Reducing the barriers to accessing psychological therapies for Bengali, Urdu, Tamil and Somali...

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Reducing the barriers to accessingpsychological therapies for BengaliUrdu Tamil and Somali communities inthe UK some implications for trainingpolicy and practiceDel Loewenthal a Ahmed Mohamed b Samyukta Mukhopadhyay c

Kalai Ganesh d amp Rhiannon Thomas ea Roehampton University Whitelands College London UKb Department of Psychiatry University of Cambridge UKc Institute of Psychiatry Kings College London UKd Independent Research Consultatione Psychotherapy in private practicePublished online 21 Oct 2011

To cite this article Del Loewenthal Ahmed Mohamed Samyukta Mukhopadhyay Kalai Ganeshamp Rhiannon Thomas (2012) Reducing the barriers to accessing psychological therapies for BengaliUrdu Tamil and Somali communities in the UK some implications for training policy and practiceBritish Journal of Guidance amp Counselling 401 43-66 DOI 101080030698852011621519

To link to this article httpdxdoiorg101080030698852011621519

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Reducing the barriers to accessing psychological therapies for BengaliUrdu Tamil and Somali communities in the UK some implications fortraining policy and practice

Del Loewenthala Ahmed Mohamedb Samyukta Mukhopadhyayc Kalai Ganeshd

and Rhiannon Thomase

aRoehampton University Whitelands College London UK bDepartment of PsychiatryUniversity of Cambridge UK cInstitute of Psychiatry Kingrsquos College London UKdIndependent Research Consultation ePsychotherapy in private practice

(Received 20 October 2010 final version received 30 July 2011)

The aim of this research was to investigate the feasibility of achieving ImprovingAccess to Psychological Therapies (IAPT) for people from Black Asian andMinority Ethnic (BAME) communities living in the UK with specific referenceto Bengali Urdu Tamil and Somali speaking communities Focus groups werecarried out with each of the communities to investigate how they conceptualiseand experience lsquomental health issuesrsquo and what they do when faced with what theyregard as these issues A thematic analysis of the data suggested that participantsdid not fully understand common conceptualisations about mental health issuesnor did they know how to seek mental health support Implications of culturalbarriers and recommendations for IAPT outcomes for the four communities arediscussed

Keywords anxiety depression Improving Access to Psychological Therapies(IAPT) training Black Asian Minority Ethnic (BAME) thematic analysisBengali Urdu Tamil and Somali

Introduction

Disparities between Caucasian and Black Asian and Minority Ethnic (BAME)

communities in terms of access to experience with and outcomes in mental health

issues have been documented (Bhui Sashidharan Cannon McKenzie amp Sims 2003

Department of Health 2005 Health 2007a 2007b Fernando 2005 Health

Commission 2007) The Department of Health (2007a 2007b) stated that a key

mental health issue for BAME communities in the UK is low uptake of

psychologicaltalking therapies which it has been argued needs to change (Mulatu

amp Berry 2001) in order to achieve equality in mental health care across UK

communities It has been argued that a lsquocircle of fearrsquo (Sainsbury Centre for Mental

Health 2005) has developed preventing ethnic minorities from accessing mental

health services defined as services offering treatments support and advocacy to

persons experiencing disturbances to their mental health It was found that

individuals are frequently accessing services later and at a more critical stage than

Caucasian service users The Department of Health report conducted by Sashidhar-

Corresponding author Email dloewenthalroehamptonacuk

British Journal of Guidance amp Counselling

Vol 40 No 1 February 2012 4366

ISSN 0306-9885 printISSN 1469-3534 online

2012 Taylor amp Francis

httpdxdoiorg101080030698852011621519

httpwwwtandfonlinecom

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an (2003) considered reasons that mental health services in the UK are failing to

meet the needs of BAME populations The report recommended the development of

the cultural capability of mental health services in the UK and the importance of

engaging the community in order to improve mental health services for thesepopulations

Providing better mental health care for BAME communities arguably requires

significantly more than the efforts currently made within our mental health care

system in the UK (Fowles 2007) The barriers for people from BAME communities

have been stated to include practicalities such as languages used for health

information through to attitudinal challenges faced by mainly Eurocentric-focused

health professionals in understanding the cultural diversity of both the expression

and treatment of mental health problems (Bhugra amp Ayonrinde 2004 Fernando2005) Related to this Sass Moffat Bhui and McKenzie (2009) have identified that

ethnic matching is a significant factor in enhancing care pathways for BAME

communities in the UK

A background to questions of cultural impact on access to psychological

therapies will now be presented followed by a discussion of language and the

categorisation of BAME communities and other cultural considerations such as

family ties and religion affecting access to psychological therapies for Bengali

Tamil Urdu and Somali speaking communities (the research group)

Cultural background

Research has indicated that mental health professionalsrsquo lack of understanding aboutthe cultural background of BAME communities negatively impacts on service usersrsquo

access to psychological therapies (Ager 1993 Beiser amp Hou 2002 Danso 2001

Silove Sinnerbrink Field Manicavasagar amp Steel 2000 Sinnerbrink Silove

Manicavasagar Steel amp Field 1996 Watters 2001 Watters amp Ingleby 2004) In

addition to this these professionalsrsquo attitudes during their interaction negative

positive or neutral left an impression on service users (Boi 2000)

McKenzie and Bhui (2007) explore the need for providing a coherent and

integrated service for minority ethnic communities They argue that emphasis isrequired on considering patientsrsquo needs improvising with existing techniques and

therapies highlighting resolutions integrated with respect for diversity at all times

evidence-based practice and success in long-term goals

There has also been criticism that in the UK diversity classification comes under

broad categories lacking specific and clear structures (McDowell Coleman amp

Ferner 2006) This is considered further below in relation to the use of terms such as

lsquoSouth Asianrsquo In addition to a loss of cultural specificity there is also the potential

difficulty inherent in defining and imposing mental health issues based onunderstandings applicable to a dominant culture This has previously been illustrated

from the perspective of transcultural psychiatry (Ellis Kia-Keating Yusuf Lincoln

amp Nur 2007 Ellis MacDonald Lincoln amp Cabral 2008 Fernando 2005)

The categorisation of communities and language issues

The use of the term lsquoSouth Asianrsquo community used to encompass individuals from

India Pakistan Bangladesh and Sri Lanka is in reality arguably too broad to enable

research on relevant factors that affect access to psychological therapies for these

44 D Loewenthal et al

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linguistically religiously and culturally distinct communities Similarities in ethnicity

spoken languages or mother tongues may not imply similarities in culture These

have been shown to be distinctive in particular within the Tamil (Ravindran 2006)

and Bengali groups (Hossain amp Khan 2006) Only religion is considered as being acommon factor affecting access to mental health services for some individuals within

the South Asian community A lack of understanding of for example the geo-

political differences within the Bengali community is seen to create an instant barrier

between practitioner and service user (Gerrish 2000 2001)

Language emerges as a key barrier to peoplersquos use of health services (Murray amp

Buller 2007 Saha Fernandez amp Perez-Stable 2007) and requests for interpreters to

address mental health issues come particularly from four major linguistic minority

communities in the UK Bengali Somali Tamil and Urdu speakers Thesecommunities have been reported to ask for more translations when accessing mental

health services than other linguistic minority communities (Aspinall 2007) and these

communities were thus a particular focus for the National Health Service (NHS)

Trust which commissioned this work As such this research focused on these four

specific languages with regard to achieving Improving Access to Psychological

Therapies (IAPT) outcomes (IAPT 2008) The question of why these particular

communities request more interpreter services compared to other often larger

minority communities within the UK is an issue that is potentially of relevance butwhich fell outside of the scope of this research

Somalian service users may therefore be discouraged from accessing mental health

services due to language barriers (Bhui et al 2003 Fernando 2005 Health

Commission 2007 McCrone et al 2005 Pumroy 2008 Warfa et al 2006) An

example of this is the fact that the UK Department of Health has translated

psychological materials including computerised Cognitive Behaviour Therapy

(cCBT) into several languages but not as yet Somali (Department of Health 2007a)

In relation to primary care services in a more general sense rather thanspecifically psychological therapies Barron Holterman Shipster Batson and Alam

