Jane O'Brien

Urban Ethnic Minority Women’s Mental Health – A Scoping Study Jane O’Brien Davis Women In Cities International January 15th, 2020

Introduction The World Health Organization (WHO) defines mental health as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to their community”1. This state of wellbeing can be understood as something many people struggle to obtain daily. However, the struggle might be greater for those with identities that are marginalized within society. It is important to be aware of the way in which power structures, such as sexism and racism, interact with each other to create an unique and isolating experience of oppression for those who live at the intersection of multiple power structures2. Due to these power structures within society certain individuals, such as ethnic minority women, are more likely to struggle with mental health3. Though women are more likely to report health issues generally, Doornbos et al. discuss how women are more likely to experience symptoms of anxiety and depression than men4. Additionally, ethnic minorities are 20% more likely to struggle with mental health and are also less likely to receive mental healthcare when they are struggling5.

Here, ethnic minorities are defined in racial terms, encompassing those who do not belong to the white dominant racial group6.

1 “Mental Health: a State of Well-Being.” World Health Organization, World Health Organization, 15 Aug. 2014, www.who.int/features/factfiles/mental_health/en/.

2 Cooper, B. (2015). Intersectionality. Oxford Handbooks Online. doi: 10.1093/oxfordhb/9780199328581.013.20 3 Doornbos, M. M., Zandee, G. L., & Degroot, J. (2014). Attending to Communication and Patterns of Interaction. Journal of the American Psychiatric Nurses Association, 20(4), 239–249. doi: 10.1177/1078390314543688 4 Ibid 5 Ibid 6 Bhopal, R. (2004, June 1). Glossary of terms relating to ethnicity and race: for reflection and debate. Retrieved from https://jech.bmj.com/content/58/6/441.

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What is more, the urban environment can have a detrimental effect on the mental health of urban dwellers, especially those who are already more susceptible to mental health struggles7.

Urban living can often result in feelings of isolation and a lower sense of social support8, as well as racially segregated living9. This can have harmful effect the mental health of ethnic minorities who often can benefit from a sense of community and belonging. For those who are not geographically isolated from their ethnic community within the city, the urban environment reproduces many of the inequalities seen in society within one’s community10, such as lower neighbourhood socioeconomic status, substandard physical conditions, a lack services and amenities, and social disorder11. Women’s mental health is also affected by the urban environment through feelings of being unsafe12 and lack of control over themselves and their surroundings13. These feelings arise through street harassment and other phenomena that feel threatening to women and therefore limit how freely they move through the city. Seeing how the urban environment can affect women and ethnic minorities, we can extend that understanding to conceptualize how the mental health people living at the intersection of those marginalizations would be affected by the urban environment.

The objective of this paper to extend the understanding of how the urban environment uniquely impacts the mental health of ethnic minority women. This will be done by conducting 7 Romans, S., Cohen, M., & Forte, T. (2010). Rates of depression and anxiety in urban and rural Canada. Social Psychiatry and Psychiatric Epidemiology, 46(7), 567–575. doi: 10.1007/s00127-010-0222-2 8 Ibid 9 Wilkes, R., & Iceland, J. (2004). Hypersegregation in the Twenty-First Century. Demography, 41(1), 23–36. doi: 10.1353/dem.2004.0009 10 Browning, M., & Rigolon, A. (2018). Do Income, Race and Ethnicity, and Sprawl Influence the GreenspaceHuman Health Link in City-Level Analyses? Findings from 496 Cities in the United States. International Journal of Environmental Research and Public Health, 15(7), 1541. doi: 10.3390/ijerph15071541 11 Kim, D. (2008). Blues from the Neighborhood? Neighborhood Characteristics and Depression. Epidemiologic Reviews, 30(1), 101–117. doi: 10.1093/epirev/mxn009 12 Krenichyn, K. (2006). ‘The only place to go and be in the city’: women talk about exercise, being outdoors, and the meanings of a large urban park. Health & Place, 12(4), 631–643. doi: 10.1016/j.healthplace.2005.08.015 13 Turner, R. J., Lloyd, D. A., & Roszell, P. (1999). Personal Resources and the Social Distribution of Depression. American Journal of Community Psychology, 27(5), 643–672. doi: 10.1023/a:1022189904602

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a) a scoping study of relevant scientific literature pertaining to this issue and b) interviews with key players in Montreal to assess what the reality of mental health services are for ethnic minority women. The combination of both sources of allows us to understand if that gaps found in the literature are echoed in practice.

Methods A scoping study aims to map the key concepts, main research questions, and types of evidence available in a particular field, and can be undertook as a stand-alone project.14 For this scoping study, to find relevant literature regarding ethnic minority women’s mental health in the various databases for scientific literature were used along with multiple search terms. The databases used were PubMed, Medline, and PsycInfo, all of which contain literature specific to health studies. The search terms depicted in the Table 1 have been divided into three categories, based on the type of data they output.

