Final Report

Jeffrey G. Reitz, Ph.D.
November 30, 1995

* This report was prepared as a joint project of the Multicultural Coalition for Access to Family Services, Toronto, and the Ontario Ministry of Community and Social Services.

Table of Contents         Executive Summary
Chapter | 1 | 2 | 3 | 4 | 5 | 6 | 7 |      Bibliography | A-B | C-I | J-O | P-Z |

To what extent are the needs and preferences of ethno-racial communities known and addressed by mainstream agencies? What is known is based largely on clinical experience working with minority cultural groups, leading to the preparation of articles and textbook discussions of the requirements for "cultural sensitivity" or "anti-racism". This topic is discussed in a rapidly growing didactic literature in the field of social work. The existence of this literature is testimony both to the growth of knowledge about the social service requirements of minorities, and the perception that only a few practitioners possess this knowledge. There are also a few studies surveying organizational attempts to address access issues.

A survey to determine the extent of cultural sensitivity of Toronto area social service agencies was conducted under the auspices of the Ontario Ministry of Community and Social Services (MCSS) by Makovec (1988). For 193 Toronto area social service agencies funded by MCSS, including 177 mainstream and 16 ethno-specific agencies, results showed: 20 per cent had a multicultural unit, 27 per cent had cross-cultural training, 18 per cent required a second language, 32 per cent had modified their guidelines for initial assessment of culturally different consumers, and between 0 and 9 per cent had information about their services in languages other than English (the per cent depending upon the language). In most respects, the ethno-specific agencies were far ahead in the area of cultural sensitivity. About one in four of the mainstream agencies stated that they were aware of a minority group which required their service but that they could not provide it. About one in five stated that they had a formal referral relationship with an ethno-specific agency.

More recently, in the Canadian federal government the National Welfare Grants program of the Department of Human Resources has undertaken a project related to diversity training for social workers, involving a review of literature, a review of social work education, and a review of social service agency training programs (Taiana 1994). The report states that the literature reflects a "lack of consensus" on what constitutes culturally-competent social work. A lack of consensus means that there is no one standard by which to judge whether social workers know the needs of minorities. There are no agreed-upon criteria by which to evaluate this question. The texts reviewed included Herberg (1993), and Yelaja and O'Neill (1990). Regarding the schools of social work, the 1994 report noted that all the university-based schools, and the majority of the schools in community colleges, offered courses preparing students to work with ethnocultural communities; they also maintained links with those communities. However, there was no information on enrolment in the courses, and no evaluation of their effectiveness. Moreover, most schools (82 per cent of persons in universities, for example) said that a number of innovations were still planned for the future, including integrating cross-cultural issues into mainstream courses, and adapting field placements.

The National Welfare Grants program review of agency training shows that while many agency staff attend training programs designed to increase their knowledge of the needs of minorities, there is little information with which to evaluate the success of these training efforts. In fact, "agencies do not appear to place a high priority on measuring the long-term impact of staff training" (Taiana 1994: 26).

Jurisdictions in the US, the UK and Australia also have expended efforts in this direction. In the US, Jenkins (1981) conducted a field study of 54 social service agencies identified as providing innovative and constructive services to ethnic clients, to see "what works and what doesn’t work." They included day-care centres, foster-care and adoption agencies, residential centres and institutions, programs giving services to children in their own homes, youth services, and multipurpose integrated service centres. Obviously many agencies in the US were responsive to ethnic diversity in 1981, though Jenkins' study does not measure the extent. Jenkins' study will be reviewed in more detail in the section below on promising service delivery models.

There are now a very large and growing number of American and British textbooks on culturally-sensitive or anti-racist social work, clinical psychology, and psychiatry. These texts are based primarily on clinical experience with minorities, and represent substantial efforts to improve knowledge of the needs of minority communities among social workers and other social services professionals, and their skills in treatment intervention (see as examples Devore and Schlesinger 1991 - in third edition, Sue and Sue 1990 - in second edition, Lum 1992 - also second edition, Gelfand 1994, Gopaul-McNicol 1993, Skellington 1992, Mincey 1994, Furuto et al.1992, Pinderhughes 1989, Burgest 1989, Davis and Procter 1989, Ho 1987, Ahmed et al. (1986), Coombe and Little 1986, Hansen and Falicov 1983, Wright et al.1983, Green 1982, and Cheetham 1982, among others). Some of these texts attempt to serve as a general overview for addressing the needs of all cultural minorities, some deal with groups of minorities such as "Asians," while others deal with specific groups such as West Indian blacks. There are many supporting journal articles which also report clinical experience and are intended as didactic messages (Segal 1991, Chau 1991, Corvin and Wiggans 1989, Fong 1994, Dillon 1994, Leung et al.1994, Krajewski-Jaime 1991, Gallegos 1984, Hirayama and Cetingoh 1988, Ryan et al.1992, Sartorius et al.1984, Blum 1986; see also the Journal of Multicultural Social Work). The reasons why social work predominates as a source of these texts, compared to clinical psychology or psychiatry, may be due to several factors. There may be a difference in the representation of cultural minorities among the clientele of social workers compared to psychiatrists and also clinical psychologists, at least in the US. It is also possible that the profession of social work may be more open to the issue of minority needs. The existence of the social work texts attests to the fact that, as Schlesinger and Devore (1995: 51-2) observe in their review article on the state of the art of ethnic sensitive social work, "There is no doubt that the profession of social work has sat up and taken notice of minority issues."

