The Impact of Demographic Shifts

The rapid growth of the Hispanic/Latino population in this country qualifies as one of the most dramatic demographic phenomena of the last century. This segment of our society is growing almost four times as fast as other groups, and it is predicted that within the next 5-7 years Hispanics will overtake African Americans as the largest minority group in the United States. A more revealing fact, that is disturbing to some, is the prediction that by the year 2050, one out of every four Americans will be of Hispanic/Latino heritage. While this phenomenon presents challenges in our urban areas, the current and predicted rate of growth, and increasing presence, of Hispanics/Latinos is significantly more impacting in rural communities.

A reality is that America will continue to be challenged, and at times burdened, with increasing demands for services on our already taxed social institutions, including the public health services system. As this demographic shift evolves, an area of increasing concern is the provision of adequate, appropriate and accessible mental health services for Hispanics/Latinos in the U.S., particularly in rural communities.

Historic Neglect and Inattention to Hispanic/Latino Mental Health Concerns

The mental health-related problems and concerns facing the Hispanic/Latino population, as well as other racial/ethnic/cultural “minorities” residing in the United States, have been long-standing and well documented in the public health and mental health literature. The concerns generally center on accessibility to quality services, the affordability of those services, and the cultural adequacy of the services made available and of the providers of those services. These concerns have long challenged the public mental health system and have recently been the target of policy and service development and improvement initiatives within the public mental health sector at the national and state levels.

While significant progress has been made to respond to the mental health service needs of the Hispanic population in general, relatively little attention has been directed to identifying, understanding and addressing the mental health service problems, concerns and needs of Hispanics/Latinos residing in rural America. There currently exist unacceptable and inexcusable disparities in the health and mental health status and accessibility to services for this segment of the Hispanic/Latino population. Despite the growth of the Hispanic/Latino population in rural communities, public sector responses to the mental health service needs of that population have been slow to come and not commensurate with the growth, verified needs, and dire circumstances of the population. Included in the latter are the harsh realities of chronic poverty, the lack of adequate and stable medical care, cultural isolation, and, quite frequently, language barriers that make available services effectively inaccessible.

The Additional Burdens of Race, Culture and Ethnicity

The need to focus additional attention and resources on minority rural mental health, in general, and Hispanic/Latino rural mental health specifically is obvious and long overdue. In addition to being affected by the same barriers to services affecting all segments of our rural society (e.g., rising costs, system fragmentation, limited access to inadequate facilities, and vast geographic distances), Hispanics/Latinos face the additional burdens of culture and language differences, poverty, immigration status, and racism at the individual, institutional and systemic levels. All these are factors that complicate Hispanic/Latino access to adequate mental health services, and heighten their awareness of their second-class status and exacerbate their level of continued marginalization in rural America.

In these regards, of particular and immediate concern is the population of migrant and seasonal farm workers living and working in remote rural areas. In addition to experiencing all the barriers to accessibility, members of this rural population of Hispanics/Latinos exist in the constant and looming shadows of the fears and misconceptions of recent immigrants, poor English-language skills, and the potentially fluid legal status of their entry to this country.

The Dire Need for Data

Little information exists, and so much is needed to better understand the health, mental health, and human service needs of Hispanics/Latinos in rural communities. It is clear that a priority needs to be established for gathering and broadly disseminating information on the financing, utilization, and health/mental health status and outcomes for all rural Hispanics/Latinos, as well as other minority populations in rural communities. Further, it is critical that planning and implementation be initiated and expedited to develop comprehensive and accessible systems of care and services in rural communities. Particular attention must be focused on the cultural, linguistic, familial, and unique health and mental health service needs of the Hispanic/Latino populations in rural America.

In addition to ensuring the collection of relevant data, it is of critical importance that Hispanics/Latinos in rural area routinely participate in the processes leading to the collection, analysis and use of that data. It is imperative that mental health policy makers and system managers aggressively solicit the active and meaningful participation of Hispanics/Latinos in rural areas as they developing policies and implement systems change initiatives designed to alleviate the most pressing mental health needs in their rural communities.

Disparities Despite Progress

Admittedly, progress has been made through the development of Offices of Minority Health at the federal level, minority public health associations and professional organizations that address and work toward improving the health status of minorities. Additionally, the increasing focus and importance being given to race-related issues by our national politicians have also helped to move more rapidly toward the identification of Hispanic/Latino mental health problems and concerns. We are, albeit reluctantly and slowly, developing strategies to minimize and eliminate barriers to equal access to mental health services by Hispanics and other minorities in this country.

However, significant and inexcusable disparities exist in health status between Hispanics/Latinos and non-Hispanics. Barriers to services identified over the past 15-20 years persist today. Unacceptable disparities exist between the plight of the “brown and poor” in urban areas, and the too often desperate struggle for survival by typically poor, often under-educated, isolated and older Hispanics/Latinos residing in rural America.

