The effectiveness of a Culturally-adapted Mental
Health Progamme for
Minorities In Hong Kong: A Randomised Controlled Trial
Eric Chen Yu Hai Chair Professor
Suen Yi Nam
Research Assistant Professor &
Research Sponsor Organiser Strategic Partner and Sponsor
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2 INTRODUCTION 01 METHODS 02 Study Design and outcome measures RESULTS 03 Statistical Findings DISCUSSION 04 AGENDA
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INTRODUCTION 01
8.4% of the population in Hong Kong are made up of Ethnic Minorities (EMs)
(Population Census, 2021)
Local EMs constitue 4.1% of the population in Hong Kong after excluding foreign domestic helpers
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Mental Health Challenges of EMs in Hong Kong
More prone to mental distress +
More vulnerable in developing mental disorders
Difficulties in social integration and cultural adaption
Racial discrimination and unfair treatment
Lower socioeconomic class
Lack of social support
Lower tendency on help-seeking behaviours
*Significant underutilization of mental health services*
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BARRIERS to receiving psychological support for EMs in HK
Broader
Language Barrier
Despite interpretation services
Lack of community
Culturally
Competent Care
Cultural and language in mainstream healthcare
Cultural Stigma
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OBJECTIVES
● To provide a culturally competent and language-appropriate Low-intensity counselling intervention to Ethnic Minorities in Hong Kong
HYPOTHESES
● To evaluate the effectiveness of the service in improving mental health of Ethnic Minorities in Hong Kong
1. Counselling service is more effective in reducing depressive and anxiety symptoms and stress level, when compared to the wait-list control group
2. There will be a higher level of quality of life, psychological and social functioning in the intervention group, when compared to the wait-list control group
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METHODS 02
Study Design & Outcome Measure
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Study Design
Study Period: January 2020 - August 2022
Sample size: 120
*up to HKD 1200 compensation to participants upon completion of all assessments
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T1 Randomisation Counselling (n = 60) Wait-list control (n = 60) Counselling Monitoring call Counselling Booster Booster T0 T2 T2 T3 T1
Intervention and control programme
Intervention group
● Culturally-adapted counselling
○ CBT-informed framework
○ 6 sessions spanning 8 weeks for mild-moderate group
○ 10 sessions spanning 12 weeks for severe-extremely severe group
● Training
○ All counsellors were trained and supervised by the lead counsellor
■ 2 days on treatment manual +
■ Weekly ongoing supervision
○ The lead counsellor received 1-2 session ongoing supervision by external supervision on monthly basis
Control group
● Monitoring purpose, to make sure urgent and acute deterioration situations were supported
● Weekly phone or text based contact
● Each contact <15 mins
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Inclusion Criteria
1. Non-ethnic Chinese resided in Hong Kong (except domestic workers)
2. Age between 15 and 64 years
3. Reached at least the mild level of mental distress (≥ 10 for Depression subscale, ≥ 8 for Anxiety subscale OR ≥ 15 for Stress subscale of DASS-21)
4. Sufficient proficiency in English, Hindi, Urdu and Nepali to understand verbal instructions
5. Able to provide informed written consent
*Those aged below 18 had to obtain parental consent before joining this program.
*DASS-21, Depression, Anxiety and Stress Scale 21-item version
Exclusion Criteria
1. Currently receiving psychiatric or psychological treatment
2. Had issues with substance abuse
3. Had active suicidal ideation, or engaged in self-harm behaviors
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OUTCOME MEASURES
depressive symptoms measured by DASS-D from
anxiety symptoms measured by DASS-A from T0
stress level measured by DASS-S from T0 to T1
quality of life measured by SF-12 from T0 to T1
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Randomisation, blinding and allocation concealment
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1:1 Individual, block randomisation
- Stratified by distress level
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Mild-moderate: DASS-D: 10-20 and/or DASS-A 8-14
and/or DASS-S: 15-25
- Severe-extremely severe: DASS-D >20 and/or
DASS-A >14 and/or DASS-S>25
- Outcome measures are self-reported → minimal assessor bias
- Randomisation conducted by computerised system → no one is aware of the next group allocation
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Data analysis
- Using intention-to-treat (ITT) and last observation carried forward (LOCF) approach
- Between-group difference of outcome measures at T1 was examined using multiple linear regression:
- Independent variable: RCT group (counselling or control)
- Dependent variables: outcome measures
- Covariates: duration of stay in Hong Kong, perceived social support from family and significant others and cultural orientation in pride
- Sensitivity analysis was conducted
- Among participants who completed 80% of the intervention (per protocol approach)
- ITT approach with multiple imputation using all baseline variables
- Subgroup analysis based on baseline characteristics
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03
RESULTS
Statistical Findings
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CONSORT flowchart
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204 Assessed for eligibility 120 Randomized 45 Ineligible 21 Receiving psychiatric service 19 With self-harm/suicidal risk 3 Substance use 2 Not meeting distress level 39 Unable to complete the baseline assessment Enrollment Allocation Follow-up 60 Allocated to counselling group 60 Allocated to wait-list control group 57 Completed T1 assessment 2 Withdrew 1 Lost to FU 53 Completed T1 assessment 6 Withdrew 1 Lost to FU 43 Completed T2 assessment 17 Withdrew 53 Completed T2 assessment 6 Withdrew 1 Lost to FU 43 Completed T3 assessment 17 Withdrew 60 included for analysis 60 included for analysis Analysis
Participant’s profile
SD, standard deviation; HKD, Hong Kong Dollar.
