Mental Health Team Blog Post – International Women’s Day

Equity vs. Equality in Health Services

This year for International Women’s Day, we are celebrating the theme of #EmbraceEquity. While the overall campaign will be focusing on the importance of gender equity, the mental health team want to highlight the importance of equity in health services.

To explore this, we have to begin with a basic understanding of the difference between equity and equality. Then we will look at the difference equity and equality have on service design, and how this impacts service users we support. Lastly, we will end with some suggestions on how health services can improve the support they offer with equity in mind, ensuring that more women are reached and given the opportunity to access support.

What is the difference between equity and equality?

To put it simply, equality is centred around giving everyone the same resources. In terms of 1:1 support, equality would involve offering all service users five 1:1 mental health sessions. That means everyone has the same amount of support. On paper, it might look nice at quick glance. But in reality, it refuses to take into consideration a very important truth - we do not all start off with the same resources. We do not all experience the same layers of systemic inequality.

Fundamentally, we must acknowledge that we are not all starting off from the same point. We are all born with various levels of privilege, and privilege takes many forms, including the following:

  • Racial Privilege
  • Class Privilege
  • Educational Privilege
  • Gender Privilege
  • Sexuality Privilege
  • Ability Privilege

Each of us exists intersectionally as well, with our different social or political identities overlapping, which means many of us will experience multiple layers of oppression that compound each other, making it even harder to access the same resources as those with higher levels of privilege. Equality does not take levels of oppression or power into consideration and assumes we can all access the same support because we are all starting with the same resources and experiences.

Going back to the 1:1 support example - if I have 10 women on my caseload, and am providing them all 1:1 support, and I offer five sessions to each woman, without considering anything else, what have I missed in terms of equity? This is where the discussion really begins. This may ignore that of the 10 women I am supporting, 5 of them have been diagnosed with complex PTSD and have been unable to access statutory support. They may need more than the other five women, because they have more complex needs, most likely due to multiple layers of oppression and trauma. When we look at the different needs and layers, it’s pretty clear that equality is just not good enough.

What can be done to implement equity in health services?

First, we acknowledge that we are not all starting off from the same point. Some of us need more support because we have experienced more oppression. If we want to break down the barriers that prevent people from receiving support, we have to make it easier for them to access services. Not by making it equal across the board, but my removing the barriers that still remain and by considering different levels of need and different starting points in our service design and delivery.

If we want to achieve equity, we have to consider what is preventing different groups of people from accessing our services. If a local perinatal group, for example, knows that they don’t have a lot of representation from asylum seeking women, and want to improve this, it would require them to closely look at their support and see what barriers may be keeping asylum seeking women from engaging. Are there interpreters available at the group for women who have different levels of English and are the activities accessible for different levels of English, or is it really just a group for English speaking women? Are there bus tickets available for women who have to make really difficult financial decisions who may not be able to afford the travel without a bus ticket? The intent may not be to exclude asylum seeking women, but if these things aren’t considered, it is unlikely that asylum seeking women will be able to participate, which means the service is actually allowing inequality to continue.

One of the biggest barriers we hear about is the length of appointment time in health services for our service users. It might be generally fine to offer each patient 10 minutes to discuss health needs with their GP, but if you know you are treating clients with complex needs, or using interpreters (which is naturally going to lengthen the time of the appointment), you have to make allowances for some people, which may not be the same for everyone, but would allow for people who need more complex support. It cannot be underestimated how scary it must feel to try to explain the symptoms of PTSD and trauma you experience, and how much they are impacting your life to your doctor in just 10 minutes. Offering holistic, person-centred support would allow for health professionals to implement equity rather than assuming people’s level of support needs are the same.

We also get a lot of feedback from our service users about counselling services that are not equitable in design or delivery. Some services are not person-centred and not culturally relevant, so some of our service users access counselling thinking they will be offered long-term, trauma-informed support, and instead are offered a very Eurocentric model of counselling that is unrealistic and isolating for women in the asylum system. When women are not able to engage with these expectations of counselling because they are unhelpful, and sometimes even triggering, their support is often ended and the reason they are given is because they were not willing or ready to engage.

But these women are not saying they are not willing or ready to engage. They just don’t want support that isn’t helpful or appropriate to them. If a service cannot change to meet the needs of women experiencing some of the most complex oppression and trauma, the service is not equitable.

On the other hand, some women like the support they receive, but are not able to attend regularly due to practical barriers, such as no access to internet or phone data, or lack of access to bus tickets or help with transport. If  a service cannot find a way to address these barriers and offer solutions, the service is not equitable.

Language is also a massive barrier preventing many health services from achieving equity. There is a massive difference between the wait time for say, an English speaker waiting for mental health support, and someone who speaks, for example, Kurdish Sorani. That means English speakers are at a massive advantage in accessing support, and not much is done to make up for the fact that Kurdish Sorani speakers may have to wait 6 months. Again, this may not be the intention or fault of the service, but it is certainly not equitable. If certain languages require longer waits, is there something else that could be offered in the meantime? Is there a psycho-social or psycho-educational group we could run while they wait, or could we partner with another organisation to provide interpreters or social opportunities for people while they are waiting? If we are not considering these things and actively trying to remove these barriers, our services are not equitable.

Caring responsibilities also play a big part in preventing women from accessing health services. A lot of women do not have support networks and cannot rely on anyone else to watch their children (or whomever they are caring for) while they attend GP appointments, group support sessions, counselling, etc. If we don’t allow women to bring their children or relatives with them, we are keeping many women from being able to access support. This puts women in danger – it means women have to decide between attending important health appointments or taking care of their children or relatives. This makes it less likely for women to attend routine check-ups, ask for help, or engage with health services. Now, it would not be appropriate to allow children or people to sit in on confidential sessions, but services could consider things such as offering a creche or operating out of community drop-ins or children centres where there may be other people who can take on the caring role while women access support.

Moving forward with equity at the core of health services

Designing a service that doesn’t actively work to remove barriers that prevent women from accessing services is simply not addressing equity. It may look equal across the board on paper, and it will probably even benefit women with multiple layers of privilege, but it is certainly not helping women experiencing multiple layers of oppression who need support. We have to do better.

We hope this will help start a conversation within health services to start to see the ways in which we are only achieving equality, at the detriment of so many people who deserve equity. We hope this helps to think about what practical support could be offered to help people access support (bus tickets, creche, interpreters) and what should be considered in service design (trauma-informed, culturally relevant, person-centred, holistic support).

While our own team strives to provide equity in our support, we also recognise where we fall short (especially guaranteed and reliable access to interpreters) and are committed to improving these areas. We are guided by women with lived experience of multiple layers of oppression who can best inform on what is needed to break down barriers and improve access for all. We hope everyone can #EmbraceEquity and wish you all a lovely International Women’s Day!


In Solidarity,

The Mental Health Team