The texts reflect accumulating knowledge, but they also reflect a perception that this knowledge requires aggressive dissemination -- an indirect acknowledgement that without special training many social workers are not sensitive to ethnic minority cultures and issues. There are no systematic field evaluations of the success that these texts have had in disseminating a knowledge of the needs of cultural minorities. One study, by Carillo, et al. (1993) measures social worker attitudes toward minorities, and the extent of inter-cultural and inter-racial tolerance. However, without systematic evaluations of direct knowledge of minority needs, the impact remains unknown.

Furthermore, as was pointed out in the Canadian review, there is no consensus on what "knowledge" actually is in the area. Sharp criticisms of the "cultural sensitivity" approach are made (e.g., Bamford 1990, Rojek et al. 1989, Clarke 1993). Gould (1995) addresses the "polarization" in the field of social work on the question of multiculturalism, and expresses the concern that "students have come to view multiculturalism in purely objective terms -- as information about other cultures that has to be mastered to work effectively with clients from 'different' groups in the broader society." The distinction is drawn between cognitive knowledge -- the kind from textbooks -- and experiential and affective components of knowledge. The efforts toward cultural sensitivity may be missing a dimension of training necessary to make practitioners truly effective in the field.

Minority representation within the social service professions is one obvious measure of knowledge of minority group needs. As has been mentioned, American blacks are vastly under-represented in these professional fields, and under-representation is even greater for most immigrant minorities (see Berger 1989).

What is known about the success of service delivery models to address barriers to access to social services by ethnocultural groups? What strategies are used to eliminate barriers to service access and utilization in mainstream agencies, and what is the role of ethno-specific agencies?

A wide range of policy ideas, service-delivery models and management strategies to make services accessible to minorities on a cost-effective basis have been proposed; some have been implemented. Many of these do in fact address barriers identified in research, and for that reason may be expected to make a positive contribution. At the same time, formal research evaluation of many of these programs and strategies is minimal, so definite statements about their effectiveness cannot be made as a research conclusion.

The following is a list of accessibility strategies, each having a cost-effectiveness rationale.

Outreach and service information: addresses the lack of information about available services, noted in most studies as a significant barrier.

Locating agencies in areas of minority concentration: addresses the problem that services are often located in central areas, and that minorities are often distant from services they need.

Provision of multi-lingual services: addresses the language barrier.

"Ethnic match": providing (or referral to) ethnic-appropriate minority-group service providers.

Multicultural training and cultural sensitivity: ensuring that majority-group service-providers have knowledge of minority-group needs and cultural patterns.

Minority service units: designating a unit within agencies to be responsible for enhancing service to minorities.

Inter-agency coordination: ensuring that agencies are aware of cultural dimensions of services provided by other agencies, to facilitate appropriate referrals

Organization of service delivery: reducing dangers that formalized or bureaucratized services may be culturally inappropriate, or may accentuate the impact of cultural differences on clients.

Equity policy models: making formal organizational commitments to service access and equity.

Community consultation: ensuring that minority group interests are reflected in decision-making by placing minority-group members in decision-making roles.

Information needs and agency action research: conducting research on minority group needs among clients, to provide input into decisions.

Supporting ethno-specific agencies: creating or funding agencies which are designed primarily to serve minority group members, with decision-making entirely in the hands of minority community members

Coordination of ethno-specific and mainstream agencies: to ensure that the optimal use is made of each type of agency

Some Existing Management Strategies. This section describes efforts in some jurisdictions to implement these various management strategies. These have been collected for this review by way of illustration of efforts currently underway. No attempt has been made to compile an exhaustive inventory, and no claim is made regarding comprehensiveness. Following this description, is a review of evaluation research which addresses these strategies.

