Article Text
PDF
Abstract
Background Culturally competent early mental health interventions for ethnic minorities (EMs) with no formal diagnoses are needed.
Objectives To determine whether 8–12 weeks culturally adapted counselling (CAC) is better than waiting (waitlist (WL) group) to reduce depressive and anxiety symptoms and stress levels among EMs with elevated mental distress.
Methods Hong Kong EMs with mild and above-mild mental distress were randomly assigned to CAC or WL in this pragmatic, randomised, WL-controlled trial. The CAC group received the intervention after randomisation and the WL group received the intervention after 8–12 weeks (T1). The prespecified primary outcomes were depressive and anxiety symptoms and stress levels measured by the Depression, Anxiety and Stress subscales of the Depression, Anxiety and Stress Scale (DASS-D, DASS-A and DASS-S, respectively) at postintervention (T1, 8–12 weeks).
Findings A total of 120 participants were randomly assigned to either CAC (n=60) or WL (n=60), of whom 110 provided primary outcome data. At T1, CAC led to significantly lower depressive and anxiety symptom severity and stress levels compared with waiting, with unstandardised regression coefficients of −8.91 DASS-D points (95% CI −12.57 to −5.25; d=−0.90),–6.33 DASS-A points (95% CI −9.81 to −2.86; d=−0.68) and −8.60 DASS-S points (95% CI −12.14 to −5.06; d=−0.90).
Conclusions CAC clinically outperformed WL for mild and above-mild levels of mental distress in EMs.
Clinical implications Making CAC routinely available for EMs in community settings can reduce healthcare burden.
Trial registration number NCT04811170.
- Depression & mood disorders
Data availability statement
Data are available on reasonable request (supplement 5).
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
Statistics from Altmetric.com
WHAT IS ALREADY KNOWN ON THIS TOPIC
Few interventions have been developed specifically for ethnic minorities (EMs), and existing approaches such as counselling have not been investigated among EMs in Asian countries.
WHAT THIS STUDY ADDS
In this randomised clinical trial of 120 participants with mild and above-mild levels of mental distress, culturally adapted counselling (CAC) led to significantly greater reductions in depressive and anxiety symptom severity and stress level at postintervention compared with waiting.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Incorporating CAC into standard mental health practices could substantially enhance the accessibility of mental healthcare for ethnic minority individuals, effectively reducing their mental distress.
Introduction
A greater emphasis has been placed in recent years on the need to resolve the mental healthcare disparity,1 2 but there continues to be a scarcity of scholarly investigations focusing on ethnic minority (EM) groups, particularly those residing in Asian countries. In Hong Kong, the South Asian EM population, primarily consisting of individuals from India, Pakistan, Bangladesh and Nepal, has increased substantially in the past decade, growing from 65 521 to 101 969 individuals.3 Lower socioeconomic statuses and challenges in assimilating to the prevailing culture due to unfair treatment and a lack of social support lead to increased mental distress4 and difficulties in obtaining effective psychological assistance in the community. The current body of research pertaining to mental health interventions tailored for this subgroup is presently inadequate, underscoring the pressing need to rectify this insufficiency within the academic and clinical literature.
Significant proportions of mental health intervention studies in the literature pertain to individuals who have already received a formal psychiatric diagnosis,5–7 which may not be sufficient for addressing the broader mental health needs of ethnically marginalised communities. More of these individuals with mental health concerns may go undiagnosed and untreated owing to the limited availability of professional mental health services,8 stigma9 and misperceptions.10 Implementing interventions that specifically target undiagnosed groups can effectively augment awareness of mental health issues at the population level and encourage individuals within these communities to seek appropriate assistance.