Table 1. Search Terms Used Mental Health Related Search Terms

Demographic Related Search Terms

Urban Related Search Terms

14 Arksey, H., & O’ Malley, L. (2005). Scoping studies: towards a methodological framework. International Journal of Social Research Methodology, 8(1), 19–32. doi: 10.1080/1364557032000119616

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Depression Depressive Disorder Psychotic Disorder

Minority Group Ethnic Group Female

Urban Health Urban Health Services Urban Population

Mental Health Anxiety Anxiety Disorder

Residence Characteristics

Built Environment Urban Environment Urban Area

Table 2. Inclusion and Exclusion Criteria for Scoping Study Inclusion Criteria Must discuss women

Exclusion Criteria Not pertaining to women or ethnic minorities

Must focus on mental health Must pertain to urban areas/the urban environment Must discuss ethnic minorities

Focus on sexual minorities Not in English

Identfcaton

Studies conducted in Canada and the US

Studies conducted outside of Canada and the United States Not focused on urban areas/the urban environment

Figure 1. Studies Included After Exclusion Criteria Applied Records identified through database searching (n = 31)

Additional records identified through other sources (n = 7)

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Screening Eligibility

Records after duplicates removed (n = 38)

Records screened (n = 38)

Included

Full-text articles assessed for eligibility (n =29)

Records excluded (n =9)

Full-text articles excluded, with reasons (n = 9)

Studies included in synthesis (n = 20)

Literature Under Review

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Through the use of the search terms in Table 1, 38 total studies were found. After further exclusions, 20 of the 38 were identified for further analysis (figure 1). These search terms were for words in title, abstract, and key words identified by the authors. The 20 studies included in this scoping study were chosen using specific inclusion and exclusion criteria, seen in Table 2.

Once the inclusion and exclusion criteria were applied to the initial data output, data was extraction was done to allow for all the various studies to be analyzed comparably. Primary research questions, the study sample, the definition of mental health used, features examined, the design of the study, analytical techniques and tools used, and the results of each study of the various studies were all compared.

Interviews with Stakeholders To complement the data from the literature under review, semi-structured interviews were used as a method to facilitate conversations with relevant stake holder working in Montreal in public health, mental health, and community support capacities. The interviews also act as a tool to understand if what is being researched and stated in the literature is being echoed in practice.

The questions asked in all interviews, and the responses from each of the stakeholders can be seen in Table 3. The series of questions posed to the stakeholders included: do you think about public accessibility of mental healthcare in Montreal? How do you think the urban environment affects the mental health of women? Ethnic minorities? How are women accessing mental health services in Montreal? How does your organization address their needs? How are minorities accessing mental health services in Montreal? How does your organizations address their needs?

How are minorities accessing mental health services in Montreal? How does your organizations address their needs?

Results

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The data from the various studies of interest were extracted in eight different sections, allowing for the studies to become more comparable to each other. These different sections include primary research question addressed, study sample, mental health definition used, features examined within the study, study design, analytical tools and techniques used, results of the study, and other notes that are important to the analysis of the study. The results of the data extraction can be seen below in Table 3.

Table 3. Data Extraction Table Study of Interest

Primary Research Question

Study Sample

Mental Health Definition used

Study Design

Analytical Tools

Results of Study

Pahwa et al., 2012

Whether longitudinal trends in mental distress vary between and within seven cultural and ethnic groups

14713 respondents 15 years or older from the first six cycles of the national population health survey

An interplay between demographi c, lifestyle, social and environment al factors Mental distress used as a measure

Longitu dinal

Multivariate logistic regression model Estimates obtained by using balanced repeated replication techniques Self-reported data

Female respondents more likely to report higher mental distress than male Respondents in urban areas reported higher distress

Turner and Lloyd 1999

Availability of personal (coping) resources differ according to social status

1393 adult residents of Toronto (18-55)

Depressive symptoms/d isorder Psychologic al distress and psychiatric disorder

Cross sectiona l

Interviews Systematic review

The higher the stress level, the greater the class differences in mental health risk (suggests that there are class differences in how people deal with stress)

Romans et al.

2010

Compare geographic variability of rates of depression and three anxiety

Canadian citizens 15 years and older were surveyed

Rates of nonpsychotic psychiatric disorders

Cross sectiona l

Health survey of sample of Canadian citizens

Weaker sense of community in urban areas Female gender associated with

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disorders in a large, random community sample of Canadian citizens

through the 2002 Canadian Community health survey 36984 sample size, 53% women

Rates of anxiety disorders and depression

increased rates of depression Stronger sense of belonging/social support reported lower rates of depression

Anglin et al.

2014

To determine the association between racial discrimination experiences and attenuated positive psychotic symptoms (APPS)

650 young urban adults attending a public university in the Northeast with a proportion of ethnic minorities and immigrants

Mental health struggles defined as depression, anxiety, and general psychologic al distress as well as psychosis and APPS

Cross sectiona l

A selfreported inventory for psychosis risk and the experiences of discriminatio n questionnair e

Racial discrimination The hypothesis that racial discrimination would be greater in the group with high levels of APPSdistress was also supported

Browning and Rigolon 2018

Focus particularly on income and race and ethnicity as moderators of the greenspacehealth links in order to understand which income and racial or ethnic groups particularly benefit from higher provisions of greenspace

496 of the 500 most populated US cities Containing 97574613 residents total

Mental illness used as umbrella term for mental health struggles

Cross sectiona l

Spatial average models tested the effect of two greenspaces measured on obesity and mental health Controlling for income, race and ethnicity, sprawl, age, sex, physical inactivity, median age of housing, and total population Analyses conducted at the city scale, comparing findings to individual and community level

