Developing Quality Standards and a Logic Model for Culturally Appropriate Advocacy in Mental Healthcare in the UK: a mixed methods study

Developing Quality Standards and a Logic Model for Culturally Appropriate Advocacy in Mental Healthcare in the UK: a mixed methods study | 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 Developing Quality Standards and a Logic Model for Culturally Appropriate Advocacy in Mental Healthcare in the UK: a mixed methods study Zoe Timimi, Anthony Salla, Karen Newbigging, Doreen Joseph, Claire Henderson, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9244010/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Advocacy is a form of liberatory practice which can enable mental health patients to have a voice, for their needs and wishes to be expressed, and for their rights to be protected, especially when power dynamics are imbalanced in favour of professionals. An independent review of mental health legislation in England and Wales resulted in a recommendation for culturally appropriate advocacy due to concerns about the needs of racialised minorities in mental healthcare not being met. Objective Objectives of this mixed methods study were developing quality standards and a logic model for culturally appropriate advocacy in relation to mental healthcare. Methods The development of our quality standards involved six stages of data collection and validation: 1. Five focus groups (41 participants involving mental health patients, carers, advocates and commissioners from diverse backgrounds); 2. A rapid appraisal followed systematic search methods using MedLINE, EMBASE, Web of Science, Psychinfo and ProQuest. Twenty-one studies met the inclusion criteria and were critically appraised using the CASP checklist; 3. The development of draft quality standards using thematic analysis of rapid appraisal and focus group data; 4. A nominal group session (17 participants with mental health patients, carers, advocates and commissioners) to prioritise and agree standards; 5. Quality standards were further refined as part of a comparative case study evaluation of two culturally appropriate advocacy pilots (65 participants) and review of organisational documentation; and 6. Evidence from stages 1, 2, 4 and 5 were used to inform the development of a logic model defining inputs, process, services and outcomes for the future delivery of culturally appropriate advocacy. Lived experience informed all stages of the project through an advisory panel. Results Twelve quality standards were developed for culturally appropriate advocacy and were organised into three categories: Equitable access; Improved experience; and improved outcomes. Each quality standard has example outputs and indicators. A logic model for culturally appropriate advocacy identifies five phases of development towards meeting medium- and long-term outcomes. Conclusion To our knowledge, the culturally appropriate advocacy quality standards and logic model are the first to be designed specifically for use in mental health settings. These outputs have implications for advocacy organisations, commissioners and mental health services for the way advocacy services are funded, developed, configured and evaluated to address racial inequities in advocacy and mental healthcare. (3 = 10): Mental Health Act reform culturally appropriate advocacy race equity mental health advocacy quality standards logic model Full Text Additional Declarations No competing interests reported. Table 1 to 7 are available in the Supplementary Files section. Supplementary Files Table1.docx Table2.docx Table3.docx Table4.docx Table5.docx Table6.docx Table7.docx Additionalfile2DraftQualityStandards.docx Additionalfile3advocacypartnertopicguide.docx Additionalfile6Pilotsiteactivities.docx Additionalfile1Focusgrouptopicguide.docx Additionalfile4Codingframework.docx Additionalfile5RapidAppraisalFinalResults.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 08 May, 2026 Reviewers agreed at journal 26 Apr, 2026 Reviewers agreed at journal 20 Apr, 2026 Reviewers invited by journal 09 Apr, 2026 Editor assigned by journal 31 Mar, 2026 Submission checks completed at journal 31 Mar, 2026 First submitted to journal 27 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9244010","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":620864543,"identity":"eb247da5-88b6-434b-8a20-557fdd9196c9","order_by":0,"name":"Zoe Timimi","email":"","orcid":"","institution":"City St Georges, University of London","correspondingAuthor":false,"prefix":"","firstName":"Zoe","middleName":"","lastName":"Timimi","suffix":""},{"id":620864544,"identity":"43af9b21-7707-438a-bf2a-60b73be5b6b2","order_by":1,"name":"Anthony 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Logic Model for Culturally Appropriate Advocacy in Mental Healthcare in the UK: a mixed methods study","fulltext":[],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":true,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":true,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-mental-health-systems","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jmhs","sideBox":"Learn more about [International Journal of Mental Health