Final Report Jeffrey G. Reitz, Ph.D.
Table of Contents
Executive Summary 2. SERVICE DELIVERY: ACCESS, UTILIZATION, AND BARRIERS Human Services: Access, Utilization and Barriers. A number of studies across Canada, the US, and Britain support the conclusion that, very often, recent immigrant groups have low rates of utilization of various social services, including human services, health services and mental health services, despite evidence of significant need for such services. Furthermore, there is a consensus on the importance of the following barriers most frequently indicated:
However, because of the nature of the evidence for these barriers, it is not known precisely how these barriers vary by type of service, jurisdiction, or by specific minorities or special populations within minority groups. Canadian studies. Canadian studies which have included the human services are based largely on surveys of service providers, and service consumers. For both groups, the studies have measured perceptions of barriers to service. In addition, consumers are able to report on their own experiences with specific services. While these studies provide convincing evidence regarding barriers to service, they do not yield precise measures of the extent of the barriers, the relative importance of barriers, or differences among services or specific minority groups. In Ontario, the first major study on minority access to services was a study in Toronto by Doyle and Visano (1987), sponsored by the Social Planning Council (SPC) of Metropolitan Toronto (a private non-profit social policy advocacy organization). Barriers were measured by questions asked of a sample of service-providers in 135 mainstream organizations, plus a sample of service consumers obtained from the organizations and expanded by the "snowball" technique. The study also surveyed key informants from 40 ethno-specific organizations. The study found that the vast majority of service providers in all types of organizations believed that important service barriers existed. These barriers include (1) lack of knowledge of services available, (2) lack of knowledge of English and French in minority communities (and lack of interpretation services in the mainstream organizations), (3) the location of services remote from consumers, (4) lack of culturally appropriate services, (5) administrative barriers such as waiting lists and forms often in English only, and (6) costs related to day care and transportation. The SPC survey of consumers provided support for the existence of these barriers. In addition, a review of health and social service policies at various levels of government showed some limited attention to the problems of minority access. Possible methods for overcoming the barriers were identified in focus group discussions and by case studies of specific innovations. These methods include providing better information on available services in languages other than English, hiring and training multilingual and culturally sensitive staff, representing minority groups on decision-making bodies, and a variety of other more specific measures. Many specific measures were already being pursued to some degree in specific organizations. Problems of funding, and the relation between mainstream and ethno-specific agencies were also addressed. Seven types of services were included, but the results are not reported separately for specific services. The Toronto SPC study was a model for similar studies in Ottawa-Carleton by Betty Bergin (1988) and in Hamilton by Gloria DeSantis (1990). Nine studies including those conducted elsewhere in Ontario, in Edmonton, and in Vancouver, were reviewed for Multiculturalism and Citizenship Canada by Bergin (1992). The results were essentially similar. The SPC studies (and similar important efforts by community groups and agencies such as the Planned Parenthood Society of Hamilton study by Damianakis, 1992, funded by the Ontario Ministry of Health) effectively convey existing perceptions of minority access problems. However, they had a number of important weaknesses, not surprising given the lack of previous research in Canada. (In fact the Toronto study was identified as the only study available at the time in the review of access to social assistance in Ontario by Agard, 1987:12). There is a need to measure and analyse actual rates of service utilization, and barriers to utilization, experienced by members of clearly defined minority population groups, to establish degrees of inequity in access to specific types of services experienced by such groups, and to measure the impact that these inequities have on the well-being of the groups or parts of the groups. To provide this information would require data collection from minority populations as a whole, not only from persons having attempted to access a particular service. It would also be useful to have data evaluating the impact that specific policy innovations might have in reducing barriers to access. None of these matters were addressed in the Social Planning Council studies. To probe perceptions of barriers in access to various health and social services across minority communities (rather than just among service users), a useful qualitative survey of 209 minority community leaders was conducted for the Ontario Race Relations Directorate by Masemann and Mock (1987) in a number of minority communities in five Ontario communities, namely Toronto, Ottawa, Windsor, Kitchener-Waterloo, and Thunder Bay. The survey included both established spokespersons and emerging leaders, and also community workers. Focus group discussions and individual interviews were held. Generally, Masemann and Mock found the perceptions of barriers by community leaders to be similar to those identified by the service providers themselves, and by service consumers, in the Doyle and Visano study: lack of information about services, language problems, and cultural insensitivity by service providers. Perceptions varied among the groups, however.
