Background
People of African descent, Indigenous people, and refugees are at high risk of emotional distress and adjustment symptoms due to their shared experience of systemic oppression [1–3]. These communities face mental health disparities due to intergenerational trauma, institutional racism, and structural inequities [4]. Despite the significantly higher prevalence of mental health disorders in these populations, the stigma associated with mental illness, the colonial and Eurocentric history of psychiatry and the lack of culturally competent and structurally competent services [4] prevents these groups from accessing and receiving culturally appropriate counselling and psychological care [5–7].
A transcultural mental health approach can improve access to care, decolonize assessment processes, and delivery and lead to more effective and culturally and structurally appropriate care. This tailored, co-created approach might be a solution for delivering culturally safe, competent and structurally competent mental health treatment to racially and culturally diverse people [8].
Transcultural mental health programs have existed for decades. In Canada, Drs. Eric Wittkower and Jack Fried founded the section of Transcultural Psychiatric Studies at McGill University in 1955, which later became the Transcultural Psychiatric Research Review and, in 1981, the Division of Social and Transcultural Psychiatry [9].
Canada has since become a leader in culturally competent mental health care. McGill University now offers services through the Cultural Consultation Service (CCS), which provides comprehensive assessments for diverse cultural groups, including First Nations, Inuit, immigrants, and refugees, as well as the Training and Research Transcultural Team, which focuses on migrant children and their families [10]. These programs set valuable frameworks, providing a benchmark for other services aiming to implement transcultural mental health services.
Contextualizing gaps and needs in mental health services for equity-denied populations in Nova Scotia
Nova Scotia, a province located in Eastern Canada, has been home to African Nova Scotians, and Indigenous people and has welcomed refugees from various parts of the world. African Nova Scotians have a long and storied history, dating back to the late 18th century when Black Loyalists, formerly enslaved people who fought for the British during the American Revolutionary War, were granted land in Nova Scotia [11]. This community and other individuals of African descent have since played a pivotal role in the province’s cultural landscape, now making up approximately 3% of Nova Scotia’s population, or 28,220 people [12].
Similarly, Nova Scotia boasts a vibrant Indigenous heritage, primarily represented by the Mi’kmaq people, who have inhabited the region for thousands of years and continue contributing significantly to its cultural fabric [13]. There are 66,748 Mi’kmaq people in the region as of 2023. However, the Statistics of Canada 2016 census shows that 168,480 claimed Mi’kmaq ancestry, but do not necessarily identify as Mi’kmaq people [14].
In more recent history, Nova Scotia has opened its doors to refugees from countries all around the globe, including Somalia, Eritrea, Sudan, Syria, Afghanistan, Bhutan, Ukraine, the former Yugoslavia, and many other countries, offering them sanctuary to those fleeing conflict and persecution [15].
The cultural and racial mosaic that characterizes Nova Scotia requires health authorities to pay extra attention to developing and implementing culturally sensitive and structurally competent mental health services, as well as fostering educational initiatives that promote cultural competence among healthcare professionals. However, amid these discernible gaps, there are notable opportunities for narrowing the disparities in mental health and addiction care. Existing dedicated primary healthcare clinics in Halifax, including the Brotherhood and Sisterhood clinics for African Nova Scotian men and women, the Mi’kmaw Native Friendship Centre for Indigenous people, and the Newcomer Health Clinic offering services in multiple languages to refugees, have emerged as invaluable resources for community members.
Additionally, community organizations have been instrumental in promoting greater equity and inclusivity in mental health care delivery.
Methods
This descriptive program-development paper outlines the collaborative processes used to design, implement, and operationalize the NSTMHP, a culturally responsive mental health initiative established within the Nova Scotia Health Mental Health and Addictions Program (NSH MHAP). The program was developed in response to recognized inequities in access to culturally safe mental health services for African Nova Scotians, Indigenous peoples, and refugees and newcomers, and individuals experiencing homelessness in Nova Scotia. The initiative was informed by principles of collaborative care, cultural safety, structural competency, and decolonizing mental health practice.
Program development processes included stakeholder engagement meetings, community consultations, establishment of culturally responsive referral pathways, development of governance structures, and integration of interpretation and translation services to address language barriers. Educational initiatives, advocacy activities, and the establishment of transcultural mental health research collaborations were also incorporated into the program framework. Governance structures, service pathways, implementation processes, educational initiatives, and research activities were reviewed descriptively using program planning documents, operational reports, stakeholder consultations, and implementation records.
