This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Research Protocols, is properly cited. The complete bibliographic information, a link to the original publication on https://www.researchprotocols.org, as well as this copyright and license information must be included.
The Care Quality Commission published a review in 2018 in England titled “Are We Listening,” which revealed that child and adolescent mental health services are not responsive to the specific needs of young Black people and other ethnic minorities even in areas with ethnically diverse populations. It found that commissioners and service planners failed to engage with these young people and their families to understand their needs and expectations.
The purpose of this study is to engage Nigerian and Ghanaian young people (NAGYP) with experiences of care for common mental disorders (CMDs) in London, to increase understanding of their needs, and to give voice to their views and preferences. Their parents’, caregivers’, and practitioners’ views will also be sought for service improvement.
Three combined contemporary complementary methodologies—thematic analysis, interpretative phenomenological analysis (IPA), and intersectionality-based policy analysis (IBPA)—will be used across 3 comprehensive phases. First, a scoping review where relevant themes will be critically analyzed will inform further phases of this study. Detailed mapping of community and mental health care services in 13 inner London boroughs to investigate what professionals actually do rather than what they say they do. Second, IBPA will be used to scrutinize improving access to psychological therapies and other legislations and policies relevant to NAGYP to undertake an intersectional multileveled analysis of power, models, and constraints. Third, IPA will “give voice” and “make sense” of NAGYP lived experiences of CMDs via a representative sample of NAGYP participants’ (n=30) aged 16-25 years, parents or caregivers’ (n=20), and practitioners’ (n=20) perspectives will be captured.
The study has been approved by the UCL Institute of Education Research Ethics Committee (Z6364106/2022/02/28; health research) and University College London (Z6364106/2022/10/24; social research). Recruitment has begun in 13 inner boroughs of London. Data collection through observation, semistructured interviews, and focus groups are expected to be finalized by early 2024, and the study will be published by early 2025.
Combining multiple qualitative methodologies and methods will enable rigorous investigation into NAGYP’s lived experiences of care received for CMDs in London. Findings from this study should enable a reduction in the negative connotations and harmful superstitions associated with mental health–related issues in this group, inform evidence-based interventions, and facilitate preventive or early access to interventions. There may also be an indirect impact on problems resulting from mental illness such as school dropout, antisocial behaviors, knife crimes, juvenile detention centers, and even death.
PRR1-10.2196/42575
Since the 1970s, there have been concerns that the mental health system in the United Kingdom does not lend itself to the specific needs of Black people [
Thus, this study aims to engage a section of 2 underserved communities, Nigerian and Ghanaian young people (NAGYP), to increase understanding of their care needs for common mental disorders (CMDs) in inner London. The study will also engage with their parents or caregivers and practitioners to capture their views on CMDs and mental health care (MHC) models. It starts from the position that MHC needs to be reflective of cultural humility toward NAGYP as conceptualized in multicultural competencies [
This is the first study in the United Kingdom to explore NAGYP mental health experiences as part of the push against a one-size-fits-all approach to MHC [
The 2011 Census analysis for ethnicity (as we wait for the 2021 Census, due to be published in early 2023 [
The 2014 age-standardized data showed that on average, Black people are more likely to report a CMD: Black and Black British 23%, mixed and other 20%, Asian and Asian British 18%, White British 17%, and White other 14% [
There are a few issues to consider regarding the lack of data and its inconsistencies. First, the data for CMD prevalence by ethnicity is grossly limited. There is evidence of variation in CMD prevalence and symptom presentation among ethnic subgroups [
Second, the data suggest links between poor mental health, youth, and gang violence [
The British Psychological Society and The Royal College of Psychiatrists recognize “depression” (including subthreshold disorders) and “anxiety” (including generalized anxiety disorder, panic disorder, phobias, social anxiety disorder, obsessive-compulsive disorder, and posttraumatic stress disorder) as CMDs [
The primary aim is to investigate the NAGYP experiences of MHC for CMDs in inner London in order to give voice to their views and preferences for service improvement. The study has 5 key objectives:
To identify the care and treatment options available for NAGYP in London living with CMDs
To evaluate how culturally appropriate and potentially adaptable the Positive Practice Guide of Improving Access to Psychological Therapy (PPG-IAPT) is for NAGYP service users, which is the first line of treatment for CMDs
To investigate the lived experience of NAGYP of care for CMDs in inner London and the views of their parent or caregiver on the construct of CMDs
To ascertain how practitioners use models in their repertoire to care for NAGYP
To understand how NAGYP’s views, preferences, and expectations could inform care and practice design
This study has chosen 3 contemporary complementary methodologies to achieve the research objectives at different phases. This choice stems from the consideration of CMDs as a phenomenon and their impact on the NAGYP social world. These philosophical underpinnings reflect the personal and professional background of the lead researcher as a Black man and a social worker, and the sensitive nature of the phenomenon, both in terms of cultural stigmatization [
While thematic analysis (TA) will focus on NAGYP’s lived experiences in terms of what a CMD as a phenomenon “looks like,” interpretative phenomenological analysis (IPA) [
Research design for NAGYP London. CMD: common mental disorder; IBPA: intersectionality-based policy analysis; IPA: interpretative phenomenological analysis; MHC: mental health care; NAGYP: Nigerian and Ghanaian young people; PPG-IAPT: Positive Practice Guide of Improving Access to Psychological Therapy; TA: thematic analysis.