The recommendations favoured by respondents included (among others) steps to increase information about services, to improve language skills, and to provide cross-cultural training for service workers. The question of minority access to social services has been a recurrent theme in academic publications in Canada. However, as the textbook overview by Henry, et al. (1994, Chapter 6) clearly shows, apart from the research noted above, there have been few actual studies based on empirical data. An early article on the situation in Québec by Bertrand Lebel (1986) discussed factors explaining low rates of utilization of social services by immigrants there. This discussion included reference to the same barriers: lack of services in minority languages, problems of inter-cultural communication, lack of awareness of social services, and lack of available services to meet particular needs such as for immigrants who have been victims of torture, tropical diseases, political imprisonment, as well as dealing with the psychological impact of being uprooted or displaced. Regarding awareness of services, Lebel notes that in many immigrants' previous country of residence, social services of the type available in Canada do not exist. A 1988 conference on "The Settlement and Integration of Immigrants to Canada" (Yelaja 1990) contained also discussions of this issue, including papers by Wilson (1990) on the abilities and needs of settlement workers, and by Allmen (1990) on mainstream and settlement services for immigrants. Again these are not based on any systematic research data. Rates of service utilization and the relative importance of specific barriers can be established reliably only in population-based studies. A study by Bernard et al. (1994) used data from a population survey, but emphasized the issue of perceived barriers rather than service use and its impact. The study showed that minority populations were much less aware of barriers to social service access than were professionals in the field. The study sampled 297 recent immigrants with at least one pre-school child and living in areas served by one of three "Local Community Services Centres" in Montréal, and 94 medical and social practitioners serving immigrants in these areas. Respondents were asked about three areas of service: health problems, social problems (job, financial, housing, discrimination, immigrant status), and cultural problems (boredom, child care, men-women relations, domestic violence). There were important and very large differences between the parents and the practitioners in the identification of priority problems, in the perceptions of access barriers, and in the perceptions of reasons for the barriers. "Families report problems in accessing services in 16% of cases in the health sector, 29% in the social sector, and 32% in the cultural sector, whereas practitioners assume that such problems exist in 79%, 72%, and 59% of cases respectively." The findings may reflect the basic lack of awareness in minority populations of the existence of social services, a factor that itself has been identified as an important barrier to service access. Related data on service use, and benefits derived, would be needed to show this directly. A useful study by Messier and Toupin (1994) showed how distinctive social service needs of minority populations may not always be addressed. They examine the over-representation of Haitians, black Anglophones and Latin-American youth in rehabilitation centres in Montréal and Laval. Data from 322 youths showed that minority youth have more problems, such as negative parent-child relations, which are partly exacerbated by periods of separation during the immigration process. The authors say that in building the family relations, it is essential for social practitioners to offer support for families.
