Final Report Jeffrey G. Reitz, Ph.D.
Table of Contents
Executive
Summary This review of nearly 400 publications from Canada, the US, Britain and Australia has identified a large number of studies supporting the conclusion that very often, recent immigrant groups experience low rates of utilization of many important social and health services, despite evidence of significant need. The barriers most often identified include those related to language, lack of information about services, cultural patterns of help-seeking, lack of cultural sensitivity by service providers, financial barriers, and lack of service availability. Because of the problem of cultural appropriateness of services, the research focus on rates of utilization may actually underestimate the barriers in access to service. Where services are used but are not appropriate to the culture of a group, equivalent benefits may not be derived. Hence access should be considered to be correspondingly less. The specific barriers to service delivery identified in the research varies according to type of service, the nature of the service delivery itself (which varies from one location to another), and minority group. The best studies most closely related to the human and family services fields are studies of minority group access to mental health services. In the human and family services field, service delivery is less standardized, and there are fewer organizational and financial resources to support extensive research. However, barriers in access to services are reported for most types of services, and in most jurisdictions. Access barriers also affect social assistance (welfare) utilization, and in Canada rates of social assistance utilization are lower for ethno-racial minorities than for the general population. In fact, contrary to widespread concerns, research on the net impact of immigrants and minorities on the public treasury consistently show that these groups receive public services below the level to which they would be entitled based on their tax contributions. A large number of innovations have been proposed by researchers and agencies. These include: improved outreach and service information; locating agencies in areas of minority concentration; provision of multi-lingual services; "ethnic match" (providing or referring to ethnic-appropriate minority-group service providers); multicultural training and cultural sensitivity; minority service units; inter-agency coordination; less formalized or bureaucratized service delivery; adoption and diffusion of equity policies; community consultation; action research to establish minority group needs; support for ethno-specific agencies; coordination of ethno-specific and mainstream agencies. Some of these innovations have been implemented; a few have been evaluated. Practitioner training programs increasingly emphasize the problem of cultural sensitivity and service barriers, reflecting both an awareness of needs and a judgement that this awareness is insufficient in the field. However, no formal assessment of practitioner awareness has been conducted. Evaluation of impact includes both impacts on utilization, and impacts on client well-being; the evidence suggests more effects on the former. Innovations designed to enable mainstream agencies to overcome information barriers, and language barriers would appear to be warranted, but there are not evaluations of their impact. "Ethnic match", which ensures that members of minority groups have the opportunity to be served by members of their own group, appears to have impacts on utilization. "Ethno-specific" agencies take a variety of forms. Evidence, the best being from the US (mainly in New York and California), suggests that ethno-specific agencies, both those fostered by state and local government initiatives, and those arising from within the minority communities, have significant benefits effects in boosting service utilization. The impact on client well-being is more difficult to assess, because of outcome measurement problems. However, the available evidence does suggest that in many instances, services provided by ethno-specific agencies are of at least equivalent quality, and may be more effective because they are more closely suited to client needs. One study suggests that cost efficiencies are achieved because the burden on emergency services is reduced. Many specific features of models for ethno-specific agencies have not been evaluated fully (e.g. forms of inter-agency cooperation). Some findings apply across minority ethno-racial groups; some do not. The reluctance to seek professional help for mental health problems seems to characterize most groups. However the reasons vary markedly among Asian, Hispanic and Black groups. Problems vary according to economic and occupational position, and immigration background (with an important distinction between refugees and others). The current research priorities should include attention to the lack of information on different minority group utilization rates for different services; lack of information on the relative importance of barriers which restrict equitable access to these services; lack of information on the consequences and costs imposed by these barriers, both on individual minority group members, and on the community at large; and lack of information evaluating the impact of promising innovations on costs and on community benefits as well as client benefits. 1. Objectives, Terms of Reference, and Introductory Comments 2. Service Delivery: Access, Utilization, and Barriers
3. Knowledge of Needs of Minorities by Mainstream Agencies 4. Promising Service Delivery Models and Management Strategies 5. Generalizability of Findings Across Ethno-Racial Groups 6. Research Issues and Priorities Bibliography with Selected Annotations This report was prepared under the guidance of a Steering Committee composed of representatives of the Multicultural Coalition for Access to Family Services (MCAFS), Toronto, and the Ontario Ministry of Community and Social Services (MCSS). Funding was provided by MCSS. The author gratefully acknowledges the valuable advice and support of Vasco Cabral and Tarik Khan of MCAFS, and also the professional assistance of Lisa Brisebois (project manager), Richard DeMarco, Suzanne Dudziak, Stephanie Potter, and Gangaram Singh. Ted Richmond of the Ontario Council of Agencies Serving Immigrants arranged a focus group session on issues addressed in the report. The report was prepared independently, however, and all responsibility for the contents of the report rests with the author. 1. OBJECTIVES, TERMS OF REFERENCE AND INTRODUCTORY COMMENTS Objectives. The objective of this report is to provide a state-of-the-art review of Canadian and international research on aspects of equitable ethno-racial access, utilization and delivery of social services. Based on this research, insofar as possible, the report describes and analyses barriers facing ethno-racial communities in the accessibility of social services, identifies the effectiveness of models proposed to overcome these barriers, and provides a guide to research issues and needed research in the area. Regarding service delivery, the following four questions will be examined:
Regarding research issues, the review includes an assessment of the following issues:
Groups Included. The specific focus of the review will be on immigrant minorities in Canada, and on research most relevant to an understanding of barriers to social service utilization experienced by these groups. Thus, the review does not include aboriginal persons or the question of equity between anglophone and francophone Canadians, since these groups occupy quite distinctive positions within Canadian society, and the factors affecting social service utilization in those groups will be quite different from those affecting immigrant minorities. On the other hand, the review includes research on immigrant and other minorities in other countries, especially the United States, the United Kingdom, and Australia, where this seems relevant to the situation of immigrant minorities in Canada, even though barriers to utilization may be somewhat different depending upon the situation of the group and the nature of the service in these different locations. Within groups and where possible, attention is given to populations with special needs, such as recent immigrants, refugees, women, children, the elderly, or the poor. Services Included. The main types of social services of interest are what are sometimes called the "human services." They include child protection services; day care; personal and family counselling; hostels, shelters, and home care for the elderly, or other populations at risk; services to the disabled or to those in receipt of social assistance; and the like. Health care services are not a priority for the review, because the delivery of health care services involves distinctive constraints, and problems of access can be quite different from what occurs in the human services field. However, mental health services are included because they are more closely related to the human services described above, and because there is a large amount of research available on minority group access to mental health services. Access to social assistance -- meaning direct cash payments to support the poor -- is included as a topic where the research seems useful or applicable. Immigrant settlement services have not been specifically identified in the review. These services are intended only for immigrants to assist in problems related to settlement and are not provided for the general population, so problems of equitable access in relation to that population cannot be addressed. Education and job training are not included, because their program delivery structures usually are quite different. The services included in the review are quite diverse, and are delivered through a variety of organizational means. It is anticipated that problems of access will be highly service-specific, and will vary considerably from one service to another. Access issues may be greater for certain sensitive services such as intervention in family conflict, or adoption, or mental health services. The review must be sensitive to these variations. Access problems may be specific to a particular group, in a particular time and place, because of group attributes, or because of the nature of the service itself in that time or place. Barriers to a given service in one country such as the United States, for example, do not necessarily imply that there will be comparable barriers in other countries such as Canada. The service may be organized differently across different jurisdictions. So the assessment of barriers must analyze the specific barriers with sensitivity to the organization of the service. Equitable Access to Services. The concept of equitable access to services for ethno-racial minorities is not a simple concept. Equitable access includes the three aspects of utilization, needs, and benefits. Our question is: do ethno-racial minorities use services they need, and do they receive intended benefits? Utilization of services by ethno-racial minorities must be assessed compared to use in the dominant ethno-racial population. Low rates of utilization in a minority group do not imply the existence of inequitable barriers, if the same service also has low rates of utilization in the general population. There may be barriers to utilization which apply across the board to all population groups. These barriers are not the concern of the present review. Rather, the concern is with barriers which affect ethno-racial minorities specifically, and block their access to services which are more readily available to other groups. Equitability implies that utilization be equal in relation to need. Whether a given level of service utilization in a minority group is equitable (compared to the general population) depends on whether that level of utilization bears the same relation to group needs. Establishing both the level of group needs, and also the specific nature of the service needed, may be quite complex when the subject is culturally-sensitive, such as is often the case with family issues, child welfare, or the status of the elderly. Finally, services used must be sensitive to the particular needs of the group, and must be designed so that intended and appropriate benefits are derived. A service which is available but which is designed only with the needs of the dominant population in mind, or which is sensitive only to cultural standards in the dominant population, may not confer any benefits to minority group members who use them. Without these benefits, access to the service cannot be said to be equitable. Because of the difficulty in establishing minority group needs compared to those of the dominant populations, and the problems of deciding how (or even who) should define those needs, the criterion of derived benefits is useful. In effect, it is suggested that services can be said to address needs equally if the services yields benefits which are equal. Hence, we provide the following definition: ethno-racial access to social services refers to the extent to which minority group members receive the benefits of social services which they need and to which they are entitled, in a form appropriate to the culture of the group, and on an equitable basis. Annotated Bibliography. A bibliography of nearly 400 items is included as part of this review. This bibliography, while large, is selective in certain respects, and is by no means exhaustive. Academic research on human service utilization in Canada is very limited, so efforts have been made to include all such research in the bibliography. The bibliography also includes as much of such research for other countries as it has been possible to locate. Most of this research is from the US and Britain. The review also attempts to include research by community groups where this is judged to have been of good quality and/or particularly influential. Minority access to mental health care and physical health care is far more extensively researched, not only in Canada, but especially in the United States and other countries. Hence, the bibliography is more selective in these fields, and in fact includes only a few representative items on minority access to physical health care. Government reports on access to social services have been selected to illustrate a variety of approaches to the subject. Reports are included from Toronto, from elsewhere in Ontario, from British Columbia and Quebec, and very selectively from the US, Britain, and Australia. The annotations also are selective. The level of attention to particular items reflects the role of the item in the review process. Some items received less attention because they were similar to other items which were reviewed in more detail. 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