Green space associated with better health, both physical and mental cross racial groups Racialized individuals less likely to live in proximity to greenspace

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Wilkes and Iceland 2004

Considerations of segregation among non-black racial and ethnic minorities (REMS) To understand the factors that may affect the different types of segregation among groups

Metropolita n level data from the 2000 US census

N/A

Cross Sectiona l

Multivariate analysis for metropolitan areas that had at least 1000 minority group members for the group in question

Segregation systematically undermines the social and economic wellbeing of REMs in the United States, through isolation from urban amenities Segregation worsens living conditions of REM

Maantay 2001

To determine whether public policies pertaining to zoning and land use planning are inherently discriminatory regarding the disproportionate distribution of potentially noxious land uses in poorer communities and communities of colour

Specific case study industrial communitie s within the city

N/A

Longitu dinal

Examination of the location of the city’s industrial zones and where industrial zones have increased/de creased in size within a 4-decade period (1961-1998)

Zoning is not equitable Discusses the ways in which the urban environment is inherently inequitable Zoning determines where various categories of land use may go, thereby influencing the location of resulting environmental and health impacts

Gibbons and Barton 2016

To determine whether and how a resident’s selfrated health is affected by the gentrification of their neighbourhood Investigation whether individual race/ethnicity could moderate the relationship between gentrification and health

Data from 2008 Philadelphia Health Managemen t Corporation ’s Southeaster n Pennsylvani a Household Health Survey Data from the 2000 Decennial Census Data from the 20062010 American Community Survey

Self-rated mental health definition (psychologi cal distress)

Cross sectiona l

Implementati on of logistic multilevel models to determine whether and how a resident’s self-rated health is affected by the gentrificatio n of their neighbourho od Use of hierarchical linear modeling to determine the implications of

The endurance of poor health outcomes for Blacks in these communities suggests a subtler effect of gentrification, that of cultural displacement Low income black respondents experience cultural displacement even when upper income blacks move in The longstanding segregation of black communities could undercut the positive effect of more affluent blacks residing in these places

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gentrificatio n for selfrated health

Blair et al.

2014

Assess how longitudinal changes in neighbourhood material and social deprivation affect distress outcomes in adult Canadians

Data drawn from the 4th and 7th (2000 and 2006) waves of the Canadian National Population Health Survey 2745 sample size

Mental health defined in terms of psychologic al distress Evaluating both anxiety and depression symptoms

Longitu dinal

Data analyses of Canadian National Population Health Survey Regression analysis

Martins and Reid 2007

Sought to understand the adjustment experiences of immigrant women from South Asia regarding the influence of a Canadian urban environment on their occupations Explore the experiences of new immigrant women from South Asia as they adjust to their new

12 recently immigrated women from South Asia to Canada, living in Toronto

N/A

Cross sectiona l

Modified grounded theory approach to analysis Data collection and analysis took place simultaneous ly Method of constant comparison used Qualitative study,

Lack of neighbourhood resources is commonly recognized as a culprit of poor SRH Controlling for racial change, while gentrification leading to increases in White population has no measurable effect on minority health, Black gentrification leads to marginally worse health outcomes for black respondents Neighbourhood deprivation change, in the shape of worsening material deprivation is a more important predictor of distress than changes in the social characteristics of neighbourhoods Worsening of material settings was significantly associated with low socioeconomic neighbourhouds and worsening distress scored Fitting into society and coping with new life was seen as a process to be influenced by personal and emotional factors Immigration removed them from their extended families, thereby isolating them therefore no social or familial support Benefit from living in an urban centre (Toronto) because

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lives in a North American urban setting

Becker et al.

2005

A focus on urban health can contribute to an understanding of inequalities in health between urban and suburban areas, racial, ethnic, and socioeconomic groups Examination the social contextual stressors in the neighbourhood, health outcomes, and perceived control at multiple levels beyond the individual as a protective factor

679 predominan tly low income African American women who reside on Detroit’s east side

Community level stressors defined as social contextual stressors (include threats to physical safety/viole nt crime (neighbourh ood disorder) More common in racially segregated, poor, urban neighbourho ods Individual level stressors defined as loss of loved one, financial stress, etc‌ Perceived control

Cross sectiona l

exploratory and descriptive in nature

access to education, healthcare, English classes Community centres and other resources allowed them to foster and maintain friendships

A conceptual model of the stress process Data collected through a community survey

Although stress has a consistently negative impact on health, perceived control may buffer against the deleterious effects of stress For young women perceived control was found to be health protective whereas, for older women perceived control was inversely related to health Interaction of both individual and community/neighb ourhood level stressors Many stressors found in urban communities of colour Conditioning variables/protective factors may reduce the presence of stress/degree to which they are perceived as stressful Perceived control highest with eldest groups Urban communities are more likely than nonurban communities to experience social contextual stressors resulting in part from external policies and broad

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structural factors

Krenichy n 2005

This article focuses particularly on the ways that the outdoor environment might encourage and enhance, or discourage and detract from, physical activity Does an outdoor urban space have some significance for women, more than men

Women actively using prospect park to exercise

N/A

Cross Sectiona l

Qualitative interviews

Mair et al.