Systems](http://ijmhs.biomedcentral.com/)","snPcode":"13033","submissionUrl":"https://submission.nature.com/new-submission/13033/3","title":"International Journal of Mental Health Systems","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"(3 = 10): Mental Health Act reform, culturally appropriate advocacy, race equity, mental health advocacy, quality standards, logic model","lastPublishedDoi":"10.21203/rs.3.rs-9244010/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9244010/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e \u003cb\u003eBackground\u003c/b\u003e Advocacy is a form of liberatory practice which can enable mental health patients to have a voice, for their needs and wishes to be expressed, and for their rights to be protected, especially when power dynamics are imbalanced in favour of professionals. An independent review of mental health legislation in England and Wales resulted in a recommendation for culturally appropriate advocacy due to concerns about the needs of racialised minorities in mental healthcare not being met.\u003c/p\u003e \u003cp\u003e \u003cb\u003eObjective\u003c/b\u003e Objectives of this mixed methods study were developing quality standards and a logic model for culturally appropriate advocacy in relation to mental healthcare.\u003c/p\u003e \u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e The development of our quality standards involved six stages of data collection and validation: 1. Five focus groups (41 participants involving mental health patients, carers, advocates and commissioners from diverse backgrounds); 2. A rapid appraisal followed systematic search methods using MedLINE, EMBASE, Web of Science, Psychinfo and ProQuest. Twenty-one studies met the inclusion criteria and were critically appraised using the CASP checklist; 3. The development of draft quality standards using thematic analysis of rapid appraisal and focus group data; 4. A nominal group session (17 participants with mental health patients, carers, advocates and commissioners) to prioritise and agree standards; 5. Quality standards were further refined as part of a comparative case study evaluation of two culturally appropriate advocacy pilots (65 participants) and review of organisational documentation; and 6. Evidence from stages 1, 2, 4 and 5 were used to inform the development of a logic model defining inputs, process, services and outcomes for the future delivery of culturally appropriate advocacy. Lived experience informed all stages of the project through an advisory panel.\u003c/p\u003e \u003cp\u003e \u003cb\u003eResults\u003c/b\u003e Twelve quality standards were developed for culturally appropriate advocacy and were organised into three categories: Equitable access; Improved experience; and improved outcomes. Each quality standard has example outputs and indicators. A logic model for culturally appropriate advocacy identifies five phases of development towards meeting medium- and long-term outcomes.\u003c/p\u003e \u003cp\u003e \u003cb\u003eConclusion\u003c/b\u003e To our knowledge, the culturally appropriate advocacy quality standards and logic model are the first to be designed specifically for use in mental health settings. These outputs have implications for advocacy organisations, commissioners and mental health services for the way advocacy services are funded, developed, configured and evaluated to address racial inequities in advocacy and mental healthcare.\u003c/p\u003e","manuscriptTitle":"Developing Quality Standards and a Logic Model for Culturally Appropriate Advocacy in Mental Healthcare in the UK: a mixed methods study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-17 21:36:23","doi":"10.21203/rs.3.rs-9244010/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-08T11:39:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"313295455569798296827365277871587780567","date":"2026-04-26T07:16:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"224516062232252764732041401989571923095","date":"2026-04-20T18:31:31+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-09T19:26:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-01T01:20:17+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-01T01:19:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Mental Health Systems","date":"2026-03-27T11:05:34+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-mental-health-systems","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jmhs","sideBox":"Learn more about [International Journal of Mental Health Systems](http://ijmhs.biomedcentral.com/)","snPcode":"13033","submissionUrl":"https://submission.nature.com/new-submission/13033/3","title":"International Journal of Mental Health Systems","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"79d90252-496c-4997-a870-3a92598277ab","owner":[],"postedDate":"April 17th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-08T11:39:39+00:00","index":41,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-17T21:36:23+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-17 21:36:23","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9244010","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9244010","identity":"rs-9244010","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}