No statistical analyses were conducted, as the purpose of this paper was to describe program design, implementation processes, and model development rather than evaluate clinical outcomes or test hypotheses.
Results
Approach to service design
The NSTMHP was initiated as a response to the significant gaps in mental health services for equity-denied racial and ethnic populations in Nova Scotia, specifically African Nova Scotians, Indigenous people, and refugees. The program was not initiated by the local government alone; rather, it emerged through a collaborative effort involving academic institutions, healthcare providers, community organizations, and patient advocates, who collectively identified the need for culturally sensitive mental health services. The program’s development was motivated by the recognition that the mental health needs of these equity-denied populations were not being adequately met, in part due to a lack of culturally competent providers and services.
The transcultural approach was deemed necessary due to the unique cultural needs of the target populations, which require culturally competent care to be effective. The collaboration between psychiatrists and dedicated primary care clinics in each community ensures timely and comprehensive care, ultimately reducing strain on emergency and crisis services.
The first critical step in establishing a culturally sensitive mental health and addiction service that supports education, research, and innovation was the formation of various working groups. These groups included representatives from the Dalhousie University Departments of Psychiatry, Family Medicine, and Psychology and Neuroscience, the NSH/MHAP, and community organizations such as the Health Association of African Canadians (HAAC), Immigrant Services Association of Nova Scotia (ISANS), and Tajikeimik (Mi’kmaw Health Authority).
A NSTMHP Management Team (MT) comprised of representatives from NSH/MHAP and the Department of Psychiatry at Dalhousie University was established. This group was responsible for planning and overseeing the program’s implementation, monitoring, and evaluation. Representatives from the relevant community organizations (i.e.
ISANS, HAAC, and Friendship Centre), key primary care teams, the Department of Psychiatry and the NSTMHP then formed an Advisory Council to collect data on the gaps in community resources and acute mental health and addiction services for African Nova Scotians, Indigenous people, and refugees in Nova Scotia. The NSTMHP Advisory Council also offered ongoing direction, advice, and constructive feedback to the MT, to ensure the program’s initial implementation and ongoing monitoring and evaluation. Actively engaging community partners was intentional in order to develop a comprehensive, community-driven strategy to address the specific needs of equity-denied populations.
Subsequently, a snetwork of psychiatrists with cultural competencies with specific populations was established to provide culturally safe and competent psychiatric care in the NSTMHP. These psychiatrists were initially identified through their existing cultural origin and experience working with diverse populations, such as professional backgrounds, cultural training, and previous experience in transcultural mental health care. As part of the initiative, NSTMHP psychiatrists had support to ensure they were equipped to provide culturally competent care tailored to the unique needs of African Nova Scotians, Indigenous people, and refugees.
Some psychiatrists had specific experiences or areas of focus that aligned with particular populations. For example, certain psychiatrists focused more on refugee populations (e.g. Ukrainian refugees) based on their prior experiences or cultural background.
The program also emphasized a shared-care model, with psychiatrists collaborating across populations as needed, to ensure culturally competent care was provided to all patients. This approach helped balance individualized care with broad competency across the diverse communities served by the NSTMHP. These psychiatrists committed to devoting up to one full day per month to providing psychiatric consultation services in primary care settings for African Nova Scotians, Indigenous people, and refugees in Nova Scotia.
Additionally, they assisted primary care practitioners in completing mental health assessments and providing culturally-accepted treatments. This effort aimed to bridge the gap between mental health services and primary care, ensuring that equity-denied patients receive comprehensive and culturally sensitive psychiatric care inside their primary care settings. The same opportunity was opened to psychiatry residents, clinical psychology trainees, allied mental health clinicians and nurses, who would work under the supervision or alongside psychiatrists and wish to receive training in Transcultural Mental Health.
In December 2021, a significant step was taken towards providing culturally sensitive care when the first African Nova Scotian psychiatrist was hired by NSH/MHAP. This psychiatrist, who identified as an African Nova Scotian and was trained and certified in culturally competent care, was specifically focused on addressing the unique needs of the African Nova Scotian community at the Brotherhood Clinic. The establishment of this position not only provided an opportunity to deliver tailored mental health and addiction services but also paved the way for the recruitment and training of clinicians with expertise in Indigenous, refugee, and other cultural identities.
This initiative inspired the creation of similar programs, extending culturally competent care to other underserved populations in need.