The current study addresses this need by examining the effect of a counselling service for South Asian EMs in Hong Kong which is characterised by cultural sensitivity. Although counselling is a widely recognised therapeutic approach that can help individuals cope with various mental health challenges in the primary care setting,11 it has not been documented in the EM population, let alone in Asian countries. Traditional counselling methods may not adequately address the unique cultural and contextual factors that contribute to mental distress among EMs.12–14 Therefore, tailoring counselling interventions to fit the cultural values, beliefs and practices of the target population is needed. The culturally adapted counselling (CAC) service was developed through a collaborative process involving mental health professionals, community leaders and members of the target population. This intervention ensures language and cultural competence, counsellor’s cultural competence, appropriate adaptations on therapy model and cultural sensitivity, and an understanding of cultural similarities and differences in order to tailor-meet the specific needs and cultural context of the South Asian EMs.
In this study, we report the findings of a randomised controlled trial (RCT), comparing the effect of CAC to that of waiting (waitlist; WL) for EMs experiencing at least a mild level of mental distress and who were not receiving formal professional services. The predetermined primary hypothesis was that after CAC, depressive and anxiety symptom severity and stress levels would decrease greatly, from pretreatment to posttreatment, compared with those after WL. This study’s findings should inform other Asian countries or cities with larger populations of South Asian EMs, such as Singapore, Japan and Taiwan, when considering the potential clinical effects of CAC. Furthermore, by targeting undiagnosed populations, our study has the potential to promote mental health awareness, reduce stigma and encourage help-seeking behaviour within South Asian EM communities, ultimately contributing to improved mental health outcomes and overall well-being for this underserved population.
Methods
Participants
This pragmatic, 1:1 allocation, randomised, WL-controlled study compared CAC (n=60) and WL (n=60) for EMs experiencing mild or above-mild levels of mental distress (figure 1). The trial was conducted between January 2021 and August 2022 on a pilot community EM mental health service platform organised by The Zubin Foundation (TZF), which is a local non-profit organisation primarily serving EMs in Hong Kong (see the online supplement file 1). South Asians residing in Hong Kong (excluding domestic helpers) between 16 and 64 years old who spoke English, Hindi, Urdu or Nepali and had self-reported mild or above-mild levels of mental distress (10 on the Depression Subscale (DASS-D), 8 on the Anxiety Subscale (DASS-A) or 15 on the Stress Subscale (DASS-S) of the 21-item Depression, Anxiety and Stress Scale (DASS)) were recruited.15 Each DASS subscale comprised seven items measuring the respective negative emotional state in the past 7 days. Each item was scored on a 4-point scale, ranging from 0 (did not apply to me at all) to 3 (applied to me very much most of the time), yielding the total score for each subscale ranging from 0 to 21. To match the cut-off derived from the 42-item version of the DASS, the scores were doubled, with a higher score indicating a more severe negative emotional state of depression, anxiety or stress. The psychometric properties of the English, Hindi, Urdu and Nepali versions were validated across different study samples.16 Domestic helpers in Hong Kong (primarily Filipinos) were excluded from the study to maintain a more homogeneous sample, because they are a distinct subgroup of the population with a variety of stress factors, for example, long working hours, low income, relationship problems with employers and homesickness.17 Participants who belonged to high-income families (≥ HKD7500/person for a 6-person family up to HKD15 000/person for a 1-person family), were receiving any psychiatric or structural psychological intervention, had issues with substance abuse, had active suicidal ideation or engaged in self-harm behaviours were excluded from the study. All participants provided written informed consent or parental consent if they were younger than 18 years. This study followed the Consolidated Standards of Reporting Trials reporting guidelines.
Study design. CAC, culturally adapted counselling; WL, waitlist.
