Examining Brain and Mental Health Inequities from a Global Lens: Insights and Opportunities

A public health challenge affecting countries throughout the world is the effective study, promotion, and deployment of supportive services addressing brain and mental health particularly in traditionally underserved population groups. And while efforts to curb this challenge have garnered wide-ranging attention from a broad coalition of interested parties, the COVID-19 pandemic has further amplified these demands by exacerbating health disparities in brain and mental health in traditionally underserved groups (The Lancet, 2020; Glei et al., 2022; Khatana et al., 2020; Saltzman et al., 2021; Shannon et al., 2021; Thomeer et al., 2022). Furthermore, the pandemic has emphasized the need to address intersectional barriers to care across the lifespan, particularly in older adulthood. Culturally informed work that is translatable across disparate sectors (e.g., civil society, government, philanthropy, private sectors, and clinical and research settings) is paramount to addressing associated risks and barriers to facilitate these groups in obtaining adequate care. To this end, this special issue examines brain and mental health through the multifactorial lens associated with health inequities experienced by traditionally underserved older adult populations.

Studies highlighted in this special issue range in focus: from individual-level factors (e.g., modifiable lifestyle factors, social determinants of health) and community-level factors (e.g., group perceptions of mental and brain health) to broader research and funding considerations that are pertinent to brain and mental health research with traditionally underserved populations. Additionally, the current issue elucidates the importance of considering biopsychosocial contributions (Engel, 1977) and the various communities that individuals identify with (Bronfenbrenner Ecological Systems Theory, 1977), in understanding disparities in risk, prevalence, and receipt of treatment in the context of marginalized groups. For example, one may wonder how disparities in structural changes in and pattern of brain aging across African American, Latino/minoritized groups in comparison to White individuals (Turney et al., 2022) may be moderated by specific individual or community-level factors for these groups in the USA. Consistent with foundational theories in psychology, this special issue further parallels the Health Disparities Framework (Hill et al., 2015) which captures how these health factors interact in the context of older adulthood.

Curating complementary viewpoints to identify gaps and barriers

Acknowledging that the most effective and enduring approaches to combat inequities demand multisectoral solutions, this special issue includes invited commentaries from a Federal public health agency (the Centers for Disease Control and Prevention, CDC), an international public health organization (the World Health Organization, WHO), and a joint perspective from the philanthropy and advocacy communities (Grantmakers in Aging, GIA; American Psychological Association, APA). Authors from the CDC (Olivari et al., 2022) raised the importance of adopting social determinants of health framework, discussed tailored methods for communication with underserved populations, and described how the agency is employing these frameworks in their national initiatives in the United States. Complementing this perspective, authors from the WHO (Seeher et al., 2022) examined disparities in dementia diagnosis in low-resource countries by highlighting the poor clinical implications stemming from inter-relationships among stigma, inadequate knowledge, illness misconceptions, and scant health policies in underserved populations. Furthermore, with a focus on research and philanthropy, authors from GIA and APA (Goldman & Vinson, 2022) offered applicable and translatable considerations across fields for increasing the effectiveness of brain and mental health research specifically to address these inequities.

Following these commentaries is a comprehensive review of brain health as part of the Worldwide FINGERS Network initiative highlighting the importance of modification of various risk and lifestyle factors and explores adaptation of findings to groups across various geographic, cultural, and economic settings (Coon & Gomez-Morales, 2022).

Advancing global understanding of ways to achieve brain and mental health equity for all

A set of original research studies focused on underserved population groups including Asian Americans, Black Americans, Hispanic/Latino Americans, Asian Americans, and Aboriginal and Torres Strait Islanders. Concentrating on a sample of participants from nine different ethnic groups (Arabic-, Hindi-, Tamil-, Cantonese-, Mandarin-, Greek-, Italian-, Spanish-, and Vietnamese-speaking communities), Brijnath et al. (2022) created a culturally tailored dementia prevention film which found that the mode of delivery, imagery and tone of the resource are important linguistic considerations that can inform tailored psychoeducation about brain health. Shifting focus to Latin American groups, Moreno et al. (2022) concluded that the lack of an adequate workforce and diagnostic assessments represent barriers in treatment of Spanish-speaking Latino American groups in the USA. Also, within the Latino American group, Light et al. (2022) conducted semi-structured interviews with 30 Spanish-speaking older adult immigrants and described how variable perceptions of aging and brain health may hinder adequate knowledge, help seeking, and treatment outcomes in this group. In a related study examining barriers to research participation and attitudes toward dementia among 50 Black American older adults, Amofa et al. (2022) highlighted the importance of considering time demands, mistrust, lack of knowledge about research, and stigma in understanding this reality.

