Why culture counts

18 March 2022

Alis Rasul looks into a recent evaluation of how the mental health of BAME Muslim families can be supported when health visitors deliver a culturally sensitive early intervention parenting programme.

Perinatal mental health is a significant public health concern (NICE, 2014). It is a major risk factor during the perinatal period as it is associated with maternal complications, as well as poor cognitive and emotional outcomes for the baby (Napier et al, 2014; Stein et al, 2014; Pawlby et al, 2009). If left untreated, perinatal mental health problems can escalate into more severe mental illness. Maternal suicide remains the leading direct (pregnancy-related) cause of death in the first year after pregnancy (MBRRACE-UK, 2021).

Research has found a strong association between the socioeconomic backgrounds of some communities and cultures and a greater risk of perinatal mental health issues. Black, Asian and minority ethnic women (BAME) are most at risk (Cooper et al, 2013). Psychological and physical wellbeing varies across cultural societies (Henshaw et al, 2017; Sewell, 2009). A recent Lancet Commission on culture and health evidenced a fundamental argument that ‘the systematic neglect of culture in healthcare is the single biggest barrier to the advancement of the highest standard of health worldwide’ (Napier et al, 2014).

Significant gaps in mortality rates between women from different ethnic groups, levels of deprivation and of different ages exist. For example, women from Asian ethnic groups are almost twice as likely to die in pregnancy as white women (MBRRACE-UK, 2021).

A lead service that supports the early assessment and identification of perinatal wellbeing issues is that of the health visitor (Public Health England, 2016; Lewis et al, 2011).

HVs play a key role in ensuring that the impact of perinatal mental illness (which can vary from universal to complex) and other complications do not adversely affect the child’s health and wellbeing (NICE, 2014; Public Health England, 2021).

The project

In 2017, Birmingham Community Health Care NHS Foundation Trust, in partnership with St Paul’s Children’s Centre, agreed to fund two health visitors, who would be trained in the Approachable Parenting programme. For more than 10 years, the programme has been providing support and information to local black, Asian and minority ethnic (BAME) families – in particular Muslim families. Birmingham has one of the highest Muslim populations in the country at around 27% (Miller and Rodger, 2019), up from 21% in 2011 (Birmingham City Council, 2022) and this opportunity allowed for the evaluation of the co-delivery of the Approachable Parenting programme, and in particular the delivery of a culturally sensitive service by health visitors to enable equity in healthcare.

Project aim

To evaluate the role of the HV in delivering a culturally sensitive early intervention parenting programme to support the mental health of Muslim families.

Project objectives

  • To map the Approachable Parenting programme’s objectives to the HV role in improving public health outcomes for the mental health of Muslim families.
  • To identify Muslim parents’ views on the sociocultural factors that would enable them to engage with the HVs in delivering the aims of the programme.
  • To establish Muslim parents’ sociocultural perceptions of mental health needs, both for themselves and their children.
  • To compare and map Approachable Parenting objectives to Care Quality Commission equality indicators for service improvement in the wider context of health visiting for Muslim families.
  • To determine the impact of relational HV support in promoting Muslim families’ mental health and resilience through delivery of the programme.


The ‘logic model’ (Public Health England, 2017) was used to inform a realist evaluation of the HV role in enabling and delivering the culturally sensitive elements of the Approachable Parenting programme for Muslim parents. Realist evaluations offer a focus on real-world practice. It allows for a greater depth of data to be collected in relation to everyday process outcomes, which in turn are likely to reflect more complex interventions (Doi et al, 2017). Focus groups were conducted with parents who attended the Approachable Parenting programme, and self-evaluation forms were completed by the parents in order to produce a robust report of the topic. 


Three themes emerged from the findings of this study: relationships, trust, and ‘me time’. The findings indicate the need for health organisations, policymakers, Health Education England and academia to work together to support the perinatal mental health of BAME communities as early as possible. Future health services need to evidence equity in healthcare with service user involvement so that the services provided are fit for purpose and receive full engagement from the communities that they serve. These services should also be identified by the service users as high quality and culturally safe for them.

A range of services is required to assist in preventing these effects where possible, as well as to identify and seek treatment to reduce the impact on the family (PHE, 2021). This is strongly endorsed by the NHS Long-term plan (2019), with a major shift towards and focus on prevention in tackling health inequalities. This is done by meeting the health needs of communities through integrated care schemes working across organisational boundaries.

Other support for parents, in particular in relationship building, can be provided by parenting programmes (Symonds, 2018). In particular, there has been growing evidence to support culturally-competent parenting programmes (Vesely et al, 2014; Calzada, 2010). The Approachable Parenting programme is one such programme, and has been in practice in Birmingham, Manchester and London for the past 10 years. The Approachable Parenting programme was developed with BAME parents – and particularly Muslim parents – in mind. This is because access, engagement, and retention by traditional parenting programmes of BAME communities has previously been low (Wells et al, 2015; Ullfsdotter et al, 2014; Barker et al, 2010; Griner and Smith, 2006).

There is evidence to suggest the benefits of the Approachable Parenting programme on both maternal and child mental health of Muslim families in Birmingham (Thomson et al, 2018). This has also been evidenced in other BAME communities (Griner and Smith, 2006). The overall aim of parenting programmes is to promote positive parenting by employing attachment and social learning theories. These theories support parents in strengthening their relationship with their child and improve their mental health.