2008

Review of published observational studies of neighbourhoods and depression/depres sive symptoms was conducted to inform future directions for the field

45 cross sectional and longitudinal studies that analyzed the effect of at least one neighbourh ood level variable on either depression or depressive symptoms were analyzed

N/A

Systema tic Review

Systematic Review

Many femalespecific reasons for lower levels of physical activity Urban greenspaces as more restorative than other urban spaces Safety as pertinent aspect of women’s level of activity Greenspace and physical activity has positive effect on mental health Ethnic minority women more likely to be inactive 37/45 studies reported associations of at least one neighbourhood characteristics with depression/depressi ve symptoms

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Doornbos et al.

2014

To document expressions/comm unication and patterns of interaction that can then be incorporated into the design of culturally sensitive mental health care for ethnically diverse, urban, impoverished women

61 Black, Hispanic, and White women

Symptoms of depression and anxiety

Cross Sectiona l

Community Based Participatory Research Focus Groups

Cultural universalities and cultural uniqueness relative to the communication and interaction patterns of urban, ethnically diverse, impoverished, and underserved women

Haarman s 2016

Examination of whether GRS might be associated with negative schemas and psychotic experiences in women

92 women were participants, half of which had ethnic minority status

Defined in terms of psychosis GRS = Gender Role Strain = perceived discrepancy between actual self and gender role norm

Cross Sectiona l

Surveying of participants

Analyses suggested that the relationship between GRS and symptoms of mental illness was mediated by negative self and other schemas Specific cultural contexts strengthen idealized cultural beliefs about femininity, female chastity/purity impacting selfworth Psychosis may contribute to oversensitivity to perceived failure to conform to gender stereotypes

Phuong Do et al.

2018

Investigation of the intersection between segregation, neighbourhood poverty, race, and psychological wellbeing/distress

US born nonHispanic black and white individuals aged 25 years and over residing in metropolita n areas with at least 5000 total black people and

Psychologic al Distress

Longitu dinal

Logistic regression models, estimated separately for blacks and whites

Segregation associated with higher levels of psychological distress for the black population, especially those living in poverty The psychological harm of structural racism, resulting in segregation and concentrated poverty, is not additive but multiplicative,

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a total population over 100000 16000 blacks and 56000 whites residing in 200 CMAs

reflecting a triple jeopardy for black people

Hamdulla hpur et al.

2017

Exploration of the mental and physical health of Aboriginal and Non-Aboriginal women accessing social services agencies and shelters

Sample of over 100 women, half of whom were indigenous Women who participated were help seeking and at least 16years-old

Depression and anxiety symptoms

Cross sectiona l

Structured and semi structured interviews Regression analysis conducted

Higher rates of depression/anxiety/ medicated psychological disorders among non-indigenous women partly due to cultural differences in the expression and reporting of distress combined with the reported differences in treatment seeking Higher levels of drug and alcohol use among indigenous women Social marginalization of indigenous women in urban centres as a public health concern

Doornbos et al.

2013

Sought to identify social determinants of mental health and barriers to help seeking for this population What contributes to the experience of depression and anxiety of urban, ethnically diverse impoverished

61 white, black, and Hispanic women identified their perceived determinant s of depression/a nxiety and barriers to help seeking

Symptoms of anxiety and depression

Cross sectiona l

Community Based Participatory research and focus groups

Cultural issues such as discrimination, separation from family, neighbourhood issues, such as disinvestment/decli ne, safety/crime/gang activity, and family issues such as, single parenting, conflict in their

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van Os 2004

women?

What barriers prevent them from using existing mental health resources?

behaviour

Prospective analysis of how the urban environment contributes to symptoms and diagnosis of depression Investigates other confounding factors such as demographic variables and changing exposure status

Symptoms of depression

roles as spouses/parents all as determinants of health Practical barriers to accessing mental health support such as, absence of essentials insufficient clinics for low income people Defined in terms of overall human heath

N/A

N/A

Social environment has been shown to affect mental health Aspects of the social environment such as community level social fragmentation, social isolation and social inequality, lack of perceived safety, and social stress

Primary Research Questions Addressed Of the 20 studies included in the review, 14 of these has primary research questions that directly dealt with ethnic minorities. Seven of the 20 studies had primary research questions that directly dealt with women in the urban environment. Most of the 14 with primary research questions addressing ethnic minorities specifically did also discuss the issues facing women as well, however few spent time focusing on the specific issues that exist for individuals at the intersection of female and ethnic minority identity. However, of the seven studies with primary research questions pertaining to women specifically, six of them dealt with women living at the intersection of ethnic minority status and female identity. This means that those primary research questions addressed ethnic minority women’s access to mental health resources and support, their general experiences with symptoms of different mental illnesses such as anxiety and 16

depression, as well as the cultural adjustments needed for life in urban Canada and how that affects their mental health. Additionally, seven of the 20 studies had primary research questions that specifically referenced the urban environment, usually in conjunction with one of the other features discussed in their scoping study.

Of the 20 studies included, the primary research questions can be subcategorized into three categories. Firstly, primary research questions dealing with the urban environment’s morphology specifically, and how that contributes to positive or negative mental health for ethnic minorities and women in cities. Five of the studies discussed specifically the role of greenspace in fostering positive mental health. Secondly, the primary research question of many of the studies discussed issues of zoning policies, segregation, and neighbourhood investment/disinvestment. The studies discussed how those issues affect the mental health of those urban dwellers, especially those with marginalized identities such as ethnic minorities and women. Lastly, multiple studies focused on how immigrant status and cultural difference come into play in the urban environment and how that can affect one’s mental health, specifically in regards to mental health resources, social support, and feelings of isolation.