In the United Kingdom and England in particular, there is a body of work on CMDs in relation to ethnic minority children and young people [
The rationale and understanding of the impact of CMDs on Black African young people at a global level will be important to place our UK findings in context. Attention will be given to the location and social context from which samples were drawn.
Relevant studies undertaken in Nigeria and Ghana will be synthesized. Findings from NAGYP homelands will increase understanding of the perceptions of NAGYP, their general disposition, and what they make of CMDs. This is crucial because when people migrate, they do so with the health perceptions and cultural and religious beliefs developed within their country of origin.
In the United Kingdom, since health is a devolved matter across the constituent countries, relevant literature will have a national spread across England, Scotland, Wales, and Northern Ireland. However, the literature from England, specifically London, will, where possible, have primacy in informing further stages. London is the primary social, political, and environmental context of this study, where the researcher will engage in multimethod research activities with NAGYP, parents or caregivers, and practitioners.
The selected databases and libraries include International Bibliography of the Social Sciences, Applied Social Sciences Index and Abstract, Web of Science, SCOPUS, UCL Explore, Google Scholar, and Academic Search Complete (via London Senate House Library). These databases host a rich variety of social science peer-reviewed literature with international coverage. In addition, studies will be added through snowballing from the included studies’ reference lists [
Ethical approval has been granted by the UCL Institute of Education Research Ethics Committee (Z6364106/2022/02/28; health research) and University College London (UCL) (Z6364106/2022/10/24; social research). We are waiting for approval from the National Health Service (NHS) Health Research Authority Ethics Committee.
Rigorous community mapping will be undertaken in these inner London boroughs: Camden, Greenwich, Hackney, Hammersmith and Fulham, Islington, Kensington and Chelsea, Lambeth, Lewisham, Southwark, Tower Hamlets, Wandsworth, Bexley, and Westminster. These have been chosen from among London’s 32 boroughs because they are home to a sizable NAGYP population [
The objective is to investigate the ways and extents to which MHC and elements of models are actually adapted by practitioners to meet the specific mental health needs of NAGYP. Contacts will be made directly with these departments or teams. Permission will be sought to attend and observe selected meetings, at least one from each borough, where care plans are discussed, as well as workshops or sessions where care is delivered in action. The ones deemed appropriate will be attended to with due regard to full ethical and governance requirements. If permission is not granted, data from the relevant service websites would be analyzed instead. Some practitioners (n=20-25) will also be invited for an informal interview at this stage.
