524 Group Project

Synthesis Presentation

Group B2Tonya AdelmanNatalie HawkinsMichael HerbertMusediq Ismail-RasheedSanghee LeeRenee Sandusky

Providing Culturally Competent Care to Minority youth with

mental health issues

From: (APA, 2014), (Thomas, Temple, Perez & Rupp, 2012), and (Ngo, Asarnow, Lange, Jaycox, Rea, Landon, Tang & Miranda, 2009)

An estimated 15 million youth, or 1 in 5 children and adolescents, are currently suffering from a mental disorder. Sadly, however, only about 7% of those in need receive appropriate mental health care.

Furthermore, over two-thirds of white children receive necessary mental health care, but only about half of minority children will receive the same needed care.

Strategies for addressing mental health disparities among youth are urgently needed to help lessen the impact of the devastating and lasting effects. For example, untreated depression in the minority youth population has been associated with suicide, school dropout, pregnancy, substance abuse, and depression in adulthood.

Why Is This Important?

Population DefinitionOur population of minority youths are defined as follows:

• Minority ethnic groups:o African-Americans (blacks)o Asian-Americanso Hispanics or Latinoso Native Hawaiian and other Pacific Islandso American Indians/Alaskan Natives.

• Youths defined as people under 24 years of age. • Children defined as persons aged <18 years• Adolescents are persons aged 12–17 years

• Mental disorders:o In children, mental disorders are described as "serious deviations from

expected cognitive, social, and emotional development" and include conditions meeting criteria described by the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR) (5) or the International Classification of Diseases (ICD)

(CDC, 2013; U.S. Census Bureau, 2010)

Population Characteristics

Total youth population in 2010 43,626,342

• 13.3% African-Americans• 5.1% Asian-Americans• 16.9% Hispanics• 1.2% Native Americans.

Population living at the national poverty level:

• 28% Native Americans • 27.1% of African

Americans • 24.8 Hispanics, and • 12.5% Asian Americans

(IES, 2007)

Averaged freshman graduation rate for public high school students, by race/ethnicity:

School year 2006–07

• 13%–20% of the population under age 18 experience a mental disorder in any given year.

• In 2006, the cost of mental disorders among people under 24 years of age was estimated at $247 billion annually.

• During 2007-2010, studies found:o a 24% increase in inpatient mental health and substance

abuse admissions among children o an increase in use of psychotropic medications for teenagers.

• In 2010, mood disorders were the most common diagnoses for all hospital stays among children in the U.S.

• In 2011, substance use disorders affected 1.7 million adolescents aged 12–17 years.

(CDC, 2013)

Population Health Assessment

• Attention-deficit/hyperactivity disorder (ADHD, 6.8%)o The prevalence was highest among black and white children

and lower among Hispanic children.

• Conduct Disorder (3.5%)o The highest prevalence was found among black children.

• Anxiety disorder (3.0%)o Black children were less likely than white children to have

had anxiety or have current anxiety.

• Depression (2.1%)o Black adolescents were less likely to have had a major

depressive episode than white adolescents.

• Autism spectrum disorders (ASD, 1.1%)o The prevalence tends to be lower among minority children.

(CDC, 2013)


• Illicit drug use disorder (4.7%)o The prevalence was highest among Hispanic adolescents.o 39.9% of students had used marijuana; 6.8% cocaine; 11.4%

inhalants; 2.9% heroin; 3.8% methamphetamines.o 25.6% of students had been offered, sold, or given an illegal drug

by someone on school property.

• Alcohol use disorders (4.2%)o The prevalence was higher among Hispanic and white

adolescents than among black adolescents.o 70.8% of students had at least one drink of alcohol.

• Cigarette dependence (2.8%)o The highest prevalence was found among white adolescents.o 44.7% of students had at one point tried cigarette smoking.

(CDC, 2013; CDC, n.d.)


• 28.5% of high school students reported that they had felt sad or hopeless. o The prevalence was higher among Hispanic students

than white or black students.

