#91. Understanding Health Inequalitites: From Police & Veterans to Ethinic Minorities - Dr. Patsy Irizar

Do police officers drink more than the general population? How does racial discrimination affect mental health? And what can large-scale data tell us about health inequalities?

In this episode, we sit down with Dr. Patsy Irizar from Liverpool John Moores University to explore two seemingly different but deeply connected areas of research: alcohol use and mental health in the police and military, and the impact of racial discrimination on psychological wellbeing.

Dr. Irizar shares her journey, discussing her groundbreaking PhD work examining alcohol use among UK police officers and the culture surrounding drinking in policing. We unpack findings from a dataset of 40,000 officers, challenge stereotypes about the “hard-drinking cop,” and explore the complex relationship between alcohol and mental health.

The conversation then turns to health inequalities, where Patsy explains how the COVID-19 pandemic highlighted long-standing racial disparities in health outcomes. We discuss how discrimination can become biologically and psychologically embedded, why social determinants matter, and what researchers are learning from the largest survey of minoritized ethnic groups conducted in the UK.

Along the way, we talk about:

•  Why people use alcohol to cope with mental health difficulties 
•  The changing drinking culture within UK policing 
•  The “sick quitter” hypothesis 
•  Trauma, occupational stress, and mental health 
•  COVID-19 and ethnic health inequalities 
•  Structural and institutional racism 
•  How discrimination affects mental health over time 
•  Improving mental health services and treatment pathways 
•  The role of research in creating meaningful social change 

Whether you're interested in psychology, public health, policing, addiction research, or social inequality, this episode offers a fascinating look at how our environments shape mental health.

Transcript

0:03

So hello, hello, hello. Welcome to the Smooth Brain Society. Today, we are joined by Patsy Irizar from Liverpool John Moores University. And honestly, this is someone whose research I find really fascinating because it covers very two completely different worlds. On one hand, Patsy spent her PhD investigating why UK police officers drink so much and what that has to do with their mental health, producing the first ever study on heavy drinking and co-ahearing mental health problems in UK policing. On the other hand, she's done incredible work on how racial discrimination gets under the skin and affects mental health using the largest survey of minoritized ethnic groups ever conducted in the UK. She's a proper Liverpool academic, a BSc, two MSCs, PhD, all in Liverpool, and now she's just across the road at LGMU. bringing all of this together. And it's so interesting. My cat Moose has actually joined us today if you hear some aggressive peering. So welcome Patsy. Thank you, thanks for having me. Awesome. Uh Patsy, uh I guess we'll start where we start with everybody uh who's on. Could you give us a little bit of your origin story into how you got into the work you do?'Cause like Bet mentioned, it's it's coup couple different elements in there. Yeah, definitely. So when I was at uni, when I did my undergrad, I was, I've always kind of been interested in mental health and mental health research. And when I was at uni, I actually wanted to be a clinical psychologist. So that was always my goal throughout my undergraduate. And then when it got to my final year, when I did my dissertation, I started to realize how much I actually loved doing research and creating my own research project, collecting data, analyzing data. And also started to realise that there was quite a lot about mental health care that could still be improved and that research was one way to actually improve the mental health treatment that people received. So I thought that even if I'm not a clinical psychologist, I can still make a difference to people's mental health through research. And then during this time, when I started to become more interested in research, I started to realise that people around me were maybe using alcohol to cope with their own mental health and then seeing how that heavy drinking then actually made their mental health worse, made me realize that that was an area that I was quite interested in researching. So I ended up doing my PhD with Dr. Laura Goodwin m at the University of Liverpool. And I'd come to her and said, I'm really interested in looking at alcohol and mental health and how these are related. And we came up with this idea to look uh alcohol and mental health in police officers because it had never really been looked at before. So we used this massive data set of about 40,000 police officers and we looked at the prevalence of harmful drinking in police officers and we looked at the relationship with mental health. And I did a bit of qualitative research as well so did some interviews with police officers to understand their experiences of drinking and what the drinking culture was like within the police. And we did some comparisons as well with the armed forces. So the military is another kind of occupational group that's quite similar to the police in a way. So they've got, you know, heavy norms around alcohol use and quite high levels of exposure to trauma. So we thought they'd be a good comparison to do. But then as I was kind of finishing, my PhD. So this is where I've got these kind of two strands as I was kind of finishing my PhD. It was around the time of the pandemic. So the pandemic started just as I was finishing my PhD. And I started to see all these news stories about how ethnic minority groups were more likely to become infected with COVID and die from COVID. But all of the news stories seem to be blaming this on like genetics or biology. But Because my research has always kind of looked at like health inequalities and the social determinants of alcohol use and mental health and I guess more broadly physical health. I knew that this was due to sort of kind of health inequalities and the ethnic minority groups are more likely to experience socio economic disadvantage, which I believe is a result of kind of structural and institutional racism. So As I was finishing my PhD, this is where I was more interested in ethnic inequalities and COVID-19 health outcomes. And I was really lucky to get a postdoc job at the University of Manchester to actually look at ethnic inequalities and COVID-19 health outcomes. So I did that for a year and then I managed to get a research fellowship. So this was really interesting because I got to develop my own idea and I wanted to build on some of the research that I've been doing on ethnic inequalities and COVID health outcomes to then look at how the pandemic impacted ethnic minority groups in terms of their mental health, but with a big focus on how experiences of racism can contribute to physical and mental health inequalities. So that's kind of, yeah, my journey so far and now I'm at... John Moores and I kind of continue in all of the different strands of research. So I'm still doing a lot of work on alcohol use and mental health em in the general population, but also doing a bit more work on uh military personnel and veterans to try to improve treatment uh journeys, treatment experiences and treatment outcomes for the general population and for veterans who have