Various spontaneous, unscheduled interviews will be undertaken with practitioners after meetings or observed sessions, either to clarify or better understand certain approaches or practices. These informal interviews are meant to complement what the researcher observes as part of ethnographic interviews [
The qualitative data generated in this phase will be analyzed using the framework approach. Framework matrices (called charts) enable the analysis of data from a wide variety of sources, such as websites, PDFs, audio or video recordings, blog posts, field notes, memos, and transcripts generated from informal interviews. The approach allows all data to be collected before analysis begins. The data will be imported into NVivo (QSR International), where it will be summarized in charts according to predetermined themes [
Stages of the framework approach [
The IBPA will be used to scrutinize the PPG-IAPT as the main MHC national policy, as well as other organizational internal policies and procedures for NAGYP and its constituents with CMDs. IBPA is an “equity-promoting public policy analysis” framework [
The social structures of institutions, powers, or orders on one strand
Social identities consisting of being Black race, culture, religion, and so forth, as the second strand
Practitioner’s disposition, MHC model, and practice constraints as the third strand
The aim is to ascertain the PPG-IAPT and the related policy of its cultural adaptiveness and appropriateness to the specific needs of NAGYP service users. The 2 core components of IBPA will be used. They are (1) a set of guiding principles (see
The design is for the principles to be used with the questions (including the subquestions) simultaneously. Each question will be asked and answered in a manner that would depict explicit intersectionality-informed analysis. The aim is to draw attention to those assumptions that characterize policy formulation without robust direct engagement with those whom the policies are intended for [
The 12 questions are divided into 2 categories; the first 5 are termed “descriptive.” This will expose the critical background information about the problem in the PPG-IAPT and its related policies for ethnic minorities. This phase will pay particular attention to how the problems the policy is meant to ameliorate are identified, deconstructed, and then addressed. For example, only 1 Nigerian and no Ghanaian people were involved in the focus group in the formulation of the PPG-IAPT. This will bring to light the assumptions as well as the inequities or privileges, if any, that inundate the policy position. The remaining 7 questions are termed “transformative.” These are intended to help identify alternative policy responses or proffer suitable solutions that could provoke social and structural change. Phase 1 will play a fundamental role in this. The overarching goal of IBPA is to reduce inequities, if not completely eradicate them, and ultimately to promote equity and social justice [
Hankivsky et al [
Guiding principles of intersectionality-based policy analysis [
What knowledge, values, and experiences do you bring to this area of policy analysis?
What is the policy “problem” under consideration?
How have representations of the “problem” come about?
How are groups differently affected by this representation of the “problem”?
What are the current policy responses to the “problem”?
What inequities actually exist in relation to the “problem”?
Where and how can interventions be made to improve the “problem”?
What are the feasible short-, medium-, and long-term solutions?
How will proposed policy responses reduce inequities?
How will implementation and uptake be assured?
How will you know if inequities have been reduced?
How has the process of engaging in an intersectionality-based policy analysis transformed:
Your thoughts on relations and structures of power and inequity?
The way you and others engage in policy development, implementation, and evaluation?
Broader conceptualizations, relations, and effects of power asymmetry in the everyday world?
This is the core of the study and provides, through semistructured interviews, an in-depth understanding of the lived experiences of NAGYP on the MHC received for CMDs. Their parents’ and practitioners’ views are a key part of this. The focus of this is to use IPA to “give voice” and “make sense” [
Around 25 to 30 NAGYP participants in the age range of 16-25 years will be identified and recruited from the phase 1 exercise. In addition, participants will be recruited through local gatekeepers such as notable voices, faith and community leaders, local associations, and voluntary service providers within the community. The interview will explore themes related to the following topics:
Meaning and perception of CMDs
Experience during therapy
Views, preferences, and expectations
Anything particularly helpful in MHC
What to stop, start, or continue
This is aimed at capturing about 15-20 NAGYP parents’ views and perceptions of the CMD and MHC constructs. Topics will aim to enable the following:
Reducing the negative connotations and harmful superstitions of CMDs that characterize NAGYP communities
A more liberal understanding of CMDs
Improving access to early intervention or professional help
Parents and caregivers will be interviewed because the meaning they attach to CMD discourses, negative or positive, is often passed on to their young people due to the strong family ties that exist among Black parents, children, and young adults resulting from their cultural dispositions of the family unit [
The interviews will be designed to elicit the practitioner’s practical knowledge of MHC models. They are aimed at practitioners in the selected London areas who have delivered MHC to NAGYP. Up to 15-20 participants will be identified from phase 1. One practitioner will be included in an embedded pilot. The knowledge generated from this research activity would be used to categorize the different practitioners’ understandings of MHC models relating to the services they provide for NAGYP as well as the options available within and across disciplines. The dimensions of the categorization will be substantiated in the domain of MHC models in existing literature, as currently understood. However, their preference for modification or for new MHC models for NAGYP will be benchmarked against the medical and social models of disability [
The most prevalent CMD diagnosis for NAGYP service users
Own experience as a therapist supporting NAGYP
Professional training received in response to meeting the needs of NAGYP, or Black young people in general
Perception of the most suitable model of intervention
Effective ways of integrating the model with the PPG-IAPT
Challenges and key determinants of success in providing MHC to NAGYP
Potential examples of positive practice
The future of MHC for NAGYP
This phase will culminate in the IPA protocol. The most recent changes to the terminology of IPA will be adopted in the analysis. For example, the usual emergent themes and superordinate themes will be called experiential statements and personal experiential themes, respectively [
Step 1: Starting with the first case: reading and rereading, be immersed in the transcript. This is to make sure the respondent becomes the focus of the analysis. Similar to thematic analysis.
