Sarah Amani

Reach Out Project

Exploring the factors affecting access to mental health services for the Nepali community in Rushmoor, North East Hampshire.

Contents
1. Executive Summary 2. Acknowledgements 3. Introduction 3.1 Rushmoor Borough Council 4. Literature Review 4.1 The Mental Health of South Asian Groups in the UK 4.2 Early Intervention 4.3 The Role of Community Health Ambassadors (CHAs) 4.4 Health Promotion in Mental Health 4.5 Cultural Competency 5. Project Methods 5.1 Community Listening Events 5.2 Forming the Reach Out Project Steering Group 5.3 Recruiting & Training Community Health Ambassadors 5.4 Developing & Issuing the Mental Health Service Survey 5.5 Running the Mental Health Promotion Campaign 5.6 Reach Out Conference & CHA Graduation Ceremony 6. Survey Findings 7. Discussion 7.1 Limitations 8. Conclusion 9. Recommendations 9.1 Key Messages For Service Providers 9.2 Key Messages for Commissioners 9.3 Key Messages for Policy Makers 10. References 11. Appendices

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4 7 9 10 11 11 12 13 14 15 16 16 17 17 19 20 23 24 37 38 39 40 40 40 40 41 44

Images, Graphs and Tables

Images & Graphs
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. Figure 1: Map of Rushmoor Borough Council, Figure 2: Greatest health issues for migrant populations in the South East UK Figure 3: The factors we most control have the most impact on our health Figure 4: Shows the process by which the training took place Figure 5:Screenshot of the mental health first aid e-learning program Figure 6: Sarah Amani's Twitter feed screenshot Figure 7: The CHAs Website screenshot Figure 8: The mental health mobile app screenshots Figure 9: What action was taken by those with a mental health problem? Figure 10: Local mental health services that participants had heard of Figure 11: Local mental health services that Nepalese participants Figure 12: Mental health service usage by different ethnicities Figure 13: Difficulty finding out about mental health services for different ethnicities Figure 14: Challenges that participants encountered when accessing a Mental Health Service Figure 15:Challenges that Nepalese participants encountered when accessing a Mental Health Service (MHS) Figure 16: Aspects of the mental health services participants found useful Figure 17: Aspects of the mental health services Nepalese participants found useful Figure 18: What participants would find helpful to improve awareness of local mental health services Figure 19: What Nepalese participants would find helpful to improve awareness of local mental health services

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10 12 14 18 18 20 21 22 24 27 27 28 29 30 31 32 33 34 35

Tables
20. 21. 22. 23. 24. Table 1: Age of respondents Table 2: Percentage of respondents divided by gender Table 3: Percentage of respondents divided by ethnicity Table 4: Registration with a GP Table 5: Do you know anyone with a mental health problem? 24 24 24 24 25

12. Appendices
1. 2. 3. 4. 5. 6. 7. 8. Mental Health Services Survey Survey Participant Information Sheet Mental Health First Aid Training Timetable Video Shoot Schedule Incentives and Disincentives of Community Health Ambassadors Community Attitudes towards Mental Illness Questionnaire Its Good Chat Campaign Posters Mental Health First Aid Assessment 44 47 49 50 52 53 54 56

1. Executive Summary
A person with a long-term health condition will spend on average 12 hours a year interacting with their health or social care workers. Individuals with transient or less severe health conditions will spend less than 4 hours a year with their health or social care workers (Asch et al, 2012). People will spend the remainder of their time, which averages at 5000 hours a year, interacting with their social networks at home, work, school and social gatherings. The usual focus of health and social care has been on the limited times when individuals interact with health and social care workers. The Reach Out project set out to focus on the 5000 hours a year when individuals interact with each other in informal settings, sharing information and influencing each others choices, including health choices. These interactions offer ample opportunity to raise mental health awareness and reduce mental health stigma. By providing support and training to community figures in mental health first aid, the Reach Out Project aimed to arm the community with mental health awareness and guidance on how to promote positive mental health to their respective and varied social networks. Objectives: The objectives of the Reach Out project were to: 1. Survey the mental health awareness in the Nepali community of Rushmoor, North East Hampshire; 2. Train community figures in mental health first aid so they could become Community Health Ambassadors (CHAs) and raise mental health awareness; 3. Launch a mental health promotional campaign using posters, leaflets and digital mediums such as the CHAs website and a mobile app to provide convenient at your fingertips information about mental health and local mental health services. Method: The project began with the project team attending listening events to get views from the Nepali community on mental health and wellbeing. A steering group was formed to represent a cross section of the local community and guide the project. Following approval from Surrey & borders Partnership NHS Foundation Trust (SABP), a mental health survey was issued. Between April 2012 and May 2012, a total of 55 individuals were surveyed using the Mental Health Services Survey (Appendix 1) to determine perceptions and awareness of local mental health services. Between November 2011 and February 2012, a two-week long mental health first aid training programme was delivered to eight community figures, seven of whom were Nepalese and one White British. The trainees graduated as CHAs at the Reach Out Conference held on 31st May 2012. They celebrated their achievements and were joined in their graduation ceremony by 120 attendants. The CHAs developed campaign materials and led a comprehensive mental health promotion campaign to raise mental health awareness and reduce stigma.

Results: The CHAs feedback has been very positive. They report improved confidence and knowledge about mental health and being able to signpost people to the services available for those experiencing mental health issues. Furthermore, some CHAs reported improved relationships with family members and friends as a result of their improved understanding of the role and impact of beliefs, emotions and behaviours on everyday life. A baseline of the mental health awareness of the Nepalese community was determined by the mental health survey. Of the 70 surveys issued, 55 were returned. This 73% response rate is a good result in view of the difficulties typically experienced in engaging newly settled migrant communities such as the Nepalese community. The Nepali respondents generally had noticeably lower awareness of mental health services and lower utilization of mental health services as compared to those who described their ethnicity as White British. Nepalese respondents also expressed more preference to use universal services such as religious centres and community figures as a source of mental health support. The survey has shed light on some of the factors affecting access to mental health. Other findings show that the CHAs have been successful in raising mental health awareness. For example, of the community mental health services reported to be most commonly known among the Nepalese respondents, the top 4 had been visited by CHAs as part of their mental health first aid training. The project has successfully initiated the positive attitudinal change in a hard to reach group by mobilizing key community figures to promote mental health in their local communities. The CHAs have led a comprehensive mental health promotional campaign to raise mental health awareness using face-to-face interactions and web based technologies such as the CHAs website (www.itsgoodtochat.com), a mobile phone app, Facebook and YouTube. The CHAs have managed to Reach Out to their communities. For instance, one of the CHA videos was watched by 2000 viewers between April 2012 and by the time of writing this report in July 2012. Furthermore, early results from the mental health service survey conducted between April May 2012 shows better awareness of the services that the CHAs visited during their mental health first aid training. This suggests that the spreading of information by CHAs through their various networks is indeed working. The impact of the CHAs activities on community mental health service utilization is yet to be determined. Conclusion: The Reach Out project managed to forge powerful connections across the community and inspire action. The project successfully engaged the Nepali community in Rushmoor in promoting mental health and wellbeing. Eight members of the community trained in mental health first aid and led a popular mental health awareness campaign, which garnered local and national attention for its creativity and energy. The mental health survey conducted as part of the project provides a snapshot and baseline of the level of mental health awareness in Rushmoors Nepali community. Training the community in mental health first aid therefore appears to be a positive step towards promoting mental health awareness and improving mental wellbeing. A further survey in the future would determine any changes in the level of mental health awareness, the impact on utilisation of community mental health services and provide further evidence of the effectiveness of this approach in promoting mental health.

Recommendations
1. Service Providers
Recruit, educate and support volunteers from marginalized communities to engage as partners in health promotion campaigns aimed at those targeted communities.
Key Messages:
Community Health Ambassadors are individuals who are selected by their own communities, engaged, trained and supported to inspire and help their friends, families, neighbours and work/education peers to make healthier decisions; There is enormous potential to be realized from empowering the community in promoting health via their various social groups and networks; For CHAs to be able to make an effective contribution, they need to be selected by the target community, appropriately trained and very importantly adequately and continuously supported.

2. Commissioners
Utilize the Commissioning for Quality & Innovation (CQUIN) payment framework to incentivize services to evidence meaningful engagement of marginalized communities.
Key Messages:
Community Health Ambassadors are effective health promoters capable of reducing the social and economic burden of illness; The delivery of successful CHA programmes requires change across whole systems; Commissioners have a whole range of contract management levers through which they can drive and support this change.

3. Policy Makers
Include and involve representatives from marginalized communities when developing health and social policies.
Key Messages:
The CHA model is an effective way of reducing health inequalities for marginalized groups. The potential benefits of CHA programmes, in the context of health promotion and equality, are unlikely to be achieved or sustained unless CHA schemes are integrated into mainstream health and social care policies; The progressive integration of CHA programmes requires mainstream support at a local, national and international level via research and dissemination.

