A scoping review to identify opportunities and challenges for communities of South Asian (SA) origin in accessing mental health services and support in high- income countries

A scoping review to identify opportunities and challenges for communities of South Asian (SA) origin in accessing mental health services and support in high- income countries | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A scoping review to identify opportunities and challenges for communities of South Asian (SA) origin in accessing mental health services and support in high- income countries Gayathri Menon, Haribondhu Sarma, Amy Bestman, Cathy O'Callaghan, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4798223/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Nov, 2025 Read the published version in BMC Public Health → Version 1 posted 12 You are reading this latest preprint version Abstract Introduction: Communities of South Asian (SA) origin in high-income countries experience the highest prevalence of mental health (MH) disorders amongst culturally and linguistically diverse (CALD) community groups. Emerging evidence highlights community experiences of socio-cultural and systemic challenges to MH care access; however, there is no comprehensive qualitative evidence regarding these opportunities and challenges. To address this knowledge gap, this review aimed at exploring the lived experiences of SA CALD communities through opportunities and challenges experienced in accessing MH care across four high-income nations (the United Kingdom, Australia, the United States, and Canada). Methods This scoping review followed reporting guidelines for scoping reviews outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A search was conducted to identify studies published in English between 2000- January 2023 in three electronic databases: PubMed, Web of Science, and Scopus. The search strategy included keywords related to SA CALD communities, MH and access to health care in four high-income countries. Extracted qualitative data were analysed using a thematic analysis approach. Results Analysis of the data from 25 eligible studies across all four high-income identified interlinked opportunities and challenges informing their ability to access MH care that supports their needs. Findings have been structured according to the five dimensions of accessibility of services ( 1 ) approachability, 2) acceptability, 3) availability and accommodation, 4) affordability, and 5) appropriateness). Our study identified myriad challenges faced by SA CALD communities in four high-income nations, including inflexible accessibility to diverse MH care, difficult family dynamics, stigma and acculturative issues hindering MH care usage and poor MH care experiences informing perceptions of MH care and re-engagement. Conclusion The research finds that access to MH care for CALD communities requires a comprehensive and nuanced framework that addresses population-specific factors. Recommendations include increasing cultural safety, facilitating flexible models of care and service delivery in practice alongside policy and funding reflective of systemic MH care access issues, and implementation research to assess the effectiveness of such recommendations. South Asian Mental health Opportunities and challenges Figures Figure 1 Figure 2 Figure 3 Introduction Mental health conditions (MH conditions) include mental, behavioural, or emotional disorders causing varied impairments through interlinked biological, psychological, social, environmental and economic factors ( 1 ). Global MH condition-associated disability-adjusted life-years (DALYs) rose from 80.8 million (1990) to 123.5 million (2019), with increasing proportions of total MH condition-associated DALYs ( 2 ). Mental health is a crucial health marker for culturally and linguistically diverse (CALD) populations who face unique acculturative stressors, challenges and experiences ( 3 – 5 ). The unique pre and post-migratory experiences of CALD population alongside socio-historical contexts, significantly shape the community and individual well-being and health ( 4 , 5 ). South Asian origin (Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka) CALD communities in high-income nations experience the highest MH condition prevalence amongst all CALD groups ( 6 , 7 ). Four high-income nations (defined by the Organisation for Economic Co-operation and Development) with considerable South Asian (SA) diasporas include Australia, the United Kingdom (UK), Canada and the United States (USA). SA CALD communities comprise heterogeneous demographics - different origin countries, socio-economic status, religion, cultural practices and beliefs, resulting in diverse migration cohorts and SA communities ( 8 – 11 ). Relative to non-SA Canadians, SA people experience the highest anxiety and mood disorder rates but are 85% less likely to seek treatment ( 12 – 14 ). Fifteen per cent of Indian-Australians report ‘high to very high’ psychological distress levels (comparable to the general population), with 72% accessing health care professionals (HCP) services and 9% seeking psychological consultations ( 15 ). Relative to white UK populations, Pakistani middle-aged men and Indian and Pakistani older-aged women reported higher anxiety and depression rates (age and socioeconomic status adjusted) ( 16 , 17 ). In their lifetime, 1 in 5 USA-residing SA people reported experiencing anxiety or mood disorders ( 18 ). Despite this higher MH condition prevalence, SA people seek mental health care (‘MH care’) less ( 6 ). Emerging evidence from high-income countries highlights SA-specific MH care access challenges due to external and internal stigma, culturally derived illness beliefs and limited accessibility to culturally appropriate resources and services ( 6 ). This is underpinned by adaptive and cultural challenges associated with socio-economic hardships, migration contexts (refugee, skilled migrant, migration cohorts), language and cultural differences, and challenges navigating different health systems ( 6 , 19 ). Despite efforts to deconstruct these barriers, accessing quality, reliable, easily navigable and culturally safe MH care remains challenging in high-income nations ( 19 ). This can also be attributed to the multi-faceted nature of accessibility not being reflected in current literature and models that describe accessibility as a linear and static concept. However, to allow for systematic change to increase accessibility, this must be reflected in the literature exploring the opportunities and challenges of MH care access. The need for this care is critical due to implications associated with decreased healthcare utilisation and greater relative chronic disease risk (for example, cancer, respiratory problems, cardiovascular disease and diabetes mellitus) of this cohort ( 19 – 21 ). Exploring intersectional and multidimensional SA community experiences is essential to bridge MH care gaps with strengths-based, person-centred and sustainable approaches that mobilise existing positive attributes and resources of the target population ( 21 – 23 ). To date, there has been limited primary and secondary evidence examining SA MH care access in high-income nations. Primary and secondary evidence exists examining SA MH care access in high-income nations (i.e. Canada and the UK); however, Australian studies often highlight particular communities (i.e. India or Pakistan), refugees or examine general health or healthcare access ( 4 , 6 , 13 , 24 – 28 ). To address this gap, this review examines the lived experiences of SA CALD communities accessing mental health care (MH care) across four high-income nations (UK, Australia, US, and Canada) through two interlinked research questions: What are the lived experiences and perceptions of SA CALD communities in four high-income nations with large SA diasporas in terms of accessing MH care? What are the key opportunities and challenges evident in the literature regarding accessing MH care amongst SA CALD communities in high-income nations? Methods This scoping review followed scoping review reporting guidelines and criteria set by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and The Joanna Briggs Institute's (JBI) (29,30). Database searches were conducted in English using different keyword combinations ( Table 1 ) in three electronic databases: Medline/PubMed , Scopus and Web of Science between January 2000 and January 2023. This review was guided by the Arksey & O'Malley, 2005 (31) five-stage framework (identification of research question, identification of relevant studies, selection of studies, data charting and summarisation and dissemination of results) (31). Operational definitions utilised are outlined in Table 2 Positionality: GM, HS, and senior author UNY are South Asian researchers with particular expertise in health systems and implementation science. AM and CO are researchers who have rich experience working with culturally diverse communities and priorities in an Australian setting. Search strategy Search terms pertained to seven key domains through combinations of keywords related to South Asian CALD communities, mental health, Levesque’s Conceptual Framework of Access to Healthcare, four high-income nations with large South Asian CALD communities (UK, Australia, USA and Canada) and qualitative studies – utilising Boolean operators including “OR” or “AND”, brackets and asterisks (32,33). These search terms were guided by the modified framework ( Figure 1 ), which recognises the multidimensional components of MH care access for SA CALD communities. Inclusion and exclusion criteria Table 3 outlines the inclusion and exclusion criteria for this review: it captures relevant qualitative research examining experiences and perceptions of SA CALD communities in four high-income countries of interest while excluding research irrelevant to the research questions. Study selection All research results identified from databases were exported to EndNote X9 (citation manager) and subsequently uploaded onto COVIDENCE. Two reviewers conducted title and abstract screening, with the guidance of automated duplicate removal via COVIDENCE. Subsequently, the reviewers selected relevant papers using inclusion and exclusion criteria. One reviewer independently assessed full-text articles that met inclusion criteria. Discrepancies were resolved through discussion to reach a consensus within the study team. Quality assessment and critical appraisal All included studies were subject to quality assessment and critical appraisal using the JBI Critical Appraisal Checklist for Qualitative Research , which utilises ten questions (which can be answered as yes, no, unclear or not applicable) to examine the possibility of bias in each study design, conduct or analysis (30). Data extraction and data synthesis The primary investigator conducted data extraction of all included studies (satisfying full-text analysis) from the abstract, introduction, results and discussion, through inductive thematic analysis, allowing charting and coding of findings relevant to the research questions (34). Data extraction was guided by two frameworks, the Conceptual Framework of Access to Healthcare by Levesque, Harris & Russell, 2013 (32) and the migrant trajectory perspective by Edberg, Cleary & Vyas, 2011 (35),(36). The Framework of Access to Healthcare defines accessibility through 5 dimensions: acceptability, availability/accommodation, affordability, appropriateness and approachability (32,33). These correspond to the population's ability to seek, perceive, reach, pay or engage with healthcare (32,33,35). The migrant trajectory perspective explores dynamic relationships between migrants and health services (29,31,32,35). Findings were charted in a spreadsheet and coded into broad iterative themes (34,37). Subsequent sub-group analysis further grouped findings and refined emerging themes (34,37). Deductive thematic analysis was utilised to code opportunities (internal or external facilitators) and challenges (internal or external barriers) to MH care access (34,37). Descriptive data (i.e., high-income countries, participant demographics) on each study was collected (Supplementary file 1) to provide a contextual understanding of the collected themes. Descriptive synthesis techniques, as per the JBI Reviewers manual, were utilised to synthesise and analyse collected data and extrapolate relationships and differences between different themes and sub-themes on opportunities and challenges to accessing MH care (38). Results A total of 2068 initial articles were identified from three databases, of which 54 duplicates were removed, and 1789 studies were title and abstract screened ( Figure 2 ). Of these, 178 were initially deemed eligible; however, 153 studies were excluded for not meeting the inclusion criteria. Finally, 25 qualitative studies (two from Australia, one from Canada, 16 from the UK, and six from the USA) were included in the final review ( Supplementary File 1) and critically appraised (Supplementary File 2 ). The following presents the qualitative analysis according to the dimensions of access to health care (32). Results have been structured according to the five dimensions of accessibility of services:1) approachability, 2) acceptability, 3) availability and accommodation, 4) affordability, and 5) appropriateness). These results have been summarised in Table 4 . Consistent with the work by Levesque and colleagues, this paper examines how each dimension interacts with the abilities of the individual to generate access (including examining how the dimensions of the health system side impact an individual’s ability to perceive, ability to seek, ability to reach, ability to pay, and ability to engage). Figure 3 presents challenges and opportunities for MH care access for SA CALD communities in selected high-income countries. Approachability To address healthcare needs, services must be approachable and ensure that people know that MH care services exist (32). Approachability is linked to factors such as health literacy and knowledge of health issues. This literature review found that perceptions of needs and desires for MH care are impeded by individual and service level stigma, compounded by the challenges of ethnically matching care. Cultural shame informed community expectations (i.e., upholding honour), limiting the social acceptability of MH care (39-41). However, the multi-layered nature of stigma for SA CALD communities creates complex experiences with MH and stigma. Conceptually, MH is stigmatised as an abnormal Western concept inapplicable to SA experiences, with SA people resonating more with issues like experiences of racism (42). The current literature review identified that SA people expected community and healthcare stakeholders to provide MH and MH care information; however, limited MH literacy and resources for SA community members created language challenges, non-representative health promotion and difficulties comprehending medical explanations, evoking isolation (40-48). Generational disparities in MH knowledge and skills/language to recognise MHD also created challenges within families (48). This increases apprehension towards MH care as individuals may desire ‘curative’ treatment, hold beliefs that stopping overthinking or resolving situational stressors will address MH or characterise help-seeking as a last resort (45,49,50). Improving MH literacy while deconstructing mistrust and stigma was raised as an opportunity. Effective strategies included tailored opportunities for psychoeducation, service diversification and feasible multi-agency collaborations with communities (40,43,47,51-53). Acceptability Acceptability refers to the cultural and social factors that impact on whether an individual accepts the service and the appropriateness to seeking care (32). Mental health stigma (including, personal, interpersonal and intergenerational) was evident across many studies, leading to shame, internalised discrimination, trivialisation of MH and denial (39-43,45-48,50,52,54-59). Fears of stigmatising experiences with healthcare professionals, exacerbated by overly clinical environments, encouraged MH care avoidance or pressure to distort relationships between culture and MH, to evade cultural stereotyping (41,60,61). This review found limited appropriate and safe MH care for SA CALD communities alongside sociocultural issues such as gender roles and unmet healthcare needs due to delayed presentation or MH care re-engagement. SA culture and stigma informed dominant MH beliefs, negative attitudes (questioning efficacy of socially stigmatised HCPs - psychiatrists), treatment acceptability (i.e. discordance with rigid care models like CBT even when ethnically-matched), poor MH self-acceptance and limits suitable alternatives (religious or cultural constraints) (43,44,47-49,54,56,58). Service-user shame and mistrust were prominent despite varied MH care initiation pathways (47). Seeking MH care with “outside people” was often avoided due to privacy concerns, potential isolation or subsequent MH care disengagement if information spread via community or non-medical staff (40,45,48,54,55). Non-culturally informed MH care deterred access as most SA services-users were assigned to white healthcare staff, creating difficulties in exploring cultural drivers of MH care (40,51). SA individuals described HCPs as paternalistic “god-like” decision-makers, due to their inaccessibility rooted in cultural unawareness, unresponsiveness/dismissiveness and untrustworthy nature, especially when from shared communities (40,43,48,50,54,56,57). However, services fostering privacy and safe disclosure, encouraged open patient-provider discussions (43,49,54). Additionally, health care professionals were dismissive of concerns about familial shame, lacking cultural training and withholding referrals even if patient-requested (40,47,48,58). Accessibility challenges included provider’s preconceived notions and limited research on CALD people causing pathologisation of cultural experiences, inflexible and untailored practice and limited recognition of MH-associated co-morbidities (i.e. eating disorder) resulting in poor self-acceptance of illnesses (44,47,48,50,58). These experiences foster mistrust and internalised stigma, compromise patient safety, amplify the burden on support networks and delay MH care (40,44,54,56,58) (40,44,54,56,58). SA service users felt expected to become “cultural experts” to assist healthcare staff, which was associated with cultural and language challenges (43,50,56,58). Improvements in SA and non-SA MH care were noted with culturally aware, safe and sensitive practices and patient-provider ethnic-matching (50). Despite shortages in SA healthcare staff, ethnocultural and gender matching was important (40,46-48,50). However, challenges such as confining MH to stereotypes without recognising individuality and concerns around privacy may result in a preference for non-culturally specific (or white) providers (40,46,51,57). Amongst SA CALD people, the perceived needs and desire for care are not solely confined to the individual experiencing MH issues; it can often be a projection of familial values and religious beliefs or reflect the collectivist SA culture (40-42,44,48). Gendered burdens of shame in SA culture were found to silence women, reinforce gender roles and obstruct access to MH, portrayed as women’s “shame” (39,40,48). In SA communities, males and parents may control women’s MH care by governing medical history, treatment and MH care re-engagement (39,44,54). This is especially relevant to SA marriage culture, which encourages hiding MH conditions (39,47,55). Despite women facing great concerns about interplays between culture, familial gender roles and identity, they were more likely to discuss MH compared to men who were confined by masculinity and ingrained fears of negative societal perceptions of weakness (44,50). Availability and accommodation Availability and accommodation are the ability of services to be physically reached in a timely manner (32). Challenges to reaching MH care included referral delays and culturally derived illness beliefs. For example, HCP referral delays caused delayed MH presentation until physical manifestations or acute crisis in vulnerable populations (i.e., older SA people) (41,47,48,50,52,54,58,62). Additionally, post-referral, some SA individuals disengaged due to MH care’s perceived futility (41,47,48,52,58,62). Other challenges in reaching MH care include limited quantity, quality, safety and continuity of care, limited transport and family/employment responsibilities (40-42,52,55,58,61). Health comorbidities (i.e. eating disorders or COVID-19) impacted MH, creating unique access challenges such as access-specific support (i.e. eating disorder resources or community MH initiatives during lockdowns) (59,61,63). At the individual level, overcoming MH care access challenges requires self-motivation when social network support was absent (not SA-specific), positive community role modelling of help-seeking, service-users time availability, easily accessible services or viewing MH care as self-improvement (40,43,45,58,61,64). At the service level, reaching MH care was supported by flexible, affordable, health insurance-eligible, local and multidisciplinary/coupled healthcare (40-43,52,55,58,61). Affordability The fourth dimension of accessibility relates to affordability, or the ability to spend resources and time to use services (32). Healthcare affordability impacted MH care accessibility, facilitating non-linear MH support pathways (32) Financial challenges include decreased female financial independence, prohibitive or restrictive fees and limited health insurance or perceiving MH care as unproductive investments (41,42,54,61). Additionally, post-referral, some SA individuals disengaged due to MH care’s perceived futility (41,47,48,52,58,62). There was evidence of some free MH services, telephone helplines and accessible accessory support (i.e., nutritionist in the context of ED) (40-42,52,55,58,61). Appropriateness The final dimension, appropriateness, refers to the fit between services and client needs; this also includes the opportunity to utilise quality services (32). Mental health care access involves the initial identification, utilisation and continuation of service usage; however, for SA CALD communities’ challenges include service-based racism and discrimination alongside the complexities of migration and acculturation. Dynamic acculturation experiences adversely shape MH and MH care access, creating interpersonal, intergenerational and cultural conflict (41,42). MH care devoid of systemic and institutional changes to diversify and prioritise intersectional and person-centred approaches, even when ethnic matching is unavailable, are viewed as tokenistic and paternalistic (47,51). MH care and support must reflect heterogenous SA experiences - particularly youth unable to access support existing in echo chambers of whiteness or lacking specific culturally informed resources addressing issues like racism (41,42,51). Amongst the youth, competing identities create conflicts whilst acculturating due to changing personal ethos (42,54,56). Older generations’ slower acculturation creates diverging generational paths, inducing acculturative family distancing (42,56). Therefore, challenging traditional family roles, endowing greater familial responsibility on youth and creating pressure to uphold culturally high standards of success (40,42,56). Longer host-nation settlement facilitated addressing stigma and cultivating positive outlooks on MH care; however, this was often impeded by resource limitations (41). MH care devoid of systemic and institutional changes to diversify and prioritise intersectional and person-centred approaches, even when ethnic matching is unavailable, are viewed as tokenistic and paternalistic (47,51). To overcome healthcare access, papers supported the use of innovative approaches that met the needs of the cohort, with a priority on using community members’ preferred languages to validate heterogenous SA experiences (47,48,50). Online sources (formal and informal) introducing MH care-related information were effective, particularly for youth, when resources were tailored (44,46). Early interventions and patient-centred narrative therapy over cognitive behavioural therapy in youth were found to divert MH care goals from symptom management to storytelling – sharing distress, fostering unity and reducing individual burden (44,54,58). This was particularly effective for SA women, where group therapy fostered social support (52). Other MH care opportunities included assessments of familial psychological mindedness and discussing sensitive topics (family, drug and sexual history) directly yet respectfully (52,54). However, it is important that the information utilised was not always factual, with pseudoscientific information (distributed by family on social media) deemed as ‘curing’ symptoms (48) Opportunities to strengthen desires for care were identified by utilising social networks (i.e. religious, friends and community), pastoral support (educational institutions) and family; by harnessing SA culture (i.e. utilising oral history to navigate MH) (39). Family can define expectations, form identities and core values, influence how MH is dealt with and help to facilitate help-seeking through open discussions about MH (48,49,56,57). Across generations, integrating spirituality and faith-based practices (i.e., guidance from spiritual leaders, places of worship and prayer) supports personal MH interventions, providing stress and anxiety reduction for youth (44,46,48,50,52). Peer support facilitates positive MH experiences for SA and host populations by encouraging open conversations in diverse social networks about experiences and symptoms (48,49). Despite concerns about negative social perceptions due to their MH, opportunities exist to utilise such relationships (46,49). Unlike host populations, SA people prioritised immediate kinship relationships in facilitating initial help-seeking with social networks acting as second-line support systems (45,56). However, MH care inaccessibility rendered individuals reliant on low-efficacy family and community support due to knowledge gaps (47). However, excessive family involvement in decision-making significantly delayed help-seeking through stigma and poor health system navigation (50). Clinician perspectives outlined beneficial outcomes associated with discussing different aspects of MH (i.e., medication and illness course), encouraging patient involvement with treatment decisions to enhance compliance and building rapport (54). However, strengthening positive MH care outcomes for patients requires the utilisation of opportunities to improve MH literacy while deconstructing mistrust and stigma surrounding MH care (40,43,47,51,52). The availability of services alone will not ensure that MH care needs are met for this target population; the dimensions of access must be consistently and adequately met in response to the dynamic effects of the external cultural environments and patient needs. This requires the removal of deficit-based approaches to MH care in SA communities. For example, measures such as using patient-preferred languages allow greater expression to validate heterogenous SA experiences by improving the approachability and appropriateness of MH care (47,48,50). Discussion This review is one of the first to comprehensively understand the opportunities and challenges to MH care access in Australia, Canada, the UK, and the USA experienced by SA CALD communities. This research identified limited CALD-specific MH care exists and recognises their needs and MH explanatory models alongside cultural and familial challenges of stigma, creating limited sustainable access. There are a range of challenges and opportunities unique to CALD populations that impact MH care access. For example, poor service feasibility (for service users and carers), service mistrust and cultures of delayed presentation affect accessibility ( 65 ). Addressing structural/socioeconomic inequalities is essential to bolstering access due to the negative MH effects, creating cycles of MH care mistrust via marginalisation and help-seeking regret ( 27 , 66 – 68 ). Communication and language issues (i.e., miscommunication and non-patient-centred) often exacerbated challenges ( 69 , 70 ). While interpreters assisted, sharing community could exacerbate mistrust, due to confidentiality issues, unprofessional behaviour or interference ( 69 , 70 ). Cultural constructions of perceived stigma and shame surrounding MH care access were rooted in traditional perceptions (i.e., interconnected mind, body and soul) influencing modern SA health perceptions. Interconnected mental and physical health may explain delaying presentations until physical symptoms occur (i.e. somatisation) ( 71 ). Furthermore, flexibly accessible (i.e., financial and physical) services create help-seeking opportunities when supported by positive individual and community characteristics. We recommend the expansion of holistic health (integrating social, physical and mental care) service delivery (i.e. Transcultural Mental Health Centres) to create large-scale MH care networks, founded in strength-based approaches and increased service approachability (i.e. coupled services and proactive community engagement) ( 72 – 74 ). This includes telehealth due to its discreteness and limited physical barriers while increasing access in rural/remote settings. However, negative experiences of service users and carers accessing culturally safe services demonstrate the need for carer support and CALD liaison officers, underpinned by frameworks (such as the modified framework introduced in this study) to recognise CALD MH care experiences and their family/community effects ( 72 – 77 ). This requires policymakers to prioritise CALD-specific systemic accessibility issues to facilitate suitable primary and secondary service delivery through policy and funding arrangements deconstructing socioeconomic and structural challenges as MH systems (i.e. in Australia) are constructed around physical illness ( 73 , 78 ). Diverse MH care and HCP cultural competency supports SA MH care needs and re-engagement ( 79 , 80 ). Eurocentric-based MH care aligns with Western values (efficiency, autonomy and self-sufficiency), while neglecting Eastern values (collective harmony, social integration and balance) ( 27 ). While some SA people resonate with Western models, SA-specific MH constructions often identify life experiences as causative agents ( 27 ). The existing systems’ rigidity disregards multidimensional explanatory models while stereotyping SA experiences ( 27 ). Despite well-reported discrepancies in SA communities’ MH and MH care literacy, remedies are often rooted in Eurocentricity and comparative to host populations’ MH conceptualisations ( 27 ). Greater financial investment into co-designed CALD components of medical curriculums is necessary to address the root causes of cultural dissonance and develop robust cultural safety skills ( 81 ). While increasing general health literacy benefits SA people, practitioners must prioritise the development of recovery-enhancing environments (shaped by individual beliefs, practices, and values) to recognise intersectional experiences. Greater financial investments in service coverage (i.e. universal health care-based programs such as increasing access to Mental Health Care Plans in Australia) are essential to incentivise MH care access with appropriate and responsive services ( 81 ). While ethnic-matching addresses patient-provider cultural incongruence, our study emphasises heterogeneous SA perspectives varying across contexts. Ziguras, Klimidis, Lewis & Stuart, 2003 ( 82 ) highlighted ethnic-matching benefits with case managers in Australian psychiatric services, facilitating reduced in-patient and crisis intervention and greater community service engagement. Involving ethno-culturally matched third-sector organisation-based peer-support workers with lived experiences fosters positive person-centred social identity ( 83 ). Therefore, allowing culturally-based connections provides sanctuary from discrimination when discussing culturally stigmatised topics like MH ( 27 ). However, cultural matching confines individuals ethnically, which may disregard explorations of intersectionality between other identities (i.e., gender, sexuality, faith) ( 27 , 83 ). Regardless of ethnic-matching, this review and current literature outlined strained and uncollaborative patient-provider relationships in MH care due to power imbalances, poor communication (i.e. not utilising interpreters) and HCPs independently adopting decision-making roles ( 27 ). Positive service-user or community MH care experiences alongside clinician-identified opportunities (MH literacy improvement and innovative multi-agency collaboration) facilitate help-seeking. MH care must stop pathologising SA culture through biological or recovery-based MH theories (diminishing SA experiences); while recognising their diverse needs and contextual issues (i.e., systemic racism) ( 27 , 84 ). Increasing willing service engagement requires downstream recognition of individual needs, culturally tailored MH care and culturally inclusive co-designed national standards (i.e. National Quality & Safety Standards in Healthcare) as core priorities with stipulated targets instead of additional measures ( 73 ). Heterogenous acculturative experiences create cumulative help-seeking challenges through navigating cultural dichotomies, gender roles and widespread stigma, reducing MH care access and creating alienation ( 85 , 86 ). Existing evidence reports struggles for immigrant students experiencing cultural and identity conflict while help-seeking. However, a similar study demonstrated increasing acculturations’ (English proficiency) association with greater stigma awareness, emotional openness difficulties and decreasing psychological distress, resulting in poorer help-seeking attitudes and MH care usage ( 79 , 87 ). Unique SA stigma challenges include internalisation and upholding model minority myths to support community success and personal value in high-income countries ( 88 ). Current literature explores community contributions to or alleviation of stigma, encouraging or hindering help-seeking ( 89 – 91 ). Individuals not experiencing familial stigma and positively viewing others with MH conditions who seek MH care; had greater opportunities for unreserved MH care access ( 43 , 56 ). While we highlighted gendered shame influencing stigma, societal ‘gendering’ of MH (i.e. eating disorders as feminine, antisocial personality disorders as masculine) may have contributed ( 92 ). Cumulative impacts of gendered stigma were echoed by CALD women accessing sexual and reproductive services, a culturally bound and sensitive health issue like MH ( 93 ). Flexible patient-centred care models must be implemented through mandatory cultural safety and cross-cultural HCP training. Despite the promotion of cultural responsiveness in strategic policy, limited research on its effectiveness exists for CALD populations signifying the need for population-specific implementational research, guided by frameworks such as The Framework for Mental Health in Multicultural Australia and policy targets ( 73 ). Re-defining stigma through proactive community engagement (advocacy, partnerships, health promotion or literacy), underpinned by exposure to positive perceptions of MH in high-income countries, is necessary to normalise MH care, recognise cultural dichotomies and incentivise help-seeking ( 43 , 48 , 58 ). Challenging family dynamics and relationships create access barriers, impacting individual MH experiences through cultural burdens of MH and stigma; however, both family and social networks maintain important supportive help-seeking roles. In collectivist SA cultures, robust family and non-family relationships provide support instead of healthcare or alongside MH programs, assist with coping mechanisms, protect sensitive MH conditions against stigma and strengthen help-seeking ( 3 , 94 – 96 ). Support can lower suicide rates, and depression symptoms and provide belonging while navigating isolating MH experiences and help-seeking ( 3 , 73 , 94 , 97 ). This mutually benefits the community due to the lingering effects of stigma and providing emotional support to others ( 73 , 96 ). We recommend service integration programs (family, community or religious-based) alongside MH care, supporting varied explanatory models, encouraging holistic help-seeking opportunities, reducing presentation delays and eliciting local socio-cultural contexts ( 27 , 73 , 96 , 98 ). Strengths and limitations Strengths of this study include i) the generation of comprehensive evidence extrapolating qualitative data on opportunities and challenges faced by SA people accessing MH care in high-income countries ii) the application of iterative theme-identification processes addressing SA community perspectives iii) all three investigators holding SA heritage, ensuring that findings consider community strengths and views iv) use of critical appraisal tools to assess the included studies’ quality. Review limitations included the search being restricted to three databases with inclusions of peer-reviewed articles published in English, limitations in keywords and publication bias due to omissions of published program reports, grey literature, and policy guidelines. As echoed by SA health literature, limited studies have emerged exploring the experiences of Bhutanese, Afghani, and Maldivian people. Furthermore, nuances of MH care (i.e., mood disorders vs psychiatric disorders) affecting MH care access could not be explored due to the scope of the review. Conclusion This review highlights MH care access opportunities and challenges constructed by the dynamic nature of accessibility, family and non-family communities, experiences and views of MH and MH care, acculturative processes and the complexities of identity. Across all four high-income countries, limited CALD-specific MH care exists and recognises their needs and MH explanatory models alongside cultural and familial challenges of stigma, creating limited sustainable access. Numerous opportunities exist for strength-based approaches capitalising on diverse SA experiences, non-medical models of MH and the importance of community and family. This highlights the need for implementation research where action must be required at the individual, family/community, HCP/MH care and policy/government levels to deliver culturally appropriate MH in high-income nations for SA CALD people who are left behind by the existing MH care system. Abbreviations SA South Asian MH care Mental health care HCP Health care provider CALD Culturally and linguistically diverse MHD Mental health disorder Declarations Ethics approval and consent to participate. Not applicable Consent for publication Not applicable Availability of data and materials All data generated and analysed during this study are included in this paper and appendix. Conflict of interest The authors declare no conflict of interest. UNY is an editorial board member of BMC Public Health. Funding: The study did not receive any funding. Author contributions GM, HS, and UNY conceptualized and designed the study. GM analysed the data and interpreted the findings. 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Keywords and search terms #1 Access (Access* OR “Acceptability” OR “availability” OR “accommodation” OR affordability OR appropriateness OR approachability) #2 Mental health (“mental health disorder*” OR “mental illness*” OR “mental health condition*” OR depress* OR “Anxiety”) #3 South Asia (Afghani* OR Bangladesh* OR Bhutan* OR India* OR Maldives OR Nepal* OR Pakistan* OR Sri Lanka* OR South Asia* OR SA OR Afghani migrant OR Bangladeshi migrant OR Bhutanese migrant OR Indian migrant OR Maldives migrant OR Nepali migrant OR Pakistani migrant OR Sri Lankan migrant OR South Asian migrant) #4 Lived experiences and perceptions (Experience* OR Enable* OR Perception* OR Attitude* OR View* OR Lived experience* OR Barrier* OR Facilitat* OR Challeng* OR Opportunit*) #5 Acceptable study design (qualitative OR Exploratory qualitative stud* OR Interview OR focus group OR ethnography OR mixed methods) #6 High-income nations ("Australia" OR "Canada" OR "United Kingdom" OR “UK” OR “United States of America” OR ”USA” OR “high income country” OR “high income nation” OR “high-income country” OR “high-income nation”) Table.2. Key operational definitions Definition Health care access The definition of access to health care is adopted from the definition outlined by Graetz, Rechel, Groot, Norredam & Pavlova, 2017 (32) , “the opportunity to reach and obtain appropriate health care services in situations of perceived need for care” . Mental health care Mental health care includes an array of diverse services and support at the primary and tertiary level Mental health disorder A disturbance in an individual’s emotional regulation, cognition and/or behaviour which is clinically significant (33) Mental health condition This encompasses the risk of self-harm, functional impairments, and disabilities that are psychosocial in nature alongside other mental states related to severe distress and mental health disorders (33) South Asia or South Asian The following eight nations, as per the South Asian Association for Regional Cooperation definition of SA: Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka (7) Table 3: Inclusion and exclusion criteria Inclusion criteria Qualitative data (in purely qualitative or mixed methods studies) Published in English Published between 1/1/2000 and 01/01/2023 Studies conducted in four high-income nations with large SA diasporas (UK, USA, Australia and Canada) Related to MH care access All ages and genders Specific to SA people (of all ages and regardless of migration) including individuals from one or more of the following eight nations as per the South Asian Association for Regional Cooperation definition of SA: Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka (7) Studies with single-heritage SA populations (only SA people) or multi-heritage studies (more than one ethnic group included in the study) Participants in these studies are individuals of all genders and ages who have Migrated from SA, of SA origin (regardless of cohort of migration) or self-identified SA background. Peer review Exclusion criteria Non-English studies Quantitative data, Publications including letters to the editors, reviews, commentaries, and editorials Studies irrelevant to the study population or did not highlight SA-specific information amongst other study populations Table 4: Overview of themes Theme Challenges Opportunities A pproachability Individual and service level stigma Cultural shame Limited MH literacy Limited in-language resources Improving MH literacy Deconstructing mistrust and stigma Tailored opportunities for psychoeducation, Service diversification Multi-agency collaborations with communities A cceptability Fears of stigmatising experiences with healthcare professionals Service-user shame and mistrust Lack of culturally appropriate explanatory models, models of care and cultural safety training affecting service accessibility Services fostering privacy and safe disclosure Culturally aware, safe and sensitive practices A vailability and a ccommodation Referral delays Post-referral disengagement Limited quantity, quality, safety and continuity of care, Limited transport Flexible, affordable, health insurance-eligible, Local MH care Multidisciplinary or coupled healthcare (addressing comorbidities) A ffordability Decreased female financial independence Prohibitive or restrictive fees Limited health insurance Perceiving MH care as unproductive investments Free MH services, telephone helplines and accessible accessory support A ppropriateness Service-based racism and discrimination Complexities of migration and acculturation Dynamic acculturation Systemic and institutional changes to diversify and prioritise intersectional and person-centred approaches Using community members’ preferred languages to validate heterogenous SA experiences Utilising social networks Improve MH literacy Removal of deficit based approaches to MH care in SA communities Additional Declarations No competing interests reported. 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Russell, 2013 (34)\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4798223/v1/4044072defeba5340c6d2322.png"},{"id":95564335,"identity":"7bffed8a-0b02-406c-b152-08ea858d4e46","added_by":"auto","created_at":"2025-11-10 16:09:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1741028,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4798223/v1/dba903c5-1b97-45dd-8ecc-29205ba2cec1.pdf"},{"id":61431439,"identity":"42765acb-a88e-4f8f-b19c-152546cd1beb","added_by":"auto","created_at":"2024-07-30 16:00:09","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":20667,"visible":true,"origin":"","legend":"","description":"","filename":"Table13.docx","url":"https://assets-eu.researchsquare.com/files/rs-4798223/v1/2f3197a63aa8400bba901d31.docx"},{"id":61431440,"identity":"f5aa1955-275f-4edd-ba9d-81bf675c067e","added_by":"auto","created_at":"2024-07-30 16:00:09","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":17863,"visible":true,"origin":"","legend":"","description":"","filename":"Table.4..docx","url":"https://assets-eu.researchsquare.com/files/rs-4798223/v1/964d0b6403a0239244c3ffd7.docx"},{"id":61430769,"identity":"0e63dd2e-81b4-42e6-ac06-fc9f81bdd8b5","added_by":"auto","created_at":"2024-07-30 15:52:09","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":61610,"visible":true,"origin":"","legend":"","description":"","filename":"supplementaryfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-4798223/v1/fbf1431083ef630d01f54e96.docx"},{"id":61430770,"identity":"ae2c634a-2637-4c54-9109-028a4b80a106","added_by":"auto","created_at":"2024-07-30 15:52:09","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":46163,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-4798223/v1/70388ceb04a586ba3df7eec5.