1. Statistics calculated using Mann-Whitney Test for continuous variable and Chi-square test for categorical variables.
2. Others were Nepali, Filipino, Indonesian, Bangladeshi, Mixed and Srilankan
3. Others were stable relationship domicile, separated, divorced and widowed
4. Others were home ownership scheme, private estate, subdivided flat, cubicle apartment and student dormitory.
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Total (n = 120) Intervention (n = 60) Control (n = 60) Statistics1 P Female sex, n (%) 101 (84.2) 52 (86.7) 49 (81.7) 0.563 0.45 Age 29.77 (9.22) 29.67 (9.30) 30.35 (9.16) 1711.000 0.64 Education level, n (%) 0.660 0.50 Primary or below 17 (14.2) 9 (15.0) 8 (13.3) Secondary 34 (28.3) 15 (25.0) 19 (31.7) Post-secondary 69 (57.5) 36 (60.0) 33 (55.0) Ethnicity, n (%) 5.714 0.06 Pakistani 49 (40.8) 28 (46.7) 21 (35.0) Indian 36 (30.0) 12 (20.0) 24 (40.0) Others2 19 (15.8) 20 (33.3) 15 (33.3) Employment status, n (%) 2.414 0.49 Homemaker 37 (30.8) 18 (30.0) 19 (31.7) Student 22 (18.3) 10 (16.7) 12 (20.0) Part-time/ Full-time 47 (39.2) 27 (45.0) 20 (33.3) Unemployed 14 (11.7) 5 (8.3) 9 (15.0) Marital Status, n (%) 0.663 0.72 Single 49 (40.8) 25 (41.7) 24 (40.0) Married 63 (52.5) 30 (50.0) 33 (55.0) Others3 8 (6.7) 5 (8.3) 3 (5.0) Total (n = 120) Intervention (n =60) Control (n = 60) Statistics1 P Number of children, n (%) 2.295 0.51 0 62 (51.7) 34 (56.7) 28 (46.7) 1 15 (12.5) 5 (8.3) 10 (16.7) 2 22 (18.3) 11 (18.3) 11 (18.3) ≥ 3 21 (17.5) 10 (16.7) 11 (18.3) Monthly household income, n (%) 0.770 0.86 < HKD 10,000 14 (11.7) 8 (13.3) 6 (10.0) HKD 10,001 - 20,000 29 (24.2) 13 (21.7) 16 (26.7) HKD 20,001 - 30,000 51 (42.5) 25 (41.7) 26 (43.3) ≥ HKD 30,000 26 (21.7) 14 (23.3) 12 (20.0) Type of housing, n (%) 1.244 0.54 Public rental housing 50 (41.7) 22 (36.7) 28 (46.7) Private rental 42 (35.0) 23 (38.3) 19 (31.7) Others4 28 (23.3) 15 (25.0) 13 (21.7) Housing size, sq.ft. 484.23 (213.68) 500.07 (234.07) 435.47 (169.59) 1484.000 0.10 Household size 4.73 (2.01) 4.57 (2.02) 4.47 (1.68) 1779.500 0.91 Substance use, n (%) Alcohol 34 (28.3) 18 (30.0) 16 (26.7) 0.164 0.69 Illicit drug 10 (8.3) 6 (10.0) 4 (6.7) 0.436 0.51 Cigarette 16 (13.3) 9 (15.0) 7 (11.7) 0.288 0.59 Locally born, n (%) 37 (30.8) 22 (36.7) 15 (25.0) 1.915 0.17 Duration of stay in Hong Kong 17.02 (9.86) 17.54 (9.72) 14.47 (9.81) 1410.500 0.04
Outcome measures at baseline
SD, Standard Deviation; DASS, Depression, Anxiety and Stress Scale, 21-item version; DASS-D, Depression subscale of DASS; DASS-A, Anxiety subscale of DASS; DASS-S, Stress subscale of DASS; QoL, Quality of Life; and SF, Short-form.
