Community-Defined Solutions for Latino Mental Health Care Disparities
COMMUNITY-DEFINED SOLUTIONS FOR LATINO MENTAL HEALTH CARE DISPARITIES
California Reducing Disparities Project Latino Strategic Planning Workgroup Population Report
Executive summary
On behalf of the California Department of Mental Health (CDMH), we are pleased to present the research results of the California Reducing Disparities Project (CRDP): Latino Strategic Planning Workgroup (SPW). This Executive Summary offers a brief background of the CRDP Project, followed by an overview of the research purpose, mental health status of Latinos, key findings, community-identified strategies for improving mental health treatment, and strategic directions and recommendations for reducing health disparities in Latinos.
This project examined mental health disparities for the Latino population. Our aim was to develop and implement the appropriate process for identifying community-defined, strength-based promising practices, models, resources, and approaches that may be used as strategies to reduce disparities in mental health. To accomplish this goal, we adopted a set of topics from the California Department of Mental Health (2009). We also adopted the community-based participatory research (CBPR) framework from Minkler and Wallerstein (2008) to ensure a continuum of community involvement that over time builds and strengthens partnerships to achieve greater community engagement (McCloskey et al., 2011).
Our overall findings suggest that racial and ethnic minority groups in the U.S. fare far worse than their white counterparts across a range of health indicators (Smedley, Stith, and Nelson, 2003). Non-white racial and ethnic groups now constitute more than one third of the population in the United States (Humes, Jones, and Ramirez, 2011), and as the nation’s population continues to become increasingly diverse, the passing of the health care reform law (Andrulis, Siddiquui, Purtle and Duchon, 2010) becomes a critical piece of legislation in advancing health equity for racially, ethnically, and sexually diverse populations.
The California Reducing Disparities Project
In order to reduce mental health disparities, improve access and quality of care, and increase positive outcomes for racial, ethnic, LGBTQ, and cultural communities in California, the California Department of Mental Health launched a statewide Prevention and Early Intervention initiative effort utilizing allocations authorized under Proposition 63, known as the Mental Health Services Act (MHSA), to fund the California Reducing Disparities Project. The project focused on five populations: (1) African Americans; (2) Asian/Pacific Islanders; (3) Latinos; (4) Lesbian, Gay, Bisexual, Transgender, and Questioning (LGBTQ); and (5) Native Americans. As part of the project, five Strategic Planning Workgroups (SPWs), corresponding to each population, were created to provide the California Department of Mental Health with community-defined evidence and population-specific strategies for reducing disparities in behavioral health.
The Prevention and Early Intervention (PEI) initiative is key to reducing disparities and risk factors, and building protective factors and skills. The National Research Council and Institute of Medicine (NRC/IOM; 2009) defines “prevention” as programs and services that focus on “populations that do not currently have a disorder, including three levels of intervention: universal (for all), selective (for groups or individuals at greater than average risk), and indicated (for high-risk individuals with specific phenotypes or early symptoms of a disorder). However, it also calls on the prevention community to embrace mental health promotion as within the spectrum of mental health research” (p. 386).
The first activity of the Latino Strategic Planning Workgroup occurred in May 2009 when 15 individuals who are researchers, policy makers, public mental health leaders, consumers and advocates, community health leaders, ethnic services managers, and education professionals attended a one-day meeting. The initial meeting consisted of (1) a presentation and discussion of the overall goals of the Latino SPW; (2) a presentation of the CBPR model as a framework to guide the work of this stakeholder group; and (3) the creation of the California Latino Mental Health Concilio (see Appendix 2 for a list of the Concilio members). The Concilio is a core stakeholder group representing a range of constituencies and various age groups. The Concilio included mental health consumer advocates, ethnic services managers, mental health providers, promotoras, educators, and representatives of a variety of groups, including migrant workers, juvenile justice workers, and LGBTQ individuals. The California Department of Mental Health supplied funding that enabled the University of California, Davis, Center for Reducing Health Disparities (CRHD) to develop the Latino SPW and plan and execute the Latino SPW’s objectives and activities. The UC Davis CRHD was selected because of its history in studying and addressing mental health issues among Latinos in California. Moreover, at the meeting, the Latino SPW sought to develop a long-term research and policy agenda to help sustain strength-based strategies for reducing disparities in mental health services for Latinos in California.
Mental Health Status of Latinos
Many foreign-born Latinos entered the U.S. as migrant workers and, after years of hard work, brought their families to settle permanently in this country. However, the immigration process and transition from their country of origin to the U.S. has been difficult for this segment of the Latino population. Most have become susceptible to increased pressures to acculturate and assimilate, and additionally deal with stress from hardship and poverty that often accompany these difficult transitions. As a result of immigrating to the U.S., many Latinos have endured a range of life stressors and experiences (e.g., poor housing, abuse, trauma, stigma, and discrimination) that when left unaddressed and unresolved can lead to mental health problems.