Study Samples The 20 studies included in this scoping study had a significant range in terms of the sample for each of the studies. The largest sample included had 14713 participants15, where the data used for the study for each individual came from a Canadian national population survey16.

The smallest sample size included was 12 participants17. This discrepancy in sample size is due to the different designs of the studies and analytical tools used for each. The age range for 15 Pahwa, P., Karunanayake, P., McCrosky, J., & Thorpe, L. (2012). Longitudinal Trends in Mental Health Among Ethnic Groups in Canada. Chronic Disease and Injuries in Canada, 32(3), 164–176.

16 Ibid 17 Martins, V., & Reid, D. (2007). New-immigrant women in urban Canada: insights into occupation and sociocultural context. Occupational Therapy International, 14(4), 203–220. doi: 10.1002/oti.233

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participants throughout the 20 studies included was 15-55. Though many only included participants over the age of 18, few dealt with those 15 or older. As per the inclusion and exclusion criteria, all participants from each study were residing in either an American or Canadian context, and most were in urban centres. Most of the studies included participants that had ethnic minority status and/or were women.

Mental Health Definition Used The majority of the 20 studies included in this scoping review discussed mental health in terms of psychological distress, symptoms of anxiety, and symptoms of depression. Gibbons and Barton discuss psychological distress as how one would identify and rate their own mental health18. Discussing mental health in these terms allowed for the participants to discuss their mental health circumstances without an official medical diagnosis. Only one of the 20 studies gave a more descriptive definition of mental health, specifically in regards to their area of study.

Pahwa et al. discussed mental health in their study as “an interplay between demographic, lifestyle, social and environmental factors”19. This description allows the reader to see how different and multiple elements and features of an individual’s life can affect their mental health.

Study Design and Analytical Tool and Techniques Of the 20 studies included in this scope only three employed a longitudinal design20. The other 17 studies included in this scope all had a cross-sectional study design. Various analytical tools, techniques, and research frameworks were used within the studies included in this scoping analysis. Common frameworks include self-reported data collection, data from government 18 Gibbons, J., & Barton, M. S. (2016). The Association of Minority Self-Rated Health with Black versus White Gentrification. Journal of Urban Health, 93(6), 909–922. doi: 10.1007/s11524-016-0087-0

19 Pahwa, P., Karunanayake, P., McCrosky, J., & Thorpe, L. (2012). Longitudinal Trends in Mental Health Among Ethnic Groups in Canada. Chronic Disease and Injuries in Canada, 32(3), 164–176.

20 Ibid

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administered surveys and censuses, structured and semi-structured interviews, and focus groups.

Bivariate and multivariate regression analysis was a common analytical tool used, often to control for confounding variables in the analysis. Additionally, Community Based Participatory Research was used as a research framework in two of the 20 studies, both conducted by Doornbos et al21. This technique enables the researcher to see the issue fully through the eyes of the participant, which allows a greater understanding of how the issue at hand produces itself in the life of the individual of study.

Results of Study In Turner and Lloyd’s study they discuss how the psychological strain of everyday life can have a more detrimental effect on certain demographics of people22. This concept is reified within most of the other studies explored in this scoping study. Many of the studies suggest that urban women are more likely to report feelings of mental distress (Table 4). Krenichyn identifies that this is due to lack of a sense of personal safety and perceived control among women within the urban environment23. Lack of feelings of safety and control can be understood to come from threats of violence in urban public spaces that are more common amongst women, thus undermining their sense of autonomy, control of self, and creating an environment that is exclusionary and harmful. This threat is sustained in cities through phenomena such as cat calling and general street harassment, commonly perpetuated by men24.

21 Doornbos, M. M., Zandee, G. L., Degroot, J., & Maagd-Rodriguez, M. D. (2013). Using Community-Based Participatory Research to Explore Social Determinants of Womens Mental Health and Barriers to Help-Seeking in Three Urban, Ethnically Diverse, Impoverished, and Underserved Communities. Archives of Psychiatric Nursing, 27(6), 278–284. doi: 10.1016/j.apnu.2013.09.001

22 Turner, R. J., Lloyd, D. A., & Roszell, P. (1999). Personal Resources and the Social Distribution of Depression. American Journal of Community Psychology, 27(5), 643–672. doi: 10.1023/a:1022189904602 23 Krenichyn, K. (2006). ‘The only place to go and be in the city’: women talk about exercise, being outdoors, and the meanings of a large urban park. Health & Place, 12(4), 631–643. doi: 10.1016/j.healthplace.2005.08.015 24 Ibid

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It was discussed in numerous studies included in this paper’s analysis that ethnic minority status can be linked with higher levels of psychological distress. As a result of urban phenomena such as segregation, racially inequitable zoning policy, and gentrification, urban communities of ethnic minorities are more likely to display social contextual stressors as a result of structural factors and external policies25. Additionally, cultural differences that ethnic minorities might feel between themselves and North American society might lead to actual and perceived stigmatization and feelings of exclusion, which can hinder assimilation and lead to increased social isolation which can result in higher levels of psychological distress26. Hamdullahpur et al’s study discusses how cultural differences in reporting and seeking support for mental health has also acted in detriment to the urban mental health of ethnic minorities, especially women27.