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"A scoping review to identify opportunities and challenges for communities of South Asian (SA) origin in accessing mental health services and support in high- income countries","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMental health conditions (MH conditions) include mental, behavioural, or emotional disorders causing varied impairments through interlinked biological, psychological, social, environmental and economic factors (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Global MH condition-associated disability-adjusted life-years (DALYs) rose from 80.8\u0026nbsp;million (1990) to 123.5\u0026nbsp;million (2019), with increasing proportions of total MH condition-associated DALYs (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Mental health is a crucial health marker for culturally and linguistically diverse (CALD) populations who face unique acculturative stressors, challenges and experiences (\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe unique pre and post-migratory experiences of CALD population alongside socio-historical contexts, significantly shape the community and individual well-being and health (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). South Asian origin (Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka) CALD communities in high-income nations experience the highest MH condition prevalence amongst all CALD groups (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Four high-income nations (defined by the Organisation for Economic Co-operation and Development) with considerable South Asian (SA) diasporas include Australia, the United Kingdom (UK), Canada and the United States (USA). SA CALD communities comprise heterogeneous demographics - different origin countries, socio-economic status, religion, cultural practices and beliefs, resulting in diverse migration cohorts and SA communities (\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Relative to non-SA Canadians, SA people experience the highest anxiety and mood disorder rates but are 85% less likely to seek treatment (\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Fifteen per cent of Indian-Australians report \u0026lsquo;high to very high\u0026rsquo; psychological distress levels (comparable to the general population), with 72% accessing health care professionals (HCP) services and 9% seeking psychological consultations (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Relative to white UK populations, Pakistani middle-aged men and Indian and Pakistani older-aged women reported higher anxiety and depression rates (age and socioeconomic status adjusted) (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). In their lifetime, 1 in 5 USA-residing SA people reported experiencing anxiety or mood disorders (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite this higher MH condition prevalence, SA people seek mental health care (\u0026lsquo;MH care\u0026rsquo;) less (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Emerging evidence from high-income countries highlights SA-specific MH care access challenges due to external and internal stigma, culturally derived illness beliefs and limited accessibility to culturally appropriate resources and services (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). This is underpinned by adaptive and cultural challenges associated with socio-economic hardships, migration contexts (refugee, skilled migrant, migration cohorts), language and cultural differences, and challenges navigating different health systems (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Despite efforts to deconstruct these barriers, accessing quality, reliable, easily navigable and culturally safe MH care remains challenging in high-income nations (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). This can also be attributed to the multi-faceted nature of accessibility not being reflected in current literature and models that describe accessibility as a linear and static concept. However, to allow for systematic change to increase accessibility, this must be reflected in the literature exploring the opportunities and challenges of MH care access. The need for this care is critical due to implications associated with decreased healthcare utilisation and greater relative chronic disease risk (for example, cancer, respiratory problems, cardiovascular disease and diabetes mellitus) of this cohort (\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Exploring intersectional and multidimensional SA community experiences is essential to bridge MH care gaps with strengths-based, person-centred and sustainable approaches that mobilise existing positive attributes and resources of the target population (\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo date, there has been limited primary and secondary evidence examining SA MH care access in high-income nations. Primary and secondary evidence exists examining SA MH care access in high-income nations (i.e. Canada and the UK); however, Australian studies often highlight particular communities (i.e. India or Pakistan), refugees or examine general health or healthcare access (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan additionalcitationids=\"CR25 CR26 CR27\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). To address this gap, this review examines the lived experiences of SA CALD communities accessing mental health care (MH care) across four high-income nations (UK, Australia, US, and Canada) through two interlinked research questions:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eWhat are the lived experiences and perceptions of SA CALD communities in four high-income nations with large SA diasporas in terms of accessing MH care?\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eWhat are the key opportunities and challenges evident in the literature regarding accessing MH care amongst SA CALD communities in high-income nations?\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis scoping review followed scoping review reporting guidelines and criteria set by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and The Joanna Briggs Institute\u0026apos;s (JBI)\u0026nbsp;(29,30). Database searches were conducted in English using different keyword combinations (\u003cstrong\u003eTable 1\u003c/strong\u003e) in three electronic databases: Medline/PubMed\u003cem\u003e,\u003c/em\u003e Scopus and Web of Science between January 2000 and January 2023. This review was guided by the\u0026nbsp;Arksey \u0026amp; O\u0026apos;Malley, 2005 (31)\u0026nbsp;five-stage framework (identification of research question, identification of relevant studies, selection of studies, data charting and summarisation and dissemination of results)\u0026nbsp;(31). Operational definitions utilised are outlined in \u003cstrong\u003eTable 2\u003c/strong\u003e\u003c/p\u003e\n\u003ch3\u003e\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003ePositionality: GM, HS, and senior author UNY are South Asian researchers with particular expertise in health systems and implementation science. AM and CO are researchers who have rich experience working with culturally diverse communities and priorities in an Australian setting. \u003c/p\u003e\n\u003ch3\u003e\u0026nbsp;\u003c/h3\u003e\n\u003ch3\u003eSearch strategy\u003c/h3\u003e\n\u003cp\u003eSearch terms pertained to seven key domains through combinations of keywords related to South Asian CALD communities, mental health, Levesque\u0026rsquo;s Conceptual Framework of Access to Healthcare, four high-income nations with large South Asian CALD communities (UK, Australia, USA and Canada) and qualitative studies \u0026ndash; utilising Boolean operators including \u0026ldquo;OR\u0026rdquo; or \u0026ldquo;AND\u0026rdquo;, brackets and asterisks\u0026nbsp;(32,33). These search terms were guided by the modified framework (\u003cstrong\u003eFigure 1\u003c/strong\u003e), which recognises the multidimensional components of MH care access for SA CALD communities.\u003c/p\u003e\n\u003ch3\u003eInclusion and exclusion criteria\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e outlines the inclusion and exclusion criteria for this review: it captures relevant qualitative research examining experiences and perceptions of SA CALD communities in four high-income countries of interest while excluding research irrelevant to the research questions.\u003c/p\u003e\n\u003ch3\u003eStudy selection\u003c/h3\u003e\n\u003cp\u003eAll research results identified from databases were exported to EndNote X9 (citation manager) and subsequently uploaded onto COVIDENCE. Two reviewers conducted title and abstract screening, with the guidance of automated duplicate removal via COVIDENCE. Subsequently, the reviewers selected relevant papers using inclusion and exclusion criteria. One reviewer independently assessed full-text articles that met inclusion criteria. Discrepancies were resolved through discussion to reach a consensus within the study team.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eQuality assessment and critical appraisal\u003c/h3\u003e\n\u003cp\u003eAll included studies were subject to quality assessment and critical appraisal using the\u0026nbsp;\u003cem\u003eJBI Critical Appraisal Checklist for Qualitative Research\u003c/em\u003e,\u003cem\u003e\u0026nbsp;\u003c/em\u003ewhich utilises ten questions (which can be answered as yes, no, unclear or not applicable) to examine the possibility of bias in each study design, conduct or analysis\u0026nbsp;(30).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eData extraction and data synthesis\u003c/h3\u003e\n\u003cp\u003eThe primary investigator conducted data extraction of all included studies (satisfying full-text analysis) from the abstract, introduction, results and discussion, through inductive thematic analysis, allowing charting and coding of findings relevant to the research questions\u0026nbsp;(34). Data extraction was guided by two frameworks, \u003cem\u003ethe Conceptual Framework of Access to Healthcare by\u0026nbsp;\u003c/em\u003eLevesque, Harris \u0026amp; Russell, 2013 (32)\u0026nbsp;and the migrant\u0026nbsp;trajectory perspective by\u0026nbsp;Edberg, Cleary \u0026amp; Vyas, 2011 (35),(36). The\u0026nbsp;Framework of Access to Healthcare defines accessibility through 5 dimensions: acceptability, availability/accommodation, affordability, appropriateness and approachability\u0026nbsp;(32,33). These correspond to the population\u0026apos;s ability to seek, perceive, reach, pay or engage with healthcare\u0026nbsp;(32,33,35). The migrant trajectory perspective explores dynamic relationships between migrants and health services\u0026nbsp;(29,31,32,35).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFindings were charted in a spreadsheet and coded into broad iterative themes (34,37). Subsequent sub-group analysis further grouped findings and refined emerging themes (34,37). Deductive thematic analysis was utilised to code opportunities (internal or external facilitators) and challenges (internal or external barriers) to MH care access (34,37). Descriptive data (i.e., high-income countries, participant demographics) on each study was collected (Supplementary file 1) to provide a contextual understanding of the collected themes. \u0026nbsp;Descriptive synthesis techniques, as per the JBI Reviewers manual, were utilised to synthesise and analyse collected data and extrapolate relationships and differences between different themes and sub-themes on opportunities and challenges to accessing MH care (38).\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 2068 initial articles were identified from three databases, of which 54 duplicates were removed, and 1789 studies were title and abstract screened (\u003cstrong\u003eFigure 2\u003c/strong\u003e). Of these, 178 were initially deemed eligible; however, 153 studies were excluded for not meeting the inclusion criteria. Finally, 25 qualitative studies (two from Australia, one from Canada, 16 from the UK, and six from the USA) were included in the final review (\u003cstrong\u003eSupplementary File 1) and critically appraised (Supplementary File 2\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe following presents the qualitative analysis according to the dimensions of access to health care\u0026nbsp;(32). Results have been structured according to the five dimensions of accessibility of services:1) approachability, 2) acceptability, 3) availability and accommodation, 4) affordability, and 5) appropriateness). These results have been summarised in \u003cstrong\u003eTable 4\u003c/strong\u003e. Consistent with the work by Levesque and colleagues, this paper examines how each dimension interacts with the abilities of the individual to generate access (including examining how the dimensions of the health system side impact an individual\u0026rsquo;s ability to perceive, ability to seek, ability to reach, ability to pay, and ability to engage). Figure 3 presents challenges and opportunities for MH care access for SA CALD communities in selected high-income countries.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003col start=\"1\"\u003e\n \u003cli\u003e\n \u003ch3\u003eApproachability\u003c/h3\u003e\n \u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo address healthcare needs, services must be approachable and ensure that people know that MH care services exist\u0026nbsp;(32). Approachability is linked to factors such as health literacy and knowledge of health issues.\u0026nbsp;This literature review found that perceptions of needs and desires for MH care are impeded by individual and service level stigma, compounded by the challenges of ethnically matching care. Cultural shame informed community expectations (i.e., upholding honour), limiting the social acceptability of MH care\u0026nbsp;(39-41). However, the multi-layered nature of stigma for SA CALD communities creates complex experiences with MH and stigma. Conceptually, MH is stigmatised as an abnormal Western concept inapplicable to SA experiences, with SA people resonating more with issues like experiences of racism\u0026nbsp;(42).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe current literature review identified that SA people expected community and healthcare stakeholders to provide MH and MH care information; however, limited MH literacy and resources for SA community members created language challenges, non-representative health promotion and difficulties comprehending medical explanations, evoking isolation\u0026nbsp;(40-48). Generational disparities in MH knowledge and skills/language to recognise MHD also created challenges within families\u0026nbsp;(48). This increases apprehension towards MH care as individuals may desire \u0026lsquo;curative\u0026rsquo; treatment, hold beliefs that stopping overthinking or resolving situational stressors will address MH or characterise help-seeking as a last resort\u0026nbsp;(45,49,50). Improving MH literacy while deconstructing mistrust and stigma was raised as an opportunity. Effective strategies included tailored opportunities for psychoeducation, service diversification and feasible multi-agency collaborations with communities\u0026nbsp;(40,43,47,51-53).