The study suggests that when mainstream agencies cooperate with ethnic community associations, social service needs can be met more effectively. In 1992, the National Welfare Grants, Human Resources Development Canada, initiated the "Culturally Appropriate Social Services Project." One activity for this project was a "review of literature" on accessibility of social services in Canada. The "Phase II Summary" (Filice and Vincent 1994: 7) notes the difficulty in locating studies representative of the major cities in Canada. It nevertheless pointed out that the "gaps noted in accessibility studies are consistently the same" (p. ii), namely information, language, culturally-appropriate services, lack of funding for ethno-specific programs, lack of mental health services, and lack of appropriate programs for women, children, and seniors. To the question "Are the needs of diverse communities adequately being met," the review noted that "Overall the answers are more positive than negative" (p. 21). It is difficult to evaluate such a conclusion directly, because not definition of "adequacy" was specified. The study also stated that in certain areas and for certain groups such as "seniors and very isolated women, services are still inadequate and accessibility barriers prevail" (p. 21). This 1992 review of Canadian literature is based on studies most of which are of the type reviewed above (for example, those by local Social Planning Councils), and contains the same strengths and weaknesses. These studies adequately reflect the informed perspectives of service providers and many consumers of social services in diverse communities. However, they are not based on systematic population surveys of utilization, and they do not measure the impact of specific barriers and combinations of barriers to specific services on specific minority groups in specific locations. Hence, while they measure and reflect the sense of the social service community and its clients, the conclusions reached should not go beyond what can be said based on such information. Apart from reflecting a value judgement, the conclusion that "overall the answers are more positive than negative" probably does go beyond this limit. There are insufficient data on actual access to services to form the basis for a statement of this kind. In June 1994, Health and Welfare Canada sponsored a national symposium on "Access to Social Services", with over 100 participants including both academics and practitioners. Summaries of some new research is provided (Jacobs 1995). American studies. In the United States, there is a similar consensus among researchers that minority populations are poorly served by human and family services, compared to the majority or dominant populations. Much of the evidence for this statement is to be found in the research on access to mental health care specifically, in extensive published reports of clinical experience with minority clients which underscores the need for "culturally-sensitive" professional practice, and in studies of the impact and uses of ethno-specific services. These topics are reviewed in separate sections below. Apart from this, there are only a few studies of human service utilization and access, focusing mainly on the black population. In the US, the issues of access to social services are somewhat different than in Canada, but the research is relevant to Canada nonetheless. One difference is the greater attention given in the US to how minorities are affected by the general level of service, which is perceived to be low. A second difference is the greater attention to how financial barriers affect access to services, particularly health care services. A third difference is that there is less attention in the human services field to the treatment of immigrant minorities as compared to the native-born African-American group. However, when these differences are taken into account, it is possible to see how patterns of service utilization are affected by other factors common to the two countries. Black children receive different treatment regarding adoptions, foster care, and out-of-home care. Black children are more likely to be in foster homes, less likely to receive adoptive placement, and over-represented in child abuse and neglect reporting (Hogan and Sui, 1988; Jenkins and Diamond 1985). When adopted, it is more often by white parents. Few black families seek to adopt, but when they do, they encounter negative stereotypes which discourage agencies from placing black children with them (Stehno 1982; McRoy 1989; Leashore et al. 1991). In effect, the agencies discriminate against black applicants seeking to adopt. A large national study based on data from the National Study of Social Services to Children and their Families (1978), shows that minority children are neglected in out-of-home care, and receive more haphazard service (Olsen 1982). Black mothers are also much less likely to have adequate access to day care than white mothers (Hogan et al. 1990). Studies of a variety of other social services areas show differential treatment of minorities. Gruber (1980) showed that blacks are not only more often institutionalized, they are institutionalized in different ways. They are most over-represented in corrections and to some extent in mental hospitals; they are less often living in homes for the mentally handicapped. Gruber suggests that this difference is due not to different problems and needs in the black population, but rather to race biases in the diagnosis of these problems and needs. Another study of 456 programs intended to combat juvenile delinquency across the US (Hawkins and Salisbury 1983) showed that those serving primarily minority populations tended to be less family-oriented. The authors suggest that social