These results allow us to see how the urban environment can be more harmful for the mental health of some over others. Additionally, the six articles that focused specifically on women who also have ethnic minority status gave the reader the understanding to conceptualize how mental health issues in the city are especially impactful for people living at the intersection of two marginalizations, such as ethnic minority women. Becker et al. discuss how ethnic minority women in urban communities are more susceptible to the effects of social contextual stress, such as racial discrimination, as a result of broad structural factors, leading to the detriment of their mental health28. It should be noted that scientific studies that discuss the mental 25 Becker, A. B. (2005). Age Differences in Health Effects of Stressors and Perceived Control Among Urban African American Women. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 82(1), 122– 141. doi: 10.1093/jurban/jti014 26 Martins, V., & Reid, D. (2007). New-immigrant women in urban Canada: insights into occupation and sociocultural context. Occupational Therapy International, 14(4), 203–220. doi: 10.1002/oti.233 27 Hamdullahpur, K., Jacobs, K. J., & Gill, K. J. (2017). A comparison of socioeconomic status and mental health among inner-city Aboriginal and non-Aboriginal women. International Journal of Circumpolar Health, 76(1), 1340693. doi: 10.1080/22423982.2017.1340693 28 Becker, A. B. (2005). Age Differences in Health Effects of Stressors and Perceived Control Among Urban African American Women. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 82(1), 122– 141. doi: 10.1093/jurban/jti014

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health of ethnic minority women exclusively and specifically are far and few between, as represented by the small proportion of studies included in this analysis that deal with the issue.

This represents a lack of research and therefore a gap the relevant literature within health studies.

Interview Results Each of the three respondents were asked the same questions allowing for comparability between the interviews. These questions can be seen in Table 4. Many of the questions lead to a more open conversation, resulting in a semi-structured interview design. It should be noted that the respondents were only asked to answer the questions if they felt as though it was relevant to them as professionals. This paper will elaborate on the questions that elicited responses that are relevant and key to this scoping study.

When discussing the level of public accessibility to mental health services in Montreal, respondents one and three both indicated that presence of barriers. They discussed how government implemented changes to the public mental health provision system led to the increase in waitlists to access care and the reduction of resources and professionals. Respondent three indicated how this is especially harmful for low income individuals, who are disproportionately ethnic minorities, many of whom do not have another option for seeking mental healthcare. Respondent two felt as though they could not respond to this questions as it fell outside the scope of their profession.

In the interviews, the discussion around how the respective organizations of each of the respondents addressed the needs of women specifically is also key in complementing the scoping portion of this study. None of the organizations of the three respondents had female specific programming. What is more, all three respondents indicated that women’s specific needs in terms of mental health are not being met. Respondent one discussed barriers such as child care that

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disproportionately affect women, who are commonly the primary child care provider, and might hinder their efforts to seek mental healthcare. Respondent two did not elaborate on their comment. Respondent three indicated that mental illnesses such as Borderline Personality Disorder (BPD) and anxiety disorders are more common amongst women, and this is an issue that is not being addressed in practice.

The interviews also addressed how the needs of ethnic minorities are addressed or not by the organizations of each of the respondents. All three respondents indicated that ethnic minorities constitute a notable amount of their clients. Respondent one described mental healthcare specific to ethnic minorities as a “work in progress”, highlighting how culturally specific mental healthcare provision is important but not widely practice. Respondent three highlighted this point as well. They shared a story of one of their clients that by chance was connected within a network of mental healthcare professionals that all share similar racialized lived experiences, and how this was extremely beneficial for the client’s mental health progress.

The need for culturally specific mental healthcare is great, as many professionals in the field do not have the social or cultural context or experience to address the needs or understand the experiences of ethnic minorities who are seeking help. Additionally, ethnic minorities may have greater trust in an mental healthcare practitioner who has lived a similar racialized experience.

The last key theme discussed within each of the interviews was how the urban environment affects mental health, specifically ethnic minority women’s mental health.

Respondent one discussed this issue in terms of housing, and how Montreal’s housing availability, affordability, and quality is on the lower end. They referenced issues of bed bugs and cockroaches. This issue can be understood to affect ethnic minority women, as ethnic minorities are more likely to be lower income and therefore have less housing option; women

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disproportionately spend more time in the home compared to men, therefore much of the stress caused by low quality housing falls on them. This would add to the everyday stress that can be harmful for one’s mental health. Respondent two discussed the urban environment in a positive light, highlighting how it allows one to be in contact with their community and have access to more resources. Lastly, respondent three asked how one is expected to protect themselves from “the ills of society” that are reproduced within the urban environment, and highlighted how this must be especially detrimental for the mental health of ethnic minority women. This can be understood as respondent three referencing how sexism and racism are reproduced within the city, and therefore uniquely affects the mental health of ethnic minority women.

Table 4. Interview Grid

Respon dent 1

Respon dent 2

Respon dent 3

What do you think about public accessibility of mental healthcare in Montreal?

How do you think the urban environment affects the mental health of women?

Ethnic minorities?