The lack of culturally and linguistically appropriate mental health services (e.g., in the preferred language of clients), compounded by mental health stigma, keeps many Latinos with mental illness from seeking services. A lack of sufficient bilingual and bicultural mental health professionals usually translates into language barriers and often results in miscommunication and misinterpretations. Language is an important factor associated with the use of mental health services and the effectiveness of treatment. Unfortunately, the number of Spanish-proficient providers remains insufficient to meet the needs of Latinos, especially monolingual immigrants. Latinos with limited English proficiency frequently do not have critically important information, such as how and where to seek mental health services. Moreover, language barriers contribute to the problems Latinos face when accessing public transportation to visit mental health clinics and to the difficulties that they encounter with completing required paperwork at clinics.
Access: Individual, Community, and Societal Barriers to Care
The central focus of this study was to identify effective, community-defined practices for increasing awareness and access to mental health services and to improve prevention and intervention for Latinos in California. This portion of the report is organized into three major areas: (1) individual- level barriers, (2) community-level barriers, and (3) societal barriers.
Key Finding 1: Study and forum participants saw negative perceptions about mental health care as a significant factor contributing to limited or no access to care. Among the many concerns, stigma, culture, masculinity, exposure to violence, and lack of information and awareness were the most common.
Forum participants reported that limited or no access to mental health services was a significant factor affecting the mental health of the Latino community. The participants also cited barriers to accessing mental health services and identified many causes related to these barriers. The content analysis of the Mesas de Trabajo summaries and focus groups generated five major themes related to individual-level barriers: (1) stigma associated with mental health problems, (2) cultural barriers, (3) masculinity, (4) violence and trauma, and (5) lack of knowledge and awareness about the mental health system. We have outlined each barrier, and included quotations to allow the reader to understand the views of the forum participants in their own words.
Key Finding 2: A substantial proportion of the Latino participants believe that limited access and underutilization of mental health services in the Latino community are primarily due to gaps in culturally and linguistically appropriate services, in conjunction with a shortage of bilingual and bicultural mental health workers, nonexistent educational programs for Latino youth, and a system of care that is too rigid.
From the content analysis, four persistent community- level themes emerged throughout the Mesas de Trabajo. The themes, which are barriers that contributed to inadequate care and overall poorer mental health and outcomes, included: (1) a shortage of culturally and linguistically appropriate services, (2) a shortage of qualified mental health professionals, (3) a shortage of academic and school-based mental health programs, and (4) structural barriers to care. These four key themes were viewed as common areas of concern in addressing the causes of mental illness, and were considered barriers to accessing and utilizing mental health services.
Key Finding 3: Participants identified social and economic factors as major causes of mental illness and significant barriers to achieving and sustaining wellness among Latinos.
Social determinants of mental health were an overarching theme across all groups. Social determinants refer to the social conditions in which people grow, live, work, and age, and which have a powerful influence on people’s health (Commission on Social Determinants of Health, 2007). The content analysis revealed the following three key barriers: (1) social and economic resources and living conditions, (2) inadequate transportation, and (3) social exclusion.
Strategies to improve access to existing programs and services
This section of the report identifies and describes strategies that address the issues relating to reaching out and engaging the Latino community in California. Specifically, it focuses on identifying community-defined strategies to improve access, quality of care, and increase positive outcomes for Latinos in California. This portion is organized into two major areas: (1) community and cultural assets, and (2) community-identified strategies for prevention and early intervention programs.
Key Finding 4: Participants identified community assets that promoted the mental health of their communities. Our data indicated that the elements that are critically important in improving access to care consist of five community and cultural assets: (1) individual and community resiliency; (2) family involvement; (3) church and religious leaders; (4) community role models and mentors; and (5) community Pláticas.
Community assets and strengths can be understood as the total participation of individuals and community organizations coming together to mobilize and leverage existing community resources to improve access to existing programs. Participants believe that co-locating services is a strategy that can maximize community resources and give families and consumers a voice in their recovery. Co-location is an approach through which community-based organizations collaborate and share resources to better serve the Latino community.
Key Finding 5: Participants recommended that prevention and early intervention can best be achieved by following six strategies: (1) school-based mental health programs; (2) community-based organizations and co-location of services; (3) community media; (4) culturally and linguistically appropriate treatment; (5) workforce development to sustain a culturally and linguistically competent mental health workforce; and (6) community outreach and engagement.
Our data indicated that the practice of co-locating services may play an important role in building a mental health infrastructure that is culturally relevant and comfortable for the Latino community. The participants outlined numerous potential benefits of co-locating services for Latinos. For example, one ethnic services manager (ESM) participant remarked, “Latino families benefit when agencies collaborate and share resources within the community, as opposed to making the consumer come to our agency.”