The program has also identified research opportunities within routine and planned clinical programs and services for African Nova Scotians, Indigenous people, and refugees in Nova Scotia to enhance research capacity. It also established a formal Transcultural Mental Health Research Group/Program within the Global Mental Health Research Group/Program at the Department of Psychiatry and NSH. Collaborations with funding agencies and health foundations were pursued to initiate innovative clinical and research programs supporting the mental health of the targeted populations.
Additionally, efforts were made to build a national and international network of transcultural mental health practitioners and researchers, fostering collaboration, knowledge exchange, and global-scale advancements in transcultural mental health. Finally, an International Fellowship in Transcultural Mental Health was established to further contribute to the field.
To address language barriers, the NSH has established contracts with Access Language Services and Language Line. These services provide in-person, virtual, or telephone interpretation for clinicians and patients facing language discordance. Additionally, they have increasingly provided translation services, enabling the conversion of written materials into different languages.
These language services aim to facilitate effective communication and accessibility for individuals with diverse linguistic backgrounds, ensuring that language barriers do not hinder their access to healthcare services and information.
In line with the collaborative approach outlined, the development of a comprehensive logic model (Fig. 1) was critical to guiding the NSTMHP’s structure, implementation, and evaluation. The NSTMHP’s logic model outlines key components: inputs, activities, and short-, medium-, and long-term outcomes.
Inputs include partnerships with academic institutions, healthcare services, and community organizations. Activities focus on integrating culturally competent psychiatrists, collecting community data, and providing culturally safe care. Expected outcomes involve enhanced clinical capacity, increased community engagement, and improved access to culturally responsive mental health care for African Nova Scotians, Indigenous people, and refugees.
This logic model is the framework for the program’s ongoing assessment and future expansion.
Fig. 1Nova Scotia transcultural mental health logic modelThis logic model outlines the pathway from inputs and activities to short-term, medium-term, and long-term impacts aimed at reducing gaps in culturally appropriate mental health care in Nova Scotia. Inputs include advisory boards, culturally competent psychiatrists, culturally-specific primary care clinics, referral pathways, and culturally-sensitive mental health care based on shared care approaches.
Activities involve comprehensive mental health assessments, culturally appropriate care plans, culturally and language-appropriate education, telephone consultations, detailed consultation reports, shared care between psychiatrists and primary care providers, and training to build clinical capacity. Short-term impacts focus on capacity changes such as improved access to culturally sensitive mental health care, decreased discrimination, increased adherence to treatment, improved mental health literacy, emotional relief, improved access to culturally competent expertise and training, better coordination of treatment plans, and improved access to transcultural mental health knowledge. Medium-term impacts reflect behavior changes including greater likelihood of individuals seeking help, increased ability to identify pathways to care, improved coping skills and self-management, enhanced in-house capacity for mental health care with better collaboration, increased confidence and competence of primary care providers, improved knowledge sharing and integration of mental health expertise, and increased cultural humility among mental health teams.
Long-term impacts represent population-level and system benefits such as reduced reliance on crisis and emergency departments, prevention of mental health deterioration, increased patient ability to navigate mental health challenges, enhanced equity in access to specialized services, improved coordination and continuity of care, reduced referrals easing healthcare burden, increased skilled workforce in transcultural mental health, and enhanced patient satisfaction and experience through shared care approaches. The model shows a sequence where inputs and activities lead to capacity changes, which then lead to behavior changes, culminating in broad system and population benefits.
Implementation and structure
Following the completion of the preparatory phases, the NSTMHP was officially launched in March 2022, supported by the guidance of the NSTMHP Advisory Council (NSTMHP-AC). The 19-member council, representing key organizations (i.e. Dalhousie University DoP and Family Medicine, NSH/MHAP, NSH Patient, Family & Public Advisory Council, IWK/MHAP, NSH Primary Care Program, Newcomer Health Clinic, Tajikeimik, Friendship Centre, ISANS, HAAC) plays a crucial role in advising the NSTMHP Management Team (NSTMHP-MT) on service gaps and culturally competent care.
Council members provide ongoing feedback, are informed by their respective organizations, and advocate for resources and training to meet the needs of equity-denied populations. The five co-chairs, drawn from various partner organizations, lead the council and communicate decisions to the NSTMHP-MT. Members serve three-year terms with the option for renewal.