service agencies unfortunately may be wary of offering "family-strengthening services" to blacks. This appears to be a reference to the possibility that, because the issue of the black American family has been a sensitive one in the United States, agencies may fear criticism for offering services which seem to endorse negative stereotypes. One survey of the immigrant elderly in southeast Florida (including Miami) found that knowledge and use of "health-related social services" (in-home chore services such as laundry, cleaning, and shopping; health support services such as physical therapy or medication assistance; and in-home health aide services for personal needs) was lower for immigrants, despite their generally poorer state of health (Sowers-Hoag and Siddharthan 1992). Three studies deal with cultural barriers to service utilization. One study of wife-battering in the Korean community in Chicago (Song-Kim 1992) suggested that in the Korean community there are high rates of reported spousal abuse, and that because spousal abuse is tolerated or even justified by Korean culture, Korean women are under pressure not to report their problem or seek help, and few do. Studies of this kind obviously generate controversy. Those who dispute the findings may point to the possibility that such reports create negative stereotypes which could hamper equal access. Those who believe the findings have substance may suggest that the problems could be ignored by mainstream social services either not aware of them, or not wishing to acknowledge them. A second study of drug treatment in Los Angeles based on 1107 drug users arrested in Los Angeles between 1988 and 1990 found that after controlling for non-ethnic variables, Hispanic and black drug users were less likely to participate in treatment. The Hispanics were likely to say they didn’t need it ("I can quit on my own"), the blacks to have unfavourable views of treatment ("I don’t like the types of treatment available"). These cultural variations in predispositions affecting treatment serve as barriers to the use of drug treatment programs (Longshore, et al.1992). A third study by Takeuchi et al. (1988) used a state-wide survey in Hawaii (N=2503) to measure variations among whites, Filipinos, Japanese and Native Hawaiians in perceptions of barriers to seeking help for two types of problems: alcoholism and severe emotional problems. They found that all three minorities perceived more barriers than whites, with Filipinos perceiving the greatest barriers, and that these differences held after taking account of the effects of demographic variables affecting these perceptions (sex, income, education, marital status and age). The barriers most often perceived as preventing help were embarrassment and shame at admitting to having a problem, somewhat greater for alcoholism than for severe emotional problems. Lack of awareness of how to seek help, and belief that professional help is inappropriate, were secondary barriers. Cost, and lack of "ethnic match" (professionals from one’s own group), were far less often mentioned as barriers. The findings suggest that simply removing structural barriers to utilization may not sufficiently reduce the perceived barriers to help-seeking among ethnic minorities. British studies. In Britain there has been substantially more attention to minority access to human and family services (Connelly 1988, 1990). Section 11 of the Local Government Act 1966 provided funds to appoint persons to address access issues, and Section 71 of the Race Relations Act 1976 requires equal access to social services. These measures reflect a long-standing concern with the issue. A systematic review of social services department policies by a joint working party of the Association of Directors of Social Services and the Commission on Racial Equality, Multi-Racial Britain: The Social Services Response (1978), provided a benchmark against which later outcomes can be examined. Young and Connelly (1981) reviewed the activities of local authorities ensuring that their operations, including education, social services, and employment, are in compliance with racial equality requirements of Section 71. Focusing on Asians and West Indians in six local authority case studies (chapter six), and using a method of qualitative organizational observation, they found wide variations in the extent to which the needs of minorities were taken into account in the six social services departments. Some departments professed that groups should not be taken into account, and that needs should be assessed on an individual basis. Some provided separate services, some made adjustments to services (especially regarding foster care for children -- finding black parents, reducing procedural complexity, avoiding taking minority children into care where possible), some provided new services (Asian meals on wheels, multi-lingual services), and some attempted to develop strategies related to minorities. Consultations with local groups, including Community Relations Councils, were in their infancy. Cheetham (1982) prepared a joint study on social work services for ethnic minorities in Britain and the US, interviewing staff in 18 British social service departments, then comparing with experiences in 30 US agencies, and drawing implications for Britain. Issues included: recording ethnic data, assessing needs of persons from different cultures, disproportionate use of child care services, concern about balancing shortcomings of generic (mainstream) services and separate services organized on ethnic lines; recruiting ethnic minority workers. Other concerns, including the relation between public agencies and self-help groups, were neglected despite their importance. One study by Horn documents under-use of social