1. Statistics calculated using independent two-samples t-test or Mann-Whitney Test if the assumption of normality violated.
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Total (n = 120) Intervention (n = 60) Control (n = 60) Statistics1 P 7-day Depressive symptoms (DASS-D) 20.12 (8.93) 20.30 (9.30) 19.93 (8.62) 0.224 0.82 7-day Anxiety symptoms (DASS-A) 18.12 (8.35) 18.03 (8.57) 18.2 (8.19) –0.109 0.91 7-day Stress level (DASS-S) 22.82 (7.82) 22.57 (7.58) 23.07 (8.10) –0.349 0.73 Mental health-related QoL (SF12-MCS) 31.64 (11.53) 31.72 (10.89) 31.57 (12.23) 0.068 0.95
≥moderate level ≥severe level ≥moderate level Below norm of HK people
Other measures at baseline
Clinical Outcomes in Routine Evaluation – Outcome Measure.
1. Statistics calculated using independent two-samples t-test or Mann-Whitney Test if the assumption of normality violated.
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Total (n = 120) Intervention (n = 60) Control (n = 60) Statistics1 P 30-day Distress level (K6) 18.48 (5.40) 19.05 (5.31) 17.92 (5.48) 1.150 0.25 Lifetime traumatic event exposure (LEC-5) 1.93 (1.79) 2.10 (1.97) 1.75 (1.58) 1665.500 0.47 12-month threatening event exposure (LTE) 2.66 (2.03) 2.78 (1.99) 2.53 (2.07) 1615.000 0.32 Overall QoL (SF-index) 0.65 (0.12) 0.65 (0.12) 0.65 (0.11) 1746.000 0.78 Physical health-related QoL (SF12-PCS) 44.17 (10.04) 43.50 (9.58) 44.84 (10.51) 1674.000 0.51 Rumination (RRS-22) 56.63 (12.43) 57.35 (12.09) 55.92 (12.83) 0.630 0.53 Resilience (CD-RISC-10) 19.53 (7.37) 20.22 (7.60) 18.85 (7.13) 1.016 0.31 Help seeking intention - personal/emotional problem (GHSQ-emotion) 37.30 (8.24) 36.18 (8.21) 38.42 (8.19) –1.492 0.14 Help seeking intention - suicidal episodes (GHSQ-suicide) 34.87 (12.24) 34.02 (11.39) 35.72 (13.07) –0.759 0.45 Mental health seeking attitude (MHSAS) 5.95 (0.97) 5.98 (1.05) 5.92 (0.89) 1687.500 0.55 Stigmatising attitude towards mental illness (LPDDS) 32.37 (6.23) 32.10 (6.53) 32.63 (5.96) –0.467 0.64 SD, Standard Deviation; DASS, Depression, Anxiety and Stress Scale, 21-item version; K6, Kessler Psychological Distres Scale, 6-item version; LEC-5, Life Event Checklist-DSM-V; LTE,Life Threatening Event Checklist; QoL, Quality of Life; SF, Short-form; PCS, Physical Component Score; RRS, Rumination Response Scale; CD-RISC-10, Connor-Davidson Resilience Scale
GHSQ,
MHSAS,
and CORE-OM,
10-item version;
General Health Seeking Question;
Mental Help Seeking Attitude Scale; LPDDS, Link's Perceived Discrimination and Devaluation Scale
Other measures at baseline
SD, Standard Deviation; PWB, Ryff’s Psychological Well-Being Scales; MSPSS, Multidimensional Scale of Perceived Social Support; GEQ, General Ethnicity Questionnaire.
1. Statistics calculated using independent two-samples t-test or Mann-Whitney Test if the assumption of normality violated.