co-occurring alcohol and mental health problems. But then I'm also still doing some work on ethnic inequalities in mental health and trying to understand inequalities in access to and then longer term outcomes of mental health services. So yeah, that was a big waffle about my journey. N No, that's so fascinating. Beth, which one do you want to start with first? Because I feel we could roughly break it down into two strands, couldn't we? We could like sort of ethnic minorities as one and sort of like veterans and police and asites as the other. I reckon maybe we we go with the police one first so we'll marry up together. So I think there's a bit of a stereotype of the hard drinking cop who's seen too much and that's just the way that he is. But I mean, guess you were kind of like asking about this and literally testing that. Can you maybe tell us a bit more about the PhD and how that looked and what actually was going on with the... the police officers. Yeah, definitely. So yeah, we thought that the kind of prevalence of really heavy drinking would be high in the police. What we actually found was that the prevalence of, you know, really harmful drinking. So this is where people are drinking more than 50 units if you're a man and more than 35 units if you're a woman per week. That was only about 3 % of police officers. And that's actually really similar to what we see in the general population. So there's quite comparable rates of really harmful drinking in the police compared to the general population. But then when we looked at hazardous drinking, so higher risk drinking, but not quite at that really harmful level. So this is where you're drinking more than 14 units per week. So that's the kind of recommended amount that you're supposed to drink. You're not meant to drink more than 14 units per week. We found that police officers It was about a third of police officers were drinking to these hazardous levels. So about 33%, I think it's about 16 % in the general population at that time. So yeah, the really harmful levels of drinking, not as high as we thought, but that middle group, the increased risk drinking had quite a high prevalence. And... When we looked at mental health, we found that police officers who were drinking to those really harmful levels, they were more than twice as likely to have a mental health problem. So this suggests that people were kind of drinking to cope. But then a really interesting and slightly unexpected finding was that police who didn't drink alcohol were also more likely to have a mental health problem. And this is compared to police who were quite low risk drinkers. drinkers, so drinking less than 14 units per week. And there's a hypothesis called the sick quitter hypothesis and this suggests that people who have previously drank to quite harmful levels, they end up stopping drinking because of the impact that it's had on either their physical or mental health. So that's the kind of hypothesis that I went with for this is that it could be that quite a lot of police officers had stopped drinking because of the impact that it was having on their mental health or they stopped drinking to try and improve their mental health. So this is what we had found with the quantitative data and that was something that we then wanted to explore with the interviews. So when I interviewed police officers I had two groups. So I had a group of police officers who were drinking to em at least kind of hazardous levels and then I had a group of police officers who had previously drank alcohol but had stopped drinking. And we did find that quite a lot of people said that they had stopped drinking because it was having a negative impact on their mental health or they were quite worried about how much they were drinking so that their level of alcohol use was becoming a bit of a problem to them so they stopped drinking altogether. But there was also a couple of police officers that we spoke to who said that just The drinking culture has changed quite a lot and I think back in the day there was a big drinking culture in the police. So they used to have pubs in the kind of police stations so people would drink after work together. There was always that kind of stereotype that know you'd finish a shift and you'd have a drink and a lot of people who do shift work might drink after shifts and things like that to help them sleep. But that culture has changed quite a lot and there's a lot more of an emphasis on being healthy and on exercise and the police that we spoke to said that there's a lot more em activities and you know, if there's kind of activities to increase group cohesion, they were less focused around alcohol and more on things that people could enjoy without drinking. Yeah, that's really interesting. So um what you're saying is that, do you think it was the fact that there was mental health before the drinking or it was the drinking that was called, that was at the chicken or the egg situation? It's a really difficult question and the data that we had was only cross-sectional so it was only at one point in time so it's not really possible to know from the data which came first and the interviews can kind of help in a way but I think what you have is this kind of circular relationship and it's different for different people so it might be some people start with a mental health problem and then they start drinking more to cope with their mental health. And then for some people, they might be drinking quite a lot. And then the amount that they're drinking is actually having a negative impact on their mental health. So then they might then stop drinking. So I think it's a dynamic relationship and I think it also differs for different people, which means it's really hard to see that in the data because people have these different sort of trajectories. Not everyone is the same in their relationship with alcohol and mental health. Yeah, that makes sense. I I only know one, I think he's a detective and he's T total. Tom's being T total because he said the stuff that he sees in his job is, you can see himself going down a very dangerous line if he's not careful. That's an N of one everybody, so please ignore that. That's anecdote just to share. But yeah, it was interesting when you're talking about it that yeah, maybe it's the fact that like, more healthy, just being more healthy behaviors are going on. Yeah, and I think we're definitely seeing a shift in the drinking culture just more generally anyway and people are more aware of the impact that alcohol can have on your mental health. So I think like you say with your N of 1 but that person is aware that actually if you use alcohol to cope with really traumatic events then that can lead you down quite a dark rabbit hole. Yeah, that's really interesting. Is there any stories or conversations you've had in particular with this research that's really stuck with you? Oh, that's a good question. new one, I was just thinking we're talking about stories and like you can think, how's about do you want me to come back to it in five minutes or not at all? One thing that I don't know why it's just come to me from my PhD was the lack of awareness of whether at the level of drinking being harmful. And I remember in the group of police officers that were drinking to at least hazardous levels, a lot of people For them, it was just the kind of norm to drink every day, know, drink a bottle of wine every night and people didn't recognize that that could