This study explored whether there were any inequities in accessing EI care for FEP patients in Ontario. After adjusting for relevant sociodemographic factors, participants from the Asian and the other ethnicities groups were 4 times more likely to use ER as their first point of contact compared with participants from the white or black groups. (The other ethnicities group included participants identified as Latin American and Aboriginal). This finding should raise concerns. Participants from the Asian and other ethnicities groups experienced disproportionately high, yet early, ER exposure, experiences that have been shown to promote future hospitalizations and to deter outpatient engagement.53
It is conceivable that there may be cultural practices adopted by these 2 groups that make them vulnerable to ER use as the first point of contact. Unfortunately, explanations or discussions on the role of cultural practices based on this study's findings may be misleading or even inaccurate given the limitations in the design; this study assigned people of diverse cultures into each group. However, there were no significant ethnic differences in education, employment status, or any demographic factors that could be considered proxies for socioeconomic status. The lack of interaction between ethnicity and sociodemographic factors suggests that social disadvantage was not an important issue, but replication of this finding is warranted with a larger sample and a more culturally valid classification system.
In attempting to understand the higher use of ER by the Asian and other ethnicities groups,12
one should consider the role of problems with the healthcare system, in particular, the language barriers faced by patients and the level of cultural competency demonstrated by the healthcare professionals. One might argue that a critical mass of patients from a particular ethnic group may be needed before healthcare professionals obtain the requisite experience needed to provide culturally and linguistically appropriate services. Given the large number of different Asian languages and cultures within Canada, and the relatively small proportion of people who represent each Asian culture, (the same argument could be made for the other ethnicities group), it may be a challenge for each healthcare service to develop the requisite cultural competency. The same issues apply to the cultures represented by the “other ethnicities group.” Communities that have a lower proportion of participants from these ethnic groups may be more vulnerable to these problems, and hence, more apt to direct these patients to ER services. For example, in our study, London and Ottawa had the lowest proportion of participants from the Asian group; participants from London and Ottawa were twice as likely to use ER services, compared with Toronto and Hamilton.
Other studies suggest that ER services are utilized more often by ethnic groups if language poses a significant barrier to usual mental healthcare services.12
Although all participants spoke sufficient English to enter this study, previous work suggests that some bilingual individuals with psychosis lose some of their proficiency in their nondominant language during an acute bout of psychosis.54
The nuances of verbal communication are more important for mental health than physical health problems, conceivably because mental health assessments of psychosis are more reliant upon language than assessments of physical health. Along related but different lines, knowledge about how to access the system may be more limited for ethnic groups who represent more recent arrivals to Canada. On the surface, these hypotheses appear plausible, but they all require the scrutiny of future research to assess their usefulness in understanding the differential use of ER.
Economic factors are considered to be significant determinants of disparities in accessing healthcare in a privately funded healthcare system12
; however, these factors may also be important in a publicly funded system, such as the one in Ontario. A trend emerged suggesting that psychologist services, as the first point of contact, were more common among participants from the white group. Psychologists are not covered by the universal healthcare plan in Ontario. Although we failed to collect data on private insurance coverage, this trend suggests that there may be ethnic disparities in private healthcare coverage in Ontario. This trend warrants further investigation into whether disparities exist in accessing psychologist and counseling services. Nevertheless, other causes for this disparity, such as cultural or social factors, should be investigated; eg, patient attitudes toward psychologists and counseling services. In comparison to their white counterparts, Asian and black patients with nonaffective psychosis in the United States were less likely to believe their problems were psychological in nature and less likely to perceive themselves as needing treatment for psychiatric problems.10,13,22
On the other hand, compared with the other groups, participants from the white group had significantly more service contacts before entering EI services. This finding may reflect better engagement with service contacts who may share the same cultural perspective as the participants from the white group.40,55
In addition, it may also reflect a surprising tendency for mental health services to delay treatment of a first episode of psychosis if the individual is already in the system for treatment of prodromal symptoms when they convert to psychosis,30
even though this delay in accessing EI services may not be sufficient to lead to an overall increase in DUP.56
Overall, our study findings suggest there were many more similarities than significant differences in the pathways to care for the various ethnic groups. Family physicians and ER services were commonly accessed by all groups as the first point of contact. Two Canadian studies have already demonstrated the prominent role that ER services and family physicians play in facilitating more direct pathways to care.29,30
In contrast, unlike these 2 previous Canadian studies, a considerable proportion of participants from our study also approached naturopaths, clergy, and other nonmedical supports as their first point of contact in their pathways to care. In fact, clergy, naturopathic healers, and other nonmedical contacts were used more commonly as the first point of contact than psychiatrists and psychologists. Although many patients from developing countries and from ethnic minority communities seek help from both medical and alternative therapy practices,32,57
current research suggests that nonmedical contacts may be sought preferentially by patients if there is denial about the presence of a medical illness or if there is a greater sense of stigma associated with accessing mental health services.58
Regardless, there is a growing trend towards use of traditional healing practices and alternative therapies for psychiatric problems,59
and our findings may reflect this reality.