2. Acknowledgements
First and foremost I would like to thank Mary Seacole, who paved the way all those 150 years ago and encouraged us to strive to treat all people equally and fairly. I would also like to take this opportunity to thank my friends, family and my parents who continue to cheer me on, all the way from the Warm Heart of Africa, Malawi. Thanks also to my older brothers and sister who have nothing but encouraging words. All too often in life, we see injustice and inequality. We may walk away thinking that we are too small to make a positive difference. Every so often an opportunity to do something about inequality comes along. For me, the Mary Seacole Leadership Award was that opportunity to do my part in setting right in a small way, the health inequality experienced by the Nepali community in Rushmoor and in so doing promote community integration and cohesion. I would also like to thank everyone who has made contributions to this project, in particular the 8 dedicated people who volunteered to become Community Health Ambassadors: Ramji Tiwari Roshani Gurung Purna Bahadur Gurung Deepak Neupane Anjila Gurung Mary Everley Madhukar Gurung Dambar Bahadur Gurung

Alongside, the ever hard working Early Intervention in Psychosis Team members: Dr Glenn Cornish Consultant Psychiatrist Louise Lunn Support Time & Recovery Worker Jessica Goddard Research Assistant Dr Sofia Efstratiou Specialist Psychiatric Doctor Letitia Cooper Team Medical Secretary Lexy Rose Honorary Psychology Assistant Joyce Sims Community Mental Health Nurse Emma Malyon Occupational Therapist Jackie Whittington Community Mental Health Nurse Dr Payal Amin Counseling Psychologist

The Reach Out Project would not have achieved its objectives without the steering group, which includes the following members from various agencies: Major (Retired) Tikendra Dewan Greater Rushmoor Nepalese Community Charity Colette Lane Ins!ght Forum James Keenan - Ins!ght Forum Perry Clifton - Ins!ght Forum Dr Olive Fairbairn GP & Mental Health Lead for NE Hampshire & Farnham CCG James Phillips Increasing Access to Psychological Therapies (TalkPlus)

Sheila Limbu Naya Yuva Nepalese Youth Group Raj Chhetri Older Adults Services, Surrey & Borders Partnership NHS Foundation Trust Eleanor Atkinson Speech & Language Therapist, Surrey & Borders Partnership NHS Foundation Trust Madhu Gurung - Rushmoor Borough Council Cherry Sullivan Catch22 24/7 Service Alison Smith Mental Health Faculty Lead, University of Surrey Claire Bampton Carer Support, Surrey & Borders Partnership NHS Foundation Trust Jake Ballard Trainer of Basic Awareness in Autistic Spectrum Disorders Howard Childs Behaviour Specialist, Surrey & Borders Partnership NHS Foundation Trust Michael Llewellyn Acute Services, Surrey & Borders Partnership NHS Foundation Trust Patricia Crawford Community Mental Health Recovery Service, Surrey & Borders Partnership NHS Foundation Trust Dr Marie Casey NHS Hampshire

My gratitude also goes to the leaders at Rushmoor Borough Council who were kind enough to give a talk at the Reach Out Conference on 31st May 2012: Peter Moyle Head of Councilors Peter Crerar Deputy Mayor Colin Alborough Environmental Health Manager

Lastly, a special thank you to Surrey and Borders Partnership NHS Foundation Trust colleagues and seniors as well as my Mary Seacole Award mentors who provided much appreciated guidance and support throughout the project: Obi Amadi Mary Seacole Award Mentor Dr Janet Scammell Mary Seacole Award Mentor Mike Poulter Service Improvement Manager David Sandy Web Developer Nicky Palmer Manager for Learning Disability Services Pat Keeling Director of Strategic Change Jo Lynch General Manager of Children & Young Peoples Specialist Services Dr Rebecca Andrew Chartered Senior Clinical Psychologist Susie Hartley Communications Officer Mandy Dunn Director of Children & Young Peoples Services Alex Martin Associate Director of Equality & Human Rights Nicki Rayment Associate Director of IT Janet Fevrier Associate Director of Membership & Involvement Stephanie Cotgrove Associate Director of Marketing Jo Young Director of Operations Mandy Stevens Director of Quality Julie Gaze Deputy Chief Executive Fiona Edwards Chief Executive

3. Introduction
Mental health services in the United Kingdom (UK) made notable strides during the twentieth century. Arguably the most notable shift in practice resulted from the Mental Health National Service Framework, which modernized community mental health services in a bid to bring an emphasis on preventative and recovery focused mental health care (NMHDU, 1999). Whilst this shift profited some, there is evidence to show that Black and Minority Ethnic (BME) groups benefited less than the dominant ethnic group. BME groups are underserved by these modernized community mental health services and over represented in mental health hospitals, with poorer clinical outcomes and worse patient experiences (DoH, 2007; DoH, 2010; Friedli, 2009; Marmot, 2010). Time and time again, a key recommendation for addressing the health disparities faced by BME groups has been to involve the target communities in devising ways to diminish stigma, promote awareness and reduce health inequality (DoH, 2007, WHO, 2007; DoH, 2010; NHS Confederation, 2012). This way the community is more likely to own the initiative and commit to its goals. One approach aimed at improving mental health equality across ethnic groups has been to involve these communities in developing Community Health Workers (CHWs). The World Health Organization (WHO) describes CHWs as follows: Community health workers should be members of the communities where they work, should be selected by the communities, should be answerable to the communities for their activities, should be supported by the health system but not necessarily a part of its organization, and have shorter training than professional workers. WHO (2007) CHW programmes have typically been trialed in projects aimed at improving the physical health of underserved populations (Curtale et al, 1995; Patel et al, 2011). The Reach Out project extended the scope of this concept by applying it to mental health awareness and mental health promotion. To ensure that there was a distinction between this project and others before it, the lay mental health workers took on the title of Community Health Ambassadors (CHAs). Whilst CHWs and CHAs are based on a similar concept it is important to draw two key distinctions between the two types of community workers: Unlike CHWs who train in physical health, CHAs undertake a training programme focused on mental health which is aimed at raising awareness and changing attitudes towards mental illness; The CHA training programme was designed to be longer than the typical CHW training, the former lasted 2 weeks spanning over 3 months as opposed to the typical 2-day courses of some of the CHWs;

3.1 Rushmoor Borough Council

Figure 1

Figure 1 shows Rushmoor Borough Council, where the project was established. Rushmoor Borough Council is located in North East Hampshire, approximately 30 miles south east of London. The two main towns in the borough, Aldershot and Farnborough, both have historical significance. Aldershot is recognised as the home of the British army and Farnborough as the birthplace of British aviation. Latest demographic figures from 2011 show the population of Rushmoor to be 96, 700 residents (Hampshire County Council, 2011). Assisted by the campaigning of Joanna Lumley, the residency rights of former Nepalese Gurkhas changed in 2008 leading to an influx of people from Nepal to this area, including the military town of Aldershot. A major stumbling block for any researcher or policy maker is the paucity of local data on the local Nepalese community and their needs (Casey, 2010). Rushmoor has an estimated 6000 12 000 people of Nepalese origin (Casey, 2010). Research on Nepali populations in Rushmoor has had to resort to estimates as the Census and data gathering tools do not specify Nepalese as a choice when asking for ethnic background, leaving those from Nepal to choose the Asian Other option.

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4. Literature Review
Before initiating the project, a literature search and review was undertaken to address five key questions: Q1. What is known about the mental health of South Asian groups in the UK? Q2. What is the clinical and financial impact of early intervention? Q3. What is the impact of CHAs on outcomes, particularly mental health awareness, help-seeking behavior, satisfaction with and usage of mental health services and resulting health outcomes? Q4. What impact does mental health promotion have on clinical and financial outcomes? Q5. What role does cultural competency play in promoting mental health? The literature search was conducted using the following words: Nepalese South Asian Mental Health Community Health Workers Health Promotion Cultural competency on online databases Athens, CINAHL and Pub Med. Thirty papers that addressed the issues of mental health and illness as pertaining to South Asian communities in the UK; CHW/CHAs on the health of communities, the value of mental health promotion and role of cultural competency in promoting mental health were chosen and analyzed as follows:

4.1 The Mental Health of South Asian Groups in the UK

One significant problem encountered when undertaking a literature review focused on this topic is the data shortages on the mental health of the Nepali community in the UK. This imposes some limitations both on the conclusions drawn and the applicability of some of the interventions that have worked with other South Asian groups. There is evidence to show that people of a South Asian background tend to seek help from friends and family for mental health problems (Jha, 2007). This is a good thing as this social support is very important for recovery however; sometimes social support is not enough. The Equality Act (2010) and Equality Delivery System rightfully emphasizes the impetus to make the option to access community mental health services be available to all, regardless of protected characteristic (NHS Employers, 2012). The Family Matters research study carried out by Time to Change in 2010 in Harrow (North West London) explored the attitudes towards mental illness in the South Asian community. The study found that mental illness was a taboo subject for the South Asian community in Harrow and concluded that this taboo is present in other South Asian populations. The key issues identified by the study were:

The causes of mental health problems were often misunderstood Shame, fear and secrecy surrounded mental illness Some families were caring and whilst others were very isolating There was social pressure to conform People with mental health problems were generally not valued by family or friends Marriage prospects were damaged if a family member experienced mental illness

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Figure 2

What are the greatest health issues for migrant populations in the South East UK?
30 20 10 0

Significant Problem

Minor Problem

Not Known

No Problem

Source: Understanding the Health Needs of Migrants in the South East Region (Department of Health, 2010) The Family Matters research study focused on a South Asian population in one part of London (Time to Change, 2010). Figure 2 shows the results of the migrant health needs assessment carried out by the Department of Health in 2010 in the South East of England. Of those surveyed the majority (28%) of people identified mental health issues to be their most significant problem. Perhaps this should not be too surprising given that one in four people in the UK will experience a mental illness in their lifetime (DoH, 1999). Furthermore, mental illness is currently the leading cause of disability in the world (WHO, 2007). Despite our knowledge of this high prevalence, suicide remains the leading cause of death for young males under the age 35 in the UK (DoH, 2010).

4.2 Early Intervention

The team that undertook the Reach Out Project works with people experiencing a less prevalent yet more debilitating group of mental illnesses collectively known as psychosis. Psychosis is a group of serious mental illnesses characterized by a loss of touch with reality (Wong et al, 2009). Psychosis affects 1-3% of the population with 7,500 young people developing the illness every year in the UK (Jones et al, 2010). Chronic versions of the illness (Schizophrenia and Bipolar Disorder) reduces life expectancy by 15-20 years, limits employment prospects by 84%, costs society 6.7 billion a year and leads to suicide in 10% of those affected (Jones et al, 2010; McCrone et al, 2010). Working with people affected by the above has shed light on the devastating impact this illness can have on the individual, their family and their community. The statistics paint a bleak picture, but it does not have to be this way. Recent research into UK Early Intervention in Psychosis Services (EIIP) has shown this approach to be more effective, both clinically and economically, than traditional community mental health services (Jones et al, 2010).

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EIIP services have delivered better prognosis for those experiencing first episode of psychosis and led to improved health and social outcomes (McCrone et al, 2010). Financially, this approach saves 4972 for every person who is treated by reducing use of acute care e.g. hospitals and preventing chronic mental illness in the majority of cases (Knapp at al, 2011, Amani et al, 2012). Detecting and treating the symptoms of mental illness early instead of waiting for the severe mental illness to take a firm and permanent hold works and it works well (Jones et al, 2010).