In Toronto, policies to increase minority access to social services have been adopted by both levels of municipal government. The Municipality of Metropolitan Toronto is the main local provider of social services within its jurisdiction. Its Multiculturalism and Race Relations Division has developed an ethno-racial access program (Metropolitan Toronto 1990, 1991, 1992), and its recent publication New Directions, New Realities (1991) describes the creation of information access centres to ensure the dissemination of information about available programs to minority communities. Other municipalities in the area have developed programs as well (e.g., the City of Toronto’s Multicultural Access Program, Toronto Department of City Clerk 1988, 1991, 1994; see also Currents 1987).

Local non-governmental organizations in the Toronto area, such as the United Way, the Social Planning Council of Metropolitan Toronto, and the Ontario Council of Agencies Serving Immigrants (OCASI), as well as the Multicultural Coalition for Access to Family Services (MCAFS), also have studied minority access issues and have published reports outlining promising service delivery models (see also Canadian Urban Institute 1991). Following its own research cited earlier, The Social Planning Council has established the Access Action Council which promotes policies of minority access, such as those listed above (Doyle and Rahi 1990). The United Way’s publication Action, Access, Diversity (United Way 1991) provides policy and program guidelines for United Way member agencies (see also James 1995, Medeiros 1987). OCASI (1988) and MCAFS (Mederios 1991, Kasozi 1994) have delineated ethno-specific services as a mode of service delivery (see also OCASI 1987a and b, 1989, 1990a and b). A description of one such agency, the Hong Fook mental health agency serving the Chinese community in Toronto, established with provincial funding, is described by Lo and Lee (1993).

The Ontario government also has pursued related policies, including the "Bridging Initiative" (Ontario Ministry of Community and Social Services 1991a and b; see also Ontario Premier’s Council 1995, and Ontario Ombudsman 1995). Other agencies, such as the Addiction Research

Foundation (see Tsang 1994) have issued reports on how social service agencies can accommodate cultural diversity.

Other jurisdictions in Canada have taken initiatives, including policy initiatives. In Quebec, an overview is provided by Kein and Garon (1987), and a specific action plan by the Quebec Ministry of Health and Social Services (Ministère de la Santé et des Services Sociaux 1990). In the British Columbia Ministry of Social Services, the Minister's Staff Advisory Committee on Multiculturalism (1992) has provided some broad guidelines toward cultural sensitivity in the social services. A Community Panel Family and Children's Services Legislation Review (1992) has offered more detailed suggestions relating specifically to children's services. Elsewhere in Canada, we found that the report of Planned Parenthood Manitoba (Stevens 1993) to be useful (see Allman, in Yelaja 1990).

The Canadian federal government offers a very brief report on the status of minority access to social services in its annual report from the Multiculturalism Department (see for example, Annual Report 1995: 11-12).

In the United States, there have been many policy initiatives, as will become clear in our discussion of evaluation research, most of which is American. At the same time, we found only a few prominent policy pronouncements by governments, at the federal, state or local levels (for an example of a federal report, see Cross, et al. 1989, on mental health services for children). It appears that only a few jurisdictions have made minority access to social services a major policy initiative. Rather, a pragmatic interest in the issue does characterize various government activities with regard to specific social services; policy conferences and discussions, as well as evaluation research, abound. Jenkins' (1982) early review showed that an ethnic dimension characterized many social service agencies, and later (Jenkins 1988) illustrated how New York State contracts with ethno-specific agencies for services. As we will explore later in discussing evaluation research, Los Angeles County has initiated ethno-specific service agencies, which may become private non-profit agencies after the startup period.

In the United Kingdom, the Commission on Racial Equality (1989), has compiled a survey of policies in social services departments around the country. Some important initiatives in Britain include the Race Relations Act 1976, which mandates equal access to social services as a legal right. An earlier piece of legislation, Local Government Act 1966, Section 11, provided grants for local governments to hire workers who would spend a minimum of their time addressing service needs of minorities. Mark Johnson (1992) has described a more recent "Citizens’ Charter", a government white paper, including a statement on service access.

The Australian federal government adopted "Access and Equity" as official policy in 1985 (National Population Council, 1985; Office of Multicultural Affairs, 1990, 1991; see also the Jupp Report 1986; and the earlier Galbally report 1978). This program mandated equal access to social services across Australia. An evaluation of the policy focused on implementation rather than on impacts (Office of Multicultural Affairs, 1992, 1994). Some commentary suggests that this policy has not had a major impact on service delivery (Jayasuriya 1987, 1990).

Evaluation Research. A substantial attempt to test how community health agencies are affected by the distribution of information related to equity was reported by Windle et al. (1979). A national follow-up study reported that the project was largely ineffective (Windle and Wu 1981). On the other hand, there is evidence that outreach programs do work to increase utilization (Watkins and Gonzales 1982). Some studies are very specific to the experience of certain types of minorities. Achata (1993) showed that an immunization program was successful in reaching Mexican migrant farm workers' children through day care centres.