Procedures
Participants were recruited through social media and outreach activities of the TZF. Baseline assessments were completed before the random assignment. To ensure allocation concealment, we employed a centralised, web-based randomisation system within the Qualtrics platform. This system was designed to automatically assign participants to either the intervention or control group without any involvement from the researchers. Access to the randomisation sequence was impossible, as the allocation was entirely machine-initiated based on specific rules, such as random block sizes of 4 and 8. Participants were stratified into two groups based on their highest scores among the three DASS subscales. Those who scored 10–20 on the DASS-D, 8–14 on the DASS-A or 15–24 on the DASS-S were randomised within the mild-moderate strata, while those who scored above 20, 14 or 24 on the three subscales were randomised within the severe to extremely severe strata. The CAC group completed self-reported measures at baseline (T0), postintervention (T1) and postbooster (T2), while the WL group completed the same measures at baseline (T0), post-WL (T1), postintervention (T2) and postbooster (T3). The participants were administered assessments via a Qualtrics survey with the assistance of a skilled research assistant, either in-person or remotely through Zoom. All self-report questionnaires were translated into English, Urdu, Hindi and Nepali by a professional organisation in Hong Kong that supports medical interpretation services, before the study launch. Participants were compensated with up to HKD1200 (US$153) on completion of all assessments.
Intervention
Following randomisation, participants assigned to the CAC group received counselling services from experienced South Asian counsellors from TZF, whereas those assigned to the WL group had to wait 8 or 12 weeks (depending on whether they belonged to the mild and moderate or severe and extremely severe groups, respectively) before receiving counselling. The cultural-adaptive features of the intervention can be found below, and the detailed treatment manual can be obtained from the corresponding authors with justification. The counsellors who participated in our study included social workers and mental health counsellors, with varying levels of experience ranging from 2 to over 10 years in the field of mental health counselling. They were carefully selected based on their expertise and demonstrated proficiency in providing mental health support. Prior to their involvement in the study, all counsellors underwent a two-session training on the treatment manual and received weekly supervision to discuss their progress, address any challenges and receive ongoing guidance from the lead counsellor to ensure consistency and adherence to the intervention protocol. This two-session training included an overview of the study’s objectives, a detailed review of the intervention techniques and role-playing exercises to practise the delivery of the intervention. Owing to the COVID-19 pandemic, the original intervention manual, which was created for the face-to-face modality, was later modified to fit the online modality. Each counselling session lasted for approximately 1 hour and was available in English, Hindi, Urdu and Nepali (based on a participant’s preference). The number of sessions was also based on the level of mental distress: those with mild to moderate levels received six sessions over an 8-week period, while those with severe to extremely severe levels received ten sessions over a 12-week period. Within a month of the main intervention, the participants received two 1-hour booster sessions. The general officers of the TZF called the WL group every 2 weeks for a quick update to ensure that none of them was actively contemplating suicide or had deteriorated and required immediate medical attention.
The culturally adaptive features of the intervention are as follows:
Language competency: One of the key aspects is employing counsellors proficient in the common languages spoken by the South Asian population in Hong Kong. This language proficiency should facilitate effective communication and allow clients to express their concerns in their native languages.
Culturally informed counsellors: Counsellors come from South Asian backgrounds and possess a deep understanding of the cultural aspects shared by the South Asian population are preferred (see online supplemental file 2a for further information). This knowledge enables them to better address culture-specific issues and helps clients feel understood and comfortable during therapy sessions.
Adaptive therapy model: The therapeutic approach is tailored to meet individual client needs, taking into account their cultural backgrounds and preferences. For example, religious coping strategies, such as prayers, can be incorporated into emotional management tools, based on clients’ beliefs. The counselling style can also be adjusted to focus on emotional regulation and problem-solving strategies for clients who may not be comfortable with cognitive restructuring due to cultural factors.
Ongoing cultural sensitivity supervision: To ensure that the changes introduced were culturally sensitive, ongoing supervision and training for counsellors are needed. This includes regular discussions on cultural issues encountered during therapy sessions (see online supplemental file 2b for further information), sharing experiences and insights, and refining the intervention strategies accordingly.
Able to address cultural similarities and differences: While there are common cultural aspects shared by the South Asian population, we recognise that there might be slight differences among English-speaking, Hindi-speaking, Urdu-speaking or Nepali-speaking clients (see online supplemental file 2c for further information). Our counsellors, being knowledgeable about these cultural nuances, were able to adapt the intervention strategies according to each client’s specific cultural context.