NSTMHP model of care
An overview of the NSTMHP pathway and model of care is demonstrated in Fig. 2. The NSTMHP has the mission to provide accessible, culturally sensitive, culturally safe, and collaborative mental health and addiction care for historically marginalized racial-ethnic populations of Nova Scotia - African Nova Scotians, Indigenous people, and refugees - aiming to achieve equity in access to mental health and addiction care for all residents of Nova Scotia while also considering the sustainability of the program as well as the unique cultural needs of each population.
The NSTMHP is exclusive for African Nova Scotians, Indigenous people, and refugees and it is not open to other individuals who are not part of these communities. However, patients from these populations can access other mental health services within the province, including Community Mental Health Services, Specialty Programs and Emergency Care.
The clinical service delivery scope of the program is focused on providing:
Direct and indirect psychiatric consultations within primary care settings as part of a shared care model.Culturally competent mental health and addiction counseling within the NSH Community Mental Health Program as needed.Education for medical students, residents, family physicians, international fellows, and graduate students.Innovative research and approaches in transcultural mental health.Collaborative development of assessment and treatment pathways tailored to specific populations.Advocacy and pursuit of agreements to prevent harm and ensure long-term sustainability of the program.
The NSTMHP model of care has a structured pathway that ensures that patients can access timely, culturally sensitive psychiatric care within their primary care settings. It begins when a patient discusses their mental health concerns with their primary care provider (e.g., family doctor, nurse practitioner, or mental health team member). The healthcare provider then refers the patient via central intake system, which coordinates direct or indirect referrals to culturally competent psychiatrists, who assess patients at designated clinics, including the Brotherhood, Sisterhood, Newcomer Health, and Weji’winen Health Centre clinics.
As mentioned above, the program currently has an African Nova Scotian mental health clinician, with plans to hire Indigenous and refugee mental health clinicians for the Friendship Centre and Newcomer Health Clinic, respectively.
Indirect consultations involve case discussions between the primary healthcare provider and the NSTMHP psychiatrist. These consultations focus on providing diagnostic advice, treatment recommendations, and system navigation support. In contrast, direct consultations occur when the patient meets with the NSTMHP psychiatrist, where comprehensive psychiatric assessments are conducted.
These assessments aim to clarify diagnoses and create evidence-based, culturally sensitive treatment plans, which may include medication and psychotherapeutic options. Consultations are conducted in person or via Zoom Healthcare. Additionally, psychiatrists and primary care providers conduct case reviews by phone or in person on designated days or at mutually agreed times.
As well, embedding psychiatrists within the primary care setting facilitated informal conversations with family physicians about potential and shared cases leading to improved collaboration and efficiency in care delivery. In the NSTMHP model, family physicians remain the primary care providers for patients undergoing psychiatric evaluations. Patients continue to rely on their primary care practitioners, with timely access to psychiatric services as needed.
Those without a primary care provider are registered with a culturally specific clinic to ensure access to mental health and psychiatric care within the program.
A consultation report is prepared for each patient, summarizing their history, mental status exam, collateral information, assessment results, and management recommendations. This report is promptly shared with the referring primary care provider. Routine medication prescriptions are managed by the primary care provider, with psychiatrists providing initial prescriptions only in exceptional cases.
Psychiatrists may conduct follow-up assessments, or the primary care provider may request a second consultation. For complex cases, psychiatrists may recommend connecting with enhanced community resources through MHAP. In cases of acute risk or psychosis that cannot be managed in the community, psychiatrists will either refer the patient directly or advise the primary care provider to send the patient to the Emergency Department for further evaluation.
Fig. 2Nova Scotia transcultural mental health program pathway and model of careThe image explains the pathway and model of care for a transcultural mental health program. It shows a patient presenting a mental health concern to a primary healthcare provider, who collaborates with the patient to develop care plans.
The primary healthcare provider facilitates referral pathways through central intake and receives detailed consultation reports from the NSTMHP psychiatrist. The psychiatrist provides telephone consultations and supports primary care providers, offers direct or indirect psychiatric consultations within culturally specific primary health care clinics, and prioritizes follow-up psychotherapy at mental health clinicians in CMHA clinics. Patients are seen in culturally specific primary care clinics where culturally sensitive and comprehensive mental health assessments occur.
The diagram uses arrows to indicate the frequency and direction of contact and processes among the patient, primary healthcare provider, central intake, NSTMHP psychiatrist, culturally specific clinics, and mental health clinicians.