(2010) sought to investigate the awareness and views of ethnic minority community

members towards primary health care interpreting provision in Hertfordshire This

study identified the importance of the provision of high quality language

interpretation services for enabling access In particular this study highlighted the

importance of trust confidentiality accuracy and independence in an interpreter preferred to be from their own culture and gender (Barron et al 2010) This was an

issue that was also of concern for the participants in this research on access topsychological therapies

Other cultural considerations affecting access to psychological therapies for BengaliUrdu Tamil and Somali communities

Stigmas associated with mental health continue to exist within both majority and

minority communities living in the UK While the stigma associated with mental

health issues is thus not exclusively an issue for BAME communities there aredimensions of this which arise specifically for these minority groups For the

communities considered as the focus of this research negative connotations include

for example Somalis who have been shown to be not only shameful about mental

illnesses but also fearful of mental health professionals leading them to conceal

mental health issues (Whittaker Lewis amp Buchan 2005) Bradby et al (2007)

British Journal of Guidance and Counselling 45

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pp 24162417) offer a similar view on the particular negative connotations attached

to mental illness among people of South Asian origin

Family ties are seen to be of particular importance within the research group

communities as they greatly impact on culture hence influencing both access to

psychological therapies as well as individualsrsquo openness to mental health profes-

sionals and researchers (Finnstrom amp Soderhamn 2006 Lavender Khondoker amp

Jones 2006) Thus family and community issues in relation to the accessing of

psychological therapies appear to be of more importance for the research group

communities than for the dominant culture

Religion is another aspect shown to significantly impact upon service usersrsquo

perspectives with regard to accessing psychological therapies (Guerin Guerin

Diiriye amp Yates 2004 Whittaker et al 2005 for Somali communities Ramakrish-

nan 1984 Ravindran 2006 for Tamil communities Gerrish 2001 King Weich

Nazroo amp Blizard 2006 Lavender et al 2006 for Bengali and Urdu communities)

Religious observance is often seen as an alternative means of alleviating symptoms of

psychological distress and as is discussed below in relation to Jinns mental health

concerns are frequently understood within a religious framework that is not the case

for the majority increasingly secular community within the UK The implications for

offering a clinically based secular psychological therapies service are that such a

service may not be seen by service users as relevant or able to respond to their needs

as they understand them As will be discussed below this study found that the

participants in the focus groups reinforced previous literature on the significance of

religion in relation to accessing psychological services The question as to the

accessing of psychological therapies for members of these communities who are not

religious was not raised within the focus groups conducted for this study This is an

area potentially of interest for further research but was outside the scope of this

particular studyThe intention of this research was twofold to understand how mental health

issues in particular anxiety and depression are conceptualised and experienced by

people from BAME communities with particular reference to Bengali Urdu Tamil

and Somali speaking communities in the UK (the research group) and to explore

any potential implications of this for the accessing of psychological therapies services

by the communities As part of the Department of Healthrsquos IAPT initiative (IAPT

2008) which highlighted the disparity in access to psychological therapy between the

BAME communities and the mainstream population in the UK this research

commissioned by a London NHS Mental Health Trust aimed to investigate how

specific BAME communities Bengali Urdu Tamil and Somali conceptualise and

experience anxiety and depression both directly and indirectly and how these differ

from majority conceptualisations Secondly it aimed to gain more knowledge about

the feasibility of increasing access to psychological therapies in order to address the

disparity highlighted in previous research within these communities (Department of

Health 2007a 2007b 2009 Health Commission 2007)

Method

Design

In terms of method quantitative or mixed methods approaches to data collection

and analysis were considered but rejected as the focus of the research lay in


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explicating the lived experience of the participants as described A qualitative

approach to research was chosen which acts to gain insight into the individualrsquos

experiences (Corbin amp Strauss 1998) It was felt that in understanding the

significance of a given experience a method that allowed analysis of the participantrsquos

words and personal meanings that an experience might have for the individual would

be important (Harre amp Secord 1972) It is not suggested that a person may have

exact insight into their own motives but that one can gain an understanding of anexperience as lived through a description by the person who had the experience

Focus groups are group discussions organised to explore a specific set of issues

such as peoplersquos views and experience (Basch 1987 Kitzinger 1994) Although often

seen as a convenient way to simultaneously collect data from a number of

participants the method capitalises on communication between research participants

in the generation of data (Kitzinger 1995) This means that instead of the researcher

asking each person to respond to a question in turn participants are encouraged to

talk to one another interacting and commenting on each otherrsquos experiences and

points of view The method is particularly useful for exploring peoplersquos knowledge

and experiences

Previous research on mental illness within the research group communities

indicates that focus groups are frequently used as a research method (Barron et al

2010 Halcomb Gholizadeh Di Giacomo Phillips amp Davidson 2004) Focus groups

have been used in previous studies with the Somali community (Finnstrom amp

Soderhamn 2006 Gervais 2008 Green amp Thorogood 2004 Warfa et al 2006) the

Tamil community (Bradby et al 2007 Fernando 2005 Sadavoy Meier amp Yuk2004 Whitley amp Prince 2004) Urdu groups (Acharya amp Northcott 2007) and

Bengali groups (Hawthorne Rahman amp Pill 2003) suggesting their suitability for

researching issues within these communities

This study sought to consider community perspectives and the experiences and

understandings of members of these communities as part of these groups with

subsequent implications for them as individuals As such focus groups were chosen

as the most appropriate method for this type of research study to consider the

community perspective

Further vignettes followed by questionsprobes were chosen as the appropriate

method of enabling sharing of experiences within the focus groups Within the focus

group interview schedule vignettes of a person displaying anxiety and in turn

depression were presented to the focus group participants followed by questions

about the participantsrsquo experiences in relation to the vignette Vignettes have been

widely used as a data collection technique in qualitative research (Hazel 1995

Hughes 1998) Hughes (1998 p 381) describes vignettes as lsquostories about

individuals situations and structures which can make reference to important pointsin the study of perceptions beliefs and attitudesrsquo

Vignettes provide a valuable technique for exploring peoplersquos perceptions beliefs

and meanings about specific situations and are particularly useful in exploring

potentially sensitive topics that participants might otherwise find difficult to discuss

(Neale 1999) Use of vignettes within a lsquofocusrsquo group is becoming increasingly

popular with social researchers (Wilkinson 1998) Maclean (1999) writing on the

use of vignettes within focus groups commented that it encouraged even the quietest

group member to voice an opinion

According to principles that guide the use of vignettes in research the vignettes

were created in a way that made them appear plausible and real to participants and


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that contained sufficient context for participants to understand the situation

depicted The researchers then endeavoured to follow the vignette with questions

directed towards the beliefs assumptions and experiences of the participants with

regard to personal experiences of anxiety depression how participants cope withmental health issues limitations of mental health services and possible solutions for

the community involved

As a result for the purposes of this study mental health services were defined as

services carried out by mental health professionals in which treatments support and

advocacy to persons are offered to people experiencing mental health issues

(disturbances to their mental health) As a result this incorporates a breadth of

mental health services and professionals such as General Practitioners (GPs)

community mental health teams mental health nurses counsellors psychotherapistsoccupational therapists and clinical and counselling psychologists

The research also made use of respondent validation conducted on an individual

basis to consider how if at all the perspectives of participants as individuals differed

from those of the particular community interviewed (Silverman 2000) In particular

the aim of the interviews was to clarify the themes emerging from the focus groups to

ensure that the themes derived from the focus groups interviews were captured

accurately As Herrel et al (2004) p 349) argue lsquo otherwise possible misinterpre-

tation due to translation can occur and responses can be influenced by other focusgroup membersrsquo

Participant recruitment

As previously mentioned Bengali Urdu Tamil and Somali speaking communities

were sampled specifically for this study They form a particular focus for the NHS

Trust in that they have been reported to ask for more translations when accessingmental health services than other linguistic minority communities (Aspinall 2007)