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003col start=\"2\"\u003e\n \u003cli\u003e\n \u003ch3\u003eAcceptability\u0026nbsp;\u003c/h3\u003e\n \u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAcceptability refers to the cultural and social factors that impact on whether an individual accepts the service and the appropriateness to seeking care\u0026nbsp;(32). Mental health stigma (including, personal, interpersonal and intergenerational) was evident across many studies, leading to shame, internalised discrimination, trivialisation of MH and denial\u0026nbsp;(39-43,45-48,50,52,54-59).\u0026nbsp;\u0026nbsp;Fears of stigmatising experiences with healthcare professionals, exacerbated by overly clinical environments, encouraged MH care avoidance or pressure to distort relationships between culture and MH, to evade cultural stereotyping\u0026nbsp;(41,60,61).\u0026nbsp;This review found limited appropriate and safe MH care for\u0026nbsp;SA CALD communities alongside sociocultural issues such as gender roles and unmet healthcare needs due to delayed presentation or MH care re-engagement. SA culture and stigma informed dominant MH beliefs, negative attitudes (questioning efficacy of socially stigmatised HCPs - psychiatrists), treatment acceptability (i.e. discordance with rigid care models like CBT even when ethnically-matched), poor MH self-acceptance and limits suitable alternatives (religious or cultural constraints)\u0026nbsp;(43,44,47-49,54,56,58).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eService-user shame and mistrust were prominent despite varied MH care initiation pathways\u0026nbsp;(47). Seeking MH care with \u0026ldquo;outside people\u0026rdquo; was often avoided due to privacy concerns, potential isolation or subsequent MH care disengagement if information spread via community or non-medical staff\u0026nbsp;(40,45,48,54,55). Non-culturally informed MH care deterred access as most SA services-users were assigned to white healthcare staff, creating difficulties in exploring cultural drivers of MH care\u0026nbsp;(40,51).\u0026nbsp;SA individuals described HCPs as paternalistic \u0026ldquo;god-like\u0026rdquo; decision-makers, due to their inaccessibility rooted in cultural unawareness, unresponsiveness/dismissiveness and untrustworthy nature, especially when from shared communities\u0026nbsp;(40,43,48,50,54,56,57). However, services fostering privacy and safe disclosure, encouraged open patient-provider discussions\u0026nbsp;(43,49,54).\u0026nbsp;Additionally, health care professionals were dismissive of concerns about familial shame, lacking cultural training and withholding referrals even if patient-requested\u0026nbsp;(40,47,48,58).\u0026nbsp;Accessibility challenges included provider\u0026rsquo;s preconceived notions and limited research on CALD people causing pathologisation of cultural experiences, inflexible and untailored practice and limited recognition of MH-associated co-morbidities (i.e. eating disorder) resulting in poor self-acceptance of illnesses\u0026nbsp;(44,47,48,50,58).\u0026nbsp;These experiences foster mistrust and internalised stigma, compromise patient safety, amplify the burden on support networks and delay MH care\u0026nbsp;(40,44,54,56,58)\u0026nbsp;(40,44,54,56,58). SA service users felt expected to become \u0026ldquo;cultural experts\u0026rdquo; to assist healthcare staff, which was associated with cultural and language challenges\u0026nbsp;(43,50,56,58). Improvements in SA and non-SA MH care were noted with culturally aware, safe and sensitive practices \u0026nbsp;and patient-provider ethnic-matching\u0026nbsp;(50). Despite shortages in SA healthcare staff, ethnocultural and gender matching was important\u0026nbsp;(40,46-48,50). However, challenges such as confining MH to stereotypes without recognising individuality and concerns around privacy may result in a preference for non-culturally specific (or white) providers\u0026nbsp;(40,46,51,57).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmongst SA CALD people, the perceived needs and desire for care are not solely confined to the individual experiencing MH issues; it can often be a projection of familial values and religious beliefs or reflect the collectivist SA culture\u0026nbsp;(40-42,44,48). Gendered burdens of shame in SA culture were found to silence women, reinforce gender roles and obstruct access to MH, portrayed as women\u0026rsquo;s \u0026ldquo;shame\u0026rdquo;\u0026nbsp;(39,40,48). In SA communities, males and parents may control women\u0026rsquo;s MH care by governing medical history, treatment and MH care re-engagement\u0026nbsp;(39,44,54). This is especially relevant to SA marriage culture, which encourages hiding MH conditions\u0026nbsp;(39,47,55). \u0026nbsp;Despite women facing great concerns about interplays between culture, familial gender roles and identity, they were more likely to discuss MH compared to men who were confined by masculinity and ingrained fears of negative societal perceptions of weakness\u0026nbsp;(44,50).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003col start=\"3\"\u003e\n \u003cli\u003e\n \u003ch3\u003eAvailability and accommodation\u0026nbsp;\u003c/h3\u003e\n \u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eAvailability and accommodation are the ability of services to be physically reached in a timely manner\u0026nbsp;(32).\u0026nbsp;Challenges to reaching MH care included referral delays and culturally derived illness beliefs. For example, HCP\u0026nbsp;referral delays caused delayed MH presentation until physical manifestations or acute crisis in vulnerable populations (i.e., older SA people)\u0026nbsp;(41,47,48,50,52,54,58,62). Additionally,\u0026nbsp;post-referral, some SA individuals disengaged due to MH care\u0026rsquo;s perceived futility\u0026nbsp;(41,47,48,52,58,62).\u0026nbsp;Other challenges in reaching MH care include limited quantity, quality, safety and continuity of care, limited transport and family/employment responsibilities\u0026nbsp;(40-42,52,55,58,61). Health comorbidities (i.e. eating disorders or COVID-19) impacted MH, creating unique access challenges such as access-specific support (i.e. eating disorder resources or community MH initiatives during lockdowns)\u0026nbsp;(59,61,63). At the individual level, overcoming MH care access challenges requires self-motivation when social network support was absent (not SA-specific), positive community role modelling of help-seeking, service-users time availability, easily accessible services or viewing MH care as self-improvement\u0026nbsp;(40,43,45,58,61,64). At the service level, reaching MH care was supported by flexible, affordable, health insurance-eligible, local and multidisciplinary/coupled healthcare\u0026nbsp;(40-43,52,55,58,61).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003col start=\"4\"\u003e\n \u003cli\u003e\n \u003ch3\u003eAffordability\u003c/h3\u003e\n \u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe fourth dimension of accessibility relates to affordability, or the ability to spend resources and time to use services\u0026nbsp;(32). Healthcare affordability impacted MH care accessibility, facilitating non-linear MH support pathways\u0026nbsp;(32)\u0026nbsp;Financial challenges include decreased female financial independence, prohibitive or restrictive fees and limited health insurance or perceiving MH care as unproductive investments\u0026nbsp;(41,42,54,61). Additionally,\u0026nbsp;post-referral, some SA individuals disengaged due to MH care\u0026rsquo;s perceived futility\u0026nbsp;(41,47,48,52,58,62).\u0026nbsp;There was evidence of some free MH services, telephone helplines and accessible accessory support (i.e., nutritionist in the context of ED)\u0026nbsp;(40-42,52,55,58,61).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003col start=\"5\"\u003e\n \u003cli\u003e\n \u003ch3\u003eAppropriateness\u0026nbsp;\u003c/h3\u003e\n \u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe final dimension, appropriateness, refers to the fit between services and client needs; this also includes the opportunity to utilise quality services\u0026nbsp;(32). Mental\u0026nbsp;health care access involves the initial identification, utilisation and continuation of service usage; however, for SA CALD communities\u0026rsquo; challenges include service-based racism and discrimination alongside the complexities of migration and acculturation. \u0026nbsp;Dynamic acculturation experiences adversely shape MH and MH care access, creating interpersonal, intergenerational and cultural conflict\u0026nbsp;(41,42).\u0026nbsp;MH care devoid of systemic and institutional changes to diversify and prioritise intersectional and person-centred approaches, even when ethnic matching is unavailable, are viewed as tokenistic and paternalistic\u0026nbsp;(47,51).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMH care and support must reflect heterogenous SA experiences - particularly youth unable to access support existing in echo chambers of whiteness or lacking specific culturally informed resources addressing issues like racism\u0026nbsp;(41,42,51). Amongst the youth, competing identities create conflicts whilst acculturating due to changing personal ethos\u0026nbsp;(42,54,56). Older generations\u0026rsquo; slower acculturation creates diverging generational paths, inducing acculturative family distancing\u0026nbsp;(42,56). Therefore, challenging traditional family roles, endowing greater familial responsibility on youth and creating pressure to uphold culturally high standards of success\u0026nbsp;(40,42,56). Longer host-nation settlement facilitated addressing stigma and cultivating positive outlooks on MH care; however, this was often impeded by resource limitations\u0026nbsp;(41). MH care devoid of systemic and institutional changes to diversify and prioritise intersectional and person-centred approaches, even when ethnic matching is unavailable, are viewed as tokenistic and paternalistic\u0026nbsp;(47,51).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo overcome healthcare access, papers supported the use of innovative approaches that met the needs of the cohort, with a priority on using community members\u0026rsquo; preferred languages to validate heterogenous SA experiences\u0026nbsp;(47,48,50). Online sources (formal and informal) introducing MH care-related information were effective, particularly for youth, when resources were tailored\u0026nbsp;(44,46). Early interventions and patient-centred narrative therapy over cognitive behavioural therapy in youth were found to divert MH care goals from symptom management to storytelling \u0026ndash; sharing distress, fostering unity and reducing individual burden\u0026nbsp;(44,54,58). This was particularly effective for SA women, where group therapy fostered social support\u0026nbsp;(52). Other MH care opportunities included assessments of familial psychological mindedness and discussing sensitive topics (family, drug and sexual history) directly yet respectfully\u0026nbsp;(52,54). However, it is important that the information utilised was not always factual, with pseudoscientific information (distributed by family on social media) deemed as \u0026lsquo;curing\u0026rsquo; symptoms\u0026nbsp;(48)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOpportunities to strengthen desires for care were identified by utilising social networks (i.e. religious, friends and community), pastoral support (educational institutions) and family; by harnessing SA culture (i.e. utilising oral history to navigate MH)\u0026nbsp;(39). Family can define expectations, form identities and core values, influence how MH is dealt with and help to facilitate help-seeking through open discussions about MH\u0026nbsp;(48,49,56,57). Across generations, integrating spirituality and faith-based practices (i.e., guidance from spiritual leaders, places of worship and prayer) supports personal MH interventions, providing stress and anxiety reduction for youth\u0026nbsp;(44,46,48,50,52). Peer support facilitates positive MH experiences for SA and host populations by encouraging open conversations in diverse social networks about experiences and symptoms\u0026nbsp;(48,49). Despite concerns about negative social perceptions due to their MH, opportunities exist to utilise such relationships\u0026nbsp;(46,49). Unlike host populations, SA people prioritised immediate kinship relationships in facilitating initial help-seeking with social networks acting as second-line support systems\u0026nbsp;(45,56). However, MH care inaccessibility rendered individuals reliant on low-efficacy family and community support due to knowledge gaps\u0026nbsp;(47). However, excessive family involvement in decision-making significantly delayed help-seeking through stigma and poor health system navigation\u0026nbsp;(50).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eClinician perspectives outlined beneficial outcomes associated with discussing different aspects of MH (i.e., medication and illness course), encouraging patient involvement with treatment decisions to enhance compliance and building rapport (54). However, strengthening positive MH care outcomes for patients requires the utilisation of opportunities to improve MH literacy while deconstructing mistrust and stigma surrounding MH care (40,43,47,51,52). The availability of services alone will not ensure that MH care needs are met for this target population; the dimensions of access must be consistently and adequately met in response to the dynamic effects of the external cultural environments and patient needs. This requires the removal of deficit-based approaches to MH care in SA communities. For example, measures such as using patient-preferred languages allow greater expression to validate heterogenous SA experiences by improving the approachability and appropriateness of MH care (47,48,50).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis review is one of the first to comprehensively understand the opportunities and challenges to MH care access in Australia, Canada, the UK, and the USA experienced by SA CALD communities. This research identified limited CALD-specific MH care exists and recognises their needs and MH explanatory models alongside cultural and familial challenges of stigma, creating limited sustainable access.