Evidence of the effectiveness, and indeed the distinctive contributions, of ethno-specific social service providers in the United States was provided in a series of two books prepared by Shirley Jenkins, then Professor of Social Work at Columbia University. The first, The Ethnic Dilemma in Social Services (Jenkins 1981), showed that ethnic group participation in social services agencies can and should be a factor in service delivery. The book reports a field study of 54 "ethnic agencies" in the United States, social service agencies identified as providing innovative and constructive services to ethnic clients. The purpose of the study was to see "what works and what doesn’t work" in these agencies. They included day-care centres, foster-care and adoption agencies, residential centres and institutions, programs giving services to children in their own homes, youth services, and multipurpose integrated service centres. Auspices were divided: 25 public, 9 private sectarian, and 20 nonsectarian. Though fewer than half were public, 94 per cent had public funding. They served mainly low income blacks (in Philadelphia), Asians (in New York and San Francisco), Puerto Ricans (in New York), Mexicans (in Texas), and native Americans (in North Carolina). All agencies served as least 50 per cent persons from the particular group; in 31 agencies the director was from the minority group in question. Questionnaires from agency staff were compared with responses from a national sample of social workers. Parents were also interviewed. Experiences in Israel and Britain are discussed. It is recommended that ethnic factors be incorporated in social service delivery.

The second book, Ethnic Associations and the Welfare State: Services to Immigrants in Five Countries (Jenkins 1988), examined the role of ethno-specific organizations in service delivery in the US (New York), Britain, Israel, the Netherlands, and Australia. The concluding chapter agrees with one of the New York social workers who said of the ethnic associations that "This is the best-kept secret in social work."

Not in the mainstream, not taught about in the school curriculum, not integrated into the formal social service system, and not run by established professionals, nevertheless, uncounted numbers of ethnic associations are giving support, counsel, training, referrals, and refuge to other members of their own ethnic groups. Slowly their work is being recognized, and gradually both the public and voluntary service systems are beginning to respond to the potential that exists in ethnic associations for improving service delivery, in particular for new immigrants (p. 276).

In Chapter 2, Jenkins and Mignon Sauber reported a qualitative study of the work of 30 ethnic associations in New York. Some of them were "self-help" groups, but others were called MAAs (mutual assistance associations), and were under contract with the New York State Department of Social Services. MAAs performed a key role in coordinating service delivery to new immigrants.

Characteristic of the MAAs at the present time is that they function as liaisons between newcomers and the formal service providers. The New York State Department of Social Services, for example, has contracts with MAAs for the delivery of services which are seen as filling gaps in existing programs directed at promoting the successful resettlement and acculturation of refugees and entrants (p. 103)

Government subsidies were a key to the success of these groups.

This may be a model, however, that only works when there are funding programs to back it up. Still to be determined is whether the MAAs have the cohesion and community support to function when, or if, the specialized entitlements expire. This will be the test of whether they are viable ethnic associations, or whether they are primarily extensions of federal programming. In the meantime they are important providers of services, which is to be expected since that is what they are mandated to do (p. 103)

The study showed that linkages between ethnic associations and the formal service structure not only exist, they are "essential for appropriate access by newcomers to services" (p. 103). However, this connection is better developed for refugee groups who have special legal entitlements, and "is sporadic for other groups of immigrants" (p. 104). Jenkins and Sauber favour subsidies for ethnic associations as an important means for providing access to services for all recent immigrants who need them.

Juliet Cheetham replicated the New York study in Britain, based on interviews with 29 ethnic associations mainly in London and the Midlands (chapter 3). About half received public funding, but often from the Greater London Council, which was abolished by Prime Minister Margaret Thatcher in 1986. Cheetham concluded that "ethnic associations may now provide the only decent or nearly decent help available to some minority groups, especially those for whom there are serious language problems, or a great reluctance, for cultural reasons, to seek outside help. These associations can reach out to people when public authorities assume that lack of demand reflects a degree of self-help that renders state interventions unnecessary" (p. 147).

Smaller-scale replications in Israel and in the Netherlands, and a review of the situation in Australia, develop similar themes. Lack of resources were a problem for ethnic associations in all countries. The study in Australia noted that lack of resources may threaten the contribution of the ethno-specific associations, leading to the marginalization of immigrant communities.

"Ethnic Match". A number of studies in the US, mostly in California, have examined the effect of an ethnic match between client and service-providers. The results show clearly that the ethnic match increases service utilization, and reduces drop-out. The effects on service outcomes are more difficult to measure, and the results are more ambiguous for this reason. There are indications of positive outcomes, however, and of gains in cost-effectiveness. None of the studies showed indications of negative outcomes.