Attempts being made to ameliorate wait times Group therapy approach being rolled out to reduce amount of people on waitlists N/A

Noise levels Housing quality, which is serious challenge in Montreal

Not totally included in the

City has a positive effect on mental health, allowing similar individuals to find each other and offers access to more resources “How do you protect yourself

How are women accessing mental health services in Montreal? How does your organization address their needs?

Public mental health services not directed towards men or women specifically

How are minorities accessing mental health services in Montreal? How does your organizations address their needs?

What does mental healthcare access/services look like at the community level?

Work in progress Supports put in place for new arrivals Lack of coordination and not enough support for this demographic

Social workers and General practitioners available at community locations for walk in and short term solutions

In terms of accessing their organization’s services: Provides work experience, many new coming women do not have any

No comment regarding mental health Many of the people accessing their organization’s community support are ethnic minorities

Social community as imperative to wellbeing

Their organization

Clients mostly white Institutionalized

Large proportion of the services they offer are run

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public health framework Long waitlists to see a mental health professional Not equally accessible to all

from the ills of society present in the city?�

Hard to be in tuned in the city and be mentally safe

doesn’t differentiate between men and women in terms of service provision Working with the situation of the individual Certain mental illnesses are more common amongst women, therefore service provision differs there in detriment of women

racism coming up through clients towards other clients Working with individual situation of each client for their best outcome Story: One client was by chance was put in contact with a mental health network who all shared similar racialized lived experiences, this worked in the benefit of the client

or helped run by volunteers from the community Volunteers take clients out for activities within the community they live

Discussion Within this scoping study a few notable patterns were found. Many of the studies in question discussed the uniqueness of women’s mental health, the mental health of ethnic minorities, and many discussed these features in relation to the urban environment. However, there is a prominent gap in research regarding how the mental health of individuals with the intersecting marginalizations of sexism and racism are affected by urban environment. This is notable because cities are commonly areas of ethnic and cultural diversity, and therefore home to many individuals who have a unique experience with mental health that is under-researched.

This gap in knowledge and research was seen to translate into gap in practice in regard to mental health support and services for this demographic. Through the interviews conducted, it became clear that there is a gap in practice regarding the mental healthcare of ethnic minority women in Montreal. Mental healthcare has many barriers to accessing it, some of which specific to women and some of which specific to ethnic minorities. This can be understood as doubly harmful for women who are also ethnic minorities, as they are less likely to receive care, and if

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they do it is not likely to address their needs. This demographic is also more susceptible to mental health struggles and illness, which can be understood as symptomatic of city dwelling.

This susceptibility in addition to the barriers and limits of care leads to ethnic minority women being at an especially vulnerable place in terms of mental health. It should be noted that this study included only three interviews with stakeholder. This gives us only a glimpse into mental health care practice in Montreal. This segment of the larger mental health care system in Montreal can be used for analysis, but may not represent all services available.

What is more, in multiple studies immigrant status and ethnic minority status equated.

This overlooks the needs of ethnic minorities who were born in either the United States or Canada. Additionally, in many studies ethnic minority status was also equated with low socioeconomic status, which is also not a universal experience. It can be understood that this disregard in research can result in another gap in practice, as well as the universalizing of the experiences of ethnic minority women. Universalization stops individuals from being seen as such, therefore preventing their specific needs from being met in terms of mental healthcare.

Conclusion This scoping review has attempted to expand the definition of mental health by addressing it through an urban lens, with a focus on the experiences of ethnic minority women.

This has been done through the analysis of various studies that have been conducted on the topics of women’s mental health, the mental health of ethnic minorities, the effects of the urban environment on mental health, and the intersection of the three. These studies were found through the use of various databases such as PubMed, Medline, and PsycInfo. Interviews and discussions with relevant stake holders within Montreal’s mental healthcare, public health, and

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community support network have also been held in order to understand if what is being discussed in the literature is being echoed in practice.

Through this analysis, the effects of the urban environment on the mental health of certain demographics has become apparent. Light has been shed on how those effects might be more of a burden on some urban dwellers more than other due to their identities, namely ethnic minorities and women. What the literature has also made clear is that there is gap in research as to how intersecting identities are uniquely affected, in terms of mental health and access to mental healthcare, by the urban environment. Through discussions with relevant stakeholder regarding ethnic minority women’s mental health in Montreal, this gap in research and echoed in practice. This is important because ethnic minority women already live an especially vulnerable existence, specifically in regard to mental health. Though this study is limited in scope, it underlines the fact that more research must be done on the mental health of urban ethnic minority women, so that appropriate supports can be provided for the mental healthcare of this demographic.

Bibliography Anglin, D. M., Lighty, Q., Greenspoon, M., & Ellman, L. M. (2014). Racial discrimination is associated with distressing subthreshold positive psychotic symptoms among US urban ethnic minority young adults. Social Psychiatry and Psychiatric Epidemiology, 49(10), 1545–1555. doi: 10.1007/s00127-014-0870-8

26

Arksey, H., & Omalley, L. (2005). Scoping studies: towards a methodological framework. International Journal of Social Research Methodology, 8(1), 19–32. doi: 10.1080/1364557032000119616 Becker, A. B. (2005). Age Differences in Health Effects of Stressors and Perceived Control Among Urban African American Women. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 82(1), 122–141. doi: 10.1093/jurban/jti014 Bhopal, R. (2004, June 1). Glossary of terms relating to ethnicity and race: for reflection and debate.