Context – Mechanism – Outcome

The Muslim population of the city is estimated to be 27% (Miller and Rodger, 2019), with the English average being 5% (Birmingham City Council, 2022). A large proportion of Muslims are from a south Asian background, and 38% have a Pakistani heritage (Muslim Council of Britain, 2015). There are currently limited statistics on religion and perinatal mental health, particularly for Muslim women. However, research shows that depression is higher in Pakistani women in the UK who confirmed their religion as Islam (31%) compared with their white counterparts (12.9%) (Husain et al, 2012).

Depression is higher in Pakistani Muslim women in the UK compared with their white counterparts

Culture and perinatal mental health

There is a strong evidence base on cultural perceptions and stigma of perinatal mental health in BAME communities (Watson et al, 2019; Anderson et al, 2017; Prady et al, 2016; Husain et al, 2012). Some of the studies reviewed note that Muslim women felt they had to keep their mental health issues to themselves and not share them with family and friends. There was also some indication that some Muslim women disassociate themselves from mental illness altogether, since it is culturally considered a form of physical deformity; the mental health of some of the mothers was thus not considered a priority (Hanley and Brown, 2014; Parvin et al, 2004; Fazil and Cochrane, 2003). This could be related to Muslim populations increasingly using spiritual and/or cultural coping mechanisms compared to women from other beliefs in the UK (Meer and Mir, 2014).

The law

The NHS is under a legal and moral duty to deliver services to local people and communities who share protected characteristics, as defined in the Equality Act (2010). This duty is further laid out in the NHS constitution (2015).

However, there still appear to be major gaps in both service provision and major statistical data. For instance, infant mortality is nearly double in Asian babies (highest in the Pakistani ethnic group) and higher still for babies in the black ethnic group compared to that in white infants (ONS, 2021). Service delivery, access to service, and culturally sensitive services are still major problems in mental health services for BAME families (Prady et al, 2016).

Evaluation design

To ensure that evaluations succeed in achieving the desired outcomes, the chosen method for this study is that of realist evaluation. Realist evaluation has been distinctive in asking the questions of what works, for whom, how, in what circumstances, and why, as opposed to merely ‘does it work’ (Pawson and Tilley, 2013). Realist evaluation offers an understanding of social systems described as programmes, and describes a continuously evolving interplay between human agency and social structures. The realist theory has three main components: building, testing, and refining programmes theories. This is undertaken by exhibiting the core interaction of context, mechanism and outcomes (CMOs): see table on opposite page.

Seventeen parents registered for the programme, of whom 11 completed the Approachable Parenting requirements. The reasons parents gave for not completing was because of family circumstances or childcare issues. This report is, therefore, based on the 11 parents who completed the course and both the pre- and post-programme questionnaires.

The following three main themes of interest emerged from the thematic analysis: relationships, trust and ‘me time’. The relationships theme covered the context of the initial programme theory; the trust theory was in relation to the mechanism; and the ‘me time’ covered the outcome. These themes will be discussed further below, when presenting the results and discussing the findings.

Most participants openly shared the importance of personal and professional relationships. The HV relationship was explored in this theme. Participants reported that they received significant support from the HV in all areas of health promotion and early intervention during the course of the programme.

All of the participants discussed their motivation for attending and all identified their child’s health and welfare as the primary motivator.There was also a discussion on why the Approachable Parenting programme served to motivate their attendance.

Apart from focusing on how valuable the delivery of the culturally sensitive Approachable Parenting programme was, a few participants consistently cited ‘me time’ as an outcome with positive results. ‘Me time’ is described as giving oneself compassionate self-care to ensure wellbeing by looking after oneself (Baker, 2019).

The findings of the present study support the wider literature conclusions: BAME patients and service users frequently experience challenges in seeking and accessing support for perinatal mental health services (Watson et al, 2019; Masood et al, 2015; Husain et al, 2012; Templeton et al, 2003). Furthermore, the present findings reveal that BAME patients and service users are generally willing to engage actively with services. Significant evidence also states that it is not only challenges in seeking, accessing support for mental health service but also attitudes of professionals referring into services as well as those delivering services, which causes ‘othering’ and mistrust of BAME service users (Watson et al, 2019; Anderson, 2017; Prady, 2016; Husain et al, 2012).

The present findings reveal that BAME patients and service users are generally willing to engage actively with health services. There is a reduction in service uptake only when there is a conflict in understanding information about services. Further to this, participants confirmed a mismatch of perception of ill health that service users cannot relate to when services are not adapted.

These findings indicate that services will only be fully endorsed by BAME communities when they are perceived safe. There also needs to be some recognition that health services for BAME communities should be delivered and developed by BAME professionals – this may not have come out directly during the focus groups but will need further exploring. The study also demonstrates hope: the participants reaffirmed that where there is co-production through ‘true’ engagement, compassion and trust, our health services can be considered culturally diverse.

Culture matters, as it is in the hearts and minds of individuals. There are core beliefs that individuals and communities hold when accessing, receiving and evaluating their healthcare. If there are current or developing trends in these core beliefs, these need to be explored further, as the duty of care lies with the healthcare organisations and practitioners whose role it is to facilitate the engagement. This is especially important in health visiting, since the HV acts in a core community capacity role.

It matters that all children receive a fair start in life and fair access to services that meet their cultural needs. These should be services that they can relate to, understand and implement in daily life. It matters because every child matters, and no parent should lose a child, regardless of their belief, ethnicity or culture.

Alis Rasul is Interim Divisional Lead HV for Birmingham Community Healthcare. Her study was funded through a Mary Seacole scholarship.


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Image credit | iStock |Study-by-Alis-Rasul

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