services by Asians in Bradford, and the distinctive types of problems presented. Horn reports on analysis in 1978 of referrals to four social area offices, considering child care, care for the handicapped, for the elderly, and others. Referrals of non-Asians are about four times that of Asians, compared to what would be expected based on population. The authors are, of course, unable to determine whether this discrepancy is due to a smaller incidence of problems, a preference for solving problems outside established services, or barriers such as lack of information about problems, or bad experiences with agencies. Another study (by Waller) in the same volume discusses the impact of Section 11 of the Local Government Act 1966, which provided funding to hire persons who would spend at least 50 per cent of their time dealing with problems arising from the presence of minority groups among those being served. Finally, a third essay (Ahmed) discusses problems of hiring minority social workers. There have been many other later studies of barriers to social service access in specific local authorities. Fenton (c. 1985), for example, surveyed 253 members of Afro-Caribbean and South Asians in four central Bristol districts, presenting reasons given for non-use of social services. Ellis (1991) studied the need for a community centre in Coventry providing services including social services specifically for the Muslim community. Attention to the needs of Asians in general has not led to provisions for Muslims who have distinct needs. "There are indications ... that the nature and extent of disability within the Muslim community remains hidden, and that Muslim families caring for disabled family members are receiving inadequate support within the community and through statutory services." (p. 17) The study focuses on political processes within the community; no detailed study of service access is provided. Swarup (1992) studied analysis of barriers to social, housing, education and health service utilization in South East Hampshire, based on a survey of 308 persons in the black and Asian communities, and social service providers. The minority communities were identified by community organizations, supplemented by reviewing electoral lists. Low use of social services is attributed to lack of information about the services, language problems, culturally inappropriate services and a lack of confidence that social services are intended for minority groups. Only 10 per cent or less had used any Social Services Department service; most were satisfied. But of the non-users, two-thirds had no idea what services were available, 15 per cent had little confidence in the services provided or felt there would be difficulty in communicating, and many were unwilling to use the service because it was embarrassing, or not appropriate to their specific needs. There was no general-population comparison group, however, so it is not possible to know whether these problems were specific to the black and Asian communities, or affected other groups as well. Ahmed et al. (1986) is a collection of articles recounting experiences with black children in social service settings, minority women in women’s shelters (refuges), and young black offenders. The introduction by Cheetham lists evidence of barriers in access to ‘welfare services’ experienced by blacks in Britain. She mentions Asian mothers not helped by ante-natal services, employed black mothers to whom only poor quality day care is available, black children in care having less chance than white children of reunion with parents, and local authorities often insensitive to diverse cultural groups. Various articles provide qualitative case material on differential treatment, or on differential minority group needs not being met. For example, an article by Asrat-Girma reports experiences of mothers with negative treatment by child care workers, often based on negative stereotypes of black culture, or negative judgements of practices stemming from cultural differences. Robinson and Stalker (1993) compiled agency records in three local authorities in the UK, on the utilization of "respite care" for disabled children (temporary accommodation outside the home, mainly for children with severe learning disabilities). They found that black and Asian children were less likely to receive family-based care, and more likely to receive institutional care. An implication of lower standard of care might be drawn, though the reasons and implications were not analysed. Institutional use is also characteristic of lower social class levels, which could explain the racial pattern. Summary. The studies reviewed thus far address human and family services primarily. They all conclude that barriers exist, for the various reasons cited. Some are based on key informants, some are based on population studies, and, to varying degrees, they address the issues of utilization, needs, and benefits. They are, however, limited by the inconsistent coverage of services, and the uneven attention to specific minority groups. The research in the UK seems more extensive, and the US research more often population based, compared to the Canadian research. However, there is lack of attention to the issue of minority access in all three countries. Studies of related areas, such as mental health, health care generally, and social assistance, and the clinical experiences with cultural groups, provide information of direct relevance, and will be reviewed in subsequent sections before attention is given to the effectiveness of service delivery models. Mental Health Services: Access, Utilization and Barriers. The research on immigrants and minorities using mental health care services finds the same list of barriers: lack of services in minority