The four samples of participants were recruited through the various Bengali

Urdu Tamil and Somali community associations with which the NHS Trust was in

contact sometimes working directly on mental health issues and IAPT The process

of selection was opportunistic sampling based on those who volunteered to take part

after having been invited to do so verbally by senior members of these community

associations In particular the recruitment method was seen as one that was

culturally acceptable to the selected communities With permission posters were alsoplaced in community buildings to advertise the study Those who volunteered were

then supplied with additional information about the study and informed consent was

required from each participant

Participants

Bengali community participants

Two focus groups were conducted for Bengali speaking participants The first group

consisted of eight female participants and the second group consisted of four female

and two male participants As participants were recruited through opportunistic

sampling there was an inconsistency in the malefemale participation ratio

With regards to the six respondent validation interviews four female participants

were recruited and two male participants


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014

Demographically the age group of all participants was 50 and above All

participants reflected Bangladeshi heritage and identified with Islam as their religion

Urdu community participants

Two focus groups were conducted with 21 participants in total The first group

consisted of 15 female participants and the second group consisted of six maleparticipants marking a separation of the groups based on gender

A further six participants (three males and three females) were selected for the

respondent validation interviews

Demographically the age group of all participants was 40 and above A variety of

participants were recruited whose origins reflected a diversity of the Urdu speaking

population Even though most participants were of Pakistani origins some

participants stated their heritage to be East African and even Indian The majority

of the participants stated Islam to be their religion

Tamil community participants

The two focus groups were made up of 18 participants in total The first groupconsisted of 10 males and the second of eight female participants making a

separation of the groups based on gender

For the respondent validation interviews six interviews were carried out with

four males and two females

All participants fell within the age range of 40 and above

Somali community participants


consisted of 14 female participants and the second group consisted of 10 male

participants marking a separation of the groups based on gender

A further six participants three males and three females were selected for therespondent validation interviews

Demographically the age group of all participants was 40 and above

Data collection and analysis

Two open-ended focus groups were carried out with each of the separate Bengali

Urdu Tamil and Somali groups with the Community Development Workers

(CDWs) present The CDWs were involved due to their knowledge of the community

and ability to aid set up and implementation of the focus groups The respondent

validation interviews were then conducted with six individuals from each of the

community groupsDue to cultural considerations the four researchers all of whom were themselves

born outside of the UK and in terms of their languages and cultural backgrounds

members of the respective communities relevant to this study conducted the focus

groups and respondent validation interviews with the male and female participants

separately (with the exception of the Bengali participants who requested mixed

gender participant groups) The focus groups and respondent validations for each


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group were carried out in the four languages by researchers who spoke these as their

first languages

It is important to note that before both the focus groups and respondent

validation interviews participants were supplied with information about the studyThis process included outlining confidentiality as well as the participantsrsquo right to

withdraw from the study In turn the study required a consent form to be signed by

each participant

Focus group interview schedule

Figure 1 details the interview schedule used in each of the focus groups Initially a

culturally appropriate vignette is read in which a person displaying anxiety is

Figure 1 Focus group interview schedule


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Figure 1 Continued


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described Following this certain questions are asked of the participants The process

is then repeated using a vignette describing depressive symptoms

Respondent validation interviews

Once the core themes emerged from the focus group data six different participants

from each of the communities were chosen from volunteers who had not taken part

in the focus groups and they were interviewed about the extent to which they

agreed or disagreed with the themes that had emerged from the first level interviews

(Figure 2)

Data analysis

Focus groups

The recorded focus groups were then transcribed and translated into English and a

thematic analysis of the data carried out by the four researchers (Braun amp Clarke

2006) The first step involved the researchers reading and re-reading each set of focus

group data noting down initial ideas and manually generating a list of initial codes

The data were then considered inductively and the researchers investigated what was

of relevance to the initial codes which was then identified as common to the entire

data set (Stiles 1993) No attempt was made at this stage to focus on the specific

research questions of this study Instead the intention was to be open to the

participantsrsquo entire data set which was seen to constitute the general themes

The second step involved generating initial codes by categorising features of the

data in a systematic fashion across the entire data set and collating data relevant to

each code focusing on the specific research questions of this study The themes were

then reviewed by checking to see if they correlated with both the coded extracts and

the entire data set The reviewed themes were then refined defined and named These

constituted the specific themes

Figure 2 Respondent validation interview schedule


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If the respondent validation interviews presented different perspectives on the

question to that of the focus groups the comments and criticisms from the

respondent validation interviews would be incorporated within the thematic data

analysis Alongside this incorporation the analysis would specify that the particular

information was provided as part of the respondent validation

However the data collected from the respondent validation interviews concurredwholly with the data collected from the focus groups and therefore the thematic

analysis did not require any modification to the data gathered as part of the focus

group stage indicating that the individual community members agreed with the

researcherrsquos findings from the focus group

Researcher reflexivity

Within this study the researchers acknowledged the requirement for reflexivity in

qualitative research in the self-exploration of the presuppositions held and decisions

made by the researchers This was particularly important as within the datacollection stages the four researchers collected data from their respective commu-

nities Therefore it was important that the researchers were transparent and reflexive

about their research process theoretical perspectives and researcher values in

maintaining the quality of the research (Seale Gobo Gubrium amp Silverman 2004)

As Nightingale and Cromby (1999 p 228) suggest personal reflexivity urges us lsquoto

explore the ways in which a researcherrsquos involvement with a particular study

influences acts upon and informs such researchrsquo

Further epistemological reflexivity requires us to engage with questions such ashow the research has been defined and how the methods have lsquoconstructedrsquo the

findings Thus epistemological reflexivity encourages us to reflect upon the

assumptions about knowledge that we have made in the course of the research

enabling us to consider the implications of the assumptions for the research (Willig

2001)

The researchers attempted to achieve researcher reflexivity through frequent

group supervision both prior to and throughout the research process where the

researchers would discuss their assumptions and processes with regard to theresearch as a group Researchers were also encouraged to keep research diaries

within which they reflected on different aspects of the research process and their role

within the construction of research knowledge (Blaxter Hughes amp Tight 2001) The

sharing of this information in group supervision sessions was paramount in enabling

researchers to consider the place they took in the research thereby ensuring the

quality of the research

Results

Following the thematic analysis (Braun amp Clarke 2006) the participantsrsquo experiences

were characterised by four common themes in relation to accessing psychological

therapies which emerged across all groups

(1) Understanding of lsquomental health issuesrsquo and available mental health services

(2) Cultural barriers to approaching service providers


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(3) Interpreter and General Practitioner (GP) services

(4) Religion

Each theme will now be discussed in turn using verbatim examples from theindividual participants to illuminate the theme


The findings across all focus groups indicate a lack of understanding of the Western

conceptions of depression and anxiety to differing degrees All 10 members of the

Urdu female focus group struggled with the concept of anxiety partially as stated

because there is no directly equivalent concept available in Urdu The Somali male

and female groups spoke of anxiety as a lsquonon-clinical disorderrsquo conceptualised by a

male Somali participant as lsquoa fleeting situational discomfort that passes awayrsquo even ifit lasts for a significant period of time Further the Somali participants indicated an

understanding of anxiety as a physical as well as emotional experience For Tamil

participants there was also a lack of knowledge of what are termed psychological

diagnoses such as anxiety As a female Tamil participant with a medical background

stated

Lots of people who come to us [GP surgery] do not have a clue of what they are goingthrough and that they suffer and live with it I am so surprised that therersquos still lack ofknowledge and awareness among this community

Similarly within the Somali community depression is conceptualised in a way that is

indistinguishable from everyday life struggles and survival Somali female partici-

pants had more understanding of lsquodisappointmentsrsquo lsquodepressive statesrsquo as well as

lsquobroken spiritsrsquo Female participants commented that families were lsquodrowning withthis plaguersquo and lsquothis darknessrsquo because they are lsquoalways downrsquo lsquothinking too deeprsquo

lsquobeing full with thoughtsrsquo and lsquofed up with life in generalrsquo They also described

hopelessness and commented that in some families lsquothe lights have been turned off rsquo

which could indicate something of how the family was functioning

However with regard to the concepts of lsquomental healthrsquo and lsquomental issuesrsquo the

participants related more easily to this concept It appeared that when discussing

lsquomental healthrsquo through the way in which the conversation flowed participants

across all four community groups and genders demonstrated more familiarity withthis as a conceptual framework Within the male and female groups a discussion of

lsquoPagolrsquo took place (the Bengali variation of the Hindi word lsquoPagalrsquo which directly

translates to denote stereotypes of intense madness and conjures images of

institutionalisation) which have a highly positive correlation to thoughts of shame

guilt and the urge to conceal any pertinent mental health problems Male and female