Table 1Felt Sad or Hopeless Among Students in Grades 9-12

(in %), 2011

Sex Black AI/AN Asian Hispanic White

Male 18.0 22.8 25.9 24.4 20.7

Female 31.4 50.0 33.5 41.4 34.3

Total 24.7 35.9 29.4 32.6 27.2


Note. From High School Youth Risk Behavior Survey Data, 2011, CDC.

(CDC, 2011)

• Suicide was the second leading cause of death among adolescents aged 12–17 years.

• In 2010, the overall suicide rate for adolescents aged 10-19 years was 4.5 suicides per 100,000 persons.o White children and non-Hispanic children of other races had

higher rates of suicide than black and Hispanic children.o The most common mechanisms of injury were

hanging/suffocation and firearms.

• Among children who died by suicide, o 35.5% had a diagnosed mental disorder at the time of deatho 26.4% were under treatment for a current mental disorder at

the time of death.

(CDC, 2013)


• Suicide attempts for Hispanic girls, grades 9-12, were 70% higher than for white girls, in 2011

• American Indian/Alaska Native (AI/AN) girls have death rates at almost four times the rate for white girls.

Table 2Age-Adjusted Death Rates for Suicide: Ages 15 -

19, 2011

Sex Black AI/AN Asian Hispanic White

Male 7.0 31.1 7.5 9.0 14.0

Female 1.8 10.7 4.2 2.8 3.5

Total 4.5 20.7 5.9 6.0 8.9


Note. From Web-based Injury Statistics Query and Reporting System (WISQARS), 2012, CDC.

(CDC, 2013)

Risk Factors for Mental Illness

Individual and family risk factors:

• History of mental disorders, e.g.,

depression, ADHD, autism spectrum

• Physical and sexual abuse

• Involvement with drugs, alcohol or tobacco

• Parental criminality, substance abuse,

psychiatric disorders

• Unwillingness to seek help because of

stigma

• Repeated experiences of discrimination;

chronic exposure to racism

(Dyson, n.d.)

Social and environmental:

• Low socioeconomic status

• Large families and overcrowding

• Unsafe neighborhoods

• Foster care placement

• High rates of unmet mental

health needs

• Diminished economic

opportunities

• Lack of adequate services within

local communities


Cultural and ethnic:

• Difficulty with assimilation

• Lack of cultural role models

• Misdiagnosis based on various

cultural presenting symptoms

• General mistrust of the healthcare

system

• Shame and stigma



The healthcare system itself creates additional risk

factors for minority populations such as:

• a lack of required training on cultural components and etiquette

• a lack of a diverse workforce

• a lack of knowledge and awareness of cultural differences among

providers

We will be addressing this final issue for the remainder of the presentation.

Population Strengths and ChallengesChallenges:• Less access to available mental health services

o Rates of use of mental health services by Hispanics are low due to lack of community- based services and language barriers

• Are less likely to receive needed mental health careo Inadequate access to care because of living in rural areas which results

in less culturally competent providers in these areas

• Often receive poorer quality careo African American adolescents are more likely to be referred to the

juvenile justice system rather than the mental health treatment system

• Are significantly under-represented in mental health professions

Strengths:• Societal/environmental factors such as Hispanics having strong

support systems which translates to better support for depression and suicide

• Many minorities have an advantage of bilingualism

Ecological ModelCultural competence includes aspects of:

• Commitment to diversity as a valued component of

organizational strategy.

• Dedication to achieving a workforce that is reflective of

the communities and regions that are served, and is

demonstrated through the behaviors of the entire

organization.

• Working to eliminate mental health care disparities with

healthcare reform.

• Having the ability to speak more than one language gives

minorities an advantage to increased communication with

healthcare providers.

Selection of Intervention and Purpose Intervention:

Enhance cultural awareness and encourage culturally

competent care.

Why is addressing cultural communication important?

• The inability of healthcare providers to connect with young

patients is a form of health care disparity.

• Minorities generally receive lower levels of “interpersonal

care” than whites.