4.3 The Role of Community Health Ambassadors

A literature review of the impact of CHWs and CHAs was undertaken using a mix of national and international research articles. The evidence from the literature showed that CHAs: o Increased health awareness and knowledge about services A global review on lay health workers by the World Health Organization (WHO) noted that communities were more receptive of health messages from CHAs, as they are perceived to be more accessible and acceptable (WHO, 2007). This was noted to be partly due to CHAs, as part of the communities they serve, being more able to deliver health information in the communities own language and with due attention to the communities culture. o Improved health and wellbeing Patel et al (2011) noted a 30% decrease in the prevalence of common mental health problems (as compared to the baseline morbidity) in their sample of 2796 participants following the work of CHWs in rural India. o Increased access and uptake of health services A key finding from the literature has been the trust generated by CHAs and similar programmes which involve individuals from the target community. The trust garnered is reported to act as a bridge between health services and marginalized groups (Curtale, 1995; WHO, 2007). o Improved cost effectiveness A recent report released by the NHS Confederation proves this very point and goes a step further. The Community Health Champions: Creating New Relationships with Patients and Communities report looked specifically at the role and impact of CHWs/CHAs in health promotion including mental health (NHS Confederation, 2012). The project which is titled All Together Better has been running in the North of England since 2009 and currently boasts 17, 000 volunteers who have trained to promote health to 105 000 people in their local community. The project used the York Health Economics Consortium to calculate a cost saving of 112.42 for every 1 spent on the scheme (NHS Confederation, 2012).

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4.4 Health Promotion in Mental Health

In 2011, a meta-analysis by Knapp, McDaid & Parsonage (2011) evaluated the clinical and financial implications of mental health promotion. The research aimed to answer the fundamental question of whether investment in the prevention of mental health needs and promotion of mental wellbeing might present a good use of available resources (Knapp, McDaid & Parsonage, 2011: 3). The research found that mental health promotion provides outstandingly good value for money with early detection and early interventions self-financing and paying for themselves over a period of time (Knapp, McDaid & Parsonage, 2011: 43). Although quite conclusive in its findings, the report admitted to some limitations due to the scarcity of data for specific mental health promotion interventions for specific mental health disorders. Studies tend to research health promotion for mental health issues as a whole rather than targeting specific disorders. The report also concluded that befriending schemes for older adults were not able to demonstrate cost savings although they did improve the quality of life of the recipients.
Figure 3 The Most Influential Factors for Health and Lifestyle Choices

The factors we most control have the most impact on our health Family and friends are key to shaping our health

YOUR LIFESTYLE 56%

YOUR NUTRITION 55%

THE ENVIRONMENT 44%

THE HEALTHCARE SYSTEM 38%

75% ME

43% FAMILY FRIENDS

20% GOVT

75% ME

36% 20% FAMILY GOVT FRIENDS

48% ME

27% BUSINESS IN GENERAL

40% GOVT

20% ME

68% GOVT

41% HEALTHCARE PROVIDER OR INSURER

Source: Elderman Health Barometer (2011) In a study by Elderman (2011) 15,165 adults in 12 countries were surveyed to find out what was the most influential group of people in their lives when it came to their choices about lifestyle and their health. Figure 3 shows some of the results indicating that respondents reported that aside from themselves, the second most influential people in their lives were family and friends. Family and friends were listed as having the highest influence on their health behaviors, including health-seeking behavior. Interestingly, the same group listed the least influential group of people when it came to these choices to be health care providers.

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4.5 Cultural Competency

Culture is a pattern of learned beliefs, values, and behavior that are shared within a group; it includes language, styles of communication, practices, customs, and views on roles and relationships (Betancourt & Green, 2010). As the UK becomes more culturally diverse, health providers require more of their staff to be able to provide good quality care to diverse populations from a range of cultures (Samuels et al, 2009). The term cultural competence elicits varied responses from health care professionals, ranging from curiosity, acceptance to dismissal and sometimes, outright derision (Beach et al, 2006). A very common mistake in health care has been to reduce and oversimplify cultural competency to simply translate to an appreciation of language barriers and knowledge of a specific ethnic group (Betancourt et al, 2005). Language does play a part in interactions, but so do other multi faceted issues related to the culture of the individual. Likewise, knowing the nuances of the Nepali community may be an advantage but it may also be a hindrance given that Nepal as a country has many sub cultures dependent on region, religion and thus applying a generalist view may lead to stereotyping. Cultural competence is not simply the dos and donts of clinical care for a cultural group. To be cultural competent there needs to be a major shift in state of mind that allows clinicians to summon adequate respectful curiosity to appreciate and appraise each individual/family and context in their own right in order to provide culturally sensitive and appropriate care (Betancourt et al, 2005). Cultural competence therefore is the ability to operate effectively in different cultural contexts with individuals from different cultural backgrounds. For this reason, more needs to be done in exploring means by which mental health professionals can become more culturally competent in order to adequately meet the needs of the diverse populations they serve (Samuels et al, 2009). The Reach Out Project not only considered the influence that culture may have on beliefs about mental illness and help seeking behavior, but also had to consider whether professionals understand the role and potential influence of their own culture on the interactions between them and the community.

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5. Project Methods
Working in collaboration is crucial. If you work in isolation, you will only succeed in dictating to the community. Its far better to work from the inside, side by side with local partners.
Amanda Lee, BME Development Worker Having determined the issues affecting the mental health of South Asian groups in the UK, the benefits of Early Intervention; the importance of friends and family in determining health behaviors; the potential benefits of CHWs/CHAs and the role of cultural competency; the project began implementing its plan. The project aimed to survey the mental health awareness in the Nepali community, train community figures in mental health first aid and raise mental health awareness using a mental health promotional campaign. The projects fundamental principles centered on respectful partnership with the community in delivering the project goals. Collaboration underpinned each of the steps taken to progress the project as follows: 1. The project team attended 10 community events to listen to the communities views 2. The team then invited a cross section of the community to form a project steering group 3. 10* community figures were recruited to train in mental health first aid 4. A mental health services survey was developed and piloted 5. A health promotional campaign was designed and developed alongside the CHAs 6. The final version of the mental health services survey was issued and the results were collated 7. The Reach Out Conference and CHA graduation event was launched with 120 attendees *2 trainees unfortunately discontinued the training due to a move out of the area and conflicting commitments.

5.1 Community Listening Events

In my 39 years as a Nepali Mental Health Nurse, I never thought I would see the day when my communitys health and wellbeing would be considered in such a respectful and proactive way.
Raj Chhetri The First Nepali Male Mental Health Nurse in the UK The project began with listening events where members of the project team attended a variety of Nepalese community gatherings to listen to issues identified by the Nepalese community. Between the months of September 2011 and February 2012, the project team attended 10

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community events including Maddhat Shamuha' (Helping Group) which attracted 450 attendants and the largest gathering, the Best of Both community cohesion event on 4 th February 2012, which saw 1600 attendants from a variety of ethnic backgrounds.

5.2 Forming the Reach Out Project Steering Group

The Reach Out Project would not have been achievable without the help of partners. On 27 th October 2012 a diverse group of people who had expressed their interest and commitment to equality and diversity met to form the Reach Out Project Steering group. The purpose of any steering group is to direct a project to achieve its identified objectives. For this reason, it was very important to identify key figures that would represent a cross section of the variety of communities and agencies in Rushmoor. This included a local GP, BME Development Worker, a Nepali Youth Group lead, a mental health service user advocacy group and a range of mental health service and substance misuse clinical and managerial representatives. The steering group met monthly and sent out project updates to the diverse range of stakeholders at 2 monthly intervals. This was crucial in ensuring the commitment to the projects aims from as many agencies in the area as possible.

5.3 Recruiting and Training the CHAs

From the variety of events attended, several individuals names kept coming up as people who were generally helpful and go to persons for a range of issues. When describing the individuals, several of these traits were repeatedly mentioned: 1. Helpful 2. Trustworthy 3. Has a wide range of life experiences 4. Knowledgeable about Nepali culture as well as English culture 5. A community leader These individuals names and contact details were sourced from community elders. The individuals were then contacted and invited to an informal lunch where the project was discussed. The training programme (Appendix 3) covered a range of topics and was delivered over a 2-week period spanning three months from November 2011 until February 2012. The training was an opportunity to access mental health training from experienced mental health professionals and people who have experienced mental health services. Face to face learning took place once or twice a week in an informal and informative setting (Appendix 3). Mental health professionals shared their expertise and aimed to get the trainees to think about their own knowledge and beliefs about mental illness. In turn, the mental health professionals used appreciative enquiry to learn about Nepali culture from the trainees.

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Figure 4

e-learning
Guided Tours of Mental Health Services
Community Health Ambassador

Face to face Mental health First Aid Training

Figure 4 shows the process by which the training took place: 1. Face to face group learning at a central location picked by the trainees; 2. An e-Learning module accessible on any internet enabled computer at home or any other place where there is internet connection; 3. Guided tours and orientation to mental health services in the local area.
Figure 5

Figure 5 illustrates a screenshot of the e-learning program used during the mental health first aid training programme. The e-learning modules were accessible 24 hours of every day with the aim of reinforcing any learning that took place during face-to-face interactions. Every mental health topic had a short assessment to help the learner check their understanding. The e-learning platform also provided the ability for the trainee to contact the project lead if they had any queries. This theoretical learning was complimented by visits to local mental health

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services. Trainees explored the range of help that is available to the local communities by being able to converse with a range of professionals in these teams about their roles and the teams functions. Following completion of the training, each CHA had to pass an assignment (Appendix 6). To maintain their level of awareness and ensure they continue to volunteer within their limitations with adequate support, the CHAs have monthly peer supervision with a qualified mental health professional. This is in keeping with good practice guidelines and reported as fundamental in the literature (WHO, 2007; Patel et al, 2011). The peer supervision offered a safe forum to bring any issues and reflect on how they have been using their training. So far the sessions are well attended with the few who have not been able to make it telephoning the project lead to discuss and reflect on their activities. There is a range of incentives and disincentives that can motivate or discourage community figures from becoming and retaining their role as a CHA (Appendix 5). Amongst these incentives is a sense of achievement and pride. Disincentives include lack of respect from health staff and lack of involvement of the community in selection of individuals who train to become CHAs. According to Bhattacharyya et al (2001) it is important to ensure that adequate support and incentives are integrated into any CHA/CHW programme if it is to sustain itself beyond the project.