Somali participants used metaphors such as lsquoHe has jumped over the fencersquo or

lsquocrossed to the other sidersquo to describe the lsquomentally ill personrsquo

At the same time both the female and mixed gender Bengali focus groups spokeof a desire for more community-based interventions such as group sessions and

other talking therapies to increase awareness of this concept within the community

and as a means of enabling members of the community to access available services

The Urdu female group stated they were interested in lsquoinformal talksrsquo and awareness-

raising forums but to fulfil the same purpose All 10 of the Urdu female group felt


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03

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014

that group sessions would be a good way to start a dialogue for one to then move on

to one-on-one sessionsIn contrast to the Somali men the women generally were not aware of alternative

ways to receive mental health support Men on the other hand were more

knowledgeable about available psychotherapy and counselling services They

commented that they would refer people to use counselling services or a

psychotherapist if that professional was knowledgeable about the Somali culture

Only one of the youngest female participants commented that talking to the patient

can alleviate common mental disorders if such talking was specifically related to

asking the patient about how he was feeling not just lsquohow are you questionsrsquo

Somali participants asked for education about lsquocommon mental disordersrsquo as

they are understood within mental health in order to better understand the provision

of available services However the participants particularly mothers in the Somali

female group and fathers in the Somali male group raised fears about the role of

social services in terms of a fear that their children will be lsquosnatchedrsquo by social

services if they asked for support They distinctly requested more information on the

role of social services


While both the female and male Bengali participant groups identified isolation as a

major factor affecting depression and anxiety within the Tamil community there was

a strong feeling that speaking about psychological problems to others is wrong This

feeling was thought to be rooted in the culture Tamil participants admitted that they

keep their worries to themselves although this seemed to be more dominant among

the female group A discussion in the female Tamil group suggested participants were

more interested in seeing professionals lsquooutside the communityrsquo Further another

Tamil female spoke of how

My friendrsquos husband knows she has a problem and he blames her and because that canlead to divorce or separation she does not talk about it she just keeps it to herself andsuffering inside

Particularly the Bengali and Tamil focus groupsrsquo discussions focused on the negative

associations with lsquomadnessrsquo leading to thoughts of shame guilt and the urge to

conceal any pertinent mental health problems due to fears of being ostracised by the

community

Within the Urdu community the issue of lsquocoping alonersquo and not having an outlet

also arose Their need to cope alone was often spoken of in regard to being seen to be

lsquoPagolrsquo as a female Urdu participant suggested

Yoursquore still aware of words like pagal which can make you very aware of what you needto do to not be pagal and therefore it stops you from exploring what is really affectingyou because yoursquore too busy trying to not act lsquopagalrsquo what is pagal anyway

However the Urdu female participants also felt that they would rather cope on their

own because sometimes it is hard to articulate and particularly shameful to speak of

the experience of mental illness as a female Urdu participant described


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It can be seen to be shameful to admit to having any problems the best reaction is tocope alone and express your pain through physical reactions like crying

Similarly five Urdu male participants specified that it can be a cultural factor to

want to cope alone due to the patriarchal nature of the community They felt that

culturally some men are still bound to not display their emotions because of a need

to appear to remain strong for others

For the Somali groups an important theme that emerged was related to a

perceived need to escape from the community if a sufferer was diagnosed with mental

illness Participants commented that they know of people especially mothers with

children who have mental health problems but these mothers move out of the area as

they feel ashamed and stigmatised by the community It was expressed by the Somali

male focus group participants that issues surrounding mental health were not

tolerated well within the community

Seven of the Somali women in particular expressed a sense of helplessness in the

face of mental illness either their own or those of others because of their place

within the Somali community As stated within the male and female Somali focus

groups one perceived solution was to provide distraction For example they said

that they would consider getting the person married so that as a female participant

stated lsquothe wedding can take such things off their mindrsquo This also seemed apparent

within the Tamil participants One male participant spoke of how

In our community when we are depressed we make our hearts strong ourselves engaging in something perhaps to get that diversion


Two female Tamil participants referred to the potential use of lsquotalking to

professionalsrsquo as useful when experiencing psychological problems because as a

female Tamil participant suggested lsquogetting five minutes to talk to someone itself is a

big thingrsquo or as a second female suggested lsquofor example middle of the night you

might feel suicidal you canrsquot sleep at 2am and feel like talking to someonersquo

However within the Tamil male focus group the issue of language was spoken of as

a barrier to Tamils seeking GP support for a psychological problem A male Tamil

participant suggested

Typically Tamil people hesitate to talk in English so language becomes a barrier when itcomes to explaining their psychological problems to the GP When we approach a GPwe never specify we have a problem

One elderly Tamil female participant from India highlighted that she had been so

accustomed to her own way of culture back home and added that because she was

not able to converse well in English she felt that the GP did not understand her

problems properly resulting in an interpretation that was not correctHowever across the focus groups participants spoke of finding interpreter

services unreliable and non-confidential The Bengali participants in particular

expressed that they were generally wary of interpreters even if as one female

participant felt they lsquoare perhaps now being trained betterrsquo They expressed that they


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wanted the independence and freedom to talk about their issues directly with the

health professional rather than relying on someone to speak for them Within the

Urdu male and female groups although there seemed to be a general view that an

interpreter would be helpful when they visit the GP there was general disagreement

among the more elderly participants from both male and female Urdu focus groups

as a consequence of experiences where interpreters have not translated correctly to

the GP

Within the Tamil female focus group as discussion took place around

misinterpretation by interpreters one female participant said

I took my mom to see the GP because she cannot speak well in English she had a lot ofpain in her leg that day I couldnrsquot go and she needed an interpreter by luck I couldgo that day and mom said since interpreter was there let her explain the interpreterwas not explaining things properly what my mom was going through you know likethat so GP started asking me questions

There was a similar concern within the Somali groups in relation to interpreters

specifically in relation to concerns about not being able to find a professional

interpreter who would keep their problems in confidence A significant proportion of

the Somali focus group participants were worried and anxious about disclosing a

mental health problem both to the general practitioner and most importantly to

the interpreter There was a general consensus amongst the Somali male and female

participants that interpreters can gossip among themselves and within the commu-

nity and this can cause huge distress to the Somali mental health sufferer who is then

labelled for lifeIt was also expressed that once someone is known to have sought treatment for a

mental health issue they will be immediately stigmatised within the community and

this causes an indirect experience of anxiety in men and depression in women Using

interpreters thus caused most of the Somali participants considerable worry As

mentioned previously being ostracised was also a related and major concern for

them and indirectly influenced their willingness to access psychological therapy A

common solution to increase access to psychological therapies that Somali

participants asked for included the provision of lsquoprofessionally trained interpretersrsquoThe majority of the participants from the research group felt that their needs were

not addressed by their GP Most of the participants felt anxious and even depressed

when their GP did not understand and address their mental health problems because

of language and cultural barriers As such participants felt that GPs were not able to

clearly understand the concerns and distress from the participantsrsquo perspective

Perhaps unsurprisingly this view was different from for example those Urdu

and Tamil participants who were able to converse well in English often those from

younger generations though they also said that they would not normally go and see

the GP unless their problems were severe

Both Bengali focus groups however stated that their GP was the first port of call

for physical and psychological ailments However these Bengali participants stated

that they were adverse to the notion of medication as a solution to psychological

issues and preferred the option of talking therapies if supported within a cohesive

structural framework and particularly if based within the community


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014

(4) Religion

Religion seemed to play a dominant role for the Tamil community regardless of

whether they are Hindu Muslim or Christian in determining whether they want to

access mental health services For example when describing how he coped with

lsquosadness and depressionrsquo an elderly male Tamil participant also spoke of lsquokeeping it

within mersquo by lsquopraying to Godrsquo

Within the Bengali community religion seemed to still be a factor albeit less so

Three participants mentioned that when trying to cope with symptoms they would

on a few occasions turn to religion as a meditative and therapeutic outlet especially

if they felt that they did not want to burden another person with their problems or if

they wanted to remain strong for their other family members This was especially the

case if there had been a major traumatic event experienced by everyone such as the

death of a family member

For the Urdu community there was a significant emphasis on how religion and

culture impact on an individual Religion was discussed with particular reference to