Step 2: Exploratory noting: disentangling semantic content, language, and conceptual comments with an open mind, noting everything of interest, and developing an avowedly interpretative statement relating to context. This will be reviewed with my supervisor.
Step 3: Constructing experiential statements: the process of consolidating and crystallizing the exploratory notes. This process represents 1 manifestation of the hermeneutic circle, that is, “the me” and the lived experiences of the participant in collaborative (cocreating) efforts. Tied within local instances in the transcript.
Step 4: Searching for connections across experiential statements: clusters of statements can be organized through different possibilities, using flexibility.
Step 5: Naming the personal experiential themes (PETs), consolidating, and organizing them in a table. Not tied within local instances but within the transcript as a whole.
Step 6: Continuing the individual analysis of other cases: steps 1-5 will be repeated for other cases in their own terms and individuality, in keeping with IPA’s idiographic commitment.
Step 7: Working with PETs to develop group experiential themes (GETs) across cases: drawing links between each PET to create GET.
To pay greater attention to the views and preferences of NAGYP toward CMDs and MHC to inform care and practice design, focus groups will be used to engage with NAGYP. Participants will be recruited through the established contacts from phase 1. In the focus group discussion, 7 to 10 NAGYP participants in the age range of 16 to 25 years will be involved. The topic guide will be informed by the data collected so far; 2 sessions are anticipated. The activities will be documented and analyzed using standards for handling data from multiple voices [
The study has been approved by the UCL Institute of Education Research Ethics Committee (Z6364106/2022/02/28; health research) and UCL (Z6364106/2022/10/24; social research). Recruitment has begun in the 13 inner boroughs of London. Data collection through semistructured interviews and focus groups is expected to be finalized by early 2024, and the study will be published by early 2025.
The study aims to investigate NAGYP’s lived experiences of care for CMDs in inner London. The study anticipates identifying the care and treatment options available; the cultural appropriateness of the PPG-IAPT for NAGYP service users, which is the first line of treatment; and parents’ views and practitioners’ dispositions on models of care. We hope the outcomes of this study will contribute to providing a response to the London Assembly’s recognition of mental disorders as a peculiar problem being faced by young Londoners, particularly from minority ethnic subgroups. The Assembly acknowledged how this could negatively impact their well-being and economic capacities [
The NHS Race and Health Observatory is an independent expert body given the responsibility of examining health inequalities experienced by minority ethnic groups in England, of which NAGYP is a major constituent. Their main findings in a review revealed that Black people’s fear and distrust of mental health services form “clear barriers to seeking help” [
The main potential limitation, while also a richness, is that qualitative methods are focused mainly on participants’ experiences [
With respect to the overarching aim of this pragmatic study, which centers on equitable MHC, Article 1 of the 1992 United Nations’ Minorities Declaration expects the state to protect a minority’s existence [
Child and Adolescent Mental Health Service
common mental disorders
intersectionality-based policy analysis
interpretative phenomenological analysis
mental health care
Nigerian and Ghanaian young people
National Health Service
Positive Practice Guide of Improving Access to Psychological Therapy
thematic analysis
University College London
The data sets collected and analyzed for the duration of this study will be made available from the corresponding author upon reasonable request.
AI had the original idea and is the key contributor. CR and GS supervised the project.
None declared.