5.4 Developing and Issuing the Mental Health Services Survey

Following approval from Surrey and Borders Partnership NHS Foundation Trust, a pilot survey was developed to find out the level of mental health awareness in Rushmoor. The survey did not require NHS ethics approval because it was a service audit rather than research (NHS Research Ethics Service, 2012). The pilot survey afforded the project team the opportunity to test whether the design was fit for purpose i.e. able to capture the level of mental health awareness in the Nepali community. The pilot survey was developed in partnership with Colette Lane (InS!ght Forum project manager) who also assisted in issuing it out to attendees alongside Madhu Gurung (Rushmoor Borough Council) at the Best of Both event held in Aldershot on 4th February 2012. The pilot was tested on respondents who took part out of the pool of 1,600 attendees to the Best of Both event. Dr Janet Scammell, Associate Professor, School of Health and Social Care at Bournemouth University provided an external review of the pilot survey. The survey was translated into Nepalese by an interpreting service to ensure that the survey was accurately translated and accessible to Nepalese speakers. The responses to the pilot survey provided feedback as to whether the questions were fit for purpose. Building upon findings from the pilot, Jessica Goddard (Research Assistant) was able to make necessary amendments to develop a fully structured questionnaire with 10 questions (Appendix 1). A convenience sample of participants from the Rushmoor community was used. Participants were recruited from a local community event, a GP surgery, and in and around Aldershot town center. The respondents were approached, given information about the project and survey (Appendix 2) and asked if they would like to participate. A participant information sheet explaining the purpose and remit of the survey was also developed and issued with the survey (Appendix 2). Participants who agreed to complete the survey were engaged in dialogue to inform them that

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they were free to withdraw from the survey at any time. Participants were also assured that they would not be directly identifiable in the reporting of the findings. The final survey was issued from the 1st April until 31st May 2012. The survey analysis was conducted over a number of stages. After all the surveys had been collected, the project team read and familiarized themselves with the content.

5.5 Running the Mental Health Promotional Campaign

A big part of the project was the mental health promotional campaign. The campaign was designed and planned with the CHAs using guidance from the project steering group. Given that a good proportion of our ability to digest and retain information is held in our visual senses, the campaign sought to stimulate dialogue by being visually and intellectually stimulating (Lindstrom, 2005). The successful use of visuals and interactive materials in other health campaigns such as the Time to Change campaign (www.time-to-change.org.uk) has led to a 7% positive shift in the attitudes of the population towards mental illness. The same principles of health promotional marketing were applied successfully to the Reach Out campaign with an array of digital and paper based promotional materials as well as Tshirts with the CHAs slogan. The CHAs expressed a need to have a slogan that was memorable which captured their beliefs about how best to tackle mental health stigma and promote mental health. They came up with the catchy phrase of:

'Its Good to Chat'

The response to the campaign was very encouraging. Between October 2011 and February 2012, the local newspapers featured the project on 3 occasions (Get Hampshire, 2011; Surrey Times, 2012; Eagle Radio, 2012). The project was also published in the Community Practitioners journal (Amani, 2012). The coverage led to contact from a variety of people including an invitation to Downing Street (Surrey Times, 2012) and contact from the local Deputy Mayor, Peter Crerar, as seen below:
Figure 6

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Figure 7

The CHA website (Figure 7) came about as a result of discussions with CHAs about means by which they could have a central point to promote their work and provide information on mental health. The www.itsgoodtochat.com website aims to provide a stimulating and engaging gateway to local mental health information in English and Nepalese. The website features the CHAs videos and quick facts about mental health with links to interactive social media platforms such as Facebook and Twitter. The videos were recorded following consent from all those who were to be featured in the filming. A filming schedule (Appendix 4) was developed with the CHAs and given to all those involved so that individuals could prepare for the filming in advance. It was very important for the campaign to be developed by the CHAs in order to ensure that they keep ownership of the initiative. We therefore designed and developed the campaign materials with input from each CHA who gave their views on the design and content. The campaign slogan, Its Good to Chat, was arrived at by the CHAs and felt to capture their view that communication is crucial in dispelling myth and promoting good mental health. The result of the campaign so far has been a very popular set of campaign materials, including posters, credit card sized information cards, leaflets and T-shirts that can be seen posted and worn in the local community. There have also been numerous requests for the CHAs to speak at events including an appearance on the British Gurkha Welfare Society radio station (radio channel 1179 AM) on 10th June 2012. With the campaign and the promotional materials, the CHAs are spreading mental health information and informing people about local mental health services, thus bridging the gap between these services and the local community.

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Figure 8

According to Ofcom (2011), over a quarter (27%) of adults and almost half (48%) of all teenagers in the UK own a smartphone. Ownership of smartphones is increasing by 10% every year. With a view to providing mental health information via these commonly used and increasingly owned gadgets, the project team devised a plan to develop a mobile phone application. Figure 8 shows the basic concept of the mobile app which will feature an interactive decision making function that will estimate the users mood and provide general mental health tips to promote wellbeing. The app will also feature: A symptom tracker Contact details of local mental health services A medication tracker Links to useful websites An ICE (In Case of Emergency) facility to store phone numbers of people to call in an emergency The mobile application is currently in production and will provide information about local services and general quick facts about mental health and mental illness. Using mobile apps for mental health promotion has shown promising results in other South Asian populations (Aggarwal, 2012). A major boost to the mobile application came about after it was shortlisted as 7th out of 500 mobile app ideas submitted to the NHS Future Forum crowd sourcing competition in February 2012 (DoH, 2012).

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5.6 Reach Out Conference & CHA Graduation Ceremony

Pictures used with individuals consent and permission

The Reach Out Conference (as seen in above pictures) was held on 31st May at Farnborough Football Club in Farnborough. The conference was attended by 120 community figures and a range of personnel from various statutory and non-statutory services. The day saw the 8 CHAs graduate and give speeches about their experience of training in mental health first aid, the impact of this experience on their lives and their plans for utilizing their training for mental health promotion. The CHAs were presented with plaques with the CHA title and the necessary logos. Professionals from statutory and non-statutory services also gave speeches to solidify partnership working in Rushmoor and encourage more community participation in improving the health and wellbeing of the borough.

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6. Survey Findings
Following the Reach Out conference, the projects focus turned to the mental health services survey. The pilot mental health services survey was conducted prior to the conference to determine the level of mental health awareness in the Nepali community in Rushmoor. The aim was to find out if the Nepali community was aware of community mental health services and determine factors influencing access to these services. The results of the survey are as follows:

Demographics
Of the 70 surveys that were issued, 55 were completed giving a 73% response rate. The 55 respondents demographics are demonstrated in Table 1:
Table 1 Ages of Respondents

Age (years) 11-20 21-30 31-40 41-50 51-60 61-70 70+ No. % 4 7 8 15 12 22 16 29 11 20 4 7 0 0

Total 55 100

As shown in Table 1, ages of respondents ranged from 11-20 years, up to 61-70 years, with the majority (29%) aged between 41-50 years. The high response from 41-50 year olds may be due to the venues and times when the questionnaires were available i.e. a community cohesion event, GP surgeries and Aldershot High Street during Monday to Friday from 9:00 am 5:00 pm. This may have limited the number of 11-20 year olds, who were the lowest group surveyed at 7%, as this age group would have been likely to be in school or college or university during this time. Table 2 shows that the majority of respondents were female, the reason for this is not yet clear but may be due to the survey collectors also being female.
Table 2 Gender of Respondents Table 3 Ethnicity of Respondents

Ethnicity Gender Male Female Total No. 20 35 55 % Nepalese 36 White (Any) 64 BME 100 Total

No. 19 28 8 55

% 35 51 14 100

Table 3 shows the percentage of respondents divided by ethnicity groups with a total of 35% participants describing their ethnicity as Nepalese. This is an improvement from the pilot study in which 15% of respondents were Nepalese. Just over half (51%) of respondents described themselves as being from a White background. Given that 86.7% of Rushmoors population is White British, the higher level of White respondents is to be expected. In total, 49% of participants were from a Nepalese or other BME group and 35% of respondents described

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their ethnicity as Nepalese.

Table 3 Are you registered with a GP?

Registered with a GP Yes No

No. 54 1

% 98 2

A majority 98% of respondents reported being registered with a GP (Table 4). The 1 participant who was not registered with a GP was from the Nepalese community. Although the sample size is small, this could be indicative that more work needs to be done to improve the Nepalese communitys awareness of how the NHS system works and to improve ease of access to health.
Table 4 Do you know anyone with a mental health problem?

Do you know anyone with a aNo. mental health problem? Yes No 38 17

69 31

The survey found that 69% of all respondents acknowledged knowing someone with a mental health problem. A higher proportion (89%) of White participants acknowledged knowing someone who had a mental health problem, compared to just 26% of Nepalese respondents who reported knowing someone with a mental health problem. This difference between the ethnic groups could simply be due to there being less members of the Nepalese community with mental health issues. However research has suggested that there is less awareness of mental health difficulties, more stigma and less willingness to talk about mental health issues in South Asian groups (Jha, 2007; DoH, 2007; Time to Change, 2010). Consequently, the lower acknowledgement of knowing someone with a mental health problem in Nepali respondents can be attributed to these cultural factors.

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Figure 9

What action was taken by those with a mental health problem?

80% 70% 60% 50% 40% 30% 20% 10% 0%

As would perhaps be expected and desired, the majority of those who had a mental health concern spoke to their GP (69%). However a larger percentage of respondents who described their ethnicity as White took this action. For example, all participants who spoke to a community leader or a Buddhist Priest were from a Nepalese or BME community. 46% of White participants had accessed a mental health service, compared to 15% of Nepalese respondents. This is a further indication that the BME communities are either less aware of how to, or less willing to access local mental health services. This supports the idea that members of those communities find it beneficial to speak to members of their own community, especially the leaders who are presumably well known and respected. This suggests a potential for a very important role in health promotion for community leaders, and validates the need for the CHAs work to be carried out by members of their own community.

