Twenty-two Chinese and 47 Pakistani adults took part in the focus group discussions. Twelve Chinese and 43 Pakistani participants lived in post code areas marked with indices of multiple deprivation that were in the top (most deprived) 10% in England, 3 and 18 respectively were not in paid work or studying, and 3 and 9 respectively left school at age 15 years or less (Additional file 1: Table S2). The focus groups were conducted in English, but in the event one older Chinese woman and three middle aged Pakistani women were not fluent in English and translation was undertaken for these participants by the community worker in the former group and other young women participants in the latter. The Chinese woman spoke Cantonese. Occasionally in the Pakistani groups, other participants spoke in their native language and the community worker translated. The native language of the young and middle age Pakistani women was Pashtun. For the middle aged male group it was also Pashtun with the exception of one person who spoke Mirpuri. For the young men and the older men their language was a mixture of Urdu, Pashtun and other Pakistani languages.
Focus group discussion relating to items
All items were thought to be easy to understand with the possible exception of item 1 (optimism) among the Pakistani women. One of the younger women in the middle age group informed us that there was no translation for the word ‘optimistic’ in Pashtun. Although most in the group felt they understood the word, some understood it as ‘happy for the future’ and it was not clear that the expectation that things would work out well was understood.
One item was thought to have potential for misinterpretation. Young men, in both Chinese and Pakistani groups interpreted the item ‘feeling interested in other people’ in a sexual context.
‘Yeah man, girls! [YPM1]
Although all participants found the items easy to understand one young Pakistani man was concerned that others might not understand the items because they were not used to personal reflection. He gave this example.
‘I know a lot of people in my college ………. they’d struggle to understand. …it’d just be like I’m interested in new things. …I want to go out and get new trainers… You know’ [YPM2]
Questions which required generalisation across settings, particularly feeling relaxed and useful, were considered difficult to answer by some participants.
“This question is a bit vague, as in you mean useful at work? Useful at home?” [MPM1]
Discussion relating to the scale and coverage of concepts of well-being
Some participants observed that the WEMWBS was good to complete because it made you think about your life in terms of mental well-being. Participants in both ethnic groups talked of the importance of interpersonal relationships for mental well-being. Both groups also discussed concepts relevant to mental well-being that were not covered by the scale.
Chinese participants in general espoused an internal model of mental health, believing that it depended on your own actions and attitudes. This belief came over very strongly in all three age groups, which also encompassed people from a range of socioeconomic circumstances. The youngest group in particular expressed the view that it was unfair to burden others with your problems and that mental resilience and strength was a virtue.
It’s how you think really isn’t it? And how positive you are in life affects your well-being. [YCW1]
Your life is in your own hands. It’s down to you. You don’t blame other people for your life. [YCW2]
The Chinese tended to be dismissive of depression believing that it was over diagnosed in England.
Both groups expressed the belief that hardship was to be expected. Some went as far as to say that suffering was character building. The middle Chinese group (aged 25–49), who were mostly professionals, pointed to the importance of physical activity for mental health saying that going to the gym would give you more energy when you were feeling tired.
Most of the Chinese group was atheist, but there were two Christians. The Christians interpreted happiness as an expression of love. They said that happiness was reciprocal, in the sense that love generates love and happiness in the person who is loved.
Pakistani participants espoused a more social model of mental health. Men talked of depression in middle aged women born in Pakistan who took many years to adjust to living in England. They saw worries about the family and financial problems as the major cause of mental suffering. Men also talked about anger and frustration arising from unemployment and the problems that unemployment caused within families where the father was the only breadwinner.
But when wife got nothing – I’m not working – I’m at home yeah – She shouts at me. She shout at me that I’m here. What you doing at home? What should I do? I’m finding job I can’t find a job… . [OPM1]
They also spoke of not being able to admit to mental health problems.
You know like we’re supposed to be like these warrior people. If you do show signs of mental illness [..] it will show a weakness saying you are not all a man. [MPM1]
The item “I’ve been able to make up my own mind about things” provoked discussion in all Pakistani groups, but attitudes to autonomy and its importance for mental well-being varied. The item was perceived to implicitly value individualism, which was not universally considered a good thing. Some of the women believed that decisions, other than the most trivial, should be made with the advice of family, close friends and relatives.
“In this community you ask your elders for advice” [MPW1]
“You like other people’s opinions … family members – you’d ask them am I making the right decision?” [MPW2]
Some men gave a more considered view.
“I think of it from different sides. If you’re a bit arrogant OK then … Could be arrogance ...... But then if you’re completely indecisive then that would be a mental problem”. [MPM2]
On the other hand, many young men and women wished to have more freedom in important decisions such as marriage (men) and going to university to study (women) than the family and community allowed. One young man felt it was important to be able to make your own decisions,
“You can’t let people walk all over you. For example you know living your life for you I mean. You’ve got your own life haven’t you? ................. You need to be your own individual and make your own decisions.” [YPM2]
Some young women felt able to make their own decisions while others felt they were not allowed to and others still did not feel capable of making them.
“I’ve no choice”. [YPW3]
“I want to look to others quite often for advice…… I can’t make up my mind on my own”. [YPW4]
FT So do you think that’s a good thing or would you like to be more able to make up your own mind?
“Your confidence…”. [YPW5]
“Yeah I think I’ll always be like that” [YPW4 …]
Conflict between western and traditional ways of life in which careers and lifestyle choices were arranged for sons and daughters was considered detrimental to mental well-being.
Older Pakistani women stressed the importance of a Pashtun word which roughly translated as ‘responsibility’. Both men and women in the Pakistani groups mentioned the spiritual interpretation of mental well-being in their community and the practice of consulting local religious leaders as well as respected family members about problems. Some espoused the Islamic view that prayer five times daily would maintain good mental health while for others this was seen as a temporary solution which could not solve problems such as unemployment.