Sue et al. (1991) report a major study of a sample of approximately 13,000 outpatients in the Los Angeles County Department of Health, during a 5-year period, in four major racial-ethnic groups, African Americans, Asian Americans, Mexican Americans, and whites. Support was found for the benefits of ethnic match between patient and therapist, using two length-of-service measures -- dropping out and length of treatment. The benefits were found in each instance except for that of dropping out by African Americans. There were effects of ethnic match on treatment outcomes (measured by the Global Assessment Scale of respondents' overall psychological, social and occupational functioning) only for Mexican Americans.

Flaskerud and Liu (1990) studied 543 Vietnamese and Cambodian clients in the LA County mental health facilities between 1983 and 1988; they found an effect of ethnic match and language match on numbers of sessions, but not on length of treatment (Cambodian language match seemed to increase the dropout rate, but the effect was marginally significant, statistically). There were no effects on Global Assessment Scale gains.

Wu and Windle (1980) provide some national data. They report a study of 220 federally funded mental health centres, looking at the impact on minorities in areas of minority population concentration. It found that the larger the proportion of minority staff in a mental health centre, the higher the utilization rate by that minority. The result could be spurious if both outcomes are influenced by the ideology of the centre administration, but they are also consistent with the hypothesis that increasing minority therapists will increase minority use of therapy.

Snowden et al. (1995a) produced data suggesting that ethnic matching of clients and clinicians can reduce program costs. In a large county mental health system, they found that ethnic matching of clients and clinicians led to less frequent use of emergency services. This suggests that ethnic matching leads to treatment success in that crises of sufficient magnitude to require emergency intervention are avoided.

Ethno-specific Agencies. The research on ethno-specific agencies also shows effects in increasing utilization rates, and ambiguous but potentially positive indications of benefits in terms of substantive outcomes. Flaskerud (1986) was one of the first to report that ethnic-specific services engender greater utilization. The study by O'Sullivan, et al. 1989 also contends that ethnic minority client dropout rates have been reduced largely through the development of more ethnic-specific community health centres. Subsequent studies have provided more substantial data.

Yeh et al. (1994) studied 912 Asian American children (18 or younger) who used emergency outpatient mental health centres in LA; about half in mainstream centres, and half in parallel centres (i.e., established specifically to provide services to the Asian community; these were not ethnic organizations, but were private non-profit clinics. For example, the Asian Pacific Counselling and Treatment Center was established in 1977 by the LA County Mental Health Department, and then later privatized; two others were outgrowths of this agency). This is the first study ever conducted to test effectiveness. The parallel programs achieved "ethnic match" in 70.8 per cent of cases, compared to 7.7 per cent for the mainstream. The dropout percentage was lower (5.5 per cent vs. 27.9 per cent for mainstream) and session numbers higher. The assessment scores were higher on discharge (56 vs 49 on the General Assessment Scale, GAS). The differences hold up as significant after control for client characteristics.

Zane et al. (1994) studied 885 clients at the Asian Pacific Counselling and Treatment Centre (see above study by Yeh et al., 1994) in Los Angeles County; the clients represented a number of Asian origins, and included also 80 whites. Results show no differences in service effectiveness among the groups (premature termination, early termination, treatment duration, clinical outcome -- GAS). This suggests that parallel mental health services do foster equitable service delivery. Other interpretations are possible, and further research is suggested.

Takeuchi et al. (1994) argued that "analysis of ethnicity-specific services is an essential and exciting area of investigation that has been almost completely ignored, despite much discussion about the need for such services" (p. 643). Their study examined effects of ethnicity-specific services (those in which a majority of clients are from a specific minority group) on 1516 African Americans, 1888 Asian Americans, and 1306 Mexican Americans who used Los Angeles County Department of Mental Health services. It found that ethnicity-specific services had positive effects on length of service, even after ethnic match between therapist and client is controlled, but little effect on treatment outcomes as measured by the Global Assessment Scale of respondents' overall psychological, social and occupational functioning. The validity of the GAS is questioned as a sole measure of treatment outcome.

Flaskerud and Akutsu (1993) studied Asian American clients (N=1528) in the Los Angeles County mental health system; those seen in Asian "parallel" clinics by Asian therapists were less often diagnosed as having psychotic disorders than those at mainstream clinics, whether these were by Asian therapists or white therapists. It may be that Asians are more comfortable going to Asian clinics, and go with less troubling problems. Or, the Asian therapists at the Asian clinics may be more in tune with the needs of the Asian clients, either because they collect more detailed information, or more often speak in the Asian language, or are more recently hired and more in tune with the community.

The fact that ethno-specific agencies are more closely tied to the ethnic minority communities may affect the referral process. Akutsu et al. (1995) found in a large study of African, Asian, Hispanic, and white American users of a public mental health system that Asians and Hispanics were more often referred by national help-giving and lay sources at the ethnic-specific programs.