be harmful. It was just a habit. And that was one thing that we really wanted to kind of come out of the PhD was to have a bit more, um, like recommendations around safe levels or, you know, lower risk levels of alcohol use that could be shared with. police officers and other kind of high risk occupations. So healthcare workers as well, know, even though healthcare workers are involved in healthcare workers, I do a bit of research as well on alcohol and mental health and healthcare workers and they don't necessarily drink to as high levels, but you know, they're still the same. People aren't always aware that the level that they're drinking is um potentially harmful. Yeah, that makes sense. also hard to really tell what a unit is, right? If you tell somebody you can't have fourteen units but what's if you're supposedly pouring a drink at home or drinks at home. Yeah and even if you go out and you know there's different strengths of beers so you don't even really know how many units are in the pints that you're drinking. It's quite difficult to calculate your weekly, I don't know how many units I drink in a week, it's probably more than 40. I I guess because you were talking you you did work with veterans as sort of like a comparator because again, high stress environments. Did you see any differences between like the police and veterans that way? Yeah, we did. So I saw that, so we compared post-traumatic stress disorder and harmful alcohol use in police and the military. And what we found was that there were really similar levels of post-traumatic stress disorder, which might be unexpected because you'd think that military personnel are exposed to more trauma than police officers, but it was about 4%. And that's actually the same as the general population. So that was quite unexpected. And I think that speaks to the kind of resilience within those occupations. So these occupations, even though they're exposed to quite high levels of trauma, there must be other factors that are quite protective m and prevent people from kind of developing post-traumatic stress disorder. A kind of other caveat. of that is that in the police sample participants were only asked the PTSD questions if they had experienced a traumatic event in the last six months so that could have missed quite a lot of people who had experienced a traumatic event you know before those six months and PTSD doesn't just go away in six months for quite a lot of people so it could be really underestimating that and I think we tried to make the military sample quite comparable in that we then only tried to include people who had experienced a traumatic event, just to try and make those samples similar. But in terms of alcohol use, military personnel drank a lot more than police officers. So the prevalence of harmful drinking was a lot higher in military personnel than in police officers. So it was about 3 % in police officers, but it was about 10 % in military personnel. So yeah, quite a lot higher. just very quickly for my clarification, maybe I missed it, is so you were looking at veterans, right? So understanding is that they're they're not in active service, would that would the police officers active serving police officers?'Cause study was military serving personnel and veterans. So I used the King's Centre for Military Health Research eh Health and Wellbeing Cohort Study. So that's a longitudinal study that follows serving and ex-serving personnel. We might have only included the serving personnel to try and be similar. That's a good question. It's been a long time since I did my finished. Yeah, 'cause I I was just wondering potentially, you know, once somebody retires, is there less likelihood of using alcohol as a coping mechanism may be higher than if you have other mates around or are still actively serving. That was just I was thinking potentially. So I think we probably did only include serving personnel for that reason because you're right, know, once you've left service, there's also more opportunities to drink. So in the military, when you're actively on duty and not allowed to drink alcohol, there's only certain times where you can drink. And historically, heavy alcohol use used to be encouraged during those periods to increase unit cohesion and I guess to kind of cope. with some of the difficult things that people experienced, but that has changed quite a lot in recent years. yeah, heavy drinking isn't really encouraged anymore in the military. think there's the high prevalence of alcohol problems is quite well recognized in military personnel and veterans. So do you see like an age difference? So some of the older police officers or the military, did they drink more or was it pretty much the same across all age groups? Yeah, so it tends to be the older age groups that drink more, which I think again is quite similar to what we see in the general population is that all the age groups are drinking more than the younger age groups. And yeah, I think again, it's this change in drinking culture and people being more aware of the harms of drinking and wanting to actually look after ourselves. I think maybe a while, many years ago, we might not have... been as aware of how harmful alcohol is but people are much more aware now. So within this, you think, what do you think we can, so of course, because so I've understood that the basically police have a very kind of similar level of like um heavy drinking, but their mental health is sometimes worse if they're not drinking compared to the general population. But the army seem to have worse drinking problems, but PTSD is around the same. What is that, is that information all correct that I said there just as like a, just like making sure I'm correct on the right page there. So. wait, wait. I I think I think one thing uh which need to clarify or or I I need to check is did you say that if police officers don't drink, they're still likely to have higher mental health than the ones who are drinking to a low level but not to a hazardous level? Yeah. Haz hazardous level. were not drinking and those who are drinking to hazardous and harmful levels, they were all more likely to have poor mental health compared to people who drinking to low risk levels. Yeah, perfect. okay. So m within the police and the army, seems to be maybe, well, in the army, maybe slightly more drinking, in the police force, maybe mental health's a little bit worse. Is there anything that the police or army could be doing? or should be doing differently. Yeah, and as part of my PhD, I worked with a charity called Oscar Kilo, which is a police wellbeing charity. And they have quite a lot of guidance and support on mental health and wellbeing, but they didn't really include anything relating to alcohol use. So through working with them during my PhD, they've now actually added a section to their police wellbeing toolkit, which mentions alcohol use and gives some sort of guidance on you know low risk levels of drinking and the kind of possible dangers of using alcohol to cope with mental health. So they've got that guidance in there and when I did the interviews with police officers they did actually talk quite positively about support for mental health. And they said that there is quite good support available, but no one was really aware of any support for alcohol use. And I think it's quite tricky with the police because there's a bit of a fear of disclosing an alcohol problem because of quite strict regulations on