“Don’t talk your business”: Big and small actions to promote Black Women’s engagement with healthcare.

This week’s blog has been written by Dr Clare McFeely RM, BSc, MSc, PhD, PgCAP (@ClareUoG) & Tobi Adebayo RN, BN(Hons) from Nursing & Healthcare School (@UofGNurse), School of Medicine, Dentistry & Nursing, University of Glasgow, United Kingdom.

Clare McFeely Image (striped top, glasses)
Clare McFeely 
Tobi Abedayo Image (long hair)
Tobi Adebayo 

Black people are more likely to experience mental illness but less likely to access mental health services, than white people. Contact with mental health services is more likely to a consequence of criminal justice referral, compared to White people (1,2). Less attention is given to experiences of Black Women specifically, but our recent review indicates a similar pattern.


In the current political and social context (including activism, equalities legislation, inequalities sensitive practice, decolonisation of education settings), health professionals understand that Black Women’s experiences of accessing mental health services is a consequence of wider inequality; institutional and individual racism; and unequal representation and treatment of Black and Minority Ethnic groups in the healthcare workforce alongside perceptions of mental illness – overwhelming, persistent structural barriers, that require culture and systems change. Whilst social justice is a common motivator for working in healthcare, these barriers can feel beyond the scope of practice for small cogs in the big wheel.

In our recent systematised literature review (in preparation for publication), we identified barriers that echo across the healthcare spectrum. Barriers symptomatic of those overwhelming obstacles that are enacted on an interpersonal level, where there is space for small, but essential, movement to encourage engagement and trust.

We explored the literature relating to the intersection of race and gender on Black Women’s experience of Mental Health Services and found barriers including:
• The stigma of mental illness and consequent fear of exclusion, loss of employment, child custody or Right to Remain (3-5)
• The Strong Black Woman schema presenting barriers to help seeking (5-7)
• A lack of trust in health services rooted in generational experiences of abuse from Sim’s experimentation on pregnant enslaved women to the Tuskegee experiment which ended in 1975 (8)

At the intersection of race and gender, poverty, lack of autonomy in the workplace and unpaid caring roles (commonly childcare) created barriers to attendance (3,4,7,9). Each issue presents, and is perpetuated, in everyday healthcare encounters. For example, a pervading lack of trust, founded on perceptions of health services as “white services” created for and delivered by white people (10), is reinforced in Black women’s experiences of having their distress minimised by staff who demonstrated little understanding of their daily realities. Negative experiences such as these, in any health setting deterred future engagement with mental health services (4).

How then, do we signal recognition, respect and openness? Professional duties of conduct and candour; patients charters; shared decision-making and holistic, person-centred care, can promote trust but are often unnoticed by service users managing ill health and anxiety. We propose that opportunities lie in the detail of our everyday conversations. How do we demonstrate our knowledge of ‘big’ issues in patient interactions? Can we articulate how these issues affect health and care to service users? Do we foreground current limitations and invite discussion: “People have told us this service is not well designed for their needs….” or “We know some people worry about confidentiality…..” Do we ask: “How do you feel about coming here?” “What would you like us to do for you?” Could we challenge stigma by promoting help seeking and self-care as strengths or offer appointments at an accessible time and place?

Small cogs can disrupt the momentum of the big wheel.

1. MIND 2020, Inequalities for Black Asian and Minority Ethnic communities in NHS mental health services in England, https://www.mind.org.uk/media/6484/race-equality-briefing-final-oct-2020.pdf.
2. Myrie, CV & Gannon, K 2013, ‘“Should I really be here?” Exploring the relationship between Black men’s conceptions of wellbeing, subject positions and help-seeking behaviour’, Diversity and Equality in Health and Care, vol. 10, no. 1, pp. 1-22.
3. Woodward, J, White, J, Kinsella, K & Robinson, M 2016, ‘The Mental Health Support Experiences of Black Women, born outside of the UK, in Leeds’.
4. Edge, D & MacKian, S 2010, ‘Ethnicity and mental health encounters in primary care: help-seeking and help-giving for perinatal depression among Black Caribbean women in the UK’, Ethnicity & health, vol. 15, no. 1, pp. 93-111.
5. Edge, D 2007, ”We don’t see Black women here’: An exploration of the absence of Black Caribbean women from clinical and epidemiological data on perinatal depression in the UK’, Midwifery, vol. 24, no. 4, pp. 379-389.
6. Nelson, T, Shahid, N & Cardemil, E 2020, ‘Do I Really Need to Go and See Somebody? Black Women’s Perceptions of Help-Seeking for Depression’, Journal of Black Psychology, vol. 46, no. 4, pp. 263-286.
7. Sisley, E, Hutton, J, Goodbody, L & Brown, J 2011, ‘An interpretative phenomenological analysis of African Caribbean women’s experiences and management of emotional distress’, Health & social care in the community, vol. 19, no. 4, pp. 392-402.
8. Suite, DH, La Bril, R, Primm, A & Harrison-Ross, P 2007, ‘Beyond misdiagnosis, misunderstanding and mistrust: relevance of the historical perspective in the medical and mental health treatment of people of color’, Journal of the National Medical Association, vol. 99, no. 8, p. 879.
9. Waite, R & Killian, P 2008, ‘Health Beliefs About Depression Among African American Women’, Perspectives in Psychiatric Care, vol. 44, no. 3, pp. 185-195.
10. Memon, A, Taylor, K, Mohebati, LM, Sundin, J, Cooper, M, Scanlon, T & de Visser, R 2016, ‘Perceived barriers to accessing mental health services among black and minority ethnic (BME) communities: a qualitative study in Southeast England’, BMJ open, vol. 6, no. 11, p. e012337.

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