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Multilevel codes for barriers to implementation
Source publication
Using a multilevel ecological framework, we take a qualitative approach to examining important cultural considerations that support successful implementation of trauma-informed services within the Latinx community. We conducted key informant interviews with community practitioners recruited primarily in the Phoenix, AZ metro area. Themes that emerg...
Citations
... Another aspect of unpacking generational cultural expectations involved family therapists endeavoring to understand what exactly their Latino parent clients did expect from their children-often through gathering a thorough family history to identify transgenerational patterns. The importance of this practice has been underscored by scholarship on transgenerational trauma highlighting the consequences that can be transmitted across generations when cultural expectations go unmet (Meléndez Guevara et al. 2021;Phipps and Degges-White 2014). This practice provided Latino parents with an awareness of the transgenerational processes operating in their families and the opportunity to break the chains of generational transmission that they no longer wanted to promote. ...
Persistent ethnic–racial discrimination in the lives of minoritized clients requires a better understanding of effective practices for family therapists working with Latino families. Ethnic–racial socialization (ERS) can help mitigate the adverse effects of discrimination; however, ERS practices are less known as a therapeutic tool, resulting in a critical gap in the existing literature and limiting the support that family therapists can provide to Latino families. In response, the current study investigated family therapists' lived experiences facilitating ERS practices with Latino parents in therapy. Semi‐structured interviews with family therapists (n = 20) from 10 US states were conducted. A rigorous thematic analysis revealed two key themes related to the approaches used by family therapists for explicitly naming and navigating ERS‐related conversations when working with Latino parents and families. The results can inform recommendations for promoting conversations related to race, ethnicity, culture, ethnic–racial discrimination, and immigration with Latino parents in family therapy.
... Schools are one of the most influential systems in youth's development, and this is especially true for immigrant youth in which schools play a vital role in bridging youth's adjustment to the host country (Farmer & Farmer, 1999;Ford et al., 2021;Patel, Bouche, et al., 2023). When cultural stressors are present in the school setting, they negatively impact the school climate and increase immigrant youths' feelings of isolation/marginalization (Meléndez Guevara et al., 2021;Oxman-Martinez et al., 2012;Patel, Bouche, et al., 2023;Plenty & Jonsson, 2017). These feelings are magnified when schools do not intervene to address these issues or to support students who are experiencing them (Benner & Graham, 2011;Closson et al., 2014). ...
Objectives: Latinx immigrant youth are at greater risk for mental health (MH) concerns than their nonimmigrant Latinx peers. Efforts to address mental health disparities have resulted in the much-needed development of theoretical frameworks explaining mental health disparities in marginalized populations. A theoretical framework that is particularly relevant to mental health disparities among Latinx immigrant youth is the Cultural Stress Theory (CST); however, an expansion of this model is necessary to thoroughly describe and explain mental health risk in this population. Method: This article integrates two frameworks—Toxic Stress Theory and the National Institute of Minority Health and Health Disparities research framework—with CST to better explain mental health risk in Latinx immigrant youth. In doing so, we propose an expanded model that seeks to build on the strengths of CST in two important ways—expanding the breadth of relevant ecological domains and emphasizing the continued focus on specific mechanisms and their associations across levels. Results: The proposed expanded CST model acknowledges a range of influences from the broad systemic and sociopolitical level to the biological level to comprehensively guide research that can better explain mental health risk in Latinx immigrant youth. Conclusions: An expanded CST model that incorporates the two highlighted frameworks can elucidate additional mechanisms by which cultural stressors influence mental health risk in Latinx immigrant youth. Such mechanistic work holds the key to effectively reducing mental health disparities for Latinx immigrant youth.
... Traumainformed approaches to behavioral health services recognize the prevalence of trauma, how it is manifested, and its multifaceted effects on individuals and communities, emphasize physical, psychological, and emotional safety for both users and providers of the services, promote and support user agency, and utilize practices and procedures that minimize the likelihood of re-traumatization (22). We developed and delivered our innovative health promotion intervention using a traumainformed approach, as recommended but little researched with Latinx communities (23). ...
Background
Latinx communities are disproportionately affected by COVID-19 compared with non-Latinx White communities in Oregon and much of the United States. The COVID-19 pandemic presents a critical and urgent need to reach Latinx communities with innovative, culturally tailored outreach and health promotion interventions to reduce viral transmission and address disparities. The aims of this case study are to (1) outline the collaborative development of a culturally and trauma-informed COVID-19 preventive intervention for Latinx communities; (2) describe essential intervention elements; and (3) summarize strengths and lessons learned for future applications.
