Social Services Innovations: Bridging the Health Literacy Gap — Revisiting Cultural Competency
By Yosmayra E. Reyes, LCSW
Social Work Today
Vol. 20 No. 3 P. 28

Social work should be able to provide the best intervention in the shortest time frame at the most critical times. It is a major responsibility given the limited amount of resources allocated in any given government at any given time. With the advent of deinstitutionalization and a fluctuating economic market, we must seek to educate in the most cost-effective manner. Increasing cultural competency presents a unique and dynamic way to ensure that the health literacy gap is closed and that populations that have been underserved receive access to critical mental health care.

Community Connections
Inevitably, the social work landscape is changing with the conscientious move by health care to lower the number of emergency department visits for mental health conditions. In light of this move, a new service provider—the community—has come to the forefront. Community health services are now on the front lines of preventive medical care, making them purveyors and overseers of clinical care. If mishandled, this can be a precarious position for some agencies, leading to difficulties in service acquisition.

A barrier to managing this transition smoothly is distrust of a system due to cultural stress. In communities composed of first-generation children where multiculturalism is highlighted as a unifying factor, a feeling of distrust creates unrest in the system. This may literally translate to patients not receiving timely care when needed due to distrust in service providers, principally to avoid higher levels of care.

As social workers, we are trained to understand a system, the importance of its maintenance, and how to make repairs. Repairing distrust in a system when providing mental health care becomes a big elephant in the room. Is the patient being honest? Are they vaccinated? Have they attended school? Are they in pain? These questions should have obvious answers, but in social services at times, they pose tricky challenges. Knowing and being attuned to patients’ needs requires a reflective process, particularly when it comes to working with underserved populations.

One effective way of shortening this gap—and this distrust in providers—is increasing cultural competency as a standardized measure in community practices. Definitions of cultural competency have changed throughout the years, leading to its fluid nature, but some interesting connections have been identified. Betancourt, Green, & Carrillo (2002), in their report on improving service provisions both as a way to increase health outcomes and as a business strategy, saw the importance of tailoring a health message based on a person’s diverse values, beliefs, and/or behaviors. Current literary research reviews, such as that undertaken by Jongen, McCalman, & Bainbridge (2018), continue to highlight that continual clinician training is the only method to substantially support this practice in clinical settings.

How then do you ensure that service providers are providing culturally competent care? Suarez-Balcazar et al. (2011) set forth on that exact mission—to validate an instrument specifically on competency development in rehabilitation practitioners. An itemized list was highlighted that practitioners can self-administer based off a three-factor model that focuses on awareness/sensitivity, organizational support, and clinician skills. One caveat to successfully implementing this work, as identified by the authors, was the need for systemic adoption. This reflects the importance of staff trainings both for clinical and administrative staff. From an agency perspective, this can be anyone that may communicate with the patient at any given point while receiving care.

Ensuring all staff are conscientious about developing cultural awareness/sensitivity will result in elevating the quality of care. Community residents entering a facility reflective of their needs will ensure engagement and adherence to treatment. It would further assist by lowering defenses and increase clinicians receiving critical information regarding family needs. Many times, providing mental health care, particularly to children and adolescents, means a parallel process, understanding the events that brought a patient to treatment and the underlying needs that are present in the family. Focusing on cultural competency development indirectly assists in developing alliance between the clinician and the family by creating a patient-centered care that is both relevant and applicable.

On any given day, multicultural enclaves in New York City can include Chinese, Mexican, Central and South American, Dominican, Russian, and Middle Eastern populations, to name just a few. It would be difficult for any agency to encompass all these cultural identities in their staff pool. And even if similar identities are reflected in the cultural composition of the staff, the vast disparities in financial status from those with extended education as opposed to others with limited options in extending their education precludes commonalties in shared experiences.

Recent migration journeys, culture shock, risk of deportation, fear of being tracked, ending of service programs such as Deferred Action for Childhood Arrivals (DACA), political instability, and immigration racism all contribute to a new category: the mixed status family, i.e., people who are of the system, although not currently in the system, but could benefit from services in the system.

Where Does This Leave Us?
Faced with this fluid landscape, community health is being restructured. Social work practice interventions are shedding light on how to reach this population. With detrimental effects on providing services, providers should focus on facilitating incorporation of language, technique, and developing key strategic clinical interventions to bridge access in care. Park and Katsiaficas (2019), in “Mitigating the Effects of Trauma Among Young Children of Immigrants and Refugees,” their policy brief from the Migration Policy Institute, point to key organizational interventions that can assist in increasing cultural competency. Focusing on social-emotional health, providing infant and early childhood mental health consultations to lower adverse childhood experiences, and increasing collaborative referrals were a few recommendations highlighted, in addition to standardized culturally appropriate services.

