Bridging Barriers: Understanding Intersectional Inequities in Mental Health Talking Therapies Access through Linked Data Analysis

BACKGROUND: Mental health problems contribute substantially to the global burden of disease.

In England, access to psychological therapy (NHS Talking Therapies/ "NHSTT", previously Improving Access to Psychological Therapies, "IAPT") for depression and anxiety have increased over time, however ethnically and racially minoritised people are much less likely to access these [1].

A range of inequities have been highlighted, including longer wait times and poorer outcomes in racially minoritised people[1-2].

Reasons for this include a lack of culturally sensitive treatments, practical barriers (e.g. language), and a concern that treatments do not attend to social, cultural and holistic needs, with racism strongly implicated[1-3].

Single social identities (e.g. ethnicity, gender or class alone) fail to capture the complexities faced by multiply disadvantaged individuals.

Intersectional theory recognizes the impact of overlapping privilege and oppression (racism, sexism, classism), to create unique dynamics for people who embody multiple and intersecting social positions[4].

In this project, the PhD student will analyse mental health records linked with census data [5] to explore how ethnicity intersects with factors like age, gender, religion, and social class, affecting access and outcomes of therapy.

AIMS: To understand ethnic inequalities and other intersectional factors (e.g. age, gender, religion, country of birth, language, occupational social class, area deprivation) affecting NHSTT access and outcomes.

OBJECTIVES: In partnership with the NHS Race and Health Observatory (NHSRHO), and with people with lived experience (Lived Experience Advisory Board; 'LEAB') to: 1. Review literature, refining theories on ethnicity and intersectionality in NHSTT access/outcomes. 2. Identify intersectional positions (e.g., race/ethnicity, gender, age) linked to NHSTT inequities. 3.

Explore the role of mediators in intersectional NHSTT disparities. 4.

Develop actionable recommendations which attend to intersectional inequities impacting access and outcomes of NHSTT amongst racially minoritised people.

METHODS: CRITICAL LITERATURE REVIEW The student will undertake a literature review to understand key elements which act as barriers and facilitators for equitable NHSTT access, with a focus on intersectional inequalities. This will inform the analytic plan, refined in partnership with the LEAB (see below), and our partner, NHSRHO.

DATA, MEASURES De-identified records from South London & Maudsley Trust NHS Trust, one of Europe's largest mental healthcare providers, are accessible for research via Clinical Records Interactive Search (CRIS)[5]. CRIS offers data on NHSTT service use, covering a catchment of 1.3 million people in southeast London.

The student will utilize ethically approved person-level CRIS mental health records (up to 2019) linked to census 2011[5].

Census linkage supplements health records with attributes, such as religion, self-rated health, disability, migration, tenure, education, employment, and poverty indicators. Outcomes will encompass NHSTT contact, self-referral, therapy completion, and dropout.

LIVED EXPERIENCE ADVISORY BOARD (LEAB) The project will be informed by a LEAB, led by the supervisor, comprising six individuals with mental health service or caregiver experience.

The student will consult the LEAB ~4+ times during the project, seeking guidance on modeling, interpretation, and dissemination. LEAB members will be compensated as per guidelines, funded by the supervisor's grant.

STATISTICAL METHODS In Analysis 1, the student will conduct a descriptive analysis exploring ethnic disparities and other factors (gender, age, socioeconomic status, area deprivation, nativity, and language) in NHSTT service access and outcomes, using multivariable logistic regression. In Analysis 2, the student will develop Latent Class Analysis (LCA) approaches with a theoretical underpinning, infor