drinking. it's more, it's quite a tricky balance between wanting to ask for help through work, trying to get help through work. balanced with that fear of, you know, possibly losing your job or having sort of your hours or duties reduced. But then in the armed forces, they've been doing a lot of stuff to try and combat alcohol and mental health for a really long time. especially in kind of active duty military personnel, but then in veterans. So there's quite a lot of veterans specific mental health and drug and alcohol treatment services, which is good and unique as well. So they are a really unique group that the experiences of veterans are so different to civilian populations. So some of the work that I've been doing since my PhD is to try and understand treatment pathways for veterans who have got co-occurring alcohol and mental health problems. So I've actually just finished an 18 month project that was funded by Forces in Mind Trust. em looking at the kind of effectiveness of different treatment pathways. We did interviews with veterans to understand their experiences. We did some work with people who provide services as well and then we ended up developing recommendations to try and improve care for veterans who have got co-occurring alcohol and mental health problems. So within the NHS they've got this thing called OpCourage which is a veteran specific mental health service. So it's good that they've got a space to go, but a lot of the veterans who we interviewed weren't aware that it even exists. So I think there's a bit of a mismatch between what's available and people not actually knowing what is available to them or being aware of these services. And you still get this big challenge with co-occurring alcohol and mental health problems where a lot of mental health services won't see people who have got a drinking problem until they've stopped drinking. But that's one of the benefits of op courage is that they actually do allow veterans to get mental health support whilst they still are drinking if they've got drinking problems and they try and do, they're kind of working with some of the drug and alcohol services to try and develop more integrated care pathways. So in a way it seems like actually veteran services might be doing a bit more than civilian services in terms of co-occurring alcohol and mental health problems. That sounds like it, doesn't it? Hmm. think one of the topics that's come up the most on here, mean a good few times the fact if you have any kind of level of addiction and you have mental health problems, a lot of the time mental health problems start and then they use, they self-medicate and the mental health services refuse to those people until they've stopped drinking. But it's a real, it's like a circle that just doesn't stop. it's, yeah, it's, so that's actually, maybe we need to take a page out of the book of the, the article in this place. yeah, we need to learn from the veterans services. absolutely. I mean, w con considering one 'cause this topic comes up a lot and it one of and it is one of the largest barriers for like civilian care. What are the other sort of barriers you've seen working with veterans in terms of integrating care pathways? we've seen some veteran specific barriers, you know, barriers that veterans are maybe more likely to experience than civilians. And one of them relates to those really high levels of alcohol use in military personnel and veterans is because heavy drinking is so normalized, veterans often don't realize that they have a drinking problem. So this means they're less likely to try and get support or they'll delay getting support until their drinking problem has worsened so much that they realize it's a problem. That's normally when it's much more difficult to treat. So that was one of the barriers that we saw. Again, we see that the whole eligibility and not being eligible to mental health services, it is such a huge barrier. another barrier that we saw was that because there are these veteran specific services, not all veterans are aware of those services. So they'll go to civilian services, but these civilian services often just aren't suitable for veterans. And this whole, there's a whole thing about civilian services, not being aware of military culture. And there's almost like a, different language to speak with military personnel and veterans. I think veterans find it difficult to trust service providers who don't speak that language and don't understand the experiences that they've been through. And that came up as quite a big barrier. And it was both veterans and the people that provide services that said that that's a huge barrier is that a lot of services just aren't suitable for veterans. I guess they're going through things that every day, that, yeah, said, civilians just aren't, don't go, don't go through whatever, whatever area they're in. Yeah, I think the big thing was trust, know, like I think veterans are more likely to trust service providers who have that understanding and kind of can speak the language a little bit. And there's quite a few courses, think GPs can do a course, like a military accredited course, and then those GP services become veteran accredited GP services and then I think veterans then have more trust with those service providers who have a bit more of an understanding of their experiences. This this might be blurring into the minorities work, but I feel this is some of the similar things you might get with minorities and them accessing mental health, either the not understanding the culture or the language and what and like certain services which are provided and therefore not trusting them and that's an excellent transition into the other strand of my research is, yeah, I think one of the biggest reasons for ethnic inequalities in both physical and mental health is just these barriers within healthcare. whether that's language barriers or service providers just not having an understanding of culture, but also, you know, just discrimination within healthcare or having previous bad experiences in healthcare settings then means again it's about trust. If people lose trust in healthcare services they're not going to get help for the small things which then become big things and then that leads on to these health inequalities. So sh shall we then talk about your work there because we've tr we've slowly transitioned into it. Um, which is oh I want to know about your COVID nineteen project because you were talking about health inequalities in COVID nineteen. So could you give us a little bit more information on it and then we can go from there? Yeah, definitely. So yeah, so I did my fellowship at the University of Manchester with a really excellent team within the Centre on the Dynamics of Ethnicity. And my first postdoc role, that was looking at kind of physical health outcomes, so COVID-19 infection and mortality. And that involved the biggest systematic review that I've ever done in my life. did almost put me off doing systematic reviews forever because it was so big. But we did a kind of global review of ethnic inequalities in COVID-19 health outcomes. So we tried to get studies from all over the world that had measured ethnic inequalities in COVID-19 health outcomes. And what we found was that consistently across all countries, the minoritized ethnic groups were always more at risk of COVID infection, hostile admission and mortality compared to whatever the majority ethnic group