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

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.