We also found high rates of family physician and family member involvement for all ethnic groups. Some studies conducted in the United States have found high rates of involvement by family physicians for African Americans,53
while other studies have found low rates of involvement by family members for an episode of psychosis.10,15
On the other hand, this discrepancy between our findings and previous work could be a result of regional differences in engagement, cultural sensitivity, or acculturation, but it may simply represent differences in sampling methods.
In the present study, DUP was comparable across the 4 groups, a finding that was first obtained in the Aetiology and Ethnicity in Schizophrenia and Other Psychoses.20
Even though most previous studies found more compulsory admissions among people of African descent compared with the white majority,11
in our study, participants from the black group did not experience inequities in the use of involuntary admissions or arrests, compared with participants from the white group. These findings are quite inconsistent with results of previous work10,16,17,60
including the Canadian study conducted in Montreal28
and may reflect the high levels of family physician and family member involvement experienced by our sample. Instead, in our study, participants from the Asian group experienced significantly less involuntary hospitalizations but more ER use. Additional research is needed to understand this finding. What is the role of language barriers, cultural competencies, and cultural stereotypes? Is there evidence to support ethnic differences in clinical presentations of psychosis?
Of note, a relatively high proportion of black participants were present in the study sample. Black participants made up 15.5% of the total sample and 25% of the subsample from Toronto, and yet, in 2001, the Canadian Census revealed that individuals who identified themselves as black comprised 6.7% of the population in Toronto, the greatest proportion of black people in Ontario.61
) Sampling bias is the most probable cause for the relatively high proportion of black participants. Nevertheless, in the future, Canadian studies should address this issue because Canadian data are lacking. Patients of African descent, compared with patients of East Indian descent, were over-represented in a first-episode program in Trinidad.62
Other studies conducted in the United States63–65
, the United Kingdom,16,66,67
The Netherlands, and Sweden68
have also reported a higher diagnostic distribution of schizophrenia among people of African descent. However, ethnic differences in diagnosis were absent in a previous study where raters were blind to ethnicity,63
suggesting that rater bias or cultural differences may play a role.69
These diagnostic controversies highlight the need to examine the social, environmental, and cultural factors that are associated with schizophrenia.70,71
Limitations of the Study
Because the present study involved a convenience sample, the design should be viewed as exploratory, the results should be considered as preliminary, and the findings should be interpreted cautiously. Generalization of the findings to other regions or to nonclinic samples is not warranted. Despite these limitations, this study is of value because it is the first one, to the best of our knowledge, to examine ethnic differences in the pathways to care in Canada, and it is fairly representative of first episode of psychosis patients treated at EI services in large urban centers in Ontario.
The actual case finding rate for this study is unknown but may be short of the annual incidence rate of 7–14 per 100
000 population, aged 15–54 years, reported for schizophrenia.57
We did not conduct a leakage study to estimate the proportion of eligible persons who were missed. Uncontrolled site factors, such as the referral practices and the degree of competing services in the area, as well as the level of awareness of a new EI service, could have limited case finding for all eligible patients.1
The degree of rater drift and interrater reliability of the CORS for pathways to care was not established. This is a common limitation that exists in other pathways to care studies.10,16
In fact, a recent review revealed that none of the studies disclosed information on the psychometric properties of the measures used to specifically assess pathways to care.21
Our study excluded non-English speaking patients, thereby setting up a language barrier for entry of some patients, most likely immigrants less fluent in English. At the same time, we failed to collect data on the language spoken in the home or the immigration status of participants.
For statistical purposes, the present study classified many individuals from different ethnic communities into 4 groups. Therefore, the findings fail to represent any one specific ethnic identity or culture. The heterogeneity within each of the 4 groups may obscure the true meaning of the findings. In many ways, the findings raise more questions than they answer, but they also highlight the need for future studies on a much larger scale with classifications that are more culturally valid.
We have chosen to use the term ethnicity rather than race for the present study because the ethnic differences were conceptualized as cultural and fluid, as opposed to innate or biological. We acknowledge that there are many different ways to group people from different ethnic groups and races and that the ethnic classification that we used was somewhat subjective, arbitrary, and did not necessarily reflect the diversity of perspectives or identities represented by the participants from each group. Many researchers struggle with the operationalization of ethnicity8,41,72
; researchers want definitions that are scientifically valid yet capture the preferences of the individuals involved. Nevertheless, ethnic classifications are continually changing because they are inherently contextual, historical, often political, and somewhat sensitive and controversial.8
Because of these limitations, future research needs to better delineate the concepts of ethnicity and race and yet remain relevant within a pluralistic society. Unless future research adopts more culturally valid groupings, science will fail to advance our understanding of the reasons behind ethnic differences. Despite these limitations, society needs to support research on ethnicity to better understand the impact of culture and discrimination upon healthcare utilization and outcomes and to document any inequalities for vulnerable groups, so that these disparities can be addressed.