Commentary: Is Australian headspace socioculturally westernised,educated,industrialised,rich and democratic in conceptualisation and accessibility?

Abstract

Objective

The Australian headspace model has been proposed as an internationally significant exemplar for reducing the mental health ‘treatment gap’ amongst young people around the world. We provide a commentary that discusses the conceptualisation and delivery of headspace services within Australia, a predominantly Westernised, Educated, Industrialised, Rich and Democratic (WEIRD) society, as well as examining accessibility and suitability for culturally and linguistically diverse (CALD) communities.

Conclusion

headspace was conceptualised, designed, implemented and evaluated according in a WEIRD sociocultural context, and is therefore most applicable to that setting. Australia also has CALD communities, who have not seemed to access headspace in the reported patient and staff demographics. On this basis, there may be questions about the potential generalisability of headspace models outside WEIRD societies.

Although headspace has been proposed as an international innovation for youth mental health early intervention, ¹ there has been little evidence of the effectiveness of the model in Australia and its application to different sociocultural settings.^2,3 This is despite the considerable body of medical, social and evolutionary anthropologic research indicating that socio-cultural differences must be considered in the provision of healthcare.^4–6 This is especially relevant to mental health services. Firstly, the metaphors of communicating distress arise in part from acculturation of patients, leading to the shaping of the idioms of distress. ⁵ Secondly, separate, but related to idioms of distress, are explanatory models that patients use to describe the narrative of their illness. ⁴ Such explanatory models are partially distinguished from idioms of distress by the nature of reasoning regarding conceptualisation, aetiology, diagnosis, prognosis, and treatment of illness. ⁴

Recently, interdisciplinary anthropology has described the cultural phenomena of Westernised, Educated, Industrialised, Rich and Democratic (WEIRD) societies. ⁶ These societies are the origin of most of the medico-scientific research that underpins the understanding of mental illness.^6,7 Westernised, educated, industrialised, rich and democratic societies, primarily in Europe, North America and high-income Oceania (Australia and New Zealand) produce the bulk of modern psychological research, with the majority coming from the United States. ⁷ These societies are exceptional, representing only 12% of the world’s population. ⁶ The key characteristics of WEIRD societies include individualism and autonomy, self-expression and recognition of human rights, reputational relationships and less religiosity. ⁷ Rather than being universal societal characteristics, these may differ from the majority of societies in the world, in which collective identity, kinship networks and religiosity are more prominent.^6,7 Accordingly, healthcare programs, such as headspace, developed in WEIRD countries, based on different sociocultural values and characteristics may not be easily adaptable or relevant to the majority of non-WEIRD societies.

The conceptual model of Australian headspace – is it WEIRD?

headspace centres have been developed through Australian federal government funding of an NGO structure that acts as a primary care hub for young people to access Medicare-funded clinical consultations. ² headspace centres (numbering over 115 Australia-wide) are designed as a ‘youth-friendly’ one-stop-shop for both mental and physical health, as well as related services. ⁸

The first key principle of the Australian headspace model of care is ‘Youth participation’ which focuses on the autonomy and rights of the young person in deciding on their needs and preferences for treatment. ⁹ This focus on individualism and autonomy is a key characteristic of WEIRD societies. ⁷ However, there are a range of contexts and roles for young people in different sociocultural environments that may apply to young Australians from non-English-speaking-backgrounds and/or were born overseas. For example, a second-generation Australian–Chinese youth may have very substantial expectations from their older first-generation immigrant parents of filial piety based on traditional kinship ties, rather than valorising individualism and autonomy. ¹⁰

The second key principle of Australian headspace is family and friend participation in the care of the young person in terms of engagement, service development and evaluation and in governance. ⁹ This principle is secondary to the youth rights, but allows for the involvement of kinship networks in culturally and linguistically diverse (CALD) communities, if the young person agrees. headspace staff need the cultural sensitivity to recognise that family and friend roles can considerably differ within CALD communities. For example, in some South Asian populations, the idioms of health distress and expression may differ, and may include different explanatory models of illness related to kinship and relationship networks. ¹¹

The third key principle of community awareness ⁹ is predicated on an Australian WEIRD expectation that public discussion of mental illness and promotion of mental health literacy are necessary antecedents to young people accessing care. The means by which youth might acquire awareness of mental illness and treatment may vary by sociocultural background due to the dependence on cultural norms in the acquisition of knowledge. ¹² Therefore, different conceptual models may be needed to improve community awareness in CALD communities.