Jinns supernatural creatures in Arab folklore and Islamic teachings which occupy a

parallel world to that of mankind as a concept Participants felt that within Islam a

belief in Jinns influences the conception of mental health within the relevant

communities and how mental health can be treated but is little understood by most

Western health professionals One participant stated that lsquowhether professionals

believe it or not they need to at least respect the privacy of onersquos thoughtsrsquo The

Urdu male group discussed the potential helpfulness of community-based interven-

tions that took into account the religious needs of Urdu speakers who are

predominantly Muslim and wanted interventions that could where appropriate

be used alongside religious teaching

Of the Somali participants a majority commented that they use the Qurrsquoan to

deal with mental illness This for example means that they would shower holy water

all over the patient in an attempt to lsquorescuersquo them and lsquowash away the bad spiritsrsquo

The groups expressed that increased understanding by the service providers of the

significance of religious beliefs would allow an appreciation by mental health

professionals of how people view mental well-being and the potential to tailor

services accordingly

Discussion

Given the Department of Healthrsquos (2007a 2007b) focus on increasing the low uptake

of psychologicaltalking therapies from BAME communities the findings in this

study seem to hold an important significance in uncovering and exploring some of

the cultural religious and language barriers to access to these services

In particular the findings support previous studies that suggest that deliberate

measures may need to be put in place in enabling BAME communities to seek

psychological support In general the study supported previous findings that suggest

that barriers to improving access for BAME communities may include cultural and

community-specific language disadvantages differences in cultural interpretations of

mental health and illness and mental health services through to problems accessing

available psychotherapeutic services (Bhugra amp Ayonrinde 2004 Fernando 2005)The findings of this study may particularly be seen to highlight the potential

problems that arise by imposing what may be considered medical conceptions of


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03

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014

common mental disorders such as lsquoanxietyrsquo and lsquodepressionrsquo onto minority

communities It is not to say that Bengali Urdu Somali and Tamil speaking

communities do not experience what from a Western perspective would be

understood as anxiety and depression but that the conceptualisation and under-

standing of this was shown to be significantly different from the focus group data

This highlights previous findings that suggest the potential danger in imposing

mental health issues based on understandings applicable to a dominant culture

without taking the patientrsquos culture into consideration (Ellis et al 2007 2008

Fernando 2005)In contrast it appeared that while lsquoanxietyrsquo and lsquodepressionrsquo were concepts that

were less culturally transferable between the majority and minority community group

samples lsquomental healthrsquo or lsquomental illnessrsquo seemed more universally understood by

these communities

Importantly the participant focus groups addressed the potential barriers to

accessing mental health advice and support such as language (both in practice and

in concept) and attitudinal challenges of the patient themselves (both cultural and

religious) as located in previous work (Bhugra amp Ayonrinde 2004 Fernando 2005)

A particular highlighted concern in the focus groups across the communities was a

distrust in interpreter services emerging as a potential key barrier to peoplersquos use of

health services (Murray amp Buller 2007 Saha et al 2007) as previously noted by

Bengali Somali Tamil and Urdu speakers

However in considering how one may increase knowledge and understanding of

available services to the Bengali Urdu Tamil and Somali populations the lsquogrouprsquo or

lsquocommunityrsquo was considered a potentially valuable asset in increasing access to

available psychological therapy services This may highlight the sense of the

importance for the research group of community-focused programmes often

managed within and by the community itself

The implications of this study in particular for improving access to psychological

therapies are important As Sashidharan (2003) recommended there must be a

development of the cultural capability of mental health services in the UK to form a

coherent and integrated service for minority ethnic communities which meets the

needs of patients (McKenzie amp Bhui 2007)

While three female participants mentioned the usefulness of seeking psycholo-

gical support from lsquoa professionalrsquo either the perception of participants in the focus

groups of services available and at times past impressions of service use acted as a

barrier to future use (Boi 2000) The findings suggest a need to develop specialist

primary mental health care and culturally sensitive GP services that can be easily and

flexibly accessed by BAME communities such as Bengalis Urdus Tamils and

Somalis and particularly for people whose first language is not English Such

specialist services should focus on understanding socio-cultural issues within the

specific communities as well as recognising shared common features Of significance

here would be to improve the understanding of GPs and other primary care

professionals as to cultural and religious influences potentially affecting access and

referral to mental health services such as the psychological therapies Similarly there

is a need to develop the training of interpreters to have more relevant knowledge of

dialects and develop greater awareness of the importance of confidentiality in this

culturally sensitive area (Saha et al 2007) These findings support the Barron et al

(2010) study which highlighted the importance of the provision of high quality


Dow

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ity o

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03

07 2

5 Ju

ne 2

014

language interpretation services for enabling access and the importance of trust

confidentiality accuracy and independence in an interpreter

With reference to IAPT a focus on what are understood within the majority

community to be specific conditions and the design of psychological treatment based

on this model can be seen to create a situation where many people within minority

communities such as those who were the focus of this study do not recognise the

relevance of the service for them In particular as within the male Somali community

focus group depression was conceptualised in a way that is indistinguishable from

everyday life struggles and survival for lsquodepressionrsquo to be treated as a separate

clinical condition both by GPs and within the psychological therapies would appear

an unfamiliar concept As explored by the participantsrsquo increased understanding of

the term lsquomental illnessrsquo framing the issues in these terms may be of benefit

At the same time if the service provision is to be focused on lsquocommon mental

disordersrsquo an alternative or parallel approach is to familiarise minority commu-

nities with these terms through for example the use of local education providers

(such as English for Speakers of Other Languages [ESOL] classes) and through

community workshops Such an approach arguably does not seek to impose Western

conceptions of mental health on minority communities but instead enhances

awareness of the context in which psychological therapy services are provided and

enables potential service users to understand the potential relevance of such

provisions for them

Further it has implications for the use of psychological therapies in that

approaches which seek to treat symptoms rather than to consider the individual in

the context of the community may be particularly inappropriate for the research

group communities

A further importance of lsquocommunityrsquo emerged from the research in that it was

felt that if understanding of the conditions that might cause a person to seek

psychological therapy particularly within the framework of UK NHS provision

were increased within the community the stigma could potentially be lessened The

distinction drawn here by the participants was thus one of the significance of an

initial change in attitude at community rather than individual level with consequent

implications for individuals

Of further significance for providers of psychological therapy services is the

acknowledgement of the wariness that many members of the research groupsrsquo

communities may have in approaching health professionals This seems particularly

important given that it has been noted that Asian Bangladeshi Asian Pakistani and

Black African individuals have more difficulties in engaging with and benefiting from

talking therapy services than the average non-BAME client (Gilleard Dennis amp

Ziyal 2005) Currently therefore despite the perception that GPs could not

understand the participants or their issues while this was mainly related to language

and cultural barriers arguably such concerns could be seen as projections of shame

about mental health issues onto the GPs and the NHS

Improving access to psychological therapies is perhaps in this context about

improving the accessibility of psychological therapies through improving relations

with communities in order to increase trust in the service providers This could allow

for improved accessibility to information and education for specific services such as

social services as it could be argued that the Somalisrsquo fear of social services had a

significant impact on the way they access therapeutic services and it could also


Dow

nloa

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ity o

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03

07 2

5 Ju

ne 2

014

perhaps explain why members of the Somali community are reluctant to seek mental

health advice (McCrone et al 2005 Pumroy 2008)