The mixed-status family has many layers. To some members, language may not be a problem but status may impact educational and employment settings, such as when DACA and temporary protective status programs were recently terminated. To others who are awaiting confirmation of, or are under the process to obtain, citizenship, applying for benefits is not an option. The fear of being tracked makes parents cautious about receiving care, even if their child or adolescent is in critical need. Often when families of mixed status come to receive services, there may be much information that is withheld, placing younger patients in precarious positions under additional levels of stress.

Navigating the referral processes requires some level of ingenuity but is ultimately one of the backbones of culturally competent work. Ensuring ties with similar organizations increases a patient’s safety net and provides connections to different social service agencies that may be the first point of contact in identifying adverse childhood experiences that may be on the rise. Partnering with these additional service agencies means a much more integrated and intimate referral process. Many social rehabilitative support services can be received from a layperson but require additional time to ensure referral service completion is established. As a clinician, this intricate referral provides a proper handoff and creates smooth transitions in managing patients deemed to be at a higher or lower risk level.

The Big Picture
At the crux of the matter is one question: Are the services provided reflective of the community that they are provided for? A clear-cut answer may never exist, but what is important is to begin to have open dialogue with the aim of increasing awareness and sensitivity. This may appear easier said than done; often in mental health care there is a high turnover rate, burnout, and clinicians with limited experiences. To address this, agencies should schedule periodic sessions focused on cultural competency training and the development of language that is scripted to ensure incorporation at all levels.

Clinicians can specifically work toward tailoring their message, particularly when providing psychoeducation. Clinicians should make it a form of practice to ensure proper handoffs when making referrals. Partnering with neighboring agencies involves more follow-through and attention. When providing a referral, was it attempted successfully? If not, how could you tailor the message and rerefer? Perhaps a clergy member to introduce the topic can tag along with you, or a community health worker may visit the home. Either way, some creativity is needed to ensure that service needs are being met. It may seem like extra work, but it creates targeted strategies to ensure that transition of care becomes smooth as patients develop a stronger community network on which to rely.

Changing forms of practice requires a certain level of humility. If you find yourself going through patients via a revolving door, or having poor treatment fits, it may be worthwhile to inquire about your level of cultural competency; perhaps it’s time to increase your cultural awareness/sensitivity. One critical recommendation in the Park and Katsiaficas brief was the importance of obtaining services through a trusted source, more easily translated as word-of-mouth referrals. Increasing attention to client needs may mean additional time dialoguing, but ultimately may reflect higher productivity levels.

— Yosmayra E. Reyes, LCSW, is a psychotherapist providing care to children and adolescents with mental health challenges. She works as the weekend supervisor at Bonding Links, Coalition for Hispanic Family Services, a mental health clinic under the Office of Mental Health NY, recently awarded the Community Care Award 2019 for outstanding impact in community health.

References
Betancourt, J. R., Green, A. R., & Carrillo, J. E. (2002, October). Cultural competence in health care: Emerging frameworks and practical approaches. The Commonwealth Fund. https://www.commonwealthfund.org/sites/default/files/documents/___
media_files_publications_fund_report_2002_oct_cultural_competence_in_health_care__
emerging_frameworks_and_practical_approaches_betancourt_culturalcompetence_576_pdf.pdf.

Jongen, C., McCalman, J., & Bainbridge, R. (2018). Health workforce cultural competency interventions: a systematic scoping review. BMC Health Services Research, 18(1), 232. https://doi.org/10.1186/s12913-018-3001-5

Park, M., & Katsiaficas, C. (2019, April). Mitigating the effects of trauma among young children of immigrants and refugees: The role of early childhood programs. Migration Policy Institute. https://www.migrationpolicy.org/research/mitigating-effects-trauma-young-children-immigrants-refugees  

Suarez-Balcazar, Y., Balcazar, F., Taylor-Ritzler, T., Portillo, N., Rodakowsk, J., Garcia-Ramirez, M., Willis, C. (2011). Development and validation of the cultural competence assessment instrument: A factorial analysis. Journal of Rehabilitation, 77(1), 4-13. https://www.semanticscholar.org/paper/Development-and-Validation-of-the-Cultural-A-Suarez-balcazar-Baicazar/198c69180d0ead2fc4b0d10fc6c0b1684623326c