Dismantling stigma

July is BIPOC Mental Health Awareness Month, a month Providence Swedish Health Services’ Dr. Nwando Anyaoku feels is deeply important for the populations the month is meant to serve. Anyaoku, whose career has long focused on pediatrics, health equity, and community partnerships, became Swedish’s first chief equity officer in 2021, a position she holds alongside a number of board positions with organizations and healthcare providers that focus on uninsured and underserved communities. Anyaoku spoke with Carolyn Bick for the Northwest Asian Weekly about BIPOC Mental Health Awareness Month, and how she and other physicians can make folks in these communities feel safe and welcome in seeking mental health care.

There is a list of AAPI-focused resources for those in need at the end of this article.

Northwest Asian Weekly

July is Mental Health Awareness Month for Black communities, Indigenous communities, and communities of color. Why is it so important to highlight mental health awareness in these populations?

Dr. Nwando Anyaoku

Mental health is a national crisis. Across the country, we’ve known that for years. It got much worse during the pandemic, but within the bigger picture, the Black, Indigenous, and other communities of color are especially affected for a number of different reasons. So, the work that my team does, really, at Providence—focusing on health equity—really addresses some of these challenges, because these communities have poorer access. They have challenging experiences, and, therefore, have worse outcomes. 

So, the ability to get screened for these conditions is difficult, because a lot of these communities are overrepresented in patients who do not have insurance, who have a difficult time getting into the healthcare system, but even beyond that, there’s the matter of stigma, right? So, for these communities, having a mental health diagnosis carries a lot of stigma, so even when they’re able to get into the health system, there’s this hesitation to get screened for mental health problems. Families may not support the diagnosis or what is needed, because there is a lot of stigma in underrepresented communities around mental health. 

So, really, it’s sort of a 360[-degree] problem, right? You can’t get in, and even when you get in, the stigma presents a challenge. And yet, we know that it’s something that we have to address. So that’s why it’s important to take out a month to have a conversation specifically to these communities that let us know that this is important to talk about—it’s okay to talk about and it’s okay to ask for help.

Northwest Asian Weekly

That’s a great lead-in for this next question. How, in these communities, do you even start talking about mental health awareness, when all of these overlapping challenges exist?

Dr. Nwando Anyaoku

We think about the principle of co-creating solutions with communities—really understanding the community, because I think for the healthcare industry for years, we didn’t even focus on the fact that there is a unique problem in these communities, which is stigma, separate from access. 

As we recognize it, then we surface the conversation, and we find trusted partners in the communities to help us bring the message, right? So, it’s one thing for somebody from these underrepresented communities to hear me talking about it, but it’s a different thing for them to hear being talked about from someone that they already know—trusted elders, trusted voices in the community, community health workers, cultural navigators—people who are of the community, who then partner with us as health care, to bring these conversations in a way that’s non-threatening, that builds trust. 

If you’re thinking about it in the clinical space—I’m a physician, the patient comes to me—it’s important for me, to have top of mind, to specifically ask the question, in a way that lets them know that this is a safe space to talk about it. 

We often say that the work of health equity moves at the speed of trust. People need to feel like, “Oh, this person looks like me. They sound like me, they understand where I’m coming from. And they are saying that it’s okay. All right, well, then, tell me some more.” That’s how you start to bring those conversations to the top. 

I’m actually intentional about building trust around these conversations with my patients. That’s the way you think about it. Like I said, it’s a problem, so you’ve got to think about going upstream to the community, but also, at the point that it comes to the healthcare system, we have strategies that we’re putting in place to help increase our screening rates to increase the trust of the community so that they’re willing to talk to us so we can provide them help.

Northwest Asian Weekly

And this brings up a really good point. Black, Indigenous, and communities of color are not a monolith, even within the “umbrellas” under that term itself, down to the individual. Are there any frameworks in place in doctor’s offices to start conversations like this in these communities, given that everyone is an individual?

Dr. Nwando Anyaoku

Exactly. And that right there is the key. Everybody is an individual. And one of the things we talk about in Providence is we talk about the “sacred encounter,” that each person is unique, and so that you need to enter that space focusing on the person in front of you, their particular story, their particular needs, Don’t lump them into a bucket, because all Black people are X, or all Asian people are Y. Because each person in front of you has a unique story. That’s challenging for [healthcare workers] who are trying to move quickly, do care, but if you build that muscle, then you have the opportunity to just be open—have open-ended conversations with people so that they feel like they can be themselves in your space. There is no judgment. 

We try to manage our biases, so that people feel safe in our healthcare system. But there is no one formula for talking to African Americans [for example], because African Americans—you’ve got Africans from the diaspora, their needs are different. But at the end of the day, everybody wants to be seen, everybody feels heard. And that’s the muscle that we build.

Northwest Asian Weekly

How did you come to focus on mental health?

Dr. Nwando Anyaoku

What we’ve done is really look at our data. Because we said, “What are the things that we can measure to see where the disparities lie?” 

We have metrics that we collect baseline, that we look at those things from the perspective of quantitative and qualitative. So, what are the stories? What are the challenges that we’re hearing on a recurring basis that literature shows is a prominent issue? And what are the things that our data, which we pulled out of our electronic records across our footprint, are showing us that they had gaps in different populations? 

In the past, people would just report quality metrics. So, if you’re looking at depression screening, for example, you look at screening across our footprint, we’re doing great. But when you disaggregate the data—which is really where the key is; break down the data by race, ethnicity, and language—now you start to see opportunities. You can see that if you look at it for the majority—so, everybody, because the majority has so many—we’re doing great. But when you look at subsets, you start to see that in certain subsets, we’re not doing as well. And I think of those as opportunities. 