Supplemental material
Measures
Participants reported their sociodemographic characteristics, exposure to lifetime traumatic events and recent stressful life events, and family psychiatric history at baseline. The primary outcome measures included the severity of depressive symptoms, anxiety symptoms and stress levels assessed using the DASS-D, DASS-A and DASS-S, respectively, at T1. The secondary outcome was mental-health-related quality of life (MH-QoL) at T1. It was assessed using the mental component score, ranging from 0 to 100, derived from the 12-item Short Form Health Survey (SF-12),18 with higher scores indicating better MH-QOL. Additionally, the study collected data on other measures to further understand the intervention’s impact on outcomes. Further details on these measures can be found in online supplemental file 4 eTable 1.
Statistical analysis
Statistical analyses were performed using SPSS V.28 and R V.4.2.2 for Mac. The sample size was determined aiming to detect a between-group effect size of 0.58, based on the difference between the reported between-group effects of non-directive counselling.19 Recruiting 60 patients into each arm provided 80% power with a 5% alpha and a two-sided t-test, while allowing for 20% attrition at T1. Therefore, a total sample size of 120 was needed.
Outcome evaluation
Between-group differences were estimated using generalised linear models, adjusting for significantly different baseline variables between the groups. The unstandardised coefficients and effect sizes (Cohen’s d) with 95% CIs were calculated. P values for primary outcome measures that required correction for multiple testing were false discovery rate-corrected using the Benjamini and Hochberg method. We used the intention-to-treat principle (ITT) for all outcome measures, with the baseline observation carried forward approach as the primary analytical approach for missing data. This approach assumes no changes in outcome measures for participants with missing T1 data. Additionally, we employed multiple imputations (MI) as a secondary analytical approach, generating 50 imputations per missing value. To maintain consistency between the imputation and analysis models, we incorporated the group variable, all baseline variables, and T1 variables into the imputation model as the auxiliary variables.20 We also conducted a per-protocol (PP) analysis to estimate the maximum possible effect size of CAC. This analysis excluded participants in the CAC group who completed less than 80% of the counselling sessions, as well as any participants who missed measurements. Furthermore, we performed exploratory subgroup analysis to evaluate the robustness of our results across participants with diverse profiles, using 1000 bootstrapped samples.
More detailed information on the above and supplementary analyses can be found in the eMethods section of online supplemental file 4.
Results
Participants
As shown in figure 2, this study screened 204 participants, of whom 120 were enrolled in the trial (participation rate, 60%): 60 were randomly assigned to the CAC group and 60 were assigned to the WL group. At T1, assessments were completed with 53 (88%) and 57 (95%) patients in the CAC and WL groups, respectively.
CONSORT flow diagram (CAC for EM study).The reasons for withdrawal at T1 can be found in online supplemental file 3. CAC, culturally adapted counselling; CONSORT, Consolidated Standards of Reporting Trials; EM, ethnic minority; ITT, intention to treat; WL, waitlist control.
Baseline characteristics were similar between the groups, except for duration of stay in Hong Kong (table 1), perceived social support from family members and significant others, and cultural orientation in pride (online supplemental file 4 eTable 2). Most participants were female (101, 84.2%), Pakistani (49, 40.8%) or Indian (36, 30.0%), and had completed postsecondary school education (69, 57.5%). The participants’ median (IQR) age was 29 (22–37) years. Baseline characteristics were compared between T1 assessment completers and non-completers, with no significant difference found (online supplemental file 4 eTables 3 and 4), and between counselling completers and non-completers (online supplemental file 4 eTables 5 and 6), finding that counselling completers were more likely to be homemakers with children than be unemployed individuals.