\u003c/p\u003e \u003cp\u003eThere are a range of challenges and opportunities unique to CALD populations that impact MH care access. For example, poor service feasibility (for service users and carers), service mistrust and cultures of delayed presentation affect accessibility (\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e). Addressing structural/socioeconomic inequalities is essential to bolstering access due to the negative MH effects, creating cycles of MH care mistrust via marginalisation and help-seeking regret (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan additionalcitationids=\"CR67\" citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e). Communication and language issues (i.e., miscommunication and non-patient-centred) often exacerbated challenges (\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e). While interpreters assisted, sharing community could exacerbate mistrust, due to confidentiality issues, unprofessional behaviour or interference (\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e). Cultural constructions of perceived stigma and shame surrounding MH care access were rooted in traditional perceptions (i.e., interconnected mind, body and soul) influencing modern SA health perceptions. Interconnected mental and physical health may explain delaying presentations until physical symptoms occur (i.e. somatisation) (\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e). Furthermore, flexibly accessible (i.e., financial and physical) services create help-seeking opportunities when supported by positive individual and community characteristics. We recommend the expansion of holistic health (integrating social, physical and mental care) service delivery (i.e. Transcultural Mental Health Centres) to create large-scale MH care networks, founded in strength-based approaches and increased service approachability (i.e. coupled services and proactive community engagement) (\u003cspan additionalcitationids=\"CR73\" citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e). This includes telehealth due to its discreteness and limited physical barriers while increasing access in rural/remote settings. However, negative experiences of service users and carers accessing culturally safe services demonstrate the need for carer support and CALD liaison officers, underpinned by frameworks (such as the modified framework introduced in this study) to recognise CALD MH care experiences and their family/community effects (\u003cspan additionalcitationids=\"CR73 CR74 CR75 CR76\" citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e). This requires policymakers to prioritise CALD-specific systemic accessibility issues to facilitate suitable primary and secondary service delivery through policy and funding arrangements deconstructing socioeconomic and structural challenges as MH systems (i.e. in Australia) are constructed around physical illness (\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDiverse MH care and HCP cultural competency supports SA MH care needs and re-engagement (\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e, \u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e). Eurocentric-based MH care aligns with Western values (efficiency, autonomy and self-sufficiency), while neglecting Eastern values (collective harmony, social integration and balance) (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). While some SA people resonate with Western models, SA-specific MH constructions often identify life experiences as causative agents (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). The existing systems\u0026rsquo; rigidity disregards multidimensional explanatory models while stereotyping SA experiences (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Despite well-reported discrepancies in SA communities\u0026rsquo; MH and MH care literacy, remedies are often rooted in Eurocentricity and comparative to host populations\u0026rsquo; MH conceptualisations (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Greater financial investment into co-designed CALD components of medical curriculums is necessary to address the root causes of cultural dissonance and develop robust cultural safety skills (\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e). While increasing general health literacy benefits SA people, practitioners must prioritise the development of recovery-enhancing environments (shaped by individual beliefs, practices, and values) to recognise intersectional experiences. Greater financial investments in service coverage (i.e. universal health care-based programs such as increasing access to Mental Health Care Plans in Australia) are essential to incentivise MH care access with appropriate and responsive services (\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhile ethnic-matching addresses patient-provider cultural incongruence, our study emphasises heterogeneous SA perspectives varying across contexts. Ziguras, Klimidis, Lewis \u0026amp; Stuart, 2003 (\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e) highlighted ethnic-matching benefits with case managers in Australian psychiatric services, facilitating reduced in-patient and crisis intervention and greater community service engagement. Involving ethno-culturally matched third-sector organisation-based peer-support workers with lived experiences fosters positive person-centred social identity (\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e). Therefore, allowing culturally-based connections provides sanctuary from discrimination when discussing culturally stigmatised topics like MH (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). However, cultural matching confines individuals ethnically, which may disregard explorations of intersectionality between other identities (i.e., gender, sexuality, faith) (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e). Regardless of ethnic-matching, this review and current literature outlined strained and uncollaborative patient-provider relationships in MH care due to power imbalances, poor communication (i.e. not utilising interpreters) and HCPs independently adopting decision-making roles (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Positive service-user or community MH care experiences alongside clinician-identified opportunities (MH literacy improvement and innovative multi-agency collaboration) facilitate help-seeking. MH care must stop pathologising SA culture through biological or recovery-based MH theories (diminishing SA experiences); while recognising their diverse needs and contextual issues (i.e., systemic racism) (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e). Increasing willing service engagement requires downstream recognition of individual needs, culturally tailored MH care and culturally inclusive co-designed national standards (i.e. National Quality \u0026amp; Safety Standards in Healthcare) as core priorities with stipulated targets instead of additional measures (\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHeterogenous acculturative experiences create cumulative help-seeking challenges through navigating cultural dichotomies, gender roles and widespread stigma, reducing MH care access and creating alienation (\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e, \u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e). Existing evidence reports struggles for immigrant students experiencing cultural and identity conflict while help-seeking. However, a similar study demonstrated increasing acculturations\u0026rsquo; (English proficiency) association with greater stigma awareness, emotional openness difficulties and decreasing psychological distress, resulting in poorer help-seeking attitudes and MH care usage (\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e, \u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e). Unique SA stigma challenges include internalisation and upholding model minority myths to support community success and personal value in high-income countries (\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e). Current literature explores community contributions to or alleviation of stigma, encouraging or hindering help-seeking (\u003cspan additionalcitationids=\"CR90\" citationid=\"CR89\" class=\"CitationRef\"\u003e89\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e). Individuals not experiencing familial stigma and positively viewing others with MH conditions who seek MH care; had greater opportunities for unreserved MH care access (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e). While we highlighted gendered shame influencing stigma, societal \u0026lsquo;gendering\u0026rsquo; of MH (i.e. eating disorders as feminine, antisocial personality disorders as masculine) may have contributed (\u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e). Cumulative impacts of gendered stigma were echoed by CALD women accessing sexual and reproductive services, a culturally bound and sensitive health issue like MH (\u003cspan citationid=\"CR93\" class=\"CitationRef\"\u003e93\u003c/span\u003e). Flexible patient-centred care models must be implemented through mandatory cultural safety and cross-cultural HCP training. Despite the promotion of cultural responsiveness in strategic policy, limited research on its effectiveness exists for CALD populations signifying the need for population-specific implementational research, guided by frameworks such as \u003cem\u003eThe Framework for Mental Health in Multicultural Australia\u003c/em\u003e and policy targets (\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e). Re-defining stigma through proactive community engagement (advocacy, partnerships, health promotion or literacy), underpinned by exposure to positive perceptions of MH in high-income countries, is necessary to normalise MH care, recognise cultural dichotomies and incentivise help-seeking (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eChallenging family dynamics and relationships create access barriers, impacting individual MH experiences through cultural burdens of MH and stigma; however, both family and social networks maintain important supportive help-seeking roles. In collectivist SA cultures, robust family and non-family relationships provide support instead of healthcare or alongside MH programs, assist with coping mechanisms, protect sensitive MH conditions against stigma and strengthen help-seeking (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR95\" citationid=\"CR94\" class=\"CitationRef\"\u003e94\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR96\" class=\"CitationRef\"\u003e96\u003c/span\u003e). Support can lower suicide rates, and depression symptoms and provide belonging while navigating isolating MH experiences and help-seeking (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan citationid=\"CR94\" class=\"CitationRef\"\u003e94\u003c/span\u003e, \u003cspan citationid=\"CR97\" class=\"CitationRef\"\u003e97\u003c/span\u003e). This mutually benefits the community due to the lingering effects of stigma and providing emotional support to others (\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan citationid=\"CR96\" class=\"CitationRef\"\u003e96\u003c/span\u003e). We recommend service integration programs (family, community or religious-based) alongside MH care, supporting varied explanatory models, encouraging holistic help-seeking opportunities, reducing presentation delays and eliciting local socio-cultural contexts (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan citationid=\"CR96\" class=\"CitationRef\"\u003e96\u003c/span\u003e, \u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e98\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eStrengths of this study include i) the generation of comprehensive evidence extrapolating qualitative data on opportunities and challenges faced by SA people accessing MH care in high-income countries ii) the application of iterative theme-identification processes addressing SA community perspectives iii) all three investigators holding SA heritage, ensuring that findings consider community strengths and views iv) use of critical appraisal tools to assess the included studies\u0026rsquo; quality. Review limitations included the search being restricted to three databases with inclusions of peer-reviewed articles published in English, limitations in keywords and publication bias due to omissions of published program reports, grey literature, and policy guidelines. As echoed by SA health literature, limited studies have emerged exploring the experiences of Bhutanese, Afghani, and Maldivian people. Furthermore, nuances of MH care (i.e., mood disorders vs psychiatric disorders) affecting MH care access could not be explored due to the scope of the review.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis review highlights MH care access opportunities and challenges constructed by the dynamic nature of accessibility, family and non-family communities, experiences and views of MH and MH care, acculturative processes and the complexities of identity. Across all four high-income countries, limited CALD-specific MH care exists and recognises their needs and MH explanatory models alongside cultural and familial challenges of stigma, creating limited sustainable access. Numerous opportunities exist for strength-based approaches capitalising on diverse SA experiences, non-medical models of MH and the importance of community and family. This highlights the need for implementation research where action must be required at the individual, family/community, HCP/MH care and policy/government levels to deliver culturally appropriate MH in high-income nations for SA CALD people who are left behind by the existing MH care system.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSA\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSouth Asian\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eMH care\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMental health care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eHCP\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealth care provider\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCALD\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCulturally and linguistically diverse\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eMHD\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMental health disorder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated and analysed during this study are included in this paper and appendix.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interest.\u0026nbsp;UNY is an editorial board member of BMC Public Health.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThe study did not receive any funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGM, HS, and UNY conceptualized and designed the study. GM analysed the data and interpreted the findings. GM was responsible for writing the first draft of the paper. AB, UNY and CO provided significant scientific input to improve the quality of the manuscript. All the authors made critical revisions and approved the final version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003cp\u003e1.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Manderscheid RW, Ryff CD, Freeman EJ, McKnight-Eily LR, Dhingra S, Strine TW. Evolving definitions of mental illness and wellness. Prev Chronic Dis. 2010;7(1):A19.\u003c/p\u003e\n\u003cp\u003e2.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;GBD 2019 Mental Disorders Collaborators. Global, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. 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PLOS ONE. 2023;18(6).\u003c/p\u003e\n\u003cp\u003e80.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Rogers-Sirin L, Melendez F, Refano C, Zegarra Y. Immigrant perceptions of therapists\u0026rsquo; cultural competence: A qualitative investigation. Prof Psychol Res Pr. 2015;46(4):258-69.\u003c/p\u003e\n\u003cp\u003e81.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Khatri RB, Assefa Y. Access to health services among culturally and linguistically diverse populations in the Australian universal health care system: issues and challenges. BMC Public Health. 2022;22(1):880.\u003c/p\u003e\n\u003cp\u003e82.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Ziguras S, Klimidis S, Lewis J, Stuart G. Ethnic Matching of Clients and Clinicians and Use of Mental Health Services by Ethnic Minority Clients. Psychiatr Serv. 2003;54(4):535-41.\u003c/p\u003e\n\u003cp\u003e83.