Mental health disorders among minority women: risk factors and consequences from a life-course perspective

Minority women often report more mental health difficulties than both majority women and minority men, yet they are underrepresented in mental health care. Most studies in Norway are limited to studies comparing groups in at one point in time. To better identify risk factors of mental disorder, we need longitudinal studies. Further, we know little about the life consequences of mental disorders among minority women. The main aim of the project was to gain an overview over mental health service use (we focused on outpatient mental health (OPMH) services) among minority women over time and to identify risk factors for, and consequences of, mental disorders (measured through OPMH service use) over the life-course. By minority women, we mean migrant women and their female descendants. The project was register-based, giving national coverage, and involved the linkage of several sociodemographic registers to the Control and Payment of Health Reimbursements Database (KUHR). KUHR contains information on contact with, among others, general practitioners (GPs) and OPMH services. At the population level, we found that women with migrant background had lower chance of using OPMH services at least once over a five-year period than majority women. Use varied considerably by region of origin and length of residence. OPMH service use only reached the same level as majority women among migrant women had lived in Norway for more than 20 years. We also found that women from countries outside of the EEA, USA, Canada, Australia and New Zealand who had used OPMH services had fewer consultations than majority women. Among those with a recognised mental health problem diagnosed by a GP, however, differences in use of OPMH services between migrants and the majority population were smaller. Other findings from the project suggest that migrant women who use OPMH services do not experience greater negative socioeconomic consequences than their majority counterparts. The likelihood of high school completion, for instance, was lower among young women who had attended OPMH services than for young women who had not, regardless of migrant background. However, the relative difference was no larger among migrant women than their majority counterparts, and for some groups, it was smaller. Further, we found that young women also experienced loss of income in the years after entering OPMH treatment. Those with low income experienced the greatest loss. Although migrant women are over-represented in low-income groups, the relative income loss within most migrant groups was not significantly larger than for majority women. We also investigated whether known sociodemographic risk factors for mental disorders in the general population also predicted future OPMH service use. Several factors were less important for OPMH service use among women with migrant background compared to majority women. While growing up in low-income families, not being in the workforce and lower education levels were associated with higher use of OPMH services for majority women, the associations were weaker, non-existent or in the opposite direction for many groups of migrant women. Thus, it appears that migrant women who have lower education, who have not been in the workforce, who have grown up in low-income families appear to be under-represented in OPMH services. Although we did not have information on women’s actual mental health status in this project, we know from previous research that many migrant women experience greater barriers to care and tend to report poorer mental health. Therefore, a probable explanation for our findings is that women with fewer socioeconomic resources are less likely to access OPMH services when experiencing a mental disorder. Factors which are typically protective of mental disorder such as higher education and workforce participation may instead help facilitate access to care among migrant women who experience mental disorder. As such, OPMH service use is most likely to be a poorer proxy of mental disorder among women with migrant background than for majority women. The associations between the risk factors for using OPMH services which we have found, will therefore not necessarily reflect the associations between these risk factors and actual mental disorder among migrant women. Our findings may instead point to an inequity in accessing OPMH services. Interventions to increase help-seeking and improve access to mental health care should therefore target migrant women with fewer socioeconomic resources as well as shorter length of stays.

One outcome of the project includes increased interdisciplinary and international research collaboration and laid important collaborative groundwork for future research. Our findings seem to indicate that migrant women with fewer socioeconomic resources experience greater barriers to care, highlighting that we have yet to achieve an equitable health service. Through dissemination of our results to user groups and other stakeholders, these finding can be used to argue the need to make changes and work towards a more equitable health service. The project has also raised awareness of migrant women’s mental health and mental healthcare service use through dissemination of our findings with clinicians, with non-governmental organisations, key stakeholders in municipalities and among some migrant communities. At the same time, our findings point to weakness in using register data on mental health service use as an indicator of mental disorder among migrants. There is a need for better ways of measuring of mental disorder in this population. Studies which combine sources such as diagnostic interviews/self-report data with register data on health service use may give a better understanding of which factors are associated with increased risk of mental disorder and which are associated with mental health service use among the migrant population.

Minority women often report more mental health difficulties than both majority women and minority men, yet are underrepresented in mental health care. Most studies in Norway are limited to cross-sectional studies, comparing groups at one timepoint. Mental health disorders can occur and reoccur throughout the life cycle and are often the result of an accumulation of stress factors. Thus, there is a need for longitudinal studies using a life-course perspective in order to identify risk factors and treatment patterns. Further, we know little about the consequences of mental health disorders among minority women. The aim of the current project is to determine the extent of mental health service use among minority women over time and to identify the causes and consequences of mental health disorders over the life-course. We will consider how the timing, length of exposure and sequencing of events such as poverty, unemployment and marital transitions impact mental health disorders, assessed by use of mental health care services, and how mental health disorders impact future outcomes such as sick-leave, disability, marital transitions, education, employment and income. In addition to looking at women in general, we will also focus on young women in particular and include immigrants, descendants of immigrants and non-immigrants in our analyses. By using longitudinal data from national register studies, we can obtain a better overview of health care needs. This will aid future health care planning as the minority population continues to grow and diversify. Additionally, we can also gain insight into risk and protective factors for mental health disorders across the lifespan of minority women, helping with prevention strategies. Finally, the project has implications at the societal level; we will determine if particular groups of minority women need extra support in order to obtain higher education, reduce sick leave or to stay in the labour market.