20 Total (n = 120) Intervention (n = 60) Control (n = 60) Statistics1 P Self-reported psychological wellbeing (PWB) Autonomy 24.33 (6.97) 24.22 (6.47) 24.43 (7.50) –0.169 0.87 Environmental mastery 24.28 (5.48) 23.42 (5.38) 25.15 (5.49) –1.747 0.08 Personal Growth 28.14 (5.66) 27.95 (6.18) 28.33 (5.13) –0.370 0.71 Positive Relations 26.14 (6.68) 25.08 (7.12) 27.20 (6.08) –1.752 0.08 Purpose in life 27.14 (5.71) 26.68 (6.04) 27.60 (5.37) –0.879 0.38 Self-acceptance 23.54 (7.03) 22.70 (6.96) 24.38 (7.06) –1.315 0.19 Perceived Social Support (MSPSS) Overall 4.63 (1.65) 4.07 (1.19) 4.80 (1.26) –3.284 0.001 Significant others 4.48 (1.55) 4.23 (1.66) 5.04 (1.56) 1312.500 0.01 Family 4.20 (1.74) 3.98 (1.50) 4.98 (1.45) 1119.500 <0.001 Friends 4.44 (1.27) 4.00 (1.79) 4.40 (1.69) 1519.000 0.14 Cultural orientation (GEQ) Language 22.28 (6.07) 22.68 (6.69) 21.87 (5.41) 1720.000 0.67 Social 22.39 (4.45) 21.65 (4.73) 23.13 (4.04) 1.846 0.07 Activities 5.26 (1.96) 5.18 (1.73) 5.33 (2.17) 1782.500 0.93 Pride 12.08 (2.43) 11.72 (2.44) 12.45 (2.39) 1402.500 0.03 Media 12.29 (3.48) 11.87 (3.41) 12.72 (3.52) –1.343 0.18 Food 9.77 (3.32) 9.45 (3.27) 10.08 (3.38) 1590.500 0.27
Outcome measures
Crude score changes
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symptoms Anxiety symptoms Stress level Mental health-related QoL
Depressive
Effect of intervention on outcome measures
Statistical testing
intention-to-treat; LOCF, last observation carried forward;
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ITT (LOCF) ITT (MI) PP B S.E. 95%CI P B S.E. 95%CI P B S.E. 95%CI P Primary outcomes Depressive symptoms -8.91 1.92 -12.70, -5.12 <.001 -9.48 -4.75 -13.40, -5.56 <.001 -10.93 1.93 -14.76, -7.11 <.001 Anxiety symptoms -6.33 1.82 -9.94, -2.73 .001 -6.31 -3.42 -9.93, -2.69 <.001 -7.45 1.86 -11.13, -3.77 <.001 Stress level -8.60 1.85 -12.27, -4.92 <.001 -8.89 -4.63 -12.65, -5.12 <.001 -10.54 1.87 -14.25, -6.84 <.001
Mental health-related QoL 11.97 2.34 7.33, 16.61 <.001 11.70 2.59 6.60, 16.81 <.001 13.23 2.32 0.05, 0.15 <.001 ITT,
MI, multiple imputation; PP, per protocol ***p < .001, ** p < .01, * p < .05
Secondary outcomes
Subgroup analysis
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N P-values for multiple linear regressions Median cut/ binary TotalCounselling control Depressive symptoms Anxiety symptoms Stress level QoL Gender Male 19 8 11 0.358 0.631 0.036 0.501 Female 101 52 49 <0.001 <0.001 <0.001 <0.001 Age <29 59 31 28 0.003 0.004 0.002 <0.001 ≥29 61 29 32 0.002 0.041 0.002 0.002 Education ≤Secondary 51 24 27 0.100 0.162 0.025 0.025 Post-secondary 69 36 33 <0.001 <0.001 <0.001 <0.001 Ethnicity Others 71 32 39 <0.001 <0.001 <0.001 <0.001 Pakistani 49 28 21 0.004 0.119 0.002 0.003 Employment Others 73 33 40 0.003 0.005 0.003 0.001 Fulltime/parttime 47 27 20 0.001 0.147 0.001 <0.001 Marital status Others 57 30 27 0.008 0.030 0.028 0.003 Married 63 30 33 0.002 0.039 <0.001 <0.001 Income ≤20,000 43 21 22 0.003 0.055 0.033 0.011 >20,000 77 39 38 0.006 0.016 <0.001 <0.001 Type of housing Others 70 38 32 <0.001 <0.001 <0.001 <0.001 Public rental 50 22 28 0.025 0.189 0.025 0.013 Locally born No 83 38 45 0.006 0.106 0.009 <0.001 Yes 37 22 15 <0.001 <0.001 <0.001 0.008 Duration of stay <16 59 23 36 0.020 0.352 0.013 0.002 ≥16 61 37 24 <0.001 <0.001 <0.001 <0.001 Distress strata Mild-moderate 29 13 16 0.026 0.351 0.014 0.020 Severe-e.severe 91 47 44 <0.001 <0.001 <0.001 <0.001 Had a child No 62 34 28 <0.001 