While this study reinforces many of the arguments put forward by for example

Wharfa et al (forthcoming) McKenzie and Bhui (2007) the findings here are

perhaps limited by a number of factors Firstly by carrying out consultation through

community associations the emphasis on the importance of the community and

community interventions may have been over-emphasised in that the volunteers who

came forward were those already involved with those community associations

Similarly the particular emphasis on religion as an influence on the conception of

mental health as of relevance for members of for example Somali and Urdu

communities may again have been drawn into particular focus due to contacting the

participants through their respective community associations which were often

religiously based

Additionally while the researchers were all themselves immigrants to the UK who

spoke either Bengali Urdu Tamil or Somali as their first languages it is perhaps of

significance that female researchers interviewed the Bengali Urdu and Tamil male

and female groups while a male researcher interviewed the Somali groups In relation

to the importance of cultural sensitivity acknowledged through the separation of the

focus groups into male and female the gender of the researchers and indeed the age

of the researchers two of whom were in their early twenties may have influenced

the findings in terms of their own place within the community they were researching

for example when speaking to older members or those of the opposite sex Parallel

to this is the issue that while the dangers of projection were discussed with the

researchers before the empirical phase was carried out the question arises as to

whether in the interpretation of the data as a thematic analysis it is possible to

bracket out fully the researcherrsquos own perspectives on the research question

In terms of the question of language which was a central issue for this study

while the interviews were conducted in the relevant community languages by a

researcher for whom that language was the first language it is acknowledged here

that in terms of validation the translation of the focus group findings into English

and then back into the original languages prior to the respondent validation phase

could have enhanced the reliability of these findings The limitation here was one of

time constraints but it is acknowledged that this could potentially have enhanced

understanding of the conceptualisations and provided a more developed idea of the

level of accuracy they achieved

There are implications of this study for individual and community-based

interventions and in particular for the training and professional development of

GPs interpreters and psychological therapists working with such BAME commu-

nities Further research into the design of training programmes for these groups is

now required

In turn this study has highlighted ethical implications for cross-cultural research

It has been suggested that researchers who are sensitive to and knowledgeable of

cross-cultural issues increase their chances of working in an ethical manner

particularly with participants from ethnic minority backgrounds (Ponterotto amp

Casas 1993) This study has suggested that research procedures can become more

ethically appropriate through an acknowledgement and incorporating of practices

relevant to the culture through activities such as cultural matching of researcher and

participant and awareness of specific issues such as gender during interview


Dow

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03

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ne 2

014

processes particularly when interviewing groups of participants or communities (Sue

amp Sue 1990)

This study has also highlighted the fact that researchers particularly when

researching different cultures need to be aware of the potential incongruence

between the researcherrsquos views and theoretical frameworks and those views of the

group or culture being researched Furthermore where differences occur they must

be respected and the researcher must take care not to project their own views ontothe research process or to judge the participantsrsquo views (Lee 1995) Thomason

(1999) suggests this is particularly important for cross-cultural research which

focuses on mental health issues in that researchers have tended to adopt Western

definitions of what constitutes healthy and normal functioning

Further research is needed to consider the impact of accessing talking therapies

primarily through doctors and the NHS One of the main endeavours of the Layard

Report (2006) was to move to a talking therapies intervention rather than a medical

one for mental health issues However the medicalisation of terms such as

lsquodepressionrsquo and the regarding of such conditions as lsquodisordersrsquo is different to what

is ordinarily meant by depression or anxiety

At the same time while this paper raises issues as to the different understandings

of these terms between what is assumed to be the dominant culture and those of the

research group communities a question arises as to what extent understanding of

lsquoanxietyrsquo and lsquodepressionrsquo as clinical disorders is different between health service

professionals and lay persons within the majority culture The findings here are that

the research groups have different understandings of what is meant by these terms

which may impact upon the extent to which they access psychological therapies

However it is possible that for example reluctance to accept pharmacological

intervention and to approach health service professionals and GPs is not somethingthat can be understood exclusively in terms of minority cultural factors

Conclusion

In conclusion this study aimed to explore how the Bengali Urdu Tamil and Somali

communities conceptualise and experience what health professionals term lsquoanxietyrsquo

and lsquodepressionrsquo and what they do when faced with what they regard as mental

health issues with implications of this for the training of staff involved Overall it is

suggested that common mental disorders such as lsquoanxietyrsquo and lsquodepressionrsquo were not

clearly understood within the focus group discussions across the four community

groups The findings highlight that cultural language and religious barriers were

thought to exist for the participants in seeking mental health support This may hold

important implications in particular for IAPT in creating culturally sensitive

psychological programmes programmes which through increased knowledge within

the minority communities could be more relevant for the clients Further education

at a community level could be useful in promoting services alongside promoting

mental health issues and in turn decreasing the associated stigma

Notes on contributors

Professor Del Loewenthal is Director of the Research Centre for Therapeutic EducationDepartment of Psychology Roehampton University He is also in private practice inWimbledon and Brighton He trained as an existential analytic psychotherapist at the


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03

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5 Ju

ne 2

014

Philadelphia Association and is a chartered psychologist His publications include Post-existentialism and the Psychological Therapies Towards a Therapy without Foundations(-Karnac) and Critically Engaging CBT (co-edited with Richard House 2010 PCCS Books)He is currently writing Phototherapy and Therapeutic Photography in a Digital Age(Routledge)

Ahmed Mohamed worked as a Research Assistant for the Research Centre for TherapeuticEducation He is currently doing a PhD at the Department of Psychiatry University ofCambridge focusing on neuroethics of cognitive enhancement Ahmed is interested inclinically and ethically investigating the best way of using cognitive enhancement drugs andneuroimaging techniques on healthy volunteers and patients with neuropsychiatric disorders

Samyukta Mukhopadhyay completed her undergraduate degree BSc(Hons) in Psychology atGoldsmiths University of London in 2008 and then worked as a Research Assistant at theResearch Centre for Therapeutic Education She is currently pursuing an MSc in ForensicMental Health Sciences at the Institute of Psychiatry Kingrsquos College London with an interestin re-victimization of individuals with mental health needs and their experiences of theCriminal Justice System In future she hopes to work within the mental health and disabilitysector

Kalai Ganesh-Hari was a research assistant at the Research Centre for Therapeutic Educationfollowing her PhD with the School of Education Communication and Language SciencesUniversity of Newcastle upon Tyne UK which explored the area of organizational andcognitive psychology with particular emphasis on emotional intelligence predictors andoutcomes leadership and emotions in the workplace

Dr Rhiannon Thomas is a psychotherapeutic counsellor in private practice She has previouslyworked as a counsellor in a school for children diagnosed with learning and behaviouraldifficulties and has just completed her PhD carried out at the Research Centre forTherapeutic Education Roehampton University on language and experience with particularreference to the experience of psychotherapy of mothers with children diagnosed as having asignificant language delay

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Ager A (1993) Mental health issues in refugee populations A review Working Paper of theHarvard Centre for the Study of Culture and Medicine Department of Management andSocial Sciences Queen Margaret College Edinburgh UK

Aspinall P (2007) Language ability A neglected dimension in the profiling of populationsand health service users Health amp Education Journal 66(1) 90106

Barron D Holterman C Shipster P Batson S amp Alam M (2010) Seen but not heard Ethnic minoritiesrsquo views of primary health care interpreting provision A focus group studyPrimary Health Care Research and Development 11 132141

Basch C (1987) Focus group interview An under-utilised research technique for improvingtheory and practice in health education Health Education Quarterly 41 18

Beiser M amp Hou F (2002) Language acquisition unemployment and depressive disorderamong Southeast Asian refugees A 10-year study Social Science amp Medicine 53(10) 13211334

Bhugra D amp Ayonrinde O (2004) Depression in migrants and ethnic minorities Advancesin Psychiatric Treatment 10 1317

Bhui K Sashidharan SP Cannon M McKenzie K amp Sims A (2003) Should there beseparate services for ethnic minority groups British Journal of Psychiatry 182 1012

Blaxter L Hughes C amp Tight M (2001) How to research (2nd edn) Buckingham OpenUniversity Press


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ne 2

014

Boi S (2000) Nursesrsquo experiences in caring for patients from different cultural backgroundsNT Research 5(5) 382389

Bradby H Varyani M Oglethorge R Raine W White I amp Helen M (2007) BritishAsian families and the use of child and adolescent mental health services A qualitativestudy of a hard to reach group Social Science amp Medicine 65 24132424

Braun V amp Clarke V (2006) Using thematic analysis in psychology Qualitative Research inPsychology 3 77101

Corbin J amp Strauss A (1998) Basics of Qualitative Research London SageDanso R (2001) From there to here An investigation of the initial settlement experiences of

Ethiopian and Somali refugees in Toronto Geo Journal 55 314Department of Health (2005) Delivering race equality in mental health care An action plan for