was in that country. It's quite difficult to do a kind of global systematic review and meta-analysis because ethnic groups and the terminology that people use across countries varies really significantly. So one way that we tried to group this all together was to group everyone as being minoritised versus the majority and it wasn't just the numerical majority, was the majority in terms of kind of power as well so it wasn't always the largest ethnic group was the majority ethnic group. m So yeah, so that was the... sorry, go on. ask certain countries, it would be quite s quite strange. So I think the two examples which I was thinking I think it's Kuwait or Qatar, I think it's Kuwait where the majority but the ruling majority is Sunni, but then majority of the population is Shia. Or then countries with like the majority of the population is probably immigrants, like in the UAE, but then the ruling majority is again the Emirati Arab, whatever communities and then the South Africa as well, right? Where like money is probably with the more whiter uh populations, but they aren't the majority. They're the minority when compared to all the groups. So then the dynamics of those also in sort of public health research. Yeah, exactly. And the kind of whole rationale behind this is that we were interested in understanding how those structures of power can disadvantage certain groups. So it's kind of really centered on structural racism and disadvantage and how, you know, the powerful groups have better health because, you know, they have more power, they have better access to... healthcare services, they've got better access to wealth, better access to support networks. So yeah, the emphasis on the majority being based on power was really important for that grouping. What's quite interesting in a lot of European countries, they don't record ethnicity at all. So they're not legally allowed to record ethnicity in healthcare records. like France, any studies that included, that we got from France, it's country of birth that they use. it was a really challenging review to try and group everything together, but it was really interesting to see that across kind of all countries, no matter how they defined ethnicity, you do see that the minoritized groups are more at risk of infection and m hospital admission and mortality compared to the majority group. I think I've got, so I think you've said something like racism is the fundamental driver of the ethnic health inequality as we saw during COVID. m I'm sure some people would have been displeased by that comment. Did you get a lot of pushback on it or were people quite open to that? Do know what? I actually didn't get much push back and I think it was maybe the context at the time. it was the COVID-19 pandemic. It was also not long after the murder of George Floyd and the All the Black Lives Matter movements. And I think it just pushed racism into the kind of forefront of people's minds. And maybe it's just the circles that I associate myself with that people often have similar views. But yeah, and I think it's about how structural racism shapes all other inequalities and how racism leads to inequalities in education, housing, employment, know, where you live, your access to green spaces, the type of job that you have, whether you're on fixed term contracts, whether you have to use public transport to get to work. And it was all of these things are driven by systemic inequalities. And people who are living in more deprived areas as well, they're also more at risk of COVID-19 infection and mortality. But for ethnic minority groups, there's like this double jeopardy of health and inequalities, so deprivation, but also racism. So experiencing discrimination in healthcare services. There's a lot of institutional racism within healthcare. And a really kind of clear example of this in terms of the COVID-19 pandemic is there's the pulse oximetry, I think that's what it's called, that measures your oxygen level. So you put it on your finger and it measures your oxygen level. And they use this to determine whether someone has severe COVID-19. And that determines whether you need to go to ICU and get intensive care treatment. But it doesn't work very well on black skin. So... A lot of black people might have been going and being struggling to breathe and they might have had severe COVID-19, but because of the tools that they used in healthcare settings, they weren't being detected, were getting turned away. And I think that's just a really clear example of how both deprivation and institutional racism come together to create this really big increased risk for ethnic minority groups. Yeah. Gosh, and is this in your analysis? You kind of spoke a little bit more about recent racism and lifetime racism in your analysis. Is it? so this is going on to my fellowship. yeah, after done that work for the postdoc, I wanted to then focus more on mental health. So that was kind of more of my interest was on mental health. And I wanted to see how the impact of the pandemic on the mental health of ethnic minority people, again, quite centered around the role of racism. So I designed my kind of fellowship application. around this data set called the Evidence for Equality National Survey. So that was created by the Centre for the Dynamics of Ethnicity at the University of Manchester. So that was a really big data set. It was the largest data set of ethnic minority people in Great Britain that's ever been created. So I think it had about 9,000 ethnic minority people and about 4,000 white British people. So I used that data to look at how racial discrimination impacted mental health. And this was more focused on interpersonal racial discrimination, where they included, I think they had about 60 questions on racial discrimination. So there was, they asked about experiences of discrimination in 10 different areas of life. So it could have been in employment, housing, with the police. m and then they asked about the timing of it as well, so whether it's in the last year, the last five years, last 10 years. So you could create this really comprehensive measure of discrimination and how that accumulates over time. So I tried to use all of those variables to look at people who'd only experienced recent discrimination, so within the past five years, and people who'd only experienced discrimination a lot longer ago, so about over five years ago. And then people who've experienced racial discrimination cumulatively over their life course, so over five years ago and also in the last five years. And then I looked at how that was related to mental health during the pandemic. So even though, again, this is cross-sectional data, because of the wording of the question, you can almost assume a bit of causality in a way. And what I found was this dose response relationship between racial discrimination and mental health. So the more racism someone had experienced in their life, the more likely they were to report a mental health problem. So the kind of risk of having a mental health problem increased with increasing experiences of racial discrimination. But yeah, important research, very important research. So when you say dose response, did it matter whether it was over five years or ago or was it more recent? Was there three groups or two groups? Sorry, just to understand, was it so? there was no discrimination at all, recent experiences only, past experiences only, and then cumulative experiences only. And