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Figure 9

Local mental health services that participants had heard of

70% 60% 50% 40% 30% 20% 10% 0%

Figure 10

Local mental health services that Nepalese participants had heard of

70% 60% 50%

40%
30% 20% 10% 0%

*Increasing Access to Psychological Therapies **Community Mental Health Recovery Services *** Hampshire Operational Model for Effective Recovery ****Early Intervention in Psychosis Team

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Figure 10 shows that 63% of the Nepalese had not heard of any of the local mental health services available in Rushmoor. However all other BME participants had heard of at least one service. This suggests that awareness of local mental health services is less apparent in the Nepalese community compared with other BME groups. This may be due to the Nepalese respondents being the most recent migrants to the area. This finding may also indicate that people from the Nepalese community may be reluctant to acknowledge a mental health problem and therefore may be unwilling to look outside their family or friends for help. The most commonly known service picked by respondents was EIIP, which is unsurprising given that the EIIP team carried out the project and survey. Better known services (recognized by 50% or more of respondents) were the Wellbeing Centre, Conifers Community Mental Health Recovery Service, Surrey Heath Community Mental Health Recovery Service, Step by Step and Hollies Community Mental Health Recovery Service. The relatively higher awareness of these services may be due to the fact that the CHAs had visited all these services on their itinerary as part of the CHAs guided tours of local mental health services. This may indicate a spreading of information about these services via the CHAs social networks. The DnA Project, which works with 14-18 year olds with substance misuse issues, was the least well known out of the services. This suggests that more work is needed to promote this service amongst all groups in Rushmoor.
Figure 11

Mental health service usage by different ethnicities

60% 50% 40% 30%

20%
10% 0% Nepalese Nepalese and other BME White (any)

When participants were asked if they knew someone with a mental health difficulty, the majority of those who indicated that they knew someone with a mental health problem were from a White ethnic group. However as shown in Figure 11, there was a relatively small difference in the percentage of Nepalese and White participants who had accessed a mental health service, 36% and 41% respectively. This supports the idea that mental health issues are not more prevalent in any one ethnic group, but that the BME groups, and perhaps in particular the Nepalese communities are less likely to talk about mental health issues.

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Figure 12

Difficulty finding out about mental health services for different ethnicities
90%
80% 70% 60% 50% 40% 30% 20% 10% 0% Very Easy Easy Neither easy, Nor difficut Difficult Very Difficult

Nepalese
Nepalese and BME White

Figure 12 shows that a majority of Nepalese respondents (40%) said that they had not found finding out about local mental health services neither easy nor difficult. Perhaps this suggests that many may not have tried to find out about mental health services. This may be linked to findings illustrated in Figure 9 which showed that a significant number of Nepalese respondents would go to their community leader if they had concerns about their mental health and might therefore forego finding out about local mental health services. Whilst 82% of those who described their ethnicity as White found services easy to find, only 40% of the Nepalese respondents said they found services easy to find out about. This may indicate a general lack of promotional activities by mental health services to raise awareness of their existence to the Nepalese community. Regardless of how easy they found it to find out about the services, a really positive finding was that all but one would recommend the mental health service they used to a friend. The one exception accessed a non-specified counseling service. It is therefore difficult to further investigate what the problem was.

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Figure 13

Challenges participants encountered when accessing a mental health service

50%

40%
30% 20% 10% 0%

Figure 13 (above) shows the challenges faced by all participants, whereas figure 14 (next page) breaks this down into the challenges faced specifically by Nepalese respondents. One of the most prominent challenges faced regardless of ethnicity is a difficulty in expressing concerns to mental health professionals. Almost half of all respondents noted this as a challenge regardless of ethnicity.

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Figure 14

Challenges Nepalese participants Encountered when Accessing a Mental Health Service

70% 60% 50% 40% 30% 20% 10% 0%
MHS Phoned GP did not Difficulty Couldn't Waiting list Didnt feel Help not couldnt MHS but no refer me to expressing get to too long understood sensitive to help with response MHS concerns to location by MHS my culture my concern MHS None Other

Although each example challenge mentioned in Figure 13 and 14 was picked by at least one person from all ethnicities surveyed, it seems clear that there were certain difficulties that the Nepalese community experienced more so than other ethnic groups that were surveyed (See Figure 14). The most commonly reported challenge in accessing mental health services, as reported by 58% of Nepali respondents, was a difficulty expressing concerns to mental health professionals. This may signify issues with language, stigma and cultural mismatches that hinder communication from both sides. The challenge of being understood is affirmed further by 16% of Nepali respondents who reported that they did not feel understood by the mental health service they had tried to access/accessed. Another commonly reported challenge, as reported by 15% of Nepali respondents, was not being able to get to appointments due to the location. This might suggest issues with transportation for the Nepali community that may be linked to financial constraints or lack of awareness of the local transport system. Overall it seems that the response to this question support the need for CHAs to help their communities express their mental health concern, a need to help communities work out various transport options and a need to improve the cultural competency of mental health professionals.

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Figure 15

Aspects of the mental health services that participants found useful

45% 40%

35%
30% 25% 20% 15% 10% 5% 0%

Figure 15 demonstrates that local mental health services can take pride in knowing that of those who had used a mental health service, the most useful attribute reported by the majority of respondents (43%) was the staffs friendly manner. However, there are areas for improvement as indicated by a very low percentage (5%) reporting that the service offered treatments sensitive to their culture. This supports the suggestion that there is a general lack of cultural competency amongst mental health staff. This is echoed by a low (10%) number of respondents reporting that they were given a choice in treatments, suggesting a tendency to treat individuals as the same regardless of ethnicity. Only 14% of respondents found the service they accessed to have a short waiting time for appointments. This may be related to greater demands on services or the national trend of reduced resourcing of mental health services. Even more concerning is the response from the 37% of respondents who said they found nothing useful about the mental health service they had accessed. These areas for improvement do not take away the positive feedback of friendly staff. However, services and access to them may well improve by raising cultural awareness of staff, offering more choices in treatments and reducing appointment waiting times. This may in turn make community mental health services more accessible and improve equal access to mental health care.

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Figure 16

Aspects of the mental health service that Nepalese participants found useful
45% 40% 35% 30% 25% 20% 15% 10% 5% 0%

Nepalese respondents who had accessed mental health services identified the friendliness of the staff (43%) to be the most helpful aspect of the service (Figure 16). However, a noticeable number of Nepalese respondents (43%) also reported that they had not found anything helpful about the service they accessed. Again, services can improve this by equipping staff with cultural competency and resourcing services adequately to offer a range of evidence based options for treatment. Aspects that arose as problems in the previous question seem to be echoed by responses to this question. This includes the waiting list not being short and none of the Nepalese thought that help was sensitive to their culture. As well as this, none of the Nepalese noted keeping their information confidential as something they found useful. Perhaps this is due to a lack of understanding on how the NHS works, or a mistrust of the service. Either way, it would beneficial to try and improve their knowledge of and access to the NHS, and perhaps in the process try and instill confidence and trust in the Nepalese so they feel confident to use the service. It is positive to see however that it was considered a positive aspect by at least some participants.

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Figure 17

What participants would find helpful to improve awareness of local mental health services
70%

60%
50% 40% 30% 20%

10%
0%

An important part of the project was to raise the communitys awareness and knowledge of local mental health services in Rushmoor, particularly for the Nepalese community. Figure 17 shows that the survey respondents chose a website as the most preferred medium to improve awareness of local mental health services. Information leaflets were picked as the second most commonly preferred means to raise awareness of local services.

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Figure 18

What Nepalese participants would find helpful to improve awareness of local mental health services
80% 70% 60% 50% 40% 30% 20% 10% 0% Information A website Information Audio A Video An open day leaflets in my Information presentation information by the MHS language e.g. a to my podcast community Other

Figure 18 shows there were 4 main options in promoting mental health awareness that were prefered. In order of popularity, these options were: 1. A website (72%) and Information leaflets (72%), 2. Information in Nepalese (68%) 3. A presentation to the community (68%) The above supports the approach taken by the CHAs who have a website and leaflets in English and Nepalese. Mental health service awareness is likely to be improved if local mental health services are listed in a directory on the CHA website with regular input from those services to ensure that the information is up to date. This can be reinforced with regular presentations to the Nepalese community groups which are already set up in the area. The least popular options for increasing awareness of mental health information was the use of audio e.g podcasts and video. This might reflect the preference of the majority of survey respondents, who were aged between 41-50 years old, who typically do not use digital mediums such as YouTube for health information (Ofcom, 2011). Unsurprisingly, 68% of Nepalese respondents specified that information in their language would be helpful in raising awareness about mental health services.

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7. Discussion
The evidence from this project highlights some important insights about mental health

promotion and provision of mental health care for the Nepalese community in Rushmoor. The key insights are as follows:
o A baseline mental health survey showed lower mental health awareness in the Nepali community when compared to other ethnic groups in the area: The analysis of the survey conducted with the Nepali community indicated that there was a lower level of awareness of local community mental health services, lower access to these services and a preference to seek help from their community leaders. The reported lower awareness of local mental health services may be due partly to the fact that the Nepalese community are the newest migrants to the area and are therefore still familiarizing themselves to local services. It may also be due to stigma associated with mental illness as evident in the research on attitudes towards mental illness in South Asian communities (Jha, 2007; Friedli, 2009; Time to Change, 2010). Whilst the majority of the Reach Out projects approach in promoting mental health and the preliminary findings from the survey is well supported by the literature reviewed (page 11), there is scope to conduct further investigation of other factors that affect access to mental health services. For instance, stigma is shown to influence help seeking behavior but was not explored specifically in this project. Some of the literature also indicates that there are differences in how mental illness is described and constructed in non-Westernized groups and this is a key consideration for future research (Jha, 2007, Friedli, 2009). o The wider communitys active engagement with the mental health promotion campaign suggests that there is potential to improve the communities health through raised awareness via social networks: The reviewed literature supports the notion that the successful implementation of health promotional campaigns generates trust between the target population and service providers (WHO, 2007). The trust garnered is reported to act as a bridge between health services and marginalized groups and lead to improved access to health (Curtale, 1995; DoH, 2005; Marmot, 2010). The Reach Out Project would appear to support the literature in that the CHAs graduation ceremony surpassed its intended attendee number of 100 and attracted 120 attendants. The number of people who attended the events arranged by and with the CHAs is a measure of success, particularly as the majority of attendants were from the target community. A global review on lay health workers by the World Health Organization (WHO) also noted that communities were more receptive of health messages from CHAs because they are perceived to be more accessible and acceptable (WHO, 2007). This was noted to be partly due to CHAs being able to deliver health information in the communities own language and with due attention to the communitys culture. The Reach Out Project was not able to specifically measure the influence of trust on mental health service utilization due to the paucity of data on the Nepalese community i.e. there was no way to accurately determine the number of Nepalese people accessing mental health