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Department of Health (2007a) Improving access to psychological therapies Computerisedcognitive behaviour therapy (cCBT) implementation guidance 126

Department of Health (2007b) Improving access to psychological therapies Specification forthe commissioner-led Pathfinder programme Retrieved from httpwwwmhchoicecsiporgukpsychological-therapies-iapt-commissionerled-pathfinder-sitesresourceshtml

Department of Health (2009) Improving access to psychological therapies Black and MinorityEthnic (BME) Positive practice guide Retrieved from httpwwwdhgovukprod_consum_dhgroupsdh_digitalassetsdocumentsdigitalassetdh_094201pdf

Ellis BH Kia-Keating M Yusuf S Lincoln A amp Nur A (2007) Ethical research inrefugee communities and the use of community participatory methods TransculturalPsychiatry 44(3) 459481

Ellis BH MacDonald HZ Lincoln AK amp Cabral HJ (2008) Mental health of Somaliadolescent refugees The role of trauma and perceived discrimination Journal of Consultingand Clinical Psychology 76(2) 184193

Fernando S (2005) Multicultural mental health services Projects for minority ethniccommunities in England Transcultural Psychiatry 42 420436

Finnstrom B amp Soderhamn O (2006) Concepts of pain among Somali women Issues andInnovations in Nursing Practice 54(4) 418425

Fowles J (2007) Positive steps supporting race equality in mental health care Department ofHealth Retrieved from httpwwwdhgovukenPublicationsandstatisticsPublicationsPublicationsPolicyAndGuidanceDH_066059

Gerrish K (2000) Individualized care Its conceptualisation and practice within a multiethnicsociety Journal of Advanced Nursing 32(1) 9199

Gerrish K (2001) The nature and effect of communication difficulties arising frominteractions between district nurses and South Asian patients and their careers Journal ofAdvanced Nursing 33(5) 566574

Gervais MC (2008) The drivers of Black and Asian peoplersquos perceptions of racialdiscrimination by public services A qualitative study Paper for Communities and LocalGovernments

Gilleard C Dennis M amp Ziyal L (2005) Ethnicity and access to talking therapies inWandsworth Report to Wandsworth PCT

Green J amp Thorogood N (2004) Qualitative methods for health research London SageGuerin B Guerin P Diiriye RO amp Yates S (2004) Somali conceptions and expectations

concerning mental health Some guidelines for mental health professionals New ZealandJournal of Psychology 33 5967

Halcomb E Gholizadeh L Di Giacomo M Phillips J amp Davidson P (2007) Literaturereview Considerations in undertaking focus group research with culturally and linguisti-cally diverse groups Journal of Clinical Nursing 16(6) 10001011

Harre R amp Secord P (1972) The explanation of social behaviour Oxford BlackwellHawthorne K Rahman J amp Pill R (2003) Working with Bangladeshi patients in Britain

Perspectives from primary health care Family Practice 20(2) 185191Hazel N (1995) Elicitation techniques with young people Social Research Update 12

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014

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Herrel N Olevitch L DuBois DK Terry P Thorp D Kind E amp Said A (2004)Somali refugee women speak out about their needs for care during pregnancy and deliveryThe Journal of Midwifery amp Womenrsquos Health 49(40) 345349

Hossain I amp Khan MH (2006) The rift within an imagined community Understandingnationalism(s) in Bangladesh Asian Journal of Social Science 34(2) 324339

Hughes R (1998) Considering the vignette technique and its application to a study of druginjecting and HIV risk and safer behaviour Sociology of Health and Illness 20(3) 381400

IAPT (2008) Improving access to psychological therapies Key performance indicators andtechnical guidance Retrieved from httpwwwiaptnhsuk

King M Weich S Nazroo J amp Blizard B (2006) Religion mental health and ethnicityEMPIRIC A national survey of England Journal of Mental Health 15(2) 153162

Kitzinger J (1994) Focus groups Method or madness In M Boulton (Ed) Challenge andinnovation Methodological advances in social research on HIVAIDS (pp 159175)London Taylor and Francis

Kitzinger J (1995) Introducing focus groups British Medical Journal 311 299302Lavender H Khondoker AH amp Jones R (2006) Understanding of depression An

interview study of Yoruba Bangladeshi and White British people Family Practice 23(6)651658

Lee CC (Ed) (1995) Counselling for diversity Needham Heights MA Allyn and BaconMaclean C (1999) Children family community and work An ethnography of the oil and gas

industry in Scotland Retrieved from httpwwwabdnacukirrarkletonpublicationschildrenshtml

McCrone P Bhui K Craig T Mohamed S Warfa N Stansfeld AS Thornicroft G ampCurtis S (2005) Mental health needs service use and cost among Somali refugees in theUK Acta Psychiatrica Scandinavica 111(5) 351357

McDowell SE Coleman JJ amp Ferner RE (2006) Systematic review and meta-analysis ofethnic differences in risks of adverse reactions to drugs used in cardiovascular medicineBritish Medical Journal 332 11771181

McKenzie K amp Bhui K (2007) Better mental healthcare for ethnic minority groups moving away from the blame game and putting patients first Commentary on Institu-Institutional racism in psychiatry Psychiatric Bulletin 31 368369

Mulatu MS amp Berry JW (2001) Health care practice in a multicultural context Westernand non-Western assumptions In SS Kazarian amp DR Evans (Eds) Handbook of culturalhealth psychology (pp 4663) San Diego CA Academic Press

Murray S amp Buller AM (2007) Exclusion on grounds of language ability a reporting gapin health services research Journal of Health Services Research amp Policy 12(4) 205208

Neale B (1999) Post divorce childhoods Retrieved from httpwwwleedsacukfamilyNightingale DJ amp Cromby J (Eds) (1999) Social constructionist psychology A critical

analysis of theory and practice Buckingham Open University PressPonterotto JG amp Casas JM (1993) Handbook of ethnicracial minority counseling research

Springfield IL Charles C ThomasPumroy S (2008) Treating mental illness in a country with no psychiatrists Retrieved from

httpwwwutnecom2008-04-03GreatWritingTreating-Mental-Illness-in-a-Country-with-No-Psychiatristsaspxblogid38

Ramakrishnan S (1984) The living culture of the Tamils Tamil Nadu Retrieved from httpwwwtamilnationorgcultureramakrishnanhtml

Ravindran G (2006) Negotiating identities in the diasporic space Transnational Tamil cinemaand Malaysian Indians Retrieved from httpwwwtamilnationorgculturedramaravindranpdf

Sadavoy J Meier R amp Yuk MO (2004) Barriers to access to mental health services forethnic seniors The Toronto study The Canadian Journal of Psychiatry 49(3) 192199

Saha S Fernandez A amp Perez-Stable E (2007) Reducing language barrier and racialethnic disparities in health care An investment in our future Journal of General InternalMedicine 22(2) 371372


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ne 2

014

Sainsbury Centre for Mental Health (2005) Breaking the circles of fear A review of therelationship between mental health services and African and Caribbean communitiesRetrieved from httpwwwscmhorguk

Sashidharan S (2003) Inside outside Improving mental health services for Black and MinorityEthnic communities in England London Department of Health

Sass B Moffat J Bhui K amp Mckenzie K (2009) Enhancing pathways to care for blackand minority ethnic populations A systematic review International Review of Psychiatry21(5) 430438

Seale C Gobo G Gubrium JF amp Silverman D (Eds) (2004) Qualitative researchpractice London Sage

Silove S Sinnerbrink I Field A Manicavasagar V amp Steel Z (1997) Anxiety depressionand PTSD in asylum seekers Association with pre-migration trauma and post-migrationstressors British Journal of Psychiatry 170 351357

Silverman D (2000) Doing qualitative research London SageSinnerbrink I Silove S Manicavasagar V Steel S amp Field A (1996) Asylum seekers

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Stiles WB (1993) Quality control in qualitative research Clinical Psychology Review 13593618

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This article may be used for research teaching and private study purposes Anysubstantial or systematic reproduction redistribution reselling loan sub-licensingsystematic supply or distribution in any form to anyone is expressly forbidden Terms ampConditions of access and use can be found at httpwwwtandfonlinecompageterms-and-conditions