Evaluation and Outcomes
Key Finding 6: Participants identified four major evaluation areas: (1) reliability and relevance; (2) knowledge and commitment to serving Latinos; (3) consumer and family participation; and (4) accountability panels. Participants perceived these areas as key components to measure and achieve positive outcomes in which Latinos would access mental health services based on the community-defined evidence practices, have high retention rates, and experience high-quality services.
Across all forums, participants emphasized that mental health agencies need to demonstrate commitment to serving Latino communities. In other words, their recommendations suggested that mental health programs receiving funding to serve Latinos and improve mental health disparities for Latinos should be required to produce outcomes that demonstrate increases in access to services, improved retention rates, reduced dropout rates, and increased quality care. One participant recommended linking funding with the number of Latinos served and determining the effectiveness of follow-ups according to the number of consumers who terminated treatment early.
Prevention and early intervention evidence-based community identified strategies for improving mental health treatment
Core Strategy 1. Implement peer-to-peer strategies, such as peer support and mentoring programs, that focus on education and support services.
Core Strategy 2. Employ family psychoeducational curricula as a means to increase family and extended family involvement and promote health and wellness.
Core Strategy 3. Promote wellness and illness management, and favor community-based services that integrate mental health services with other health and social services.
Core Strategy 4. Employ community capacity-building strategies that promote the connection of community-based strengths and health to improvements in Latino behavioral health outcomes.
Core Strategy 5. Create a meaningful educational campaign that is designed to reduce stigma and exclusion and that targets individuals, families, schools, communities and organizations and agencies at the local, regional, and statewide level.
Strategic Directions and Recommendations for Reducing Mental Health Disparities
Strategic Direction 1: Academic and School-Based Mental Health Programs
Focus on adolescents and the impact of failing to adequately detect and diagnose potential mental health issues in a timely manner. Schools represent a safe setting to educate families and their children about mental health. Tie mental health programs to academic achievement and performance.
Strategic Direction 2: Community-Based Organizations and Co-Locating Services
Increase collaboration among community-based organizations, schools, and other social services agencies by coordinating and maximizing community resources to achieve an increase in access to treatment among Latinos.
Strategic Direction 3: Community and Social Media
Use mainstream and Latino media to raise mental health awareness with messages that reduce stigma associated with mental health disorders and promote information and resources about early intervention.
Strategic Direction 4: Workforce Development
Develop and sustain a culturally competent mental health workforce consistent with the culture and language of Latino communities.
Strategic Direction 5: Culturally and Linguistically Appropriate Treatment
The key to providing high-quality care and treatment to Latino communities lies in instilling in mental health providers and support staff the importance of communicating with each consumer in a way that acknowledges the consumer’s beliefs about mental health.
Strategic Direction 6: Community Capacity-Building and Outreach and Engagement
Provide resources for grassroots community capacity-building strategies that focus on: (1) strengthening outreach and engagement; (2) building behavioral health leadership in the Latino community; (3) defining behavioral health outcomes at the community level and in terms that matter to Latinos; and (4) building local capacity aimed at reducing disparities and improving behavioral health outcomes. The capacity-building strategies should focus on convening and developing partnerships amongst mental health professionals and the indigenous community leaders to develop and strengthen their relationships. Through these partnerships, they should collaboratively implement strategies highlighted in this report and continue to develop ways in which they can act together to reduce disparities and improve behavioral health outcomes. In addition, resources should be allocated to create partnerships between community leaders associated with local capacity-building efforts and existing statewide leadership within the Latino behavioral health field to develop strategies to support local community capacity-building and implementation of the recommendations outlined in this report. Resources should be allocated to convene local and statewide leaders to educate them about the SPW recommendations and to disseminate them through a summit, educational campaigns, and other activities to best meet the needs of the Latino community.
Strategic Direction 7: Embedding the Recommendations from this Report into All MHSA Funded Programs
Encourage counties to adopt and implement the recommendations from this report to ensure that Latinos and other diverse underserved communities gain proportional access to MHSA programs.
Despite many commonalities across the various Latino groups, the existence of cultural, linguistic, educational, and socioeconomic differences sometimes requires classification of Latinos into sub-populations for investigative purposes. Distinguishing among Latino subgroups from different regions and examination of their demography, history, culture, and views on mental health are important for future research. Health professionals and researchers should not attempt to characterize all Latinos as one homogenous group and ignore between and within-group heterogeneity. Therefore, strategies and recommendations for providing mental health care for Latinos must not be based on a “one size fits all” recipe (Aguilar-Gaxiola, Sribney, Raingruber, Wenzel, Fields-Johnson, and Loera, 2011; Aguilar-Gaxiola and Ziegahn, 2011; Willerton, Dankoski, and Martir, 2008).