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Bains K, Bicknell S, Jovanović N, Conneely M, McCabe R, Copello A, et al. Healthcare professionals\u0026rsquo; views on the accessibility and acceptability of perinatal mental health services for South Asian and Black women: a qualitative study. BMC Medicine. 2023;21(1):370.\u003c/p\u003e\n\u003cp\u003e84.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Fernando S, Keating F. Mental Health in a Multi-Ethnic Society : A Multidisciplinary Handbook. London, UNITED KINGDOM: Taylor \u0026amp; Francis Group; 2008.\u003c/p\u003e\n\u003cp\u003e85.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Place V, Nabb B, Gubi E, Assel K, \u0026Aring;hl\u0026eacute;n J, Hagstr\u0026ouml;m A, et al. Perceived barriers to care for migrant children and young people with mental health problems and/or neurodevelopmental differences in high-income countries: a meta-ethnography. BMJ Open. 2021;11(9).\u003c/p\u003e\n\u003cp\u003e86.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Kapadia D, Brooks HL, Nazroo J, Tranmer M. Pakistani women\u0026apos;s use of mental health services and the role of social networks: a systematic review of quantitative and qualitative research. Health Soc Care Community. 2017;25(4):1304-17.\u003c/p\u003e\n\u003cp\u003e87.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Meyer CJ. Help seeking attitudes and behaviors of international students at architectural schools [Psy.D.]. United States -- Massachusetts: Massachusetts School of Professional Psychology; 2009.\u003c/p\u003e\n\u003cp\u003e88.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Tummala-Narra P, Deshpande A, Kaur J. South Asian adolescents\u0026rsquo; experiences of acculturative stress and coping. Am J Orthopsychiatry. 2016;86(2):194-211.\u003c/p\u003e\n\u003cp\u003e89.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Sherbourne CD. The role of social support and life stress events in use of mental health services. Soc Sci Med. 1988;27(12):1393-400.\u003c/p\u003e\n\u003cp\u003e90.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Maulik PK, Eaton WW, Bradshaw CP. The role of social network and support in mental health service use: findings from the Baltimore ECA study. Psychiatr Serv. 2009;60(9):1222-9.\u003c/p\u003e\n\u003cp\u003e91.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Vera M, Alegr\u0026iacute;a M, Freeman DH, Jr., Robles R, Pescosolido B, Pe\u0026ntilde;a M. Help seeking for mental health care among poor Puerto Ricans: problem recognition, service use, and type of provider. Med Care. 1998;36(7):1047-56.\u003c/p\u003e\n\u003cp\u003e92.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Stangl AL, Earnshaw VA, Logie CH, van Brakel W, C. Simbayi L, Barr\u0026eacute; I, Dovidio JF. The Health Stigma and Discrimination Framework: a global, crosscutting framework to inform research, intervention development, and policy on health-related stigmas. BMC Medicine. 2019;17(1):31.\u003c/p\u003e\n\u003cp\u003e93.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Mengesha ZB, Dune T, Perz J. Culturally and linguistically diverse women\u0026rsquo;s views and experiences of accessing sexual and reproductive health care in Australia: a systematic review. Sex Health. 2016;13(4):299.\u003c/p\u003e\n\u003cp\u003e94.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Doma H, Tran T, Rioseco P, Fisher J. Understanding the relationship between social support and mental health of humanitarian migrants resettled in Australia. BMC Public Health. 2022;22(1):1739.\u003c/p\u003e\n\u003cp\u003e95.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Baker AEZ, Procter NG, Ferguson MS. Engaging with culturally and linguistically diverse communities to reduce the impact of depression and anxiety: a narrative review. Health Soc Care Community. 2016;24(4):386-98.\u003c/p\u003e\n\u003cp\u003e96.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Gorman D, Brough M, Ramirez E. How young people from culturally and linguistically diverse backgrounds experience mental health: Some insights for mental health nurses. Int J Ment Health Nurs. 2003;12(3):194-202.\u003c/p\u003e\n\u003cp\u003e97.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Gonz\u0026aacute;lez-Prendes AA, Hindo C, Pardo Y. Cultural values integration in cognitive-behavioral therapy for a Latino with depression. Clin Case Stud. 2011;10(5):376-94.\u003c/p\u003e\n\u003cp\u003e98. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Bunn M, Zolman N, Smith CP, Khanna D, Hanneke R, Betancourt TS, Weine S. Family-based mental health interventions for refugees across the migration continuum: A systematic review. SSM Ment Health. 2022;2.\u003c/p\u003e"},{"header":"Tables","content":"\u003ch2 style='margin-top:8.0pt;margin-right:0in;margin-bottom:4.0pt;margin-left:0in;font-size:21px;font-family:\"Aptos Display\",sans-serif;color:#0F4761;font-weight:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003eTable 1.\u003c/span\u003e\u003c/strong\u003e\u003cspan style='font-size:16px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003e\u0026nbsp;Keywords and search terms\u003c/span\u003e\u003c/h2\u003e\n\u003ctable style=\"width:100.0%;border-collapse:collapse;border:none;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 5.06%;border: 1pt solid windowtext;padding: 0in 5.4pt;height: 68.05pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003e#1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.02%;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;height: 68.05pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;text-align:justify;'\u003e\u003cem\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003eAccess\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.92%;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;height: 68.05pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003e(Access* OR \u0026ldquo;Acceptability\u0026rdquo; OR \u0026ldquo;availability\u0026rdquo; OR \u0026ldquo;accommodation\u0026rdquo; OR affordability OR appropriateness OR approachability)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 5.06%;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 47.9pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003e#2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.02%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 47.9pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;text-align:justify;'\u003e\u003cstrong\u003e\u003cem\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003eMental health\u003c/span\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.92%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 47.9pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003e(\u0026ldquo;mental health disorder*\u0026rdquo; OR \u0026ldquo;mental illness*\u0026rdquo; OR \u0026ldquo;mental health condition*\u0026rdquo; OR depress* OR \u0026ldquo;Anxiety\u0026rdquo;)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 5.06%;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 85.3pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003e#3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.02%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 85.3pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;text-align:justify;'\u003e\u003cstrong\u003e\u003cem\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003eSouth Asia\u003c/span\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.92%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 85.3pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003e(Afghani* OR Bangladesh* OR\u0026nbsp;Bhutan* OR India* OR Maldives OR Nepal* OR Pakistan* OR Sri Lanka* OR South Asia* OR SA OR Afghani migrant OR Bangladeshi migrant OR Bhutanese migrant OR Indian migrant OR Maldives migrant OR Nepali migrant OR Pakistani migrant OR Sri Lankan migrant OR South Asian migrant)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 5.06%;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 59.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003e#4\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.02%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 59.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;text-align:justify;'\u003e\u003cstrong\u003e\u003cem\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003eLived experiences and perceptions\u003c/span\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.92%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 59.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003e(Experience* OR Enable* OR Perception* OR Attitude* OR View* OR Lived experience* OR Barrier* OR Facilitat* OR Challeng* OR Opportunit*)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 5.06%;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 28.5pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003e#5\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.02%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 28.5pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;text-align:justify;'\u003e\u003cstrong\u003e\u003cem\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003eAcceptable study design\u003c/span\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.92%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 28.5pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003e(qualitative OR Exploratory qualitative stud* OR Interview OR focus group OR ethnography OR mixed methods)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 5.06%;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 48.55pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003e#6\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.02%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 48.55pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;text-align:justify;'\u003e\u003cstrong\u003e\u003cem\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003eHigh-income nations\u003c/span\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.92%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 48.55pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003e(\u0026quot;Australia\u0026quot; OR \u0026quot;Canada\u0026quot; OR \u0026quot;United Kingdom\u0026quot; OR \u0026ldquo;UK\u0026rdquo; OR \u0026ldquo;United States of America\u0026rdquo; OR \u0026rdquo;USA\u0026rdquo; OR \u0026ldquo;high income country\u0026rdquo; OR \u0026ldquo;high income nation\u0026rdquo; OR \u0026ldquo;high-income country\u0026rdquo; OR \u0026ldquo;high-income nation\u0026rdquo;)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch2 style='margin-top:0in;margin-right:0in;margin-bottom:4.0pt;margin-left:0in;font-size:21px;font-family:\"Aptos Display\",sans-serif;color:#0F4761;font-weight:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003eTable.2.\u003c/span\u003e\u003c/strong\u003e\u003cspan style='font-size:16px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003e\u0026nbsp;Key operational definitions\u0026nbsp;\u003c/span\u003e\u003c/h2\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003ctable style=\"border-collapse:collapse;border:none;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 223.8pt;border: 1pt solid windowtext;padding: 0in 5.4pt;height: 6.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 227pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;height: 6.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family: \"Times New Roman\",serif;'\u003eDefinition\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 223.8pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family: \"Times New Roman\",serif;'\u003eHealth care access\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 227pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003eThe definition of access to health care is adopted from the definition outlined by\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003eGraetz, Rechel, Groot, Norredam \u0026amp; Pavlova, 2017 (32)\u003c/span\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003e, \u003cem\u003e\u0026ldquo;the opportunity to reach and obtain appropriate health care services in situations of perceived need for care\u0026rdquo;\u003c/em\u003e.\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 223.8pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family: \"Times New Roman\",serif;'\u003eMental health care\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 227pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003eMental health care includes an array of diverse services and support at the primary and tertiary level\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 223.8pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family: \"Times New Roman\",serif;'\u003eMental health disorder\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 227pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003eA disturbance in an individual\u0026rsquo;s emotional regulation, cognition and/or behaviour which is clinically significant\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003e(33)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 223.8pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family: \"Times New Roman\",serif;'\u003eMental health condition\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 227pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003eThis encompasses the risk of self-harm, functional impairments, and disabilities that are psychosocial in nature alongside other mental states related to severe distress and mental health disorders\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003e(33)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 223.8pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family: \"Times New Roman\",serif;'\u003eSouth Asia or South Asian\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 227pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003eThe following eight nations, as per the South Asian Association for Regional Cooperation definition of SA: Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003e(7)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style='margin:0in;font-size:19px;font-family:\"Aptos\",sans-serif;color:#595959;'\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch2 style='margin-top:0in;margin-right:0in;margin-bottom:4.0pt;margin-left:0in;font-size:21px;font-family:\"Aptos Display\",sans-serif;color:#0F4761;font-weight:normal;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003eTable 3:\u003c/span\u003e\u003c/strong\u003e\u003cspan style='font-size:16px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003e\u0026nbsp;Inclusion and exclusion criteria\u003c/span\u003e\u003c/h2\u003e\n\u003ctable style=\"width:446.3pt;border-collapse:collapse;border:none;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"10\" style=\"width: 62.1pt;border: 1pt solid windowtext;padding: 0in 5.4pt;height: 0.95pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;text-align:justify;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003eInclusion criteria\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 384.2pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;height: 0.95pt;vertical-align: top;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eQualitative data (in purely qualitative or mixed methods studies)\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 384.2pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 1pt;vertical-align: top;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003ePublished in English\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 384.2pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 1pt;vertical-align: top;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003ePublished between 1/1/2000 and 01/01/2023\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 384.2pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 1pt;vertical-align: top;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eStudies conducted in four high-income nations with large SA diasporas (UK, USA, Australia and Canada)\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 384.2pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 1pt;vertical-align: top;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eRelated to MH care access\u0026nbsp;\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 384.2pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 1pt;vertical-align: top;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eAll ages and genders\u0026nbsp;\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 384.2pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 55.95pt;vertical-align: top;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eSpecific to SA people (of all ages and regardless of migration) including individuals from one or more of the following eight nations as per the South Asian Association for Regional Cooperation definition of SA: Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka\u0026nbsp;\u003c/span\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003e(7)\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 384.2pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 1pt;vertical-align: top;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eStudies with single-heritage SA populations (only SA people) or multi-heritage studies (more than one ethnic group included in the study)\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eParticipants in these studies are individuals of all genders and ages who have\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 384.2pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 1pt;vertical-align: top;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eMigrated from SA, of SA origin (regardless of cohort of migration) or self-identified SA background.