Sociodemographic of participants (N=120)
Outcome evaluation
Table 2 presents the primary outcomes. Participants in the CAC group exhibited lower depressive symptoms (effect size, −0.90; 95% CI, −1.30 to −0.54; p<0.001), anxiety symptoms (effect size, −0.68; 95% CI, −1.06 to −0.32; p=0.02), and stress levels (effect size, −0.90; 95% CI, −1.30 to −0.54; p<0.001) than those in the WL group. For secondary outcomes, participants also exhibited greater improvement in MH-QoL (effect size, 0.99; 95% CI, 0.63 to 1.39; p<0.001) than did those in the WL group. The observed differences remained robust in both sensitivity analyses, using ITT with multiple imputations and the PP approach (online supplemental file 4 eTables 7 and 8).
Depressive and anxiety symptom severity, stress level and mental health-related quality of life: regression-model results at T1 between participants in the CAC group and WL group
Supplementary analyses
The results of the reliable change analysis, subgroup analysis, between-group comparison of the impact of the CAC intervention and mediation analysis, are detailed in the eResults section of online supplemental file 4.
Discussion
This study’s findings indicate that CAC was effective in reducing depressive and anxiety symptom severity, and stress levels, and improving MH-QoL at T1. With no serious adverse events or observable negative effects attributable to the interventions, and approximately 1/10 of the contacted service users with active suicidal and self-harm risks receiving support and referral to formal psychiatric services, the programme is regarded as effective, supportive, and safe for the EM population, with subclinical or above levels of negative emotional state. The findings of this study are consistent with prior research that emphasises the significance of cultural adaptation in the implementation of mental health interventions for diverse populations.21 Our findings also contribute to the emerging evidence on the effectiveness of counselling interventions for undiagnosed individuals in community settings.22
In this study, counsellors from ethnic backgrounds similar to those of the target group were trained and supervised to deliver CAC. For the findings to be implemented, adhering to this training and supervision process is crucial. Future research should seek to extend these findings, for instance, by incorporating more long-term assessments or qualitative investigations to enable a more thorough examination of the trajectory and mechanisms of change and identifying processes that require extra cultural sensitivity. While implementing the research results in standard clinical practice is notoriously difficult, future research should investigate the factors that facilitate the successful implementation of CAC among EMs to expedite the path to the recipient’s benefit and ensure the fidelity of the approach. Future research should assess the comparative efficacy and acceptability of CAC and other behavioural therapies commonly used for mental distress. Although a previous study reported that culturally adapted CBT for South Asian individuals in Canada delivered by individuals who did not belong to the target group but had high willingness to be trained can also achieve positive outcomes,23 there is still a need to explore the application of this approach for South Asian EMs in Asian countries. Indeed, several prior local studies have indicated that non-indigenous therapists face challenges in adequately addressing the mental health requirements of ethnically diverse populations.4 9
The results corroborate and extend the findings of previous RCTs on the effect of counselling on mental health in general.11 These previous RCTs found that counselling is effective in reducing depressive or anxiety symptom severity in individuals with formal psychiatric diagnoses. However, they could not answer the important question regarding whether counselling is a clinically effective early intervention for those with subclinical symptoms or with diagnosable severity of symptoms who were not receiving a formal psychiatric service and pharmacological treatment or that regarding the effect of counselling that is culturally adapted for EM groups. The findings of our study found that CAC appears to have specific effects on rumination, perceived subjective well-being deficits, problems/symptoms and risk/harm (given the effects on rumination and CORE-OM scales). These findings are consistent with literature that supports the effects of treatments aimed at enhancing thinking skills, such as CBT, in reducing rumination.24 Additionally, incorporating a humanistic approach in these interventions may contribute to an individual’s subjective improvement in their perception of their illness.25 26 Nonetheless, future research should investigate the mechanism of these effects in more detail. Regarding secondary outcomes, we found that CAC also had superior effects on postintervention MH-QoL, potentially extending its benefits from symptoms to functions (given that the SF-12 measures functional-based QoL). The RCTs recruited EMs from a wide variety of backgrounds and the robustness of the CAC effects in different subgroups of backgrounds suggests that the findings are highly generalisable. Given that baseline assessments were performed without knowledge of the treatment assignment, the outcome measures were self-reported, the treatment arm was concealed during data analysis, attrition was low and the possibility of bias was minimal.