• Elimination of health disparities is a Healthy People 2020 goal.

• Individualized mental health care is considered a right.

(Stewart, Simmons, & Habibpour, 2012)

Intervention Specifics

• Target: Health care providers working with desired

populations.

• Location: Large medical centers and other institutions

catering to minority clienteles.

• Intervention will primarily be conducted via training and

certification programs.

• Resources needed: Experienced culturally competent

instructor, space for training, media, and technology

available to present the training materials.

• Programs will be conducted on an annual basis.

Intervention Rationale and Delivery

Rationale:• By providing culturally competent care, evidence shows improved

access to services, improved engagement and acceptance, better

recruitment and program retention, and improved outcomes for

minority children and youth

Methods of delivery:• Courses in culturally-competent care delivery (with CEU credit)

o Include education on barriers to health literacy and its impact on

quality of patient care. For example, offering appropriate written

materials for audiences with limited literacy (brochures in different

languages)

• Monthly grand rounds-style presentations that emphasize situations

where cultural care is tantamount

• Employing staff members specializing in delivery of culturally-

competent care

(Alegria, Vallas, & Pumariega, 2010), ( Kumpfer, Alvarado, Smith, & Bellamy, 2002)

Process Objectives

• In one year, at least 85% of providers at local institutions

will have taken at least one class in culturally competent

care.

• At the end of the one-year period, 85% of providers who

have taken classes will take a brief examination that covers

selected aspects of culturally-competent care.

• At least 85% of participating institutions will designate an

official responsible for improving cultural competency at

their facility.

Outcome Objectives:

• Outcome 1: Patients will be satisfied with

communication in their cultural style as evidenced by

85% satisfaction on a survey that assesses whether or

not they are satisfied with their provider’s

communication style.

• Outcome 2: Culturally diverse patients will experience

greater participation in the health care system as

evidenced by a statistically significant increase in

resource utilization.

Plan For Process Evaluation

Factors and data analyzed throughout the evaluation

process:

Evaluating intervention materials:

• The content and accuracy of the cultural competency education and

training

o Providers and administrators will asses if topics are applicable

• Provider and Patient surveys

o For Provider: the Cultural Self-Efficacy Scale (NYSPI, 2010)

o For Patient: Client Cultural Competence Inventory

• Provider Examination at the end of program

Who is being tracked through the intervention activities:

• Patients (their usage and demographic data)

• Providers (who has attended training)

• Institutions and administrators (who is participating and

establishing protocols)

Who is conducting the intervention analysis:

• researchers, student researchers

• Statisticians

Identify possible program areas for Improvement:

• Continuous analysis of data, questioning, and ideas that inform

program process (quality control measures)

Plan For Process Evaluation

Plan For Outcome Evaluation

Measure Short Term Outcome Objectives

For short term objectives such as patient satisfaction at the end of the study:

• Measure the change between the initial patient satisfaction survey assessed before the provider received cultural competence training and their experience with their healthcare provider at the end of the study.

Data collection and evaluation will be done at the end program for outcome 1 and one year later for outcome 2.

Measure Long Term Outcome Objectives

Long-term objectives involves behavioral changes which are more challenging to quantify.

• This requires comparing and evaluating minority youth patients mental healthcare usage data during the year after the study was completed versus the initial baseline that was collected at the beginning of the program.

• Unfortunately changing behavior and attitudes can take an extremely long time and creating a direct link between long-term patient outcomes and changes in behavior and given interventions can be difficult to prove.

