Initiatives for Improving Mental Health Services to Ethnic Minorities in Australia

Difficulties in providing mental health services to ethnic minorities are well documented and include underutilization of services, communication barriers, and cultural differences in the understanding of illness and treatment (1,2,3,4). This article discusses some major policy initiatives undertaken in Victoria, Australia's second-largest state, in an attempt to address these difficulties.

Victoria has a population of 4.4 million people. Of the adult population, 20.8 percent are immigrants from countries where English is not the main language spoken; that is, they have a non-English-speaking background. These immigrants originated from more than 100 countries—from Southern and Western Europe in the immediate post-World-War-II period, and more recently from Asian and other non-European countries, including countries in Southeast Asia, South and Central America, the Horn of Africa, and the Middle East.

In Victoria, public mental health services are provided through public hospitals and nonprofit community agencies. Responsibility for policy development and funding lies with the mental health branch of the Victoria Department of Human Services. Between 1996 and 1998, after a process of consultation and planning involving policy makers, service providers, ethnic organizations, consumers, caregivers, and staff of the Victorian transcultural psychiatry unit, the department introduced several important policy initiatives, which are described below.

Policy statement

In 1996 the mental health branch released a policy document on improving services for people from non-English-speaking backgrounds (5). The report summarized current problems of access and quality of care and listed key areas for change, including service planning, interpreting and translating services, culturally sensitive service delivery, access to information, quality assurance, and research. The document included goals and standards that all services were expected to meet in each area. Examples from existing practices were also included as guides to possible strategies that could be implemented.

Weighted-population funding

Until 1994 funding for mental health services was distributed based on historical patterns, with little consideration of needs in each area. Several large inpatient institutions that covered large geographical areas consumed a significant proportion of revenue, making it difficult to establish smaller inpatient units and more locally based community services consistent with current national and state mental health policy.

In the absence of empirical data about the geographical prevalence of mental illness in Victoria, a funding framework using weighted population data to estimate the need for mental health services was developed. After a period of consultation and review, the final weighted population model included loadings for the population of persons with non-English-speaking backgrounds and for the aboriginal population (6), which meant that areas with higher proportions of these groups received relatively more funding. The additional funding was included to take into account the extra time and money involved in providing services to these groups, such as the cost of hiring interpreters and the additional time for interpreted interviews. It is not known how services chose to use these funds.

Ethnic mental health consultants

After a state government election in March 1996, the re-elected government allocated an additional $2.1 million (Australian dollars) over four years to fund strategies for ethnic mental health service improvement. The majority of these funds were used to create positions for ethnic mental health consultants in each of the five major health care networks. These positions were intended to help mental health services implement policies for improved services to persons with non-English-speaking backgrounds and develop and implement local initiatives. Although the bulk of the funding went to the Melbourne metropolitan area—based on the fact that 90 percent of the target population in Victoria lived in Melbourne—each of the five rural regions was given the equivalent of .2 of a position.

The ethnic mental health consultants program aims at increasing the accessibility of public mental health services for people from non-English-speaking backgrounds by facilitating cross-cultural training and culturally sensitive work practices, enhancing use of interpreting services and bilingual staff, and developing links and partnerships with ethnic communities. Besides playing a key role in the implementation of policy, the consultants utilize community development principles and processes to engender change from the bottom up, based on consultation with consumers and ethnic communities.

Bilingual case management program and evaluation

To increase the number and accessibility of bilingual staff in mental health services, seed funding for the establishment of ten bilingual case management positions in the western region of Melbourne was made available during 1996-1997. This program aimed at improving access to and adequacy of area mental health services for people from non-English-speaking backgrounds and to assist in accurate diagnosis and assessment of people in this population presenting to a mental health service. Other goals were to assist in the development of individual service plans for clients in conjunction with case managers and to establish, in conjunction with other staff, targeted support and educational programs for clients from a non-English-speaking background and their families. These positions were to have a primarily clinical focus but were to include secondary consultation and assessment, staff development, consumer and caregiver support and education activities, and community education (7).

The mental health branch agreed to "pump-prime" this program by providing additional funding for one year for half the positions. The positions were included in the ongoing budget of services after the first year. By the end of 1997, a total of 11 positions had been created and filled. The languages spoken by staff included Croatian, Greek, Italian, Macedonian, Turkish, and Vietnamese. An evaluation to be conducted over four years by the Victorian transcultural psychiatry unit was also funded.

Quality bonus program

The quality bonus strategy introduced new financial incentives for high-quality services, targeting in its first year—1996-1997—the areas of consumer and caregiver satisfaction, services to people from non-English-speaking backgrounds, and timeliness of data reporting. The inclusion of services for people from non-English-speaking backgrounds was partly prompted by research that had found that previous ethnic access policy had not been implemented in mental health services (8). The mental health branch developed an assessment tool to rate the achievement of service standards for clients from non-English-speaking backgrounds, as outlined in the policy document referred to above.

In January 1997 consultants were contracted to undertake an evaluation of the responsiveness of adult public mental health services to people from non-English-speaking backgrounds. All adult mental health services participated in the evaluation, which involved service visits, interviews with managers and key staff, and assessment of supporting documentation.

A report detailing outcomes of the evaluation was prepared for each service, highlighting strengths and weaknesses and pointing to potential areas of improvement. Additional funding was distributed to services based on the extent to which they had met the policy standards. After a review of the methodology, the evaluation was repeated for the 1997-1998 period. The second evaluation report concluded that "the service responsiveness evaluations have been a positive impetus for considerable development and improvement activity" and that the average scores on the rating scale had increased significantly since the previous year (9). It is noteworthy that staff at two clinics reported to the Victorian transcultural psychiatry unit that they believed their services had expended more energy on documenting proposed activities than on implementing them.

National initiatives

Two initiatives at the national policy level deserve mention, although limits on space prevent us from providing details. One initiative is the establishment of a national transcultural mental health network to promote a coherent, culturally appropriate national approach to mental health service development. The other is the inclusion of cultural awareness and sensitivity in the development of national standards for mental health services (10).

Conclusions

The programs and policies discussed in this article represent the most significant attempt yet to improve mental health services to ethnic minorities in Victoria. Whether the initiatives to improve services will be effective remains to be seen. Research is under way to examine the effects of the initiatives on service utilization and outcomes, including rates of utilization of community mental health services and outcomes for clients from non-English-speaking backgrounds.

Acknowledgments

The Victorian transcultural psychiatry unit is funded by the Victorian Government Department of Human Services. The authors thank Andrew Stripp and Val Gerrand for comments on a draft of this paper.

Mr. Ziguras is service development coordinator, Ms. Stankovska is service development officer, and Dr. Minas is director of the Victorian transcultural psychiatry unit at St. Vincent's Hospital, 41 Victoria Parade, Fitzroy 3065, Australia (e-mail, [email protected]). Mr. Ziguras is also a doctoral candidate in the School of Social Work at the University of Melbourne. Ms. Stankovska also works with Action on Disability Within Ethnic Communities in Melbourne. Dr. Minas is also associate professor of transcultural psychiatry at the University of Melbourne.