Only one source suggested the possibility that ethno-specific agencies might actually discourage utilization. Noda (1991) pointed out that the use of a Japanese community mental health service declined following the establishment of a mainstream hospital-based service in the same area. It was suggested speculatively that perhaps the Japanese preferred the anonymity of the mainstream service.

British Experience. Research in Britain on the impact of Section 11 grants and equity policies in specific local authorities had tended to focus on the political context without providing formal evaluation results. Nevertheless, an overview by Cross et al. (1988), and a very detailed study of the London Borough of Brent by Cross et al. (1991) provide a useful context for the evaluation of the partial benefits of these policies (see also Waller 1982).

To what extent are the findings generalizable among ethno-racial communities? All ethno-racial minorities are affected by the standing of their group within Canadian society. The lower the social status and standing of the group, the greater its exposure to racial discrimination, and hence the greater the strength of this type of barrier within the social services. Hence, being a member of an ethno-racial minority group may in itself create barriers to service access. In addition, barriers arise when certain specific conditions are present. Immigrants experience information barriers if they are isolated from the mainstream and come from countries with a minimal social service tradition. Language boundaries are group-specific. The economic level of the group may affect the accessibility of services where expenditures are prerequisite to service, or because of a pattern of housing and residential concentration causing barriers based on the location of services.

Cultural barriers to access are much more complex, and the question of generalizability accordingly more difficult. Every culture is different, and the fact of difference in itself may create barriers because clients and service-providers do not understand one another. The consequences of these misunderstandings may be more or less serious, depending on the nature and sensitivity of the service.

Certain items of culture may constitute barriers as well. Some studies noted that in many groups there may be a heightened reluctance to define personal problems as requiring formal treatment, such as by mental health care services, or services related to family conflict and violence. This was noted for a number of Asian groups in particular, such as Chinese, Japanese, South Asian and others.

A large part of the research on ethno-racial minorities treats these minorities in large categories, such as "black" or "Asian". Findings based on such research apply across the category, and hence any differences within them are averaged. Only a few studies examine more specific groups, such as "Filipinos", or "Cambodians".

Strategic Research Issues. The research issues identified here are those which affect research in all locations, but are of particular relevance in Canada. The Canadian research has been more often of the "action-research" variety, conducted by agencies or community groups in the field. There is more American research focusing on the effects of specific barriers to service access, or evaluating the effects of specific service delivery models. The American research reviewed here is less focused on the decision needs of specific agencies, however. The strength of the British research is that it provides more political context to the debate over social services and access.

Issue #1: Population surveys vs. agency studies. Many of the studies of barriers to social service utilization, particularly in Canada, are based on information from service providers, or clients of these service providers. This is a very different type of information than what is available from studies such as those in the rather large American literature on barriers to mental health care services. The latter is much more often based on population surveys of the catchment areas of agencies.

Surveys of minority populations provide comprehensive information on rates of utilization. In addition, such surveys can attempt to relate utilization to need, and can identify specific potential access barriers for analysis. Regarding these, however, there are important difficulties. First, defining and measuring need is by no means simple, and often the required data are difficult to acquire in a survey. Second, some barriers (language, financial) are easier to measure than others (culture, discrimination). Hence the analysis of the relative importance of barriers can be very difficult.

Agency studies which focus on perceptions of service providers and their clients (users) can provide important information about barriers and the relative importance of barriers, and yield a useful picture of what is the 'conventional wisdom' among those most familiar with the setting. However, these perceptions may not be correct, and require comparison with population survey data. In particular, barriers may be underestimated. As was shown in the study in Montréal (Bernard et al. 1994), the general population may be less aware of service barriers than are the professionals; they also may be less aware of many aspects of social service delivery.

Issue #2: Direct measurement of barriers: low utilization in relation to need. Assessment of social service needs in a population is essential to the discovery of barriers, yet is difficult. Low levels of service utilization is not in itself a problem (some see it as a benefit because then the service is not required and money can be saved).   Access barriers exist when needs exist, and are inequitably addressed. In population surveys, access barriers can be identified by measuring utilization levels for populations of equivalent need. To cite a clear example, barriers in access to social assistance exist when those who are eligible for social assistance (i.e., those who are judged to need it) do not apply.

Issue #3: Measuring the relative importance of barriers. The difference between the two approaches (population surveys vs. agency studies) is reflected clearly in assessing the relative importance of specific barriers. Agency studies can provide information based on perceptions, but the perceptions may not be correct. Population surveys, on the other hand, can provide precise information on measurable barriers, but some barriers are difficult to measure. The measurement problem becomes very pressing in the family and human services area, because it is important to take account of the diversity of services.