This brief overview of three key conceptual underpinnings of Australian headspace shows that foundational emphasis on youth autonomy is distinct to WEIRD societies. This sociocultural individualised autonomy focus likely differs from the sociocultural centrality of family and kinship networks in some Australian CALD communities and the majority of societies in the rest of the world. ⁶

Culturally and linguistically diverse people accessing headspace

At the outset, we acknowledge that only some aspects of cultural and linguistic diversity are captured in country of birth and English language proficiency.

As a baseline, we reference the 2021 Australian census data summary from the Australian Bureau of Statistics (ABS), which found that 27.6% of the Australian population were born overseas. ¹³ 13.4% of Australians come from non-English-speaking countries. ¹³ In terms of self-identified English proficiency data, 10% stated of Census respondents had limited or no English proficiency. ¹³ These population base rates are not focused on younger people, but they are offered as a reference point on CALD families, noting that base rates of diversity will vary significantly based on specific regions. There is also the caveat that the classification of English language proficiency differs across studies and with the Australian census data.

The initial evaluation of headspace centres in 2009 found that 10.4% were born overseas and only 1.9% had a main language other than English. ¹⁴ However, language data was only available on 2,627 of the 7022 participants, and country of birth for 6,547. ¹⁴ A subsequent headspace evaluation from January to June 2013 (n = 21,274) found that 7% reported being born overseas and only 6% did not speak English at home – this is somewhat less than the Census level of 10% for limited or no English proficiency.^13,15

It is unlikely that the explanation for this apparent under-representation is that migrants without Australian visa or residential status cannot access Medicare and therefore receive billable services within headspace. For instance, refugees have full entitlements to Medicare; it is only certain asylum seekers who are ineligible for billable services. In 2021, there were only 40,000 people seeking asylum through a temporary or permanent protection visa, a tiny proportion of non-English-speaking Australian residents. ¹⁶

At least part of the decreased CALD representation in headspace clientele may arise from a potential ‘healthy migrant effect’, ¹⁷ where youth might experience lower prevalence of mental illness or attribute their distress to real-world disadvantage.

Cultural and linguistic diversity of healthcare providers in headspace

There are little data available on the cultural and linguistic diversity of headspace healthcare providers. In relation to the above quoted headspace evaluations from 2009 ¹⁴ and 2014 ¹⁵ there did not appear to be any data on healthcare provider cultural and linguistic diversity. The 2020 evaluation of the headspace EIP reported no data on headspace healthcare provider cultural and linguistic diversity. ¹⁸

Discussion

On the basis of the preceding observations, the Australian headspace conceptual model of care might be considered substantively socioculturally WEIRD. There appears to be reduced accessibility of headspace for CALD youth. There are lower rates of clientele from non-English-speaking-backgrounds and those born overseas, compared to the general Australian population. The headspace model dependency on Medicare Benefits Schedule (MBS) subsidy for client consultations limits the accessibility for a small minority of migrants without Australian visa or residential status required to access Medicare. However, this would not explain the apparently low rates of attendees from non-English-speaking-backgrounds. There is also very little substantive information on the cultural and linguistic diversity of headspace healthcare providers. We recommend that headspace and the MBS collect demographic and outcome data to better understand the accessibility to young people of cultural and linguistic diversity of the services provided.

Conclusions

The Australian headspace model is mostly WEIRD in the form of its conceptualisation of its model of care and accessibility to CALD clientele. There are potential accessibility shortfalls in Australia for CALD communities that indicate possible challenges to support more diverse populations, and perhaps some of the wider international community. The WEIRDness of this model may potentially limit its translation to societies with differing sociocultural characteristics that may require alternative culturally appropriate models of care. However, at the moment, more information and research on the CALD accessibility of headspace is necessary to better understand the under-representation of these groups in the clientele. Such evidence would provide a better grounding for understanding the potential benefits and challenges for international research on headspace-type interventions.