Methods
Between June 2020 and January 2021, a multidisciplinary team of researchers and Latinx-serving partners engaged in the following intervention development activities: a scientific literature review, a survey of 67 Latinx residents attending public testing events, interviews with 13 leaders of community-based organizations serving Latinx residents, and bi-weekly consultations with the project's Public Health and Community Services Team and a regional Community and Scientific Advisory Board. After launching the intervention in the field in February 2021, bi-weekly meetings with interventionists continuously informed minor iterative refinements through present day.
Results
The resulting intervention, Promotores de Salud, includes outreach and brief health education. Bilingual, trauma-informed trainings and materials reflect the lived experiences, cultural values, needs, and concerns of Latinx communities. Interventionists (21 Promotores) were Latinx residents from nine Oregon counties where the intervention was delivered.
Conclusions
Sharing development and intervention details with public health researchers and practitioners facilitates intervention uptake and replication to optimize the public health effect in Oregon's Latinx communities and beyond.
... In conclusion, the COVID-19 pandemic has clearly widened existing racial and ethnic disparities in mental health, highlighting the need for culturally responsive services for affected individuals and communities. Delivering these services with cultural humility principles in mind will likely be beneficial for promoting equity in mental health services access and quality for diverse patients, families, and communities (Melendez Guevara et al., 2021). ...
Social and economic inequality are chronic stressors that continually erode the mental and physical health of marginalized groups, undermining overall societal resilience. In this comprehensive review, we synthesize evidence of greater increases in mental health symptoms during the COVID-19 pandemic among socially or economically marginalized groups in the United States, including (a) people who are low income or experiencing homelessness, (b) racial and ethnic minorities, (c) women and lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ+) communities, (d) immigrants and migrants, (e) children and people with a history of childhood adversity, and (f) the socially isolated and lonely. Based on this evidence, we propose that reducing social and economic inequality would promote population mental health and societal resilience to future crises. Specifically, we propose concrete, actionable recommendations for policy, intervention, and practice that would bolster five "pillars" of societal resilience: (1) economic safety and equity, (2) accessible healthcare, including mental health services, (3) combating racial injustice and promoting respect for diversity, equity, and inclusion, (4) child and family protection services, and (5) social cohesion. Although the recent pandemic exposed and accentuated steep inequalities within our society, efforts to rebuild offer the opportunity to re-envision societal resilience and policy to reduce multiple forms of inequality for our collective benefit.
... Although these cultural brokers are aware that some families are continually exposed to sources of trauma, they are careful to avoid the use of labels like "trauma" and "mental health" due to strong stigmatized perceptions which risk alienating some families further. Instead, cultural brokers and teachers alike focus their attention on best practices, mainly developing relationships and building rapport with students and their families (Meléndez Guevara et al., 2021). ...
... System-level barriers including a history of colonialism and a Eurocentric model of health care have produced inequities that disproportionately impact racialized service providers, clients, and communities. Recent studies examining the impact of racism on health equity in the child and youth mental health and addictions (CYMHA) system affirm that racialized communities experience reduced access to care (Aden et al., 2020;Alang, 2019) and greater mistrust of the health system (Fante-Coleman & Jackson-Best, 2020; Meléndez Guevara et al., 2021). These inequities have been amplified by the COVID-19 pandemic. ...
Les difficultés systématiques à fournir des services de santé mentale et de toxicomanie adaptés à la culture ont entraîné des inégalités généralisées pour les fournisseurs de services, communautés et client racialisés. Il y a un besoin urgent de changements coordonnés à l’échelle du système. Dans cet article, nous présentons les résultats d’une étude transversale à méthodes mixtes portant sur les pratiques organisationnelles actuelles en matière de promotion de l’équité raciale dans le secteur de la santé mentale et de la toxicomanie des enfants et des jeunes en Ontario. Afin de comprendre les efforts actuels et d’identifier une voie à suivre, nous avons interrogé les dirigeants de 102 agences et mené des études de cas auprès de 10 agences sur leurs pratiques dans cinq domaines : leadership organisationnel, partenariats intersectoriels, diversité et développement de la main-d’œuvre, engagement des clients et de la communauté, et améliorations continues. Les dirigeants partageaient un fort désir de faire progresser l’équité raciale et avaient commencé ce travail à des degrés divers. Cinquante et un pour cent des agences s’étaient engagées publiquement en faveur de l’équité raciale; cependant, peu d’entre elles avaient élaboré des plans écrits pour soutenir ces efforts. Plus de 60 % des agences avaient développé des relations avec des partenaires intersectoriels et communautaires pour faciliter ce travail. Soixante-quinze pour cent des agences avaient offert une formation sur l’équité raciale à leur personnel, et certaines avaient mis en place des efforts de recrutement ciblés pour le personnel racialisé. Plus de 69 % des agences fournissent des services de traduction et d’orientation vers d’autres agences, alors que seulement 39 % offrent aux clients la possibilité de demander des fournisseurs de services qui reflètent leur identité culturelle. Moins de 29 % des organismes ont recueilli et utilisé régulièrement des données fondées sur la race pour orienter leur travail. Nos conclusions, en particulier les domaines examinés et les obstacles et facilitateurs, peuvent orienter des efforts parallèles dans des secteurs connexes au Canada et à l’étranger.