Issue #4: Service-specific analysis. Social services are extremely diverse. A large number of services are required in different population subgroups. The barriers which are most important vary by type of service, because of the structure of the service, and because of the cultural and other issues which each raises. Adoption and child custody issues are very different from those raised by delinquency problems, yet both concern children. Individual or family counselling on emotional issues involves sensitivities very different from those involving child care, or support services for the elderly. There is a real problem in providing research which can address the question of barriers to all types of social services simultaneously.

The mental health field is the only one in which there are a large number of studies on a single type of social service. As mentioned above, the service is comparatively standardized, in a comparatively research-oriented professional field, and it is comparatively well-funded. Other areas of social services are far less well researched. Whether conclusions drawn about access barriers to mental health care service apply to family and human services is not known.

Issue #5: Specific ethno-racial groups. All research on ethno-cultural minorities faces the problem of defining the group boundaries, and determining whether what is true for one group applies to similar groups. Should 'South Asians', or 'blacks', 'Hispanics' or 'Chinese', be considered as distinct groups, or should their various subgroups be distinguished? Can they be subsumed under larger categories, such as 'racial minorities'? Drawing such ethnic group boundaries often raises issues within ethnic groups. The important boundaries may have cultural or political significance; the attempt to draw boundaries may raise conflicts.

Issue #6: Assessing practitioner competence. In research on service delivery, the concept of the cultural competence of practitioners is an issue. Various ethnic dimensions of service delivery are measured, including exposure by service providers to inter-cultural training, and the ethnic background of service providers. Both of these may be useful as administrative categories. However, neither is necessarily a guide to cultural competence. Inter-cultural training may be ineffective, and the appropriate content of this training is an issue. Ethnic groups are not culturally homogeneous, and contain cultural subgroups. Individuals within an ethnic group may be fully familiar with the culture of their own subgroup, but less familiar with the cultures of other subgroups. What is needed in these studies is an assessment of the actual treatment provided to persons from different cultural groups.

Issue #7: Evaluating service outcomes. Any analysis of social services must be concerned about the impact of the services on those who are served. Do they receive the benefits intended? Is their level of well-being enhanced? The ultimate criterion of whether a service barrier exists is whether the well-being of an ethno-racial minority group is compromised because of greater difficulty in accessing a needed service.

Studies of barriers to the mental health care services focus on both utilization rates and service outcomes, with effects on the former much more easily demonstrated. One of the difficulties with the outcome measures is that there is often very little professional consensus on their validity. The Global Assessment Scale, used in many of these studies, has the disadvantage that it includes many items unrelated to the objectives of the mental health care services under study. Hence, it would be surprising to see major impacts on this particular criterion, at least in the short term. At the same time, demonstrating the cost-effectiveness of a service is crucial to its evaluation. Each service in the social and human services field would have different outcome criteria.

Outcomes should be assessed in terms of impacts on individual service users, and impacts on ‘society’ or on the broader community. The rationale for social services is both compassion for individuals, and the well-being of the collectivity. Both can be assessed in many dimensions, including economic and social. For example, a service which helps someone in poverty overcome personal or family problems may enable that person to be more productive in a job, and to contribute more to the community; it may also reduce social service costs in the long term by reducing the potential for social problems in the community. These outcomes all are relevant to social service evaluation.

Issue #8: Ethnic dimensions of service delivery: costs. Sensitivity to the needs of minority ethnic group needs can be accomplished in a variety of different ways, as the discussion of promising service-delivery models showed. The American evaluation studies in the mental health service field have tended to concentrate on two: ‘ethnic match’ and ethno-specific services (defined in terms of the dominant user groups). Moreover, they have tended to concentrate on outcomes defined in terms of service-delivery rather than costs. There is a need for research which would assess cost-effectiveness, which means an emphasis on both outcomes, and the costs incurred in achieving those outcomes.

Issue #9: Quantitative, qualitative and action- research. The recent American research has a heavy quantitative emphasis, which enables the research to make relatively definite statements about the size of barriers, or the impact of service delivery systems. The British research is less quantitative, and has emphasized the political context of social services and access problems. This enables the research to show the powerful social forces at work, and the value of services in minority communities. Canadian research has been action-oriented, focusing on agencies and their client groups; there has been less academic involvement. This enables the research to address the ‘conventional wisdom’ among those most knowledgeable about service delivery in minority communities. These are broad tendencies; the different research approaches are represented in all three countries.

It is suggested that in the Canadian context, the action-research emphasis is valuable, but more attention to quantitative and qualitative research also may be considered as appropriate and useful. Adopting the quantitative emphasis found in the US research can add precision to statements about barriers; emphasis on the political context of social services and access issues, such as in British studies, can provide an appreciation of political resistance to addressing the needs of minorities.