36

services as some indicate their ethnicity simply as Asian Other. Mental health service utilization is another area that is worth exploring once ethnicity data collection improves to reflect the growing size of the Nepalese population in the UK. o Volunteers came forward to train in mental health first aid and showed a readiness to improve the mental health and wellbeing of their community. This encouraged those involved in the project to want to know more about the Nepalese culture: The mental health first aid training was well received by the 8 CHAs who received grades ranging from Excellent to Very Good for their final assignment which was assessed by an independent panel (Appendix 8). The commitment made by the 8 CHAs to attend the 2-week training (spanning a period of 3 months) is very encouraging and due in part to the careful consideration of incentives and disincentives of these types of roles (Bhattacharyya et al, 2001; WHO, 2007). For example, the training ensured there was an assessment and graduation at the end of the training in order to reaffirm the sense of mastery, pride and achievement (Bhattacharyya et al, 2001). The CHAs are not the only ones who took away key lessons and learning from the project. The interactions between the CHAs and clinicians involved in the project provided a space to exchange knowledge and debate about mental health and Nepali culture. The impact of

mixing with the Nepalese community is reported to have increased the mental health teams understanding of the community and thus likely to improve relations.
Anecdotally, this exchange of information has lead to clinicians reporting an increase in respectful curiosity with which they now approach their clinical cases. An improvement on this project would therefore be to implement a pre and post project measurement of the cultural competency of those involved to see if a similar project can change this dimension (Betancourt et al, 2005). Further learning came from managing this multi-strand project. The multiple elements of the project required developing key skills in leadership and project management. The project lead has therefore applied for leadership development opportunities and will be pursuing a formal project management qualification in the near future.

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7.1 Limitations
The mental health service survey was limited by the sample size (55 respondents) due to not realizing the potential for lower literacy rates in the Nepali community (Jha, 2007). This means that the findings, although insightful and useful for local mental health services to consider, do not have the statistical significance to justify application to other areas in the UK. In those who responded, all of the Nepalese apart from one were registered with a GP. However due to the nature of where the participants were recruited from, there is likely to be a bias, especially for the ones who were asked to fill out the questionnaire in the GP surgery. A more random sample would need to be taken to explore how many Nepalese are really registered with a GP. The findings from the mental health services survey give a baseline of mental health awareness and an insight into some of the factors that may influence access to mental health services for the Nepalese community in Rushmoor. It is not possible to make generalizations from this data beyond the sample due to the sample size. The small sample number was due partly to the literacy issues, which had not been anticipated. However, the findings clearly raise issues worthy of further investigation including research. Only 40% of people in Nepal are literate and this should be considered in any research that is undertaken in the community as it may hinder the ability to get enough research participants (Jha, 2007). One way to overcome this may be to conduct research via interviews with individuals or focus groups. The results from the survey showed that very few Nepalese people (26%) knew someone with a mental health problem (Table 4 - Page 25). Given that 1 in 4 of the population have experience of mental illness, it is likely that this lack of acknowledgement of anyone with mental health issues signifies a reluctance to talk about mental health. This may be associated with mental health stigma in the Nepalese respondents but cannot be verified by the questions asked by this survey. For future research it would be useful to find out about specific attitudes towards those affected my mental illness to determine if there is indeed more mental health stigma in the Nepalese community. This could be achieved by issuing the Community Attitudes towards Mental Illness (CAMI) questionnaire (Appendix 6) (Taylor & Dear, 1981). Although the Reach Out project recruited CHAs from suggestions from the local community, there was an uneven lean towards more Nepalese from the Gurung tribe. The significance of this is yet to be verified but it could potentially hinder the CHAs success in engaging other tribes outside of the Gurung tribe. The above limitations give scope and ideas for further exploration and future work.

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8. Conclusion
Our health care system is dominated by reactive models that deliver care when people are already very ill and in need of more intensive and costly health interventions. This approach misses the opportunity to enhance health at times when people are most receptive to information and health messages e.g. in their own environments whilst relatively mentally and physically well. Even those with severe mental illness will only spend a few hours with their health professionals in a typical year whilst spending 5000 hours a year with their peers at home, at work, at school and at other leisurely settings. By training community leaders in basic mental health first aid, services can build communities resilience against illness, raise health awareness and bridge the gap between health services and hard to reach groups. The Reach Out Project has managed to forge new links with the community and inspire action. In terms of outcomes, the project has determined a baseline level of the mental health awareness and knowledge about local mental health services in the Nepalese community in Rushmoor. The mental health services survey has also shown that Nepalese respondents prefer to seek help and advice from their friends, family and community leaders. The project has successfully trained 8 such leaders in mental health first aid to become Community Health Ambassadors. Early results show already an increased awareness of the mental health services that were visited by the CHAs during their training. This report has shown that CHAs can improve mental health awareness and raise social capital through increased confidence of those who volunteer for such roles. By collaborating for a common purpose, the Reach Out project has strengthened relationships between agencies and the communities that they serve in a bid to improve equal access to mental health. This has laid the foundation for further collaboration in keeping with the national drive for more integrated health and social services. The strengthened relationships between communities and service providers can generate value both on a personal and economic level, by enabling individuals and their families to access mental health care in the least stigmatizing and least expensive settings. CHA programmes offer an opportunity for cost savings as demonstrated by the Altogether Better project that has saved 112.43 for every 1 spent on the scheme. For these reasons, the project concludes with a recommendation for further exploration and wider adoption of CHA programs.

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9. Recommendations
9.1 Service Providers
Recruit, educate and support volunteers from marginalized communities to engage as partners in health promotion campaigns aimed at those targeted communities.
Key Messages:
Community Health Ambassadors are individuals who are selected by their own communities, engaged, trained and supported to inspire and help their friends, families, neighbors and work/education peers to make healthier decisions; There is enormous potential to be realized from empowering the community in promoting health via their various social groups and networks; For CHAs to be able to make an effective contribution, they need to be selected by the target community, appropriately trained and very importantly adequately and continuously supported.

9.2 Commissioners
Utilize the Commissioning for Quality & Innovation (CQUIN) payment framework to incentivize services to evidence meaningful engagement of marginalized communities.
Key Messages:
Community Health Ambassadors are effective health promoters capable of reducing the social and economic burden of illness; The delivery of successful CHA programmes requires change across whole systems; Commissioners have a whole range of contract management levers through which they can drive and support this change.

9.3 Policy Makers

Include and involve representatives from marginalized communities when developing health and social policies.
Key Messages:
The CHA model is an effective way of reducing health inequalities for marginalized groups. The potential benefits of CHA programmes, in the context of health promotion and equality, are unlikely to be achieved or sustained unless CHA schemes are integrated into mainstream health and social care policies; The progressive integration of CHA programmes requires mainstream support at a local, national and international level via research and dissemination.

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10. References
Aggarwal, N. (2012) Applying mobile technologies to mental health service delivery in South Asia. Asian Journal of Psychiatry Accessed at http://download.journals.elsevierhealth.com/pdfs/journals/18762018/PIIS187620181100164X.pdf on 18th March 2012. Amani, S. (2012) Improving the Mental Health and Wellbeing of the Nepalese Community in Hampshire Community Practitioner 85 (6): 43-44. Amani S., Cornish G., Rose L., Nargis F. & Lunn L. (2012) Health Promotion in Psychosis Services. Nursing Times 108 (7): 24-25. Accessed at http://goo.gl/EYNCN on 11th March 2012. Asch D., Muller R., Volpp K. (2012) Automated Hovering in Health Care Watching Over the 5000 Hours. New English Journal of Healthcare 367 (1): 1-3. Betancourt , J. & Green, A. (2010) Linking cultural competence training to improved health outcomes: perspectives from the field. Academic Medicine 85(4):583-5. Betancourt, J. Green, A., Carillo, J. & Park, E. (2005) Cultural Competence and Health Care Disparities: Key Perspectives And Trends. Health Affairs 24 (2): 499-505. Bhattacharyya K, Winch P, LeBan K, Tien M (2001). Community health worker incentives and disincentives: how they affect motivation, retention and sustainability. Accessed at http://pdf.usaid.gov/pdf_docs/PNACQ722.pdf on 19th April 2012. Casey, M (2010) Health Needs Assessment of the Nepali Community in Rushmoor. Accessed at http://www.rushmoorsp.com/pdfdocs/nepalihealthneedsassessmentoct2010.pdf on 26th April 2011. Department of Health (2007) Positive steps: Supporting race equality in mental healthcare, Crown Copyright. Accessed at http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digit alasset/dh_066061.pdf on 7th June 2011. Department of Health (2008) Health and Social Care Act. Accessed at http://goo.gl/pakvK on 10th March 2012. Department of Health (2010) Understanding the Health Needs of Migrants in the South East Region: A Report by the South East Migrant Health Study Group on behalf of the Department of Health. Accessed at: http://www.sepho.org.uk/Download/Public/13743/1/migrant_health_report_Oct10.pdf