... Because providers who work with the Latinx immigrant population have a unique perspective on the interplay between immigration and mental health and knowledge of the mental health needs this population faces, this study sought to address these gaps in the literature by interviewing providers who work directly with Latinx populations. Prior studies that interviewed providers aimed to better understand barriers Latinx individuals face when accessing mental health care (Edward & Hines-Martin, 2015;Valdez et al., 2011) and barriers providers face when delivering treatment (Meléndez Guevara et al., 2021;Olcoń & Gulbas, 2018). Access barriers include lack of insurance (Valdez et al., 2011), mental health resources (Valdez et al., 2011), language concordance (Valdez et al., 2011), and discrimination (Edward & Hines-Martin, 2015). ...
... Access barriers include lack of insurance (Valdez et al., 2011), mental health resources (Valdez et al., 2011), language concordance (Valdez et al., 2011), and discrimination (Edward & Hines-Martin, 2015). The inability to address trauma through a cultural lens (Meléndez Guevara et al., 2021), including the overreliance on culture to understand psychological distress (Olcoń & Gulbas, 2018) were identified as barriers providers faced during treatment. These studies point future research to first better understand what providers know about the mental health needs of Latinx immigrant families who are actively engaged in care and providers' experiences addressing these needs in order to improve service delivery and develop culturally sensitive mental health interventions. ...
... Understanding what providers know about complex layers of trauma in Latinx immigrants points to the necessity to identify and treat ongoing and cumulative trauma with traumainformed, evidence based, and culturally sensitive practices. Consistent with prior research, providers often lack culturally sensitive training on how to identify and treat ongoing trauma (Meléndez Guevara et al., 2021). Providers, This document is copyrighted by the American Psychological Association or one of its allied publishers. ...
Existe una grand cantidad de información que busca entender los factores que afectan la salud mental posteriores al proceso migratorio en familias Latinas inmigrantes. Sin embargo, se presta poca atención a las experiencias vividas antes del proceso migratorio o durante el mismo. Dado que los proveedores que trabajan predominantemente con la población inmigrante latina, tienen conocimiento de primera mano y pueden ofrecer una perspectiva única sobre las necesidades de salud mental de los inmigrantes latinos y la interacción entre la inmigración y la salud mental, este estudio buscó su opinión. Se incluyó información de un total de 21 proveedores. Los participantes eran proveedores que tenían una amplia experiencia trabajando con familias inmigrantes latinas. Realizamos un sobremuestreo de los proveedores de salud mental. Los datos fueron analizados mediante un análisis temático y los temas fueron relacionados con la teoría transnacional del estrés cultural. La mayoría de los proveedores (90%) eran mujeres. Dos tercios de los proveedores eran latinos. La mayoría de los proveedores (57%) tenían 5 o más años de experiencia. Surgieron cinco temas: 1) la exposición a la violencia en el país de origen de los clientes; 2) problemas de violencia y separación familiar encontrados durante el viaje de inmigración de los clientes; 3) las dificultades únicas relacionadas con la inmigración influyen en la salud mental de los clientes a su llegada a EE. UU.; 4) capas complejas de trauma; y 5) los clientes utilizan proactivamente las organizaciones comunitarias para obtener recursos y apoyo. Los hallazgos de este estudio indican que la experiencia de trauma, a lo largo de todo el proceso de inmigración, es común para las familias inmigrantes latinas. La investigación futura debe tener como objetivo la creación de capacitaciones culturalmente apropiadas y el uso de herramientas de detección de trauma validadas para identificar y tratar adecuadamente el trauma en la población inmigrante latina.
... This body of research recognizes that the unique experiences of minoritized and marginalized populations need to be acknowledged and addressed in the context of mental health interventions and care. Examples include 1) coping-focused interventions to help individuals manage or reduce distress associated with racism or other forms of discrimination, poverty, unemployment, family separations, and other challenging life circumstances (14,15); 2) trauma-informed interventions that tailor services for individuals exposed to early or chronic traumatic events or poverty-related stressors (16)(17)(18); and 3) patient navigation or service linkage interventions that connect individuals to needed health and social services and/or address access barriers to facilitate engagement in care (19,20). Such interventions, although a critical component of health and mental health care, only address the consequences of societal inequities and do not directly affect the systems and structures that cause and sustain mental health disparities. ...