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Introduction




















httpdxdoiorg101080030698852011621519


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Cultural background























Dow

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vers

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] at

03

07 2

5 Ju

ne 2

014









































Dow

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by [

Uni

vers

ity o

f N

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gham

] at

03

07 2

5 Ju

ne 2

014










































Method

Design




Dow

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by [

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vers

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f N

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] at

03

07 2

5 Ju

ne 2

014
















and experiences
































Dow

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ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014
































Participants









Dow

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ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






































Dow

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ded

by [

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vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


first languages




each participant






Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

Figure 1 Continued


Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014








(Figure 2)

Data analysis

Focus groups


















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

























2001)









Results







Dow

nloa

ded

by [

Uni

vers

ity o

f N

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gham

] at

03

07 2

5 Ju

ne 2

014


(4) Religion












stated

























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






























community









Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014







































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014







the GP


































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

(4) Religion
































Discussion














Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014












these communities





































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014





















provisions for them




group communities

























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014













religiously based



























now required










Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


amp Sue 1990)
























Conclusion

















Dow

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by [

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vers

ity o

f N

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gham

] at

03

07 2

5 Ju

ne 2

014






References











Dow

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ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

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ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014




















Dow

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ded

by [

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ity o

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] at

03

07 2

5 Ju

ne 2

014








Introduction




















httpdxdoiorg101080030698852011621519


Dow

nloa

ded

by [

Uni

vers

ity o

f N

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gham

] at

03

07 2

5 Ju

ne 2

014



















Cultural background























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014









































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014










































Method

Design




Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014
















and experiences
































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014
































Participants









Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


first languages




each participant






Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

Figure 1 Continued


Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014








(Figure 2)

Data analysis

Focus groups


















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

























2001)









Results







Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


(4) Religion












stated

























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






























community









Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014







































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014







the GP


































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

(4) Religion
































Discussion














Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014












these communities





































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014





















provisions for them




group communities

























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014













religiously based



























now required










Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


amp Sue 1990)
























Conclusion

















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






References











Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014




















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014



















Cultural background























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014









































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014










































Method

Design




Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014
















and experiences
































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014
































Participants









Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


first languages




each participant






Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

Figure 1 Continued


Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014








(Figure 2)

Data analysis

Focus groups


















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

























2001)









Results







Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


(4) Religion












stated

























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






























community









Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014







































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014







the GP


































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

(4) Religion
































Discussion














Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014












these communities





































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014





















provisions for them




group communities

























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014













religiously based



























now required










Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


amp Sue 1990)
























Conclusion

















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






References











Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014




















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014









































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014










































Method

Design




Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014
















and experiences
































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014
































Participants









Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


first languages




each participant






Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

Figure 1 Continued


Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014








(Figure 2)

Data analysis

Focus groups


















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

























2001)









Results







Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


(4) Religion












stated

























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






























community









Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014







































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014







the GP


































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

(4) Religion
































Discussion














Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014












these communities





































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014





















provisions for them




group communities

























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014













religiously based



























now required










Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


amp Sue 1990)
























Conclusion

















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






References











Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014




















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014










































Method

Design




Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014
















and experiences
































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014
































Participants









Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


first languages




each participant






Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

Figure 1 Continued


Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014








(Figure 2)

Data analysis

Focus groups


















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

























2001)









Results







Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


(4) Religion












stated

























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






























community









Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014







































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014







the GP


































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

(4) Religion
































Discussion














Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014












these communities





































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014





















provisions for them




group communities

























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014













religiously based



























now required










Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


amp Sue 1990)
























Conclusion

















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






References











Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014




















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014
















and experiences
































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014
































Participants









Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


first languages




each participant






Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

Figure 1 Continued


Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014








(Figure 2)

Data analysis

Focus groups


















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

























2001)









Results







Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


(4) Religion












stated

























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






























community









Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014







































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014







the GP


































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

(4) Religion
































Discussion














Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014












these communities





































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014





















provisions for them




group communities

























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014













religiously based



























now required










Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


amp Sue 1990)
























Conclusion

















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






References











Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014




















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014
































Participants









Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


first languages




each participant






Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

Figure 1 Continued


Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014








(Figure 2)

Data analysis

Focus groups


















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

























2001)









Results







Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


(4) Religion












stated

























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






























community









Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014







































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014







the GP


































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

(4) Religion
































Discussion














Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014












these communities





































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014





















provisions for them




group communities

























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014













religiously based



























now required










Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


amp Sue 1990)
























Conclusion

















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






References











Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014




















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


first languages




each participant






Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

Figure 1 Continued


Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014








(Figure 2)

Data analysis

Focus groups


















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

























2001)









Results







Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


(4) Religion












stated

























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






























community









Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014







































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014







the GP


































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

(4) Religion
































Discussion














Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014












these communities





































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014





















provisions for them




group communities

























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014













religiously based



























now required










Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


amp Sue 1990)
























Conclusion

















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






References











Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014




















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


first languages




each participant






Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

Figure 1 Continued


Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014








(Figure 2)

Data analysis

Focus groups


















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

























2001)









Results







Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


(4) Religion












stated

























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






























community









Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014







































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014







the GP


































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

(4) Religion
































Discussion














Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014












these communities





































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014





















provisions for them




group communities

























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014













religiously based



























now required










Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


amp Sue 1990)
























Conclusion

















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






References











Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014




















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

Figure 1 Continued


Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014








(Figure 2)

Data analysis

Focus groups


















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

























2001)









Results







Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


(4) Religion












stated

























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






























community









Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014







































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014







the GP


































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

(4) Religion
































Discussion














Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014












these communities





































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014





















provisions for them




group communities

























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014













religiously based



























now required










Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


amp Sue 1990)
























Conclusion

















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






References











Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014




















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014








(Figure 2)

Data analysis

Focus groups


















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

























2001)









Results







Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


(4) Religion












stated

























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






























community









Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014







































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014







the GP


































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

(4) Religion
































Discussion














Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014












these communities





































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014





















provisions for them




group communities

























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014













religiously based



























now required










Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


amp Sue 1990)
























Conclusion

















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






References











Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014




















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

























2001)









Results







Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


(4) Religion












stated

























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






























community









Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014







































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014







the GP


































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

(4) Religion
































Discussion














Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014












these communities





































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014





















provisions for them




group communities

























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014













religiously based



























now required










Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


amp Sue 1990)
























Conclusion

















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






References











Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014




















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


(4) Religion












stated

























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






























community









Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014







































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014







the GP


































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

(4) Religion
































Discussion














Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014












these communities





































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014





















provisions for them




group communities

























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014













religiously based



























now required










Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


amp Sue 1990)
























Conclusion

















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






References











Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014




















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






























community









Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014







































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014







the GP


































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

(4) Religion
































Discussion














Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014












these communities





































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014





















provisions for them




group communities

























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014













religiously based



























now required










Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


amp Sue 1990)
























Conclusion

















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






References











Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014




















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014







































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014







the GP


































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

(4) Religion
































Discussion














Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014












these communities





































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014





















provisions for them




group communities

























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014













religiously based



























now required










Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


amp Sue 1990)
























Conclusion

















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






References











Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014




















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014







the GP


































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

(4) Religion
































Discussion














Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014












these communities





































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014





















provisions for them




group communities

























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014













religiously based



























now required










Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


amp Sue 1990)
























Conclusion

















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






References











Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014




















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

(4) Religion
































Discussion














Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014












these communities





































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014





















provisions for them




group communities

























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014













religiously based



























now required










Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


amp Sue 1990)
























Conclusion

















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






References











Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014




















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014












these communities





































Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014





















provisions for them




group communities

























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014













religiously based



























now required










Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


amp Sue 1990)
























Conclusion

















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






References











Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014




















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014





















provisions for them




group communities

























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014













religiously based



























now required










Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


amp Sue 1990)
























Conclusion

















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






References











Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014




















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014













religiously based



























now required










Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


amp Sue 1990)
























Conclusion

















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






References











Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014




















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


amp Sue 1990)
























Conclusion

















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






References











Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014




















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014






References











Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014




















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014




















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014


























Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014




















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014




















Dow

nloa

ded

by [

Uni

vers

ity o

f N

ottin

gham

] at

03

07 2

5 Ju

ne 2

014

Reducing the barriers to accessing psychological therapies for Bengali, Urdu, Tamil and Somali...

Documents

Transcript of Reducing the barriers to accessing psychological therapies for Bengali, Urdu, Tamil and Somali...