so the cumulative experiences group, they had the strongest associations with poor mental health. Then it was the people who had experienced recent experiences of discrimination, which you might expect because... it's happened more recently so it's gonna affect you now whereas maybe if you've only experienced it in the past you might have had it might have had a negative impact on your mental health then but your mental health's okay now and that was compared to people who had had no experiences of discrimination but then because the data was so good i wanted to play around with that a bit more so the I also looked at kind of the number of domains that people had experienced discrimination in em and how many times and that was where we really saw that dose response. So was with increasing domains and increasing number of time points that people had experienced discrimination, that's where you really saw that dose response relationship. Yeah, so I could. How high was the prevalence of like how like if there's you said nine thousand individuals from minority groups from different minority groups being part uh in the in the survey, like how what percentage were experiencing or had experienced some form of racism? That's a very good question and I'm going to very quickly search my paper to try and find it. can imagine. Yeah, it's a... We're asking you for lot of facts. I all these numbers, I'm surprised I remember all the numbers from my PhD to be honest. I should have done more, I just don't want to say the wrong number because I really can't remember what it was. Let's have a look. Okay so 16 % reported past experiences of racial discrimination but no recent experiences. 25 % reported recent experiences of racial discrimination without past experiences and 30% reported this cumulative so both past and recent experiences. So that means there's only 30 % reported no experience of racial discrimination at all. And this is only looking at people who belong to ethnic minority groups. And we included white minoritised groups in that as well. m white Irish and Gypsy traveller and Roma communities as well. very quickly what's the differences between different ethnicities. So I didn't look at that and that was something that I really wanted to look at, but the model was so complicated that it probably would have been possible. It would have been a lot of interactions or I would have had to stratify the data set by the ethnic groups. And I didn't really want to aggregate ethnic groups as well. So that's something that's always been important in the research. And one of the strengths of the evidence for equality national survey is that because they've got such a big sample size, you can look at really detailed disaggregated ethnic groups. So I didn't want a group, black African, black Caribbean, just as black, you know, it was, wanted to, if I was going to look at how these associations differed across ethnic groups, I would have wanted to look at it across, you know, the really detailed disaggregated ethnic groups. So I didn't look at that. And I think that maybe the rationale for that is that it's the experience that's important. know, it's racial discrimination is such a big issue for a lot of people from ethnic minority groups and it's about that experience rather than maybe looking at differences between ethnic groups. It's looking at the real negative impact that discrimination has on mental health. Yeah, I I guess the f I guess similar follow up to like Beths was was it region specific? Like in the sense where where does this data also like kind of account for like certain regions as sort of indices of deprivation? Like are are minority communities in more deprived areas more likely to experience racism than say in like a less deprived area? Oh, that's a really interesting question. I didn't actually look at that and I'm actually, I'm not sure I'd theorise that I would think that discrimination would be higher in more deprived areas. I I mean it wasn't just a deprived thing, but I was just assuming lack of resources more likely to like scapegoat someone or something. That was how I was thinking about it. But yeah. that's that would be my thought process as well that maybe areas where there is more scapegoating and potentially more reform voters that's where you see more racial discrimination. That's also another interesting point, the survey was done during the COVID-19 pandemic and it's possible that experiences of racism have got worse in the past couple of years since then so actually during the time when I started this fellowship, I thought things were getting better because it seemed like the government had quite a big interest on trying to tackle ethnic inequalities. I think especially with COVID and I think the COVID really exposed existing ethnic inequalities in health. And I thought that some good might actually come of that. And it seemed like the government were for a bit maybe. interested in trying to tackle ethnic inequalities in health but now it seems like racism is quite high on the agenda. Sorry for getting political on your podcast. We've had some strong statements, we're here to have them. After you, I I was just gonna move on to the next step. As in are you still doing work with this data now? Do they plan on doing another survey like this?'Cause I mean COVID the during the survey during the pandemic means it was five years ago. So would they be doing one now or soon? so I think the sad thing is that they haven't been able to get funding, I don't think, to do a follow-up survey. So again, this does kind of link back to my previous point about the government and their priorities. During the pandemic, it seemed like there was quite a lot of funding to research ethnic inequalities in health, but now it seems like it's getting more more difficult to get funding for that type of research. I don't think they are planning on doing another study. I'm still doing a bit of work with the data with some people that I used to work with at Manchester and doing some kind of side projects em looking at ethnic inequalities and loneliness in the pandemic and how racism contributes to loneliness. We're trying to explore those pathways of how racism contributes to loneliness and poor mental health. So by creating uh job insecurity or financial insecurity or em not having access to community spaces or living in areas without own ethnic group density and all of those factors. So trying to actually quantify how racism impacts health. That would be very cool. Yeah, it would be. Yeah, the funding is such a problem at the moment. I've discussed this several times this week. But I mean, maybe there wasn't a chance to get around to this, what do you, mean, kind of two questions in one here. How can mental health practitioners be trained to better recognize this kind of racial stress and trauma? m And what would good mental health care look like? m for someone who is in distress and is rooted in experiences of racism. Yeah, so I tried to develop some recommendations through this fellowship research of just how we can improve practice and I think even just being aware of how racism can impact mental health, so as a practitioner when you work with ethnic minority clients to just open that conversation and be aware and actually it's quite interesting I got invited to speak on a panel em that was organised by a group of therapists with other therapists and it was about working with black people and centring