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Department of Health (2012) Maps and Apps Summary of Early Intervention in Psychosis Mobile Application. Accessed at http://mapsandapps.dh.gov.uk/2011/09/29/earlyintervention-in-psychosis-app-5-tweet-summary/ on 22nd February 2012. Eagle Radio (2012) Frimley Man Speaks on World Suicide Prevention Day. Accessed at http://www.964eagle.co.uk/news/local-news/763245/frimley-man-speaks-out-on-worldsuicide-prevention-day on 12th September 2012. Elderman (2011) Health Barometer. Accessed at http://healthbarometer.edelman.com/wpcontent/uploads/downloads/2011/10/Edelman-Health-Barometer-2011-Global-Deck10.19.11.pdf on 9th August 2012 Friedli L. (2009) Mental health resilience and inequalities. WHO, Europe. Get Hampshire (2011) Funding Success for Mental Health Nurse. Accessed at http://www.gethampshire.co.uk/news/s/2105697_funding_success_for_mental_health_nurse on 3rd April 2012 Hampshire County Council (2011) Demographic Facts and Figures for Rushmoor Accessed at http://www3.hants.gov.uk/factsheet_2011_-_rushmoor.pdf on 10th April 2011 Jha A. (2007) A Nepali Psychiatrists Struggle for Evolution. Psychiatric Bulletin, 31: 348-350. Accessed at http://www.rcpsych.ac.uk/pdf/IPv5n2.pdf on 4th July 2011. Jones P., Shiers D. & Smith, J.(2010) Early Intervention in Psychosis: Why a specialized EIP service model is preferable to a CMHT model. Accessed at http://bit.ly/dPuOVA on 26th April 2011. Knapp M., McDaid D. & Parsonage M. (2011) Mental health promotion and prevention: the economic case. PSSRU, London School of Economics. Accessed at http://www2.lse.ac.uk/businessAndConsultancy/LSEEnterprise/pdf/PSSRUfeb2011.pdf on 3rd October 2011. Lindstrom, M. (2005) Broad sensory branding, Journal of Product & Brand Management, Vol. 14 (2): 84 87. Marmot M. (2010) Fair society, healthy lives: The Marmot Review. Strategic Review of Health Inequalities in England. Social Science & Medicine 71: 1221-1222 McCrone P., Park A-L., & Knapp M. (2010) Economic Evaluation of Early Intervention (EI) Services: Phase IV Report. Personal Social Services Research Unit (PSSRU) Discussion Paper 2745. NHS Confederation (2012) Community Health Champions: Creating New Relationships with Patients and Communities. Accessed at

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http://www.nhsconfed.org/Publications/Documents/community_health_champions.pdf on 7th August 2012. NHS Employers (2012) Equality Delivery System. Accessed at http://www.nhsemployers.org/EMPLOYMENTPOLICYANDPRACTICE/EQUALITYANDDIVERSITY/ Pages/TheNHSEqualityDeliverySystem.aspx on 12th August 2012. NHS Research Ethics Service (2012) Accessed at www.nres.nhs.uk on 12th January 2012 Ofcom (2011) A Nation Addicted to Smartphones. Accessed at http://media.ofcom.org.uk/2011/08/04/a-nation-addicted-to-smartphones on 20th March 2012. Patel V., Weiss H., Chowdhary N., Naik S., Pednekar S., Chatterjee S., Bhat B., Araya R., King M ., Simon G., Verdeli H. & Kirkwood B. (2011) Lay health worker led intervention for depressive and anxiety disorders in India: impact on clinical and disability outcomes over 12 months. British Medical Journal 199: 459-466. Samuels, J., Schudrich, W., & Altschul, D. (2009). Toolkit for modifying evidence-based practice to increase cultural competence. Orangeburg, NY: Research Foundation for Mental Health. Surrey News (2012) Number 10 Reception for Nurses Working in Mole Valley. Accessed at http://www.thisissurreytoday.co.uk/Number-10-reception-nurses-working-Mole-Valley/story16228295-detail/story.html on 20th June 2012. Taylor, S. & Dear, M. (1981) Scaling Community Attitudes Towards the Mentally Ill. Schizophrenia Bulletin. 7 (2): 225-240. Time to Change (2010) Family Matters: A report into attitudes towards mental health problems in the South Asian community in Harrow, North West London Accessed at http://www.time-tochange.org.uk/files/imce_uploads/Family%20Matters.pdf on 11th February 2012 WHO (2007) Community Health Workers: What do we know about them? The state of the evidence on programmes, activities, costs and impact on health outcomes of using community health workers. WHO. Wong, C., Davidson, L., Anglin, D., Link, B., Gerson, R., Malaspina, D., McGlashan, T., Corcoran, C. (2009) Stigma in families of individuals in early stages of psychotic illness: family stigma and early psychosis. Early Intervention in Psychiatry 3(2): 108-115.

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Appendix 1
MENTAL HEALTH SERVICES SURVEY Your health influences your life in many ways. Mental health and physical health are linked and one can affect the other. The Early Intervention in Psychosis Team is conducting this mental health survey as part of the Mary Seacole Award Reach Out Project to find out the views of the community on local mental health services. We would be very grateful if you were to fill out this questionnaire. It will help services improve what they offer and provide. All your answers will be anonymous (we wont know who answered each questionnaire). Thank you for taking the time to fill out this questionnaire.

1. It would be helpful to know a little bit about you. This will not be used to identify you in any
way. What is your age in years? 11- 20 years 41 - 50 years 70+ What is your gender? Male Female 21 - 30 years 51 - 60 years 31 - 40 years 61 70 years

b) How would you describe your ethnicity? Indian Pakistani Nepalese Chinese White British White Irish White Black African Black Caribbean Black Other Mixed White and Black African Mixed White and Black Caribbean Mixed White & Black African White Asian Mixed Other Any other ethnic group (please specify)

C) Are you registered with a GP?

Yes

No

2. Do you know anyone who has had a mental health problem? (If no, go to question 4)
Yes No

3. What action did they take? (Please tick all that apply)
Spoke to family and friends Spoke to a Buddhist Priest Spoke to a community leader Accessed a mental health service Other (please specify) ______________________________

Turned to God/prayer Spoke to their GP Nothing

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4. Have you heard of any of these services? (Please tick all that apply)
Increasing Access to Psychological Therapies (IAPT) TalkPlus Step by Step Surrey Heath Community Mental Health Recovery Services The Wellbeing Centre Hampshire Operational Model for Effective Recovery (HOMER) Dn'A Project Catch22 Richmond Fellowship Hollies Community Mental Health Recovery Services Sunshine & Showers Depression Support Group Conifers Community Mental Health Recovery Service Early Intervention In Psychosis Team (EIIP) None of the above

5. What would improve your awareness of the services above? (Please tick all that apply)
Information leaflets language A website about the services Information in my

Audio information e.g. a podcast service Video Information

A presentation/workshop to my community on the

An open day by the mental health service

Other (please specify)

6. If you have accessed a mental health service recently, please tell us the name of the service (If
none, please go to question 9)

7. Overall, how easy was it for you to find out about the above service? (Please tick one)
Very Easy Easy Neither easy, Nor difficult

Difficult

Very Difficult

Yes

8. Would you recommend the above mental health service to a friend or family? (Please tick one)
No

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9. What challenges, if any, have you encountered in getting help for a mental health problem?
(Please tick all that apply) The mental health service couldn't help with my concern I phoned the mental health service but there was no response My doctor/ GP did not refer me on to a mental health service I found it difficult to express my concerns to the mental health professionals I couldn't get to appointments because of the location of the service The waiting list was too long I didnt feel understood by the mental health professionals The help offered was not sensitive to my culture None Other (please specify)

10. What did you find to be most helpful about the above mental health service? (Please tick all that
apply) Information about the service was readily available The mental health service staff were friendly There was a short waiting list The staff were non-judgmental The location of the service meant that it was easy to get to The staff took time to understand my problems The service offered me a choice of treatments The service kept my information confidential The service offered treatments that were sensitive to my culture None

Other (please specify)

Thank You
Please do not hesitate to contact the Early Intervention in Psychosis Team if you have any queries about the team or this questionnaire: Sarah Amani Team Manager/Project Lead Early Intervention in Psychosis Team Aldershot Centre for Health Hospital Hill Aldershot GU11 1AY Tel: 01252 33 55 33 www.sabp.nhs.uk/eiip

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Appendix 2 Community Mental Health Services Survey PARTICIPANT INFORMATION SHEET

You are being invited to take part in a service evaluation. Before you decide it is important for you to understand why the research is being done and what it will involve. Please take time to read the following information carefully and discuss it with others if you wish. Take time to decide whether you wish to take part. Thank you for taking the time to read this information sheet

What is the purpose of the survey? The study is part of the Reach Out Project and aims to gather views on mental health and the local mental health services. By finding out more about what people think about local mental health issues, the local services can take these views in consideration when planning changes and improvements.

Why have I been chosen? The study hopes to gather views of a diverse group of people regardless of gender, age, race or religion. You have been chosen, as you appear to be part of the local community.

Do I have to take part? No. While we appreciate everyones input into the study we also acknowledge that you have a choice and would therefore ask that you only take part if you want to.

What do I have to do? The survey has ten questions and we would appreciate it if you were to pick answers that reflect your views by either ticking or circling the answers that apply to you.

What are the possible disadvantages? No disadvantages are envisaged

What are the possible benefits of taking part? Making the service better, your views being listened

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Will my taking part in this study be kept confidential? Yes. The survey is anonymous and your answers cannot be linked to you in any way.

What will happen to the results of the research study? The results from the study will form a report that will be openly available in printed form and also available on the www.sabp.nhs.uk website. The report will summarize local peoples beliefs about mental health issues and local mental health services.