Challenges to the NSTMHP implementation
The implementation of the NSTMHP has presented several challenges that require careful consideration. A key lesson from the program’s first year is the importance of maintaining partner engagement. This could be achieved through active involvement, regular communication, feedback mechanisms, and recognition of contributions.
Following the “do no harm” principle has helped establish trust, adapt approaches for diverse populations, and promote sustainability. Flexibility, co-creation, and listening to the communities served have been crucial for genuine engagement. The NSTMHP Advisory Committee (NSTMHP-AC) has supported these efforts with its collective expertise, ensuring the program remains inclusive and aligned with its mission to provide culturally sensitive mental health and addiction services.
Sustainability also depends on system change, including establishing memorandums of understanding and securing funding to recruit culturally competent clinicians for each clinic. While the goal is to develop a culturally competent workforce across mental health and addiction services, additional resources are needed to meet the program’s target populations. Recruiting and retaining diverse clinicians is critical to meeting the needs of the populations served.
Competing funding priorities in mental health create challenges, making it essential to secure resources for program activities, such as producing multilingual mental health materials, advocacy, literacy education, and transcultural mental health research.
Visiting psychiatrists has strengthened teamwork partnerships, building trust and improving referrals, which has streamlined patient care. Creating priority criteria for psychotherapy in Community Mental Health and Addictions (CMHA) clinics has also helped allocate resources effectively, ensuring timely access to care. Collaboration with healthcare and community stakeholders is addressing barriers to care for marginalized populations by identifying obstacles and working to remove them.
Comorbidities pose a significant challenge, as individuals from diverse populations often face multiple co-occurring issues, including physical health problems, homelessness, poverty, and unemployment. An integrated approach is needed to address these interconnected challenges and provide holistic care.
However, one of the most significant challenges encountered during the implementation of the NSTMHP was the need to adapt assessment processes and treatment models to align with the diverse cultural norms and values of the communities served. A particular challenge was the decolonization of assessment practices, which required us to reconsider and revise traditional methods of psychiatric evaluation. While this presented an initial barrier, it also offered a valuable opportunity for growth.
This ongoing process of adapting our practices has been an integral part of the program’s evolution, allowing us to create more inclusive and culturally sensitive approaches to care.
The success of this adaptation process has been largely driven by strong interpersonal connections and a deep commitment to collaboration between the program and our community partners. The willingness to listen, learn, and understand the unique challenges faced by both the program and the communities has been crucial. Key to overcoming these challenges has been the individual champions within the program—people who are committed to the program’s success and who continuously strive to adapt the model of care in ways that are culturally respectful and effective.
These relationships and shared efforts have been instrumental in ensuring that the NSTMHP is responsive to the needs of diverse populations and continues to evolve toward more inclusive, equitable, and effective mental health care.
Discussion
The NSTMHP distinguishes itself by simultaneously targeting multiple marginalized groups through a shared care model that not only enhances cultural competency but also addresses structural barriers. While similar models, such as McGill University’s CCS and other culturally responsive programs, have successfully provided comprehensive assessments for marginalized populations, they typically focus on a single demographic. In contrast, we use an intersectional approach to tackling mental health disparities and serve African Nova Scotians, Indigenous people, and refugees.
By prioritizing collaborative care within primary health settings, the program integrates valuable lessons from existing models and adapts them to meet the specific needs of underserved populations in Nova Scotia.
Based on evidence from similar culturally adapted care models, such as the IMPACT program, which reported a 25% increase in service utilization among equity-denied populations [16], we expect a similar rise in mental health service use within our target populations. Additionally, we foresee qualitative feedback indicating improved trust in healthcare providers, as observed in the McGill Cultural Consultation Service (CCS) and the South London and Maudsley NHS Trust, where culturally competent care led to higher levels of patient trust and engagement [17]. Furthermore, we expect that 80% of primary care providers involved in the NSTMHP will report increased cultural awareness and confidence, aligning with findings from CAMH and other collaborative care models that demonstrated significant improvements in provider cultural competence [18, 19].
These anticipated outcomes are consistent with the successes of similar transcultural mental health programs and underscore the potential impact of the NSTMHP in Nova Scotia.
Conclusion
The NSTMHP holds excellent promise in substantially impacting mental health care for equity-denied populations. By balancing the universalist goal of increasing access to mental health services with cultural relativism, which ensures services are co-created and appropriately modified, the program offers a transformative approach to mental health care. The NSTMHP is expected to make strides in improving mental health outcomes for African Nova Scotians, Indigenous people, and refugees.