Our findings suggest that CAC, as an early intervention for mild to moderate depression, anxiety and stress, would enhance outcomes compared with minimal monitoring call support. Consequently, administering CAC routinely in the community as an early intervention for EMs with elevated mental distress should yield promising effects. This would be particularly important for EMs to have choices. Presently, only public healthcare services are practically available for EMs; however, they are perceived to lack cultural competence and are less affordable than private services.
Strengths and limitations
This study adds to the literature by focusing on an understudied population, South Asians in an Asian city, especially those without a psychiatric diagnosis. Our culturally sensitive, tailored intervention serves as a crucial resource for clinicians and researchers working with this population. Moreover, we assessed various psychological constructs beyond traditional symptom reduction, offering a comprehensive understanding of the intervention’s impact on participants’ well-being and functioning. It is believed that our findings contribute to the development of more targeted and effective interventions for diverse populations, ultimately leading to improved mental health outcomes for these individuals. However, this study also had some limitations. Approximately 20% of service users were not evaluated because they did not complete the baseline assessment; however, they were not barred from CAC and its advantages. As we used a pragmatic design, we adopted a WL control group; therefore, we could not determine the specificity of CAC in terms of efficacy. Future studies should employ psycho-educational control groups to delineate the specific effects of CAC on contact hours. The translation of scales lacking a version in the required language was outsourced to an external reputable professional organisation. Although the multilayer proofreading system ought to result in acceptable work quality, there is still a possibility that the translated version may slightly deviate from the original intent of the scale. A similar issue may have occurred when the TZF assisted participants in comprehending the questionnaire questions. A longer follow-up was not possible in the current trial because it was a pilot programme with limited resources; this should be examined further in the future.
Conclusions
This study concluded that CAC was superior in reducing depressive and anxiety symptom severity, stress level and MH-QoL at postintervention compared with waiting for EMs experiencing evaluated mental distress and not receiving formal psychiatric services or structural psychological intervention. If this study’s findings are incorporated into routine practice, it would result in a substantial increase in the number of EMs who recover from significant mental distress using services with positive effects.
Data availability statement
Data are available on reasonable request (supplement 5).
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and the trial protocol was approved by the Institutional Review Board of the University of Hong Kong Hospital Authority Hong Kong West Cluster (reference no.: UW 20-734). Participants gave informed consent to participate in the study before taking part.
Acknowledgments
We acknowledge the participants in the current evaluation study conducted in the Ethnic Minorities Mental Well-being Centres as well as the members of the advisory group: Prof. Bhugra Dinesh, Dr. Roger Ng and Dr. Paul Wong, who received no compensation. We also thank all counsellors and project officers who contributed significantly to the success of this study.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
YNS and EYHC are joint first authors.
Twitter @namsuen
Contributors Guarantor: EYHC and YNS had full access to all data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: EYHC, YNS, MTHW, SM and WN. Acquisition, analysis or interpretation of data: all authors. Drafting of the manuscript: YNS. Critical revision of the manuscript for important intellectual content: EYHC, SMYW and CLMH. Statistical analysis: YNS and EYHE. Obtained funding: EYHC, MTHW, YNS, SM and WN. Administrative, technical or material support: EYHC, MTHW, YNS, SM and WN. Supervision: EYHC and MTHW.
Funding This work was funded by the Lee Hysan Foundation (service) and the Croucher Foundation (research).
Disclaimer The Lee Hysan Foundation contributed to the design of the study but had no role in the conduct of the study; collection, management, analysis and interpretation of the data; preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.