languages, lower levels of awareness of services within the minority community, reluctance of minority group members to seek services they need, culturally-inappropriate services, lack of funds that individuals may require to access services, and lack of service availability. However, the research on minority access to mental health services is far more extensive and detailed than the corresponding research on human and family services, not only in Canada but also particularly in the US. Thus, more detailed statements can be made about the nature of the barriers in this case. There are at least two reasons why the research on mental health care is better. The most important reason may be that funding for health care research in general is less inadequate, but another reason may be that the service itself is comparatively standardized, so that issues of service delivery do not vary so much from one setting to another. Health and Welfare Canada has produced a major report on mental health issues affecting immigrants and refugees in Canada, After the Door has been Opened (Canadian Task Force 1988a). Accompanying this report is a 50-page review of literature (Canadian Task Force 1988b). The task force reviewed over 1000 publications (not all Canadian). First, regarding the mental health care needs of immigrants, they found that while immigration itself does not predict increased risk for mental disorders, it does if (as is often the case) it is accompanied by some or all of the following: drop in economic status, inability to speak the language of the host country, separation from family, lack of friendly reception, isolation from a community of compatriots, stress prior to migration, or being adolescent or senior at the time of migration. Second, regarding use of mental health services, they found that immigrants under-use services, often because of stigma attached to mental health disorders, and to seeking formal treatment, in many cultural groups. Under-use exists even with equivalent levels of need (Monroe-Blum et al. 1989). As well, the services received are often inappropriate:
The recommendations of the review were for cross-cultural training for practitioners, and improved outreach, as well as the development of cross-culturally valid research procedures to assess mental health and mental health services (see also Beiser et al.1993). In the US, a President’s Commission on Mental Health was established in 1978 by President Carter. The commission reported that racial and ethnic minorities, including immigrants, remained under-served (p. 4), and that appropriate services are not available to many of them even though their need is often high. Cultural appropriateness is an issue, and "The number of Asian and Pacific Island Americans utilizing mental health services increases dramatically when services take into account their cultural traditions and patterns." (Pp. 5-6). "A frequent and vigorous complaint of minority people who need care is that they often feel abused, intimidated, and harassed by non-minority personnel." (P. 6) Less than 2 per cent of psychiatrists in America are black. Fewer are Hispanic. Of doctoral-level service providers in psychology, only 0.9 per cent are black, 0.7 per cent Asian, 0.4 per cent Hispanic, and 0.1 per cent Indian. A review of literature on barriers to mental health care for Hispanic Americans, by Woodward et al. (1992) showed a clear consensus that utilization of mental health care services is substantially lower for Hispanic Americans, and that there are major financial barriers to mental health service access for Hispanic American populations. In 1989, 78% of whites had private health insurance, compared to 54% of blacks, and 50% of Hispanics. The authors say that research on cultural barriers to mental health care access is less consistent or conclusive. While there is agreement that language plays a role, there is less agreement on other aspects of culture and acculturation. These include Hispanic traditions of alternative methods of treatment, and prejudices by health professionals. On the other hand, there is convincing evidence that providing culturally-relevant treatment increases mental heath care utilization, as will be seen below when we examine promising service delivery models (on this point the authors cite O'Sullivan et al. 1989, Higginbotham et al. 1990, and Hall 1988). This suggests support for the importance of cultural barriers as restricting use of many of the existing mental health care services by Hispanic Americans. An interesting earlier study by Trevino et al. (1979) confirming the effects of culturally-relevant treatment, found that in one local area where Mexican-Americans are the predominant group (a Texas border city of Laredo), levels of mental health care utilization (after taking account of socio-economic characteristics) were unaffected by ethnic origins. This was true, despite the proximity of Mexico where culturally-traditional 'folk' medicine and other alternatives to standard American health care are easily accessible (on traditional medicine see Ahmad 1992, and Krajewski-Jaime 1991). Assuming that the dominance of Mexican-Americans in the local population creates an environment in which Mexican-American culture pervades most institutions including service agencies, the result suggests in a powerful way that cultural barriers are a significant factor determining levels of utilization. Moore (1970) also found that Mexicans in general (i.e. mostly not living in the situation prevailing in border cities such as Laredo) are less likely to use "formal" means to deal with personal problems. They prefer "Mexican" sources of help, and in the case of mental health services this suggests low levels of utilization anywhere there are few Mexican-oriented