Recognizing the critical role caregivers play in the continuum of care, the special issue includes articles investigating caregivers in the Asian American and Indigenous populations. Specifically, Lwi et al. (2022) identified one cultural belief (e.g., losing face) that is influential in amplifying feelings of loneliness in Chinese American caregivers and can influence their quality of life and subsequent treatment outcomes. Similarly, Ta Park et al. (2022) asserted that Korean American caregivers experience poor mental health and burden and find familism and social support particularly important when caregiving. Lastly, focusing on culturally informed clinical assessment, Russell et al. (2022) conclude that certain mental health screeners for depression and anxiety such as the KICA-dep (Kimberley Indigenous Cognitive Assessment tool for depression) and GAI (Geriatric Anxiety Inventory) are inadequate for capturing clinical symptoms in Aboriginal and Torres Strait Islander older adults, adding to the growing evidence that there is a need for informed culturally tailored intervention that accurately diagnosis individuals of different backgrounds.

Another set of empirical studies in this special issue focus on cognition, with sociodemographic considerations in mind. Arias and colleagues conducted a cross-sectional observational cohort of 547 White older adults in the city of Boston which highlighted the role of higher level (greater years) of parental education in reducing delirium risk in older adults (Arias et al., 2022). Shifting to an intervention focus, Bertrand et al. (2022) adapted and conducted a 7-week cognitive stimulation therapy program with 47 Brazilian older adults and concluded that there was a positive influence of such therapy on cognitive self-awareness (awareness of one’s own cognitive processes).

What can the global community be doing (better)?

It is abundantly clear that promoting brain and mental health is a global challenge particularly with the acceleration of health inequities brought to bear by the COVID-19 pandemic. Furthermore, it is remarkable – given what we know regarding the profound human and economic toll that brain and mental disorders have on society – that insufficient attention has been given toward evaluation and implementation of initiatives focused on prevention and treatment. A host of sociopolitical and environmental factors limiting promotion and funding of these efforts make it difficult for countries to put intervention and (particularly) prevention work at the forefront of their priority lists, even though journals such as The Lancet and organizations such as WHO and CDC have highlighted that such work is essential in delaying onset of diseases such as dementia and thus narrowing disparities (Livingston et al., 2020)

Future initiatives, programs, or services seeking to improve brain and mental health for traditionally underserved groups are imperative at this time and ideally should consider the following:

• Incorporation of group-level (e.g., socioeconomic status, resources available, group perceptions of brain and mental health) as well as individual-level factors (e.g., specific modifiable lifestyle factors, level of education, beliefs about given disease and purpose of seeking help) to maximize the holistic study of brain and mental health from systemic and intersectional perspectives;

• Adoption of a life course and preventive approach (i.e., initiatives should begin early for adequate risk prevention) as a prevention-focused approach may reduce economic, physical, mental, and the emotional toll associated with health-care costs, disease burden, and prevalence of disease for a community (McDaid et al., 2019);

• Inclusion of insights and perspectives from multiple disciplines affording the possibility of examining the multifaced barriers and enablers of diagnosis, help seeking behaviors, and treatment seeking; and

• Examination of non-pharmacological interventions via a variety of approaches (e.g., support groups, psychoeducational programs, and cognitive rehabilitation). Some have considered building trust in bolstering recruitment of marginalized communities in research initiatives (Massachusetts General Hospital, Vila-Castelar et al., 2022), and others have taken a hands-on approach to culturally tailor education and outreach for older adults from underserved communities who have concerns about their memory and mood (currently in initial stages, VA Boston Healthcare System, Azar et al., 2022) or adapted cognitive strategy tools to other languages and validated them with different cultural groups (Mayo Clinic, Santos et al., 2021). Others – for example, – have initiated non-pharmacological interventions involving education on accessible steps to maximize brain health, including the initiative led by specialists in brain health and neurodegenerative disease, as part of the Global Council on Brain Health (AARP, 2022). Still others have explored the role of intentional and inclusive technological advances in addressing disparities in brain and mental health in underserved groups (Bicket et al., 2021).

Closing thoughts

The set of thirteen commentaries and original research studies – from around the world – appearing in this special issue further accentuates the need for multidisciplinary approaches to optimize health within the US and abroad. As a collective global community, we have now a unique opportunity for science, policy, and practice to intersect and inform each other in meaningful ways – from bench to bedside – and hope this special issue helps further contribute to applicable and translational advances in health equity in the context of brain and mental health. Our further hope is that this special issue brings us closer to making considerable progress in providing culturally competent care.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

The authors reported there is no funding associated with the work featured in this article.