0.002 0.001 <0.001 Yes 58 26 32 0.004 0.067 0.003 0.005 Resilience <19 60 30 30 0.002 0.023 0.002 0.001 ≥19 60 30 30 0.002 0.022 0.001 <0.001 Rumination <56.5 60 30 30 0.190 0.325 0.152 0.061 ≥56.5 60 30 30 <0.001 0.001 <0.001 <0.001 Help seeking attitude <6.1 52 24 28 0.022 0.078 0.027 0.009 ≥6.1 68 36 32 <0.001 0.010 <0.001 <0.001 N P-values for multiple linear regressions Median cut/ binary TotalCounselling control Depressive symptoms Anxiety symptoms Stress level QoL Help-seeking (emotion) <38 58 33 25 <0.001 0.006 <0.001 <0.001 ≥38 62 27 35 0.018 0.024 0.011 0.001 Help-seeking (suicidal) <36 58 33 25 <0.001 0.002 <0.001 0.001 ≥36 62 27 35 0.073 0.173 0.059 0.001 Traumatic event exposure 0 31 15 16 0.017 0.193 0.047 <.001 ≥1 89 45 44 <.001 <.001 <.001 <.001 Stressful life event exposure <2 37 13 24 0.028 0.104 0.001 0.031 ≥2 83 47 36 <.001 0.003 <.001 <.001 Stigmatising attitude <33 59 30 29 0.031 0.105 0.026 0.015 ≥33 61 30 31 <0.001 <0.001 <0.001 <0.001 Perceived social support <4.4 59 30 29 0.001 0.031 0.001 0.002 ≥4.4 61 30 31 0.001 0.008 <0.001 <0.001 Cultural orientation (Language) <21 55 26 29 0.003 0.039 0.006 0.001 ≥21 65 34 31 <0.001 0.004 <0.001 <0.001 Cultural orientation (Social) <21 49 27 22 0.039 0.085 0.003 0.002 ≥21 71 33 38 <0.001 0.010 0.001 0.001 Cultural orientation (Activities) <5 42 21 21 0.037 0.096 0.003 0.002 ≥5 78 39 39 <0.001 0.013 0.001 0.001 Cultural orientation (Pride) <12 40 24 16 0.325 0.179 0.541 0.057 ≥12 80 36 44 0.001 0.002 0.000 0.000 Cultural orientation (Media) <12 50 26 24 0.006 0.067 0.017 0.004 ≥12 70 34 36 <0.001 0.003 <0.001 <0.001 Cultural orientation (Food) <10 53 28 25 0.004 0.001 0.011 0.001 ≥10 67 32 35 0.001 0.077 0.001 <0.001 Physical health-related QoL <44.0 59 31 28 0.007 0.005 0.003 0.003 ≥44.0 61 29 32 0.000 0.014 <0.001 <0.001 QoL index <0.6 51 26 25 0.024 0.127 0.023 0.003 ≥0.6 69 34 35 <0.001 0.002 <0.001 <0.001
The counselling service is effective in most subgroups, except participants with low rumination, better help seeking attitude when encountering suicidal matters, and other groups several with small sample size, such as the male group and high cultural orientation in pride.
DISCUSSION 04
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DISCUSSION
● The counselling effect was better in the intervention group in terms of the mood symptoms
● Low-intensity Individual counselling featured with cultural sensitivity is beneficial to EM participants in Hong Kong.
● Challenges encountered:
○ Relatively high (~10%) screened participants had suicidal risk which required formal psychiatric service but referring them to existing public service is difficult
○ COVID has added extra burden to participants’ preexisting mental distress.
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Study Implications
- The EM wellbeing centered organised by TZF has successfully engaged EMs with mental health needs and improve their mental health through providing culturally sensitive CBT-informed counselling service.
- The effectiveness is generalisable to EMs with wide range of background.
- The service model:
- on one hand, engaged EMs substantial distress level, preventing them from further deterioration
- on the other hand, connected needed ones to existing service
- The service model can be considered for more EM platforms in Hong Kong.
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THANK YOU
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