sources of psychiatric help. Virtually all studies show low levels of mental health care utilization by all major minority groups, including most Asian groups, blacks, and native Americans (Indians), as well as Hispanic groups (Andrulis 1977; Sue and McKinney 1975; Sue and Sue 1990; Sue and Morishima 1982). Some studies show that immigrant groups are affected more than native-born African Americans (Sue et al. 1974; Bui and Takeuchi 1992; different findings are reported by Windle 1980). Cultural barriers to utilization seem to affect many groups, including most Asian groups. Takeuchi et al. (1988) surveyed Hawaiians of white, Filipino, Japanese and native Hawaiian background, asking about help-seeking for two types of problems: alcoholism and emotional distress. They found that all three minorities experienced greater barriers to help-seeking, even after effects of demographic variables were taken into account. The most significant barrier was embarrassment and shame at admitting to having a problem. Other barriers included lack of awareness of how to seek help, and belief that professional help works. Cost, and the desire for a 'matching' ethnic professional, were far less often mentioned. The authors say that "simply removing structural barriers to utilization may not sufficiently reduce the perceived barriers to help-seeking among ethnic minorities." Sue and Morishima (1982) address the question of need as a factor explaining low utilization for most Asian groups, challenging the view of Asians as a "model minority" with few emotional or mental health problems (see also Crystal 1989). They consider six criteria for mental disturbance (including psychiatric diagnosis, deviation from group norms, subjective reports, presence of symptoms, presence of positive mental health indicators), and conclude that there are major difficulties in applying these criteria cross-culturally. Personality tests show higher levels of anxiety, discomfort, loneliness, and isolation among general samples of Asian American college students, suggesting more emotional distress (p. 37). The authors caution against any conclusions about levels of mental health for Asian Americans, and suggest that attention should be given to emotional stress and its alleviation. Given high rates of emotional stress for Asian Americans, their view suggests that low utilization should be regarded as a problem. An important indicator of under-utilization is the evidence from many studies that minorities more often terminate therapy early. For example, Sue (1975) found that among Asians, American Indians, blacks and Hispanics, 50% terminate therapy after one session, compared to only 30% for majority group Americans. Termination of therapy may indicate that services offered are not perceived as relevant, or otherwise discourage persons who want service from getting it. Evidence of cultural barriers for Asians is found in research showing that acculturation affects attitudes toward mental health services. Atkinson and Gim (1989) found in a sample of 557 Chinese-, Japanese-, and Korean-American students that the most acculturated students were more likely to recognize personal need for professional psychological help, most tolerant of the stigma associated with psychological help, and most open to discussing their problems with a psychologist. Their openness suggests that the less acculturated students avoid formal psychological help because of discomfort with the services offered. Refugees are a group of immigrants often at high risk for mental health problems; they have a high frequency of the usual risk factors: loss of economic status, language problems, separation from family, unfriendly reception, isolation, and stress prior to migration. Westermeyer et al. (1989) studied Hmong refugees in Minnesota during 1977, finding high rates of psychiatric disorders. This research suggests that barriers to mental health care utilization may be particularly devastating to many refugees. In sum, cultural barriers to the use of mental health care facilities have been extensively researched, and virtually all findings point toward the conclusion that most cultural minorities encounter greater difficulties with standard mental health care services. Many cultures stigmatize mental disorders, and many cultural groups prefer to address such problems without dealing with cross-cultural difficulties at the same time. Mental health care services often do not take account of distinctive needs arising from cultural differences, and this too is a significant barrier to greater use. The lack of professionals from minority groups is a factor as well. Hence low utilization of professional services is very common. The research on cultural barriers to mental health care utilization may be generalizable to at least some of the human and family services sector. Generalizability is most likely in those instances where the service involves dealing with personal problems or inter-personal relationships. This may include family counselling, dealing with child protection services, or any problem of a socially sensitive nature. Mental health services may often deal with persons confronting problems of this kind. However, in the absence of research this conclusion must remain speculative. Health Care: Access, Utilization and Barriers. There is a very large body of research on minority access to physical health care. We reviewed many Canadian publications (Masi, et al. 1993, Lui-Gurr 1995, Young et al. 1995), as well as the much larger body of research in the US (Anderson, et al. 1981, Welch, et al. 1973, Hoppe and Heller 1975, Neighbors and Jackson 1984, Dutton 1978, Currie 1995, Barrilleaux and Muiller 1992, Woolhandler et al. 1985, Okada and Aparer 1976, Bolini 1992, Morales and Bok 