black voices in therapy and I an interesting question from a white person in the audience who was like, I'm nervous to speak about racism because I don't really understand it and I think, yeah, it's just about being able to have those conversations even if they might feel a bit uncomfortable. to you and just creating that space where people feel able to talk about it. And also a lot of the times people don't recognize that the experiences that they've had are racism as well. So sometimes, you know, people can be telling a story to a mental health practitioner and maybe just helping that person to realize actually that was racism that you experienced. I think it is just about, obviously there's a whole thing about prevention. If we could prevent racism, that would be great because it clearly has a huge impact on mental health. yeah, trying to prevent it. Practitioners being more open about talking about racism and how that impacts mental health and the role of racial trauma. And yeah, I think just trying to create more equal society and more equal neighborhoods where people have access to some of the things that might improve mental health. So we've tried to look at some of the pathways through racism to mental health and it had kind of indirect effects on mental health through financial insecurity, feelings of loneliness, through a reduced sense of belonging. having more policies around trying to reduce loneliness and help create a sense of belonging in communities. targeting some of those moderating pathways might be a good way to to help as well. Yeah, like I'm sure education is probably one of the first things. I see it some of the parades, it happens to be loads in Liverpool recently, where the kids as young as five or the ones that have been in London, the behaviours, like not, that's not them thinking, that's them doing it probably because their parents are doing it and it's just, yeah. It's a scary time that we're living in. is. is. I mean there's an economic argument as well, right? Like if if X amount of your population is more likely to have mental health or like physiological health issues because of X, Y, and Z reasons then it economically you're gonna be worse off as a nation. As a gov as a government basis it's in probably in your interest to help and make sure there's more equality in access in services and access to services and treatment care and so on. Yeah and you know I haven't even really talked much about what the research that I'm kind of currently doing. I know and I feel like that was a really good segue because I think I've been trying to think about how I can tie in all of the things that I'm interested in and I'm interested in you know alcohol and substance use problems, interested in mental health problems. interested in trauma and traumatic experiences and all the like deprivation. So one thing that I'm trying to go more into now is looking at multiple disadvantages. So how all of these experiences actually do tend to co-occur. So people who have substance use problems and mental health problems also more likely to have experiences with homelessness or involvement with the criminal justice system. So I'm trying to... that's the kind of area that I'm trying to move a bit more into. So I've started doing some work looking into the Family Drug and Alcohol Courts, which is a thing that's been set up. It was set up a while ago and it's been implemented in quite a few regions, but not enough regions because I think it's amazing. So the Family Drug and Alcohol Courts is an alternative to court proceedings where So families have got involved with social services where substance use is the kind of main problem for parents. Usually you just go through kind of care proceedings and at the end of the proceedings, a judge would decide whether your children stay with you or whether they get taken into care. But with the family drug and alcohol courts, a multidisciplinary team works with the families to try and help them to address their alcohol and substance use, their mental health, getting them into secure housing, helping them with kind of experiences of domestic violence or any kind of offending, uh like criminal justice involvement. So they work through these problems with the families over a period of time. And there's some kind of preliminary evidence to suggest that this is really beneficial for families and that children are more likely to stay with their families when they go through the family drug and alcohol courts. They're more likely to stop using substances and have, well, there's not much into kind of mental health. So that's kind of what I want to look into is how the family drug and alcohol courts can work to support people who've got multiple disadvantages. No, the that sounds really, really cool. So but how far along are you with that?'Cause you say you want to look into it some Yeah, so I had submitted a grant to do like a big natural experiment evaluation but I think I maybe jumped a few steps too far ahead in my career stage and eh so it's going to be a feasibility study for a big natural experiment evaluation into how well the family drug and alcohol courts work for people experiencing multiple disadvantages eh but I didn't get that so I'm breaking it down into smaller parts. So I've got bit of internal funding at the minute. So I'm doing some interviews with people who've been involved in setting up the family drug and alcohol courts in Liverpool. So that only opened in April last year. So we're doing some interviews with people who've been setting it up to understand how it works, how it might work specifically for families experiencing multiple disadvantages. What are some of the challenges? and for getting kind of good outcomes or for even just the sustainability of the family drug and alcohol courts. What would help it to stay in Liverpool and achieve good outcomes and what might be some of those challenges? And then we're also going to be doing some interviews over the summer with parents who've engaged with the family drug and alcohol courts. And we want to understand what's the most important aspects for them. So a lot of the studies that do exist have only really focused on whether people have remained with their children at the end of the family drug and alcohol courts or whether they've stopped using substances. But when we've been doing some PPIE work, what we find is that actually em they're not always the most important outcomes for families. So I've also applied for some more funding to do some creative workshops with parents who've been through the family drug and alcohol courts. to understand what outcomes would be important to them, what do they see as the most important benefits of the family drug and alcohol courts, and we're gonna use that to then plan a big natural experiment evaluation. Nice, so basically you've just seen the wider picture, you can see it, which I think is like sometimes the hardest thing that people can get. So yeah, you've basically got to the end already. It's just getting there. That's really exciting and yeah, very much so needed. Sorry, Moose is doing a nightmare. But no, I think sometimes people struggle with the bigger picture and like the wider interpretations of it. So the fact that you already see that and it's now just building steps to get there is insane. And also leads on to my favorite question. She's Right, picture this, Patsy. It is Wednesday, 24th of June. You get an email through. You have