Research Priorities. This review suggests that the following four types of studies would be most policy-relevant in the Ontario environment under current circumstances. For each of the four, the parameters of the research in terms of types of services included, and specific minority groups included, are important issues.

(1) Relative importance of barriers. The existing research, in Canada and Ontario, and also internationally, demonstrates the existence of barriers to service utilization, but does not provide good information on the relative importance of specific barriers. Policies to break down existing barriers must be based on assumptions about the priority to be given to different types of barriers. The list of barriers identified, common to Canadian and non-Canadian studies (language, information, cultural patterns of help-seeking, lack of culturally-sensitive services, financial barriers, lack of service availability), is useful in itself, but does not provide priorities in overcoming barriers to specific services. Which barriers are most important in restricting access to which services, for which minority groups? There is very little information available which would provide specific answers to this question.

(2) Cost-effectiveness of mainstream vs. different forms of ethnic match. The research provides little information on the relative costs of different modes of delivering services to minority groups. There are now studies which provide persuasive evidence that ethno-specific services in the mental health care field improve access while maintaining service quality. There is no information in these studies about the relative costs of services provided in these ways. Assessing the value of ethno-specific services from a policy perspective requires information about these costs in relation to the demonstrated gains.

(3) Social and economic consequences of barriers in access to service. The social importance of specific barriers in access to social services depends in part on the consequences of these barriers for individuals and for the community. What happens to individuals and communities when ethno-racial minorities do not receive specific social services? What is the extent of the costs which are imposed on them, and what are the costs imposed on the community? Information about these costs would be an important tool in reaching policy decisions which would address what may be cost-efficient means for offsetting specific barriers.

As an example, one study in the United States (Snowden, et al. 1995) showed that members of ethno-racial minorities who received mental health services from members of their own group were less likely to use emergency services. This suggests that the exclusive use of majority group service-providers are less cost-effective because they do not succeed in preventing crisis situations which carry the consequence of still greater burdens on the mainstream service system. This is one small example of how barriers to service delivery carry consequences which impose costs on the community.

(4) Impact of existing policies. Little attention has been given to the evaluation of the range of innovations proposed and implemented in the field of services for ethno-racial minorities. For example, the emphasis in Metropolitan Toronto on the provision of information about service availability addresses one of the key barriers identified in research: lack of information. However, given that the research does not really assess the status of this particular barrier in relation to others, it is possible that even with the successful removal of the information barrier, other barriers still stand in the way of service utilization. In this case, efforts at dissemination of information may have little impact on service delivery. Similar remarks may be made about training in cultural sensitivity, minority service units within the mainstream service organizations, and other proposed innovations.

Technical Issues. What technical issues will affect new research, potentially limiting the usefulness of findings? There are many such issues, and only a few of the most important issues will be identified here.

(1) Identification of key services. Existing studies do not address the specificity of social services in a useful way. Studies of agencies often lump various social services together, sometimes including health care, mental health care, and a range of family and human services in a single category. Other studies focus on specific services, concentrating mostly on mental health services. Providing useful information about the need for overcoming barriers to social services requires that specific services be identified, including actual treatment applied, so that specific barriers can be located, and the consequences of not overcoming those barriers can be clearly delineated.

The importance of having information about specific services must be balanced against the importance of assessing the broad spectrum of services and not addressing only specific ones. This is a difficult issue, but what exists now -- lumping services together, or concentrating on only a few services -- is unsatisfactory. Perhaps an effort is required to identify categories of services, such as by user group (children, women, the elderly), or by function (family support, crime prevention, crisis intervention) and establish research priorities on that basis.

(2) Delineation of groups served in particular catchment areas. Population surveys are an important component of research on service utilization, and yet many of the minority groups which should be included in such studies are small and difficult to identify in random samples. US research on these issues has focused on groups within large agency catchment areas, leading to the analysis of large ethnic categories such as "Asian", "black", and "Hispanic." In the Canadian context, with lower levels of residential concentration, and often a more diverse array of immigrant groups, comparable research will have to combine perhaps even larger categories. The consequence will be a lower degree of ethnic specificity in the application of research findings.

(3) Outcome measures. The lack of valid and reliable measures appropriate to reflect the success of service delivery is a significant problem limiting existing research. The Global Assessment Scale is comprehensive, including many aspects of personal adjustment beyond those targeted by a particular service. Limiting research to utilization rates does not address the question of cost-effectiveness, however. The development of outcome measures must be service specific, and sensitive to the intended changes and patterns of change over time, and what actually happens in the process.

Table of Contents         Executive Summary
Chapter | 1 | 2 | 3 | 4 | 5 | 6 | 7 |      Bibliography | A-B | C-I | J-O | P-Z |

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Virtual Library		Updated February 09, 2004