Plan For Outcome Evaluation

Alegria, M., Vallas, M., & Pumariega, A. (2010). Racial and ethnic disparities in pediatric mental health. Child and Adolescent Psychiatric Clinics of North America 19(4), 759-774. doi:10.1016/j.chc.2010.07.001

American Psychological Association. (n.d.) Children’s Mental Health. Retrieved from https://www.apa.org/pi/families/children-mental-health.aspx

Centers for Disease Control and Prevention (CDC). (2011). High School Youth Risk Behavior Survey Data. Retrieved from http://nccd.cdc.gov/youthonline/App/Default.aspx

CDC (2011). Mental Illness Surveillance Among Adults in the United States. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/su6003a1.htm?s_cid=su6003a1_w

CDC. (2012). Web-based Injury Statistics Query and Reporting System (WISQARS). Retrieved from http://www.cdc.gov/injury/wisqars/index.html

CDC. (2013). Mental Health Surveillance Among Children--United States, 2005-2011. Retrieved from http://www.cdc.gov/mmwr/pdf/other/su6202.pdf

CDC. (n.d.). Youth Risk Behavior Surveillance System: 2011 National Overview. Retrieved from http://www.cdc.gov/healthyyouth/yrbs/pdf/us_overview_yrbs.pdf

Dyson, A. (n.d.). [Picture of a child surrounded by three hands]. Retrieved from http://www.theage.com.au/national/reforms-target-youth-mental-health-problems-20090312-8whl.html

Heron, M. (2013). Deaths: Leading causes for 2010. National Vital Statistics Reports, 62(6), 17-91. Retrieved from http://www.cdc.gov/nchs/data/nvsr/nvsr62/nvsr62_06.pdf

Institute For Education Sciences (IES). (2007). Status and trends in the education of racial and ethnic minorities. Retrieved from http://nces.ed.gov/pubs2010/2010015/figures/figure_18_2.asp.

References

Kumpfer, K. L., Alvarado, R., Smith, P., & Bellamy, N. (2002). Cultural sensitivity and adaptation in family-based prevention interventions. Prevention Medicine 3(3), 241-246. Retrieved from http://rulearning.rush.edu/bbcswebdav/pid-251504-dt-content-rid-2284162_1/courses/14SPCON-NSG-524-W1/13SUCON-NSG-524-1_ImportedContent_20130429044423/Kumpfer%2C%202002.pdf

New York State Psychiatric Institute (NYSPI). (2010). Cultural Competence Assessment Tools. Retrieved from http://www.nyspi.org/culturalcompetence/what/pdf/NYSPI-CECC_CulturalCompetenceAssessment.pdf

Pumareiga, A. J., Rogers, K., & Rothe, E. (2005). Culturally competent systems of care for children’s mental health: Advances and challenges. Community Mental Health Journal 41(5), 539-555. doi:10.1007/s10597-005-6360-4

Ngo, V., Asarnow, J., Lange, J., Jaycox, L., Rea, M., Landon, C., . . . Miranda, J. (2009). Outcomes for youths from racial-ethnic minority groups in a quality improvement intervention for depression treatment. Psychiatric Services, 60(10), 1357-1364. doi:10.1176/appi.ps.60.10.1357

Thomas, J., Temple, J., Perez, N., & Rupp, R. (2012). Ethnic and gender disparities in needed adolescent mental health care. Journal of Health Care for the Poor and Underserved, 22(1), 101-110. doi:10.1353/hpu.2011.0029

United Nations Educational, Scientific, and Cultural Organization. (n.d.). Youth-Definition. Retrieved from http://www.unesco.org/new/en/social-and-human-sciences/themes/youth/youth-definition/

U.S. Census Bureau. (2010). Racial and Ethnic Minority Populations. Retrieved from http://www.cdc.gov/minorityhealth/populations/REMP/definitions.html

US Department of Health and Human Services, Office of Minority Health. (2012). Mental Health and Hispanics. Retrieved from http://minorityhealth.hhs.gov/templates/content.aspx?lvl=3&lvlID=9&ID=6477

US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. (2012). Results from the 2012 National Survey on Drug Use and Health: Mental Health Findings. Retrieved from http://www.samhsa.gov/data/NSDUH/2k12MH_FindingsandDetTables/2K12MHF/NSDUHmhfr2012.htm#ch2

US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. (n.d.) Key Features of Risk and Protective Factors.Retrieved from http://captus.samhsa.gov/prevention-practice/prevention-and-behavioral-health/key-features-risk-protective-factors/1

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