appropriately-matched professional -Lack of perceived racism in health services -Affordable services -Perception of ease in using mental health services