Who has reviewed the study? The Reach Out project steering group including the following individuals and organisations has reviewed the study: Dr Janet Scammell (Academic Lead for Practice Learning, Bournemouth University) Surrey & Borders Partnership NHS Foundation Trust (SABP) Catch22 Talkplus (Increasing Access to Psychological Therapies) Insight Forum Community Health Ambassadors (CHAs)

Contact for further information Please do not hesitate to contact the project lead: Sarah Amani Team Manager North East Hants & Surrey Heath Early Intervention in Psychosis (EIIP) Team Aldershot Centre for Health Aldershot GU11 1AY Tel: 01252 33 55 33 E-mail: sarah.amani@sabp.nhs.uk Thank you for taking part in the Reach Out Project Survey

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Appendix 3
Mental Health First Aid Training Timetable
Thurs 3 Nov 09:00 Introduction No health without mental health Sarah Amani
rd

Wed 9th Nov

Thurs 17th Nov

Wed 23rd Nov Tues 6th Dec

10:30 10:45 12:00

Coffee Break What is mental illness? Sarah Amani

Common mental What causes Stigma & Visit to Community Mental health problems mental health mental illness Health Recovery Service James Phillips problems? Joyce Sims Dr Payal Amin (Talk Plus - IAPT) Dr Cornish Jackie Whittington Coffee Break Coffee Break Coffee Break Coffee Break Roles of mental Video CaseHealth Feedback from first week health Studies Q&A Promotion Sarah Amani professionals Dr Cornish &Sarah Amani Emma Malyon Sarah Amani & Louise Lunn Tues 31st Jan Making a difference in your community Dr Payal Amin Sarah Amani Tues 7th Feb Introduction to Working with Learning Disabilities Eleanor Atkinson & Jake Ballard Coffee Break Closing & Feedback Sarah Amani

Thurs 5th Jan 09:00

CHRISTMAS & NEW YEAR HOLIDAY Tues 10th Jan Wed 18th Jan Thur 26th Jan Drugs & Alcohol Rushmoor Cherry Sullivan & Health Needs Louise Lunn Assessment Dr Casey

10:30

12:00

Introduction to Visit to psychosis Ridgewood Sarah Amani Centre & Wellbeing Centre Michael Llewellyn Coffee Break Coffee Break Supporting Debrief & families Reflection Jackie Emma Malyon Whittington & Joyce Sims Joyce Sims

Recovery Emma Malyon Coffee Break Coffee Break Coffee Break Neighborhood Signposting & Exam prep Walk About with limitations of Sarah Amani Catch22 CHA Role Cherry Sullivan & Sarah Amani Louise Lunn

Trainers Designations:
Dr Glenn Cornish: Consultant Psychiatrist EIIP, SABP Eleanor Atkinson: Speech Therapist, Learning Disability Service, SABP Dr Marie Casey: Public Health Researcher, NHS Hampshire Dr Payal Amin: Chartered Psychologist EIIP, SABP Michael Llewellyn Community Mental Health Nurse, SABP Jackie Whittington: Community Mental Health Nurse EIIP, SABP Emma Malyon: Occupational Therapist EIIP, SABP Cherry Sullivan: Manager, Catch22 Drug & Alcohol Service Joyce Sims: Community Mental Health Nurse EIIP, SABP Louise Lunn: Support, Time & Recovery Worker EIIP, SABP Sarah Amani: Community Mental Health Nurse/Team Manager EIIP, SABP

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Appendix 4 Video Shoot SATURDAY 14TH JANUARY

NAME Roshni Amin Sarah Amani ROLE Producer / Director Team Manager NE Hants and Surrey Heath Early Intervention In Psychosis Team Community Health Ambassador Community Health Ambassador

Mary Everley Deepak Neupane

FILM
This film is a short case study focusing on the Community Health Ambassadors (Mary and Deepak). In this film we will see the Community Health Ambassadors at work, find out their reasons for taking part in the Community Health Ambassadors scheme, and discover how they plan to transfer their learning into practice, to promote health and wellbeing in their local community particularly amongst Nepalese residents.

BACKGROUND
The Community Health Ambassador (CHA) training programme is a 2 week long opportunity to access mental health training from experienced mental health professionals and people who have experienced mental health services. The 2 weeks are split across 3 months from November 2011 to January 2012 with the graduation ceremony planned for May 2012. The programme is for people who want to make a positive difference to the health and wellbeing of their local community.

LOCATION AND PICTURE SEQUENCES

1. Farnborough Football Club - Marys interview - External shots of the football club - Football club sign - Mary leading the Yoga class and interacting with the Nepalese participants - Shots of the 10 20 students exercising (apart from 6 people, all students are Nepalese) 2. Deepaks Store - Interview with Deepak - External shots of store - Behind the counter shots of Deepak with customer 3. Aldershot Town Centre - Anonymous shots of Nepalese community

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INTERVIEWEE QUESTIONS
Introduction to camera How did you hear about the CHA scheme? What are your personal reasons for deciding to take part? How do you balance / integrate your daily responsibilities alongside the CHA scheme? What topics have you covered / what have you learnt over the past 3 months? How have you applied your learning in the local community? What does this scheme mean to you and how has it benefitted or helped you?

SCHEDULE
0745 Arrive at location and set up camera 0800 Film shots of Mary and the yoga class at location 1 0830 Film shots of Farnborough Football Club 0900 Drive to location 2 0930 Arrive at location and set up camera 0945 Interview with Deepak 1030 Film shots of Deepak with store staff 1115 Drive to location 3 1130 Film shots of Nepalese people shopping in town centre 1230 LUNCH 1330 Drive to location 4 1400 Arrive at location and set up camera 1430 Film external shots of Aldershot Centre for Health 1500 Film CHAs walking 1600 WRAP

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Appendix 5
Incentives and disincentives of Community Health Ambassadors (CHAs)
Incentives Visibility & Status Accomplishment, Peer support, CHA association, Identification (badge, shirt) and job aids Status within community Preferential treatment Flexible and minimal hours Clear role Community-level factors that motivate individual CHAs Community involvement in CHA Inappropriate selection of CHAs, selection, Community organizations Lack of community involvement that support CHA work, Community in CHA selection, training and involvement in CHA training, support Community information systems Disincentives Constraints, Lack of respect from health facility staff

Factors that motivate communities to support and sustain CHAs

Witnessing visible changes, Contribution to community empowerment, CHA associations, Successful referrals to health facilities Policies/legislation that support CHAs, Witnessing visible changes, Funding for supervisory activities from government and/or community

Unclear role and expectations (preventive versus curative care), Inappropriate CHA behavior, Needs of the community not taken into account Inadequate staff and supplies

Factors that motivate mental health staff to support and sustain CHAs

Source: Bhattacharyya et al. (2001)

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Appendix 6
Community Attitudes Towards Mental Illness Questionnaire
Strongly Agree 1. One of the main causes of mental illness is a lack of self-discipline and willpower 2. There is something about people with mental illness that makes it easy to tell them from normal people 3. Less emphasis should be placed on protecting the public from people with mental illness 4. Mental hospitals are an outdated means of treating people with mental illness 5. Virtually anyone can become mentally ill 6. A woman would be foolish to marry a man who has suffered from a mental illness, even though he seems fully recovered 7. A man would be foolish to marry a woman who has suffered from a mental health illness even though she seems fully recovered 8. I would not like to live next door to someone who has been mentally ill 9. No-one has the right to exclude people with mental illness from a neighborhood 10. People with mental illness are far less of a danger than people suppose 11. Most women who were patients in a mental health hospital can be trusted as babysitters 12. Residents have nothing to fear from people coming into their neighborhoods to obtain mental health services Agree Neither Disagree Strongly Disagree Dont Know

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Appendix 7

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Appendix 8

Reach Out Project Community Health Ambassador (CHA) Assignment 8th March 2012

Community Health Ambassador Mental Health First Aid Training Training Dates: 3 Nov 2011 - 7 Feb 2012
rd th

Dear CHA Trainee, Congratulations! If you are reading this you are more than likely close to completing the Community Health Ambassador (CHA) mental health first aid training programme. You are now ready to be assessed in order to determine whether you can become a Community Health Ambassador (CHA). To complete and pass the mental health first aid training, you are required to complete an assignment to demonstrate your understanding of a mental health topic, and present your ideas on how you intend to use this understanding in your role as a CHA. You can present your assignment as a poster, short essay (1000 words), presentation, role-play or video of yourself conveying the following: 1. Your understanding of a chosen mental health topic 2. How you will apply your understanding to help improve mental health awareness in your local community You will be given 15 minutes to present your assignment. Your assignment will take place on: Date: Time: Venue: Room: 8 March 2012 09:30 am 12:30 pm Aldershot Centre for Health, Hospital Hill, Aldershot GU11 1AY Room 7, Level 4
th

For enquiries please call Sarah Amani on 01252 33 55 33

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The Assignment To ensure that you have adequate understanding of the topics covered and are ready to take up the CHA role, the programme includes an assessment. In order to pass, you need to choose one of the following 2 choices: 1. Give your fellow CHA trainees and the judging panel a 15 minute presentation/poster/role play/video on a mental health topic of your choice e.g. depression in women, effect of anxiety on employment, caring for someone affected by mental illness, Psychosis, Stigma etc. 2. Or you can submit a short report (no more than 1000 words) demonstrating your awareness and understanding of key issues that affect people experiencing mental health problems and the impact of this on wider society How your assignment will be graded: Your assignments will be graded by an independent panel of 4 individuals who have experienced mental illness, worked in mental health services and/or cared for someone who has been affected by mental health problems. Your grade will be based on the following: 1. Demonstration of your understanding and sensitivity to the stigma experienced by those affected by mental illness 2. Appreciation of the impact of migration and community perception of newcomers on mental health 3. Ability to convey non-judgmental and well considered views of a mental health difficulty e.g. depression, psychosis 4. Your ideas on how you, as a CHA, can help improve mental health awareness in your local community Grades Four levels of grades will be awarded, based on the panels due consideration of your presentation/poster/written report/video/role play: 1. Excellent: requiring little or no expansion or improvement on ideas or presentation style. 2. Very Good: Requiring minimal changes to the content and delivery 3. Good: Well thought out and well delivered but can use some moderate improvements (which will be suggested by the panel). 4. Poor: Assignment needs re-working with significant changes to demonstrate adequate understanding of the topic and how this informs CHAs role.

The Judging Panel David Knivett: David teaches on a range of topics on mental health to student nurses at the University of Surrey. Sheila Limbu: Sheila is the president of Naya Yuva, a youth group interested in guiding and motivating youth to work towards their full potential. Colette Lane: Colette is Community Projects Manager for Insight Forum. Insight Forum offers assistance and aims to give a voice to people who have mental health difficulties. Raj Chhetri: Raj is the first male Nepalese Registered Mental Health Nurse in the UK and has been nursing for 39 years. Sarah Green: Sarah works for Catch22 Hampshire 24/7 which is a youth service helping out young people to overcome drug & alcohol problems. Get Extra Help Please feel free to call Sarah Amani (Project Lead) on 01252 33 55 33 we are more than happy to look at your draft report/presentation/video with you. A BIG thank you to our collaborators:

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