1992, Smith 1993, Gillam 1990, Leclerc et al. 1994, Schulman 1995, Wells et al.1991, 1987, Cornelius 1993a, 1993b). Many of the issues are similar to those involving mental health care. Research has been stimulated by large national data sets on health care utilization, such as the U.S. Epidemiologic Catchment Area program. (For a review of the health of immigrants in Australia, see Reid and Tromph, 1990; for a discussion on some issues in the UK, see Thorogood, 1989). In the US, the issue of health insurance is probably the most critical access issue, and Davis et al. (1987) showed that improvements in black access to health care because of Medicare and Medicaid has resulted in actual improvements in the health status of the black population. At the same time, McBean (1994) showed disturbing black/white differences in surgical procedures administered. The largest differences were seen for "referral-sensitive surgeries" such as angioplasty, coronary bypass surgery, and knee and hip replacement. Whites more often received these procedures while Blacks were more often subjected to amputation and similar procedures. These differences by race suggest barriers in access to the highest quality services. Welfare and Social Assistance: Access, Utilization and Barriers. Canadian research has examined the utilization rates for social assistance by immigrants. The finding consistently has been that immigrants consume money transfers such as unemployment insurance and social assistance (welfare) at rates lower than is the case for the general population (Akbari 1989, Baker and Benjamin 1994, 1995, Lui-Gurr 1995). There are variations across cohorts of immigrants, and by gender and family status. However, most recent immigrant cohorts use public assistance at lower rates than the general population. This research forms an important component of concern with the impact of immigrants on the public treasury. This impact again consistently has been found to be positive. Akbari (1989) examined the net balance of taxes paid and public services used by immigrants and native-born Canadians, based on the 1981 Canadian census public use sample. Public services included the full range: education, health services, and transfer payments (Family Allowances, Unemployment Insurance, Canada/Quebec Pension Plan, Old Age Security, Guaranteed Income Supplements, and other federal and provincial transfers). Even after 35 years in Canada, immigrants are a net benefit to non-immigrants. Note that immigrant use of services is not compared to the use of services by non-immigrants. Whether the findings of low utilization rates arise from barriers such as those found for social services generally has not been investigated. There has been no study in Canada of whether immigrants who are eligible for public assistance fail to receive it because of discriminatory barriers. In the US, there is also a lack of research on barriers in minority group access to existing welfare and social assistance. Many publications address the question of whether racial attitudes have lead to an overall lower level of welfare support. This is based on the supposition that there is public resistance to providing any service or support where the perception is that minorities would benefit disproportionately. In effect, race has been offered as an explanation for the weak American welfare state (Piven and Cloward 1993, Peter Taylor-Gooby 1991, Quadangno 1994, Carballo and Bane 1984). Given the prevailing attitudes toward social welfare, low levels of utilization by minorities in itself is likely to be seen as evidence of lack of need. Unlike in Canada, immigrants to the US do in fact use welfare more than the native-born, because they experience higher rates of poverty. Relative to their need based on earnings, however, they tend to have comparatively low rates of welfare use. Jensen (1988) examined public assistance utilization for immigrants and the native-born in 1970 and 1980 public use microdata samples, separately for origins groups. Public assistance includes Aid to Families with Dependent Children (AFDC), General Assistance and Supplemental Security Income (Old-Age Assistance, Aid to the Blind and Aid to the Permanently and Totally Disabled). While immigrants have higher poverty rates, the rate of assistance utilization is only marginally higher. Reasons in general for lower utilization include: the fact that immigrants are risk-takers, they rely on friendship and kin networks, and they may want to avoid the social stigma because they are seeking social approval. Blau (1984) examined transfer payments to immigrants and the native-born in the US using the 1976 Survey of Income and Education. Transfers include welfare (public assistance, AFDC, and supplemental security income), and social insurance payments (social security, railroad retirement, veteran’s payments, unemployment compensation, and workers’ compensation). Immigrants use transfers more, mainly because they are older. After age and other factors are held constant, immigrant families use less welfare, and only slightly more social insurance. Welfare payments were 59 per cent lower than among comparable native-born families with male heads, and 57 per cent lower than comparable families with female heads. For recent immigrants, lack of knowledge of English reduces total transfers because of lower probability of participating in social insurance programs. The research on welfare utilization supports the findings of the research on social service utilization generally: that minorities place fewer demands than might be expected based on need. In effect, there is evidence that barriers reduce their access, creating inequities. Table of Contents
Executive Summary
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