Retrieved from https://jech.bmj.com/content/58/6/441.

Blair, A., Gariépy, G., & Schmitz, N. (2015). The longitudinal effects of neighbourhood social and material deprivation change on psychological distress in urban, community-dwelling Canadian adults. Public Health, 129(7), 932–940. doi: 10.1016/j.puhe.2015.05.011 Browning, M., & Rigolon, A. (2018). Do Income, Race and Ethnicity, and Sprawl Influence the Greenspace-Human Health Link in City-Level Analyses? Findings from 496 Cities in the United States. International Journal of Environmental Research and Public Health, 15(7), 1541. doi: 10.3390/ijerph15071541 Bécares, L., Nazroo, J., & Jackson, J. (2014). Ethnic Density and Depressive Symptoms Among African Americans: Threshold and Differential Effects Across Social and Demographic Subgroups. American Journal of Public Health, 104(12), 2334–2341. doi: 10.2105/ajph.2014.302047 Cooper, B. (2015). Intersectionality. Oxford Handbooks Online. doi: 10.1093/oxfordhb/9780199328581.013.20 Doornbos, M. M., Zandee, G. L., Degroot, J., & Maagd-Rodriguez, M. D. (2013). Using Community-Based Participatory Research to Explore Social Determinants of Womens Mental

27

Health and Barriers to Help-Seeking in Three Urban, Ethnically Diverse, Impoverished, and Underserved Communities. Archives of Psychiatric Nursing, 27(6), 278–284. doi: 10.1016/j.apnu.2013.09.001 Doornbos, M. M., Zandee, G. L., & Degroot, J. (2014). Attending to Communication and Patterns of Interaction. Journal of the American Psychiatric Nurses Association, 20(4), 239–249. doi: 10.1177/1078390314543688 Gibbons, J., & Barton, M. S. (2016). The Association of Minority Self-Rated Health with Black versus White Gentrification. Journal of Urban Health, 93(6), 909–922. doi: 10.1007/s11524016-0087-0 Haarmans, M., Mckenzie, K., Kidd, S. A., & Bentall, R. P. (2018). Gender role strain, core schemas, and psychotic experiences in ethnically diverse women: A role for sex- and gender-based analysis in psychosis research? Clinical Psychology & Psychotherapy, 25(6), 774–784. doi: 10.1002/cpp.2307 Hamdullahpur, K., Jacobs, K. J., & Gill, K. J. (2017). A comparison of socioeconomic status and mental health among inner-city Aboriginal and non-Aboriginal women. International Journal of Circumpolar Health, 76(1), 1340693. doi: 10.1080/22423982.2017.1340693 Kim, D. (2008). Blues from the Neighborhood? Neighborhood Characteristics and Depression. Epidemiologic Reviews, 30(1), 101–117. doi: 10.1093/epirev/mxn009 Krenichyn, K. (2006). ‘The only place to go and be in the city’: women talk about exercise, being outdoors, and the meanings of a large urban park. Health & Place, 12(4), 631–643. doi: 10.1016/j.healthplace.2005.08.015

28

Mair, C., Roux, A. V. D., & Galea, S. (2008). Are Neighborhood Characteristics Associated with Depressive Symptoms? A Critical Review. Journal of Epidemiology & Community Health. doi: 10.1136/jech.2007.066605 Martins, V., & Reid, D. (2007). New-immigrant women in urban Canada: insights into occupation and sociocultural context. Occupational Therapy International, 14(4), 203–220. doi: 10.1002/oti.233 Mental health: a state of well-being. (2014, August 15). Retrieved from http://www.who.int/features/factfiles/mental_health/en/.

Os, J. V. (2004). Does the urban environment cause psychosis? British Journal of Psychiatry, 184(4), 287–288. doi: 10.1192/bjp.184.4.287 Pahwa, P., Karunanayake, P., McCrosky, J., & Thorpe, L. (2012). Longitudinal Trends in Mental Health Among Ethnic Groups in Canada. Chronic Disease and Injuries in Canada, 32(3), 164– 176.

Phuong Do, D., Locklar, L. R. B., & Florsheim, P. (2019). Triple jeopardy: the joint impact of racial segregation and neighborhood poverty on the mental health of black Americans. Social Psychiatry and Psychiatric Epidemiology, 54(5), 533–541. doi: 10.1007/s00127-019-01654-5 Romans, S., Cohen, M., & Forte, T. (2010). Rates of depression and anxiety in urban and rural Canada. Social Psychiatry and Psychiatric Epidemiology, 46(7), 567–575. doi: 10.1007/s00127010-0222-2 Turner, R. J., Lloyd, D. A., & Roszell, P. (1999). Personal Resources and the Social Distribution of Depression. American Journal of Community Psychology, 27(5), 643–672. doi: 10.1023/a:1022189904602

29

Wilkes, R., & Iceland, J. (2004). Hypersegregation in the Twenty-First Century. Demography, 41(1), 23–36. doi: 10.1353/dem.2004.0009 Zoning, equity, and public health. (2001). American Journal of Public Health, 91(7), 1033–1041. doi: 10.2105/ajph.91.7.1033

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