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After decades of refugee displacement, Somalis are at increased risk for poor mental health. However, uptake of treatment referrals in primary care is low among Somalis compared to other refugee groups. The objective of this analysis was to understand specific resistances to US mental health care contributing to this gap in coverage. One hundred and sixty-eight Somali men and women over the age of 14, participated in 28 focus group from October 2017 to November 2018 discussing wellbeing and healthcare in the US. Transcripts were analyzed based on critical discourse theory, informed by the theoretical work of Michel Foucault. This study identified two primary discourses, one biomedical and the other driven by Somali community mental health knowledge and social practice. Mental health as an object of Muslim faith, nosological fusion of psychiatric illness terms, and stigmatization and internal social control to limit disclosure were discussed. US mental health services were described as giving off a bad vibe, and represented external institutions of power, exacerbated by perceived discrimination. Somali youth occupied social bridging positions between cultural vs. US knowledge and practice. Three negotiating discourses emerged wherein participants created discursive solutions to these sites of resistance, including 1) how the social acceptability of seeking psychological care might be increased while maintaining Somali emotional resilience, 2) stressing the need to seek medical care as a practical supplement to spiritual care, and 3) highlighting the need for Somali youth to enter health fields. Findings suggest that intervention strategies not only ensure that services are culturally appropriate and sensitive to religion, but also consider that services are potentially seen as both an extension of US institutional power and an affront to Somali identity making. Overcoming these challenges may involve nurturing the negotiating discourses taken up by communities. • Biomedical mental health discourse is incongruent with Somali identity making. • Participants found their own discursive solutions to these incongruencies. • Cultural values of pragmatism and bravery may offset mental health stigma. • Somali youth hold vast social and societal potential to bridge this divide. • Successful interventions will nurture communities' existing discursive solutions. [ABSTRACT FROM AUTHOR]

Across the globe, people are not equitably included or respected by health services. This results in some people being 'hardly reached' and having less access to safe and appropriate care. While some health services have adopted specific agendas to increase inclusion, these services can struggle to implement such strategies because the underlying reasons for exclusion have not been addressed. This calls for preparation prior to implementation of inclusion approaches that deconstructs discourses and practices of exclusion. This paper presents a pre-inclusion framework that seeks to deconstruct exclusion in health services. Authors developed this framework from action research in four 'mainstream' regional health services in southeast Australia over five years. Research identified dominant discourses of exclusion among staff in these services. The study also identified common experiences of residents hardly reached by these services. Following, a range of change activities were undertaken within these services to deconstruct exclusion. Researchers also kept journals, reflected on their impact, and identified lessons learned from trying to deconstruct exclusion. Triangulating these analyses, researchers developed an interdisciplinary framework that weaves together Foucauldian theory on power/discourse with continuous quality improvement processes to embed cultural humility and voices of the hardly reached in health care. The framework outlines five foundational concepts (power as productive, deconstruction, use of continuous quality improvement processes, cultural humility and voices of service users), followed by six principles (a journey, expect resistance, whole of service approach, make visible the reasons for change, we are all cultural beings and people centred care) and six actions undertaken within health services (commitment, assessment of exclusion, action plans, structural change, reflective discussions and engagement). Until such approaches to deconstruct exclusion are implemented, inclusive agendas are likely to be ineffective. • Before inclusion can be achieved, reasons for exclusion must be challenged. • Pre-inclusion readies a health service for engagement with those hardly reached. • This framework weaves Foucault, cultural humility, those hardly reached and CQI. • The framework aims to rupture power relations to privilege discourses of service users. • Health practitioners learn about their privilege and actions of exclusion. [ABSTRACT FROM AUTHOR]