\u0026nbsp;\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 384.2pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 1pt;vertical-align: top;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003ePeer review\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" style=\"width: 62.1pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 1pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;text-align:justify;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003eExclusion criteria\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 384.2pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 1pt;vertical-align: top;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eNon-English studies\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 384.2pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 1pt;vertical-align: top;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eQuantitative data,\u0026nbsp;\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 384.2pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 1pt;vertical-align: top;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003ePublications including letters to the editors, reviews, commentaries, and editorials\u0026nbsp;\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 384.2pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 1pt;vertical-align: top;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eStudies irrelevant to the study population or did not highlight SA-specific information amongst other study populations\u0026nbsp;\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp style='margin:0in;font-size:19px;font-family:\"Aptos\",sans-serif;color:#595959;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003eTable 4:\u003c/span\u003e\u003c/strong\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003e\u0026nbsp;\u003cem\u003eOverview of themes\u003c/em\u003e\u003c/span\u003e\u003c/p\u003e\n\u003ctable style=\"width:100.0%;border-collapse:collapse;border:none;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.82%;border: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eTheme\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.58%;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003eChallenges\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.58%;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003eOpportunities\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.82%;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eA\u003c/span\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003epproachability\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.58%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;margin-left:-0.25in;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eIndividual and service level stigma\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eCultural shame\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eLimited MH literacy\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eLimited in-language resources\u0026nbsp;\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.58%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;margin-left:-0.25in;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eImproving MH literacy\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eDeconstructing mistrust and stigma\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eTailored opportunities for psychoeducation,\u0026nbsp;\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eService diversification\u0026nbsp;\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eMulti-agency collaborations with communities\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.82%;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eA\u003c/span\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003ecceptability\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.58%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;margin-left:-0.25in;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eFears of stigmatising experiences with healthcare professionals\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eService-user shame and mistrust\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eLack of culturally appropriate explanatory models, models of care and cultural safety training affecting service accessibility\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.58%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;margin-left:-0.25in;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eServices fostering privacy and safe disclosure\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eCulturally aware, safe and sensitive practices\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.82%;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eA\u003c/span\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003evailability and\u003c/span\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;a\u003c/span\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003eccommodation\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.58%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;margin-left:-0.25in;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eReferral delays\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003ePost-referral disengagement\u0026nbsp;\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eLimited quantity, quality, safety and continuity of care,\u0026nbsp;\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eLimited transport\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.58%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;margin-left:-0.25in;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eFlexible, affordable, health insurance-eligible,\u0026nbsp;\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eLocal MH care\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eMultidisciplinary or coupled healthcare (addressing comorbidities)\u0026nbsp;\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.82%;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eA\u003c/span\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003effordability\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.58%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;margin-left:-0.25in;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eDecreased female financial independence\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eProhibitive or restrictive fees\u0026nbsp;\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eLimited health insurance\u0026nbsp;\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003ePerceiving MH care as unproductive investments\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.58%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;margin-left:-0.25in;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eFree MH services, telephone helplines and accessible accessory support\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.82%;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eA\u003c/span\u003e\u003cspan style='font-size:15px;font-family:\"Times New Roman\",serif;'\u003eppropriateness\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.58%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;margin-left:-0.25in;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eService-based racism and discrimination\u0026nbsp;\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eComplexities of migration and acculturation\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:11.0pt;'\u003eDynamic acculturation\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.58%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;margin-left:-0.25in;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eSystemic and institutional changes to diversify and prioritise intersectional and person-centred approaches\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eUsing community members\u0026rsquo; preferred languages to validate heterogenous SA experiences\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eUtilising social networks\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eImprove MH literacy\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;font-size:15px;'\u003eRemoval of deficit based approaches to MH care in SA communities\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Aptos\",sans-serif;'\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"South Asian, Mental health, Opportunities and challenges","lastPublishedDoi":"10.21203/rs.3.rs-4798223/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4798223/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eCommunities of South Asian (SA) origin in high-income countries experience the highest prevalence of mental health (MH) disorders amongst culturally and linguistically diverse (CALD) community groups. Emerging evidence highlights community experiences of socio-cultural and systemic challenges to MH care access; however, there is no comprehensive qualitative evidence regarding these opportunities and challenges. To address this knowledge gap, this review aimed at exploring the lived experiences of SA CALD communities through opportunities and challenges experienced in accessing MH care across four high-income nations (the United Kingdom, Australia, the United States, and Canada).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis scoping review followed reporting guidelines for scoping reviews outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A search was conducted to identify studies published in English between 2000- January 2023 in three electronic databases: PubMed, Web of Science, and Scopus. The search strategy included keywords related to SA CALD communities, MH and access to health care in four high-income countries. Extracted qualitative data were analysed using a thematic analysis approach.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAnalysis of the data from 25 eligible studies across all four high-income identified interlinked opportunities and challenges informing their ability to access MH care that supports their needs. Findings have been structured according to the five dimensions of accessibility of services (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) approachability, 2) acceptability, 3) availability and accommodation, 4) affordability, and 5) appropriateness). Our study identified myriad challenges faced by SA CALD communities in four high-income nations, including inflexible accessibility to diverse MH care, difficult family dynamics, stigma and acculturative issues hindering MH care usage and poor MH care experiences informing perceptions of MH care and re-engagement.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe research finds that access to MH care for CALD communities requires a comprehensive and nuanced framework that addresses population-specific factors. Recommendations include increasing cultural safety, facilitating flexible models of care and service delivery in practice alongside policy and funding reflective of systemic MH care access issues, and implementation research to assess the effectiveness of such recommendations.\u003c/p\u003e","manuscriptTitle":"A scoping review to identify opportunities and challenges for communities of South Asian (SA) origin in accessing mental health services and support in high- income countries","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-30 15:52:04","doi":"10.21203/rs.3.rs-4798223/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-05T16:56:03+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-17T02:49:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"64392186742805740566073395670008468910","date":"2024-10-16T22:28:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"286873040200176458092945630238196562825","date":"2024-10-09T04:53:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-09T04:02:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"71373739325990333917932046330457461345","date":"2024-09-30T06:37:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"51735405683675310148058598898253897264","date":"2024-09-23T07:54:48+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-09-23T05:17:41+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-07-29T09:41:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-29T09:22:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-29T07:22:55+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2024-07-25T01:22:40+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"935b6809-38a7-42f8-a6e8-d7a71e582b37","owner":[],"postedDate":"July 30th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-10T16:07:03+00:00","versionOfRecord":{"articleIdentity":"rs-4798223","link":"https://doi.org/10.1186/s12889-025-24619-7","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2025-11-03 15:57:43","publishedOnDateReadable":"November 3rd, 2025"},"versionCreatedAt":"2024-07-30 15:52:04","video":"","vorDoi":"10.1186/s12889-025-24619-7","vorDoiUrl":"https://doi.org/10.1186/s12889-025-24619-7","workflowStages":[]},"version":"v1","identity":"rs-4798223","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4798223","identity":"rs-4798223","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}