So, in looking at those numbers, that’s where we start to see that some … of our underrepresented communities showed mental health metrics that are not as good as we are performing with their white or Caucasian counterparts, or majority counterparts. 

We know that there’s a lot of literature … about how mental health challenges are prominent in underrepresented communities. So between the data, the literature, and the narratives, we were like, “Okay, this is an area we really need to focus on.” And Providence as an organization really has a particular focus on mental health. So working together with our partners across the enterprise, it was clear that this is an area we should focus on.

Northwest Asian Weekly

What did the data show?

Dr. Nwando Anyaoku

I would say that the answer varies depending on the geography. So, in some of our geographies, the community with the biggest disparity in mental health outcomes in some communities, they are the African Americans. In some communities, they’re the Pacific Islanders. We have pockets where they are worse than others. So, I can’t tell you that across the board, one particular group was the worst everywhere, because it varies based on our geography. 

Our geography, across the Providence footprint, is really a microcosm of the USA. We have indigenous populations, we have Pacific Islanders, we have Asian Americans—we have all different groups represented across our footprint. And those numbers vary, depending on the size of the population there, the access they have. Some of our footprint is in rural spaces, at critical access hospitals—those numbers are different. I tell my team often that we don’t have a disparity in prize. We just want to build the muscle of understanding who is not being served the way we intend. And where do we have opportunity to close disparity gaps?

Northwest Asian Weekly

What are the particular hurdles facing Asians, Asian Americans, and Pacific Islanders when it comes to mental health? How do these challenges show up both in personal spaces, like the home, and external spaces, like a doctor’s office?

Dr. Nwando Anyaoku

The specific challenges that we know is … connecting to having a regular provider. … [The AAPI community has] a lower rate of having PCPs. But the other one that we see is a bigger risk of stigma that makes them less willing to do the screening that is required for us to understand what their mental health status or depression rates are.

Northwest Asian Weekly

So, in terms of challenges someone from an AAPI background might face, after they overcome a particular stigma, are there biases that show up in a doctor’s office that might make them not come back?

Dr. Nwando Anyaoku

I don’t know that that is a huge challenge. People think that that is the case, that we all have biases, and some of those biases might suggest to people that the patient is more well than they actually are, because everything else looks okay. And so some of the things that we have to think about is how do we, as clinicians, just hold space so that we’re having open conversations with our patients. 

We build depression screening into our routine intake, so that we can just get the information, just like we’re getting blood pressure. It’s not a specific thing that you’re coming to do, that the person has to think about. It’s just part of the journey of being in the doctor’s office. So, we try to build it into routine. But if they come in and you ask them these questions, and you’re not really intentional about making it feel comfortable, they might feel like, “Oh, I don’t like that doctor, they ask me questions that are uncomfortable, and I don’t want to come back and do that again.” So it really is about building trust, and making sure that the interactions are meaningful and safe for the patient.

Northwest Asian Weekly

How in your practice do you make sure your interactions are meaningful and safe?

Dr. Nwando Anyaoku

I think it depends on the patient. Every clinician has to build trust, and that conversation depends on the patient. How do I make sure that I’m not assuming—that I’m not making assumptions, but I’m asking, and I’m pausing and listening for answers, and really making sure the patient knows that I’m there for them. That’s it. There isn’t one formula. The only formula is that you want to be intentional about doing it.

Northwest Asian Weekly

So, not asking them the same question over again, or making them feel like you’re not taking their word for it?

Dr. Nwando Anyaoku

Well, sometimes you want to ask it again, because you want to be clear. So, you can acknowledge that they probably asked this question already, but you just want to be clear. Maybe you’re missing something. There’s these conversational styles or interview styles that we talk about—motivational interviewing, or really being present. Don’t go in and say, “Well, I’m sure you’ve done X, Y, and Z.” Just ask the question, rather than assuming, because that’s a lot of what patients will say—“Oh, [the doctor] ended up just assuming X, Y, and Z about me.” And so we are constantly working on that communication, that trust-building, that really being engaged and present with our patient.

Northwest Asian Weekly

With the understanding that mental healthcare is not and never will be one size fits all, especially given the diversity within every group of people, how can mental healthcare be better tailored for AAPI folks? How can healthcare providers better meet their needs?

Dr. Nwando Anyaoku

I think one of the ways that we build across all the work that we do is really partnering with the community. If we see that there is an opportunity, like I said, there’s a disparity in this community, then you want to find out who are the leaders in your local geography who can speak to that. Is there a community center that serves a population? Is there a church that they go to? Is there a place that they gather that they feel safe that we can kind of piggyback on the trust that has been built in that space to bring that information? 

One of the things that we have very robustly built is that the traditional health workers, the community health worker, cultural navigator—they’re basically different names for the same thing, but we hire people out of the community that we’re trying to target. So, in the Swedish Washington market, for instance, we have navigators from the Vietnamese community, because we saw that there was opportunity to close gaps in that. So you bring someone from the community who understands the context, the language, and the trust factors, and they help to bridge the gap between the intention of the healthcare system and the ability of the patient. So, the community health worker can go out to the churches, they can go out to the places where they gather, and speak to the people in the community in language, and help those patients navigate their appointments with a doctor. They can be a support on their journey, help them schedule follow-ups, and reassure them about the information the doctor gave. They can review their discharge summaries with them. They kind of accompany—they’re patient advocates, who work to ease the anxiety or the mistrust that the patients from these communities may feel. So, that’s been a very intentional and effective strategy for bridging gaps.

Resources

Asian Counseling and Referral Service (ACRS)

Chinese Information and Service Center (CISC)

Filipino Community Seattle

International Community Health Services (ICHS)

International Drop-In Center (IDIC) Filipino Senior and Family Services

Neighborcare Health at Pike Place Market

Neighborcare Health at Pacific Tower