Racial, ethnic, and other mental health disparities have been documented for several decades. However, progress in reducing or eliminating these disparities has been slow. In this review, the authors argue that understanding and addressing mental health disparities requires using a multidimensional lens that encompasses a wide array of social determinants of health at individual, interpersonal, organizational, community, and societal levels. However, much of the current research on mental health disparities, including research funded by the National Institutes of Health, is characterized by a narrower focus on a small number of determinants. The authors offer a research framework, adapted from the National Institute on Minority Health and Health Disparities Research Framework, that provides examples of determinants that may cause or sustain mental health disparities and that can serve as intervention targets to reduce those disparities. They also discuss different types of mental health disparities research to highlight the need for more research testing and implementing interventions that directly modify social determinants of health and promote mental health equity.
... An often overlooked but fundamental principle of a trauma-informed approach involves cultural humility [34]. Cultural humility through culturally competent practices (e.g., acknowledgement of diverse values, beliefs, and behaviors) supports the understanding of the multilayered intersection between trauma and aspects of culture including race, ethnicity, gender, geographic location, socio-political particularities, and language [35,36]. Unfortunately, current guidelines in trauma-informed approaches do not sufficiently account for cultural humility as a facilitator of service delivery and engagement in working with ethnic/racial minorities. ...
... Unfortunately, current guidelines in trauma-informed approaches do not sufficiently account for cultural humility as a facilitator of service delivery and engagement in working with ethnic/racial minorities. As evidenced by the findings of a systematic review by Hanson and Lang [37] on the principal components of trauma-informed approaches from well-established frameworks, such as SAMHSA, cultural humility did not emerge as a core component, nor did the significant role of structural inequities on traumatic exposure or service access [35]. ...
Although there has been a significant increase in the delivery of evidence-supported, trauma-informed care over the past few years, there has been less discussion around the consideration of the broader cultural, political, and societal factors that contextualize client trauma and that also need to be recognized and understood to promote healing and prevent future trauma. In support of sharing some best practices and lessons learned, this article provides a case study of one agency that has used the Sanctuary Model®, an evidence-supported, trauma-informed organizational change model, to introduce the practice of cultural humility with staff as a facilitator of improved service delivery for clients from culturally marginalized communities. The model supports these endeavors through the adherence to the seven commitments, a set of organizational values for creating a trauma-informed community, allowing for all voices to be heard and considered and providing opportunities to begin the repair of previous experiences of inequity and suppression. Through the board of directors, leadership, and staff, the organization transformed its culture into one that truly supports and embraces diversity, equity, and inclusion in its operation for the benefit of both staff and clients alike.
... This has important implications for training in screening and intervention practices that are responsive to the unique priorities and strengths of different communities. In this sense, while imperative to understand TIA under a common definition, it is equally crucial to consider how context shapes and impacts service domains to better meet the necessities, priorities, and expectations of children and families, as well as the needs from service system themselves (Meléndez Guevara et al., 2020). Further, our findings suggesting unsupportive views of universal trauma screening practices contributes to the emerging debate on the limited clinical utility and appropriateness of child and family service settings to be employed without adequate training and availability of service infrastructure. ...
... For example, the adoption of such approach has been found to be inconsistent across practitioners and agencies (Wilson et al., 2015). This is important to consider as prior work on culturally responsive TIA practices suggest that inquiring about trauma related history with ethnic/racial minorities could alienate families from ongoing service engagement (Meléndez Guevara et al., 2020). More work is needed to elucidate recommended practices for the comprehensive integration of culturally responsive guidelines within TIAs implementation. ...
The increased awareness of the detrimental consequences of trauma exposure has led researchers to focus their attention in identifying best practices on integrating trauma-informed approaches (TIAs) to child and family services. Yet, terms related to TIAs are often utilized without an adequate definition, and most importantly, without concrete and specific strategies to ensure that services are in fact trauma-informed. Using a multi-methods approach, this project examined important practice considerations that support successful implementation of TIA in school and community-based behavioral health settings. Key informant interviews and electronic surveys were conducted with child and family systems practitioners; interviews inquired about training, current practices, and barriers to service engagement. Data was analyzed, organized, and synthesized in accordance with core domains and specific components proposed by Hanson and Lang’s (2014) trauma-informed care framework. Findings suggest that practice of TIA differed by system and was largely driven by experiential and informal learning experiences. Practitioners also report challenges unique to each system hinder the utilization of screening and intervention best practices. Salient differences included those related to knowledge and accessibility to training, utilization of evidence-based practices, application of screening tools, and availability of resources within their systems. This brings to light the importance of considering both general and system-specific practice mechanism for the successful implementation and sustainability of TIA frameworks. We suggest system-specific strategies to help integrate trauma into services, including prioritizing capacity building efforts within each system by leveraging their natural supports and identifying systems-specific assets for both screening and intervention practices.