been told you have been given two billion pounds. And the ethics committee are away on holiday for two weeks. Like, you know what, Patsy, we like your blue sky thinking. We like, you know, the bigger picture. Do what you want to do. What would it be? Okay right so I think then trying to link most of my research journey together to where I am now and with this focus on multiple disadvantages, I think what I'd want to do is I'd want to set up this intervention where people who are experiencing multiple disadvantages get all of the support that they need in one place. So they just turn up at one place and they get housing support, get drug and alcohol support, they get support for domestic violence and to help prevent future offending behaviour. And they get all of that in one area, one location. And then we follow them up over time and we see how well it works. We see whether it... people can maintain those improvements. We look at the longer term impacts on hospital admissions and mortality. Then we can do some maybe health economics analysis and we can look at the cost effectiveness of this intervention. So actually in my ideal brain, what we'd see is if we gave everyone the support that they needed in one place, then they'd have improved outcomes for a long time. They'd be less likely to use hospital services. They'd be less likely to die prematurely. They'd maybe be more likely to get back into employment and we'd have huge cost savings. And that's why it's worth investing in these services and having holistic and integrated multidisciplinary support for people with multiple disadvantages. Would you have a control group who grew up alongside them without getting all that support? Yeah, get £3 billion now. We just do a before and after, this is what it's like before and this is after, but no everyone in the whole of the country is getting the support. think that's, I agree. I guess kind of like on a kind of broader reflection topic, some of the things you've talked about quite, it's heavy, know, it's mental health, it's inequalities, it's drinking and PTSD and different cohorts. How do you find that? How do you keep yourself motivated? That's a really good question. And yeah, there's definitely been times where I've come away from an interview or a PPIE meeting and thought, you know, I do feel really heavy. You know, some of the interviews with police officers and speaking to veterans about their experiences during the pandemic, when we spoke to people from ethnic minority groups about their experiences of discrimination in healthcare. And it does, it just, it opens your eyes to. some of the really awful things that happen to people but it also motivates you to do the work that you're doing and I think that that's what I've always found is that having these difficult conversations with people who've had really difficult experiences just really motivates me to do the research that I'm doing and I love the research that I'm doing. I do like to think that one day it will make a difference, it feels hard sometimes that you're battling governments but... Mm-hmm. it. really passionate about the research that I do and speaking to people who have had lived experience just really helps to realise why it's important to do the work that you're doing. I I guess a follow-up and cause Beth asked the like the heavier question, the more lighter part is what's your fa what's been your favorite part in the research process? Cause you do so much from systematic reviews to date looking at data to interviews to writing and asking for grants and what's your favorite part? to say one specific favourite thing. So I'm going to say more generally what I just love about research is having the freedom and creativity to do what you want to do. So I that's why I've done so many different things because I get really interested in something and I get obsessed with something I think I need to research. this, so like when I've learnt about the family drug and alcohol courts I thought this is the best thing ever, I have to do research on this. So I think my favourite thing about my research journey is that freedom and create, to be creative and to come up with new research ideas and to just get stuck into something. Awesome. People don't s sometimes don't realize how much creativity actually gets goes down in research. Yeah it's actually really creative and I, do you know what weirdly I never thought that I was a creative person but now I'm doing this podcast I think I am creative because I create these ideas. yeah, and it's like how you kind of connect things of every single thing. I know I said at the start, like, seems very different, but I was like, they'll go together and you've just literally told like a really lovely story about, even when you said like, did my post-Botchenberg fellowship, I was like, well, yeah, but you're going from physical to like mental health within, you know, ethnicities, it all kind of makes sense. So, no, I think you've created a story. Yeah, it's helped me to create my own story. Nice. No, this has been so good that I was like, no yeah it's all been perfect. Good, good. Yeah, really, like, I've been like, it's fascinating for me. There's so much like fantastic bits of research. Yeah, that was really, really interesting. I was phenomenal. I guess then we have one last question to ask, which is, do you have a hot take for us? Ooh, I did think of my hot take actually, what did I... what was my hot take? Oh really thought about this before but now I'm just, I'm so hot myself because it's about 30 degrees, I'm sweating so much. No I think my hot take is that health inequalities are preventable, that's my hot take, is that health inequalities aren't just about kind of health outcomes. It's all of the inequalities that people experience in their lives throughout their entire lives. Like I say, throughout education, you know, even just where you're born, where you live, where you go to school, where you work, all of these things, inequalities and all of those things lead to inequalities in health. And there are things that we can do to reduce inequalities in all of those things that will reduce health inequalities. So that is my... hot take is that health inequalities are preventable. That's brilliant. That's very well put. Yeah, I love that. That was really good. Yeah. Perfect. Is there anything, I don't have to add this in, but kind of, what kind of, if your research could do one thing or, you know, have like a legacy, what would it be? Even just like one sentence. Honestly, if I could just do something that helped some people, I'd be really pleased with that. think all I want is just for... I guess now because I'm really interested in family drug and alcohol courts, if I could contribute in any way to making the family drug and alcohol courts a widespread thing that is just the norm in every um local authority, that would be a nice legacy to leave. Yeah, that's, I mean, you speaking about it. sounds fantastic. And yeah, like a really kind of like relatively simple way to a lot of things that you want to tackle all in one space. Yeah. No. On awesome. So on that note, thank you so much, Patsy, for coming on. Thank you very much for having me. I am going to get an ice cream. oh good. I think I would do exactly the same after this. questions. It was great to speak to you both, thank you so much. thank you so much for joining us and thank you everybody for listening. And till next time, take care. Bye.