These disparities include:

• an inadequate distribution of mental health professionals and program support staff with adequate and relevant training focused on effective treatment strategies and programming to meet the mental health service needs of Hispanics/Latinos in rural communities;
• the dearth of empirical and evidence-based data formally documenting the health/mental health status, needs and access problems for Hispanics/Latinos residing in rural communities;
• the unavailability or inaccessibility of primary and specialized services that are of high quality, comprehensive, community-based, culturally competent and linguistically accessible, and integrated with primary prevention efforts and the broader system of services;
• inadequate or no transportation to access programs and services available in the immediate regions;
• a shortage of competent bilingual mental health information and service/care providers; and
• complacent and culturally insensitive systems of service/care that do not understand, accommodate, nor utilize the alternative models of culturally-based illness and treatment that exist in, and are critical to, effective mental health interventions and treatment with Hispanic/Latino communities.

These disparities, while present in both urban and rural areas, have a more significantly negative impact on access to health services and the health status of Hispanics/Latinos in rural settings.

Areas Needing Continued Attention

The problems facing Hispanics/Latinos residing in rural America are many, are complex, and are not amenable to quick, easy, piecemeal, or “one-size-fits-all” solutions. However, it is valuable to focus briefly on and summarize the issues that more saliently affect the provision of mental health services to rural Hispanics/Latinos, and that merit additional and continuous attention and advocacy by policy makers, practitioners, and consumers.

• Policy - It is important that a priority be assigned to establishing a specific programmatic focus and supporting policy framework that will enable studying and addressing the mental health care and service needs of all Hispanics/Latinos residing in rural America. Also, serious consideration should be given to including in a cultural competence requirement to licensing, certification and accreditation standards for mental health practitioners working with rural Hispanic/Latino clientele. It is these types of policy initiatives that reflect the priority for, and evidence the commitment to, ensuring equal opportunity to quality mental health services for Hispanics/Latinos in rural communities
• Training - Additional work must be done to develop and expand the knowledge base for educating and training current and future mental health professionals to work with Hispanics/Latinos residing in rural communities. Contributions to the growing body of literature must be accelerated and expanded, with attention directed at broad dissemination of this information and encouraging educators to integrate it into their pre-service, professional, and continuing education efforts. Systematic integration of theoretical and practical notions of cultural competence into professional schools will begin to develop the needed cross-cultural knowledge, skills and abilities, and to establish an expected standard of what professionals should know to be competent in serving Hispanics/Latinos in rural areas.
• Resource Development - Because the most critical and enduring service delivery issue is accessibility, initiatives and strategies must be explored and developed to facilitate the availability of community-based mental health services that are culturally, linguistically, and financially accessible. Efforts should be focused on creating financial and other incentives for developing systems of services/care in rural areas, and more specifically toward utilizing innovative services alternatives that meet the identified needs of Hispanics/Latinos residing in rural communities.
• Practice Issues - In moving toward the availability of a more culturally competent system of mental health services for Hispanics/Latinos, it will be necessary to understand and incorporate the alternative services and treatment systems that exist within most Hispanic/Latino communities. Further, it will be necessary to continuously identify and resolve related cross-cultural issues, including:
  • Distrust based on experiences of oppression, exclusion and mistreatment
  • Language barriers and expectations
  • Culturally insensitive and biased assessment, testing and intervention modalities,
  • Conflict in value structures and constructs regarding family, children, and elders
  • Overcoming stereotypes, lowered expectations, and issues of merit
• Research - Because research typically drives policy, funding and system development decisions, it is of critical importance that research specific to the mental health of Hispanics/Latinos residing in rural area be encouraged, financed and supported. The 2000 Census presents an excellent opportunity to conduct primary research on Hispanic/Latino data sets through collecting, analyzing and reporting on the socioeconomic condition and demographics of Hispanics/Latinos in rural America.

It is also important to encourage, finance and support biomedical research into the diseases that disproportionately affect Hispanics/Latinos.

Leadership Development and Commitment; Individual and Institutional

To move the system change agenda forward toward improved services for Hispanics/Latinos in rural settings, it is incumbent on mental health service professionals and mental health system managers at all levels to commit to effectuating change and assuming roles of leadership within their spheres of authority and influence. The success of accommodation and adaptation within organizations to the expected and inevitable changes in rural-sector demographics and service needs of the Hispanic/Latino population depends on the willingness of decision makers to, at a minimum, do the following within their organization:

• Establish increasing personal and professional cultural competence as a goal and expectation for themselves and for all employees under their supervision. At minimum, every employee's position description and performance evaluation must include a statement regarding cultural competence-related goals and expectations.
• Create and maintain a discrete and adequate budget to support meaningful cultural competence and diversity related activities on a frequent and on going basis.
• Assign lead responsibility for cultural competence and diversity planning, implementation and monitoring to a high-level administrator within the organization, ensuring that the individual has decision-making authority and management support to implement the necessary programs and activities.
• Take every opportunity to communicate and emphasize that cultural competence and diversity are core values and guiding principles within the organization.
• Ensure that cultural competence and diversity are an integral and explicit part of the organization's vision and mission statements.
• Adopt a “cultural competence and diversity” policy that will serve as a clear and public statement that cultural competence and diversity are priority goals within the organization.

Jose J. Soto, JD is Vice President for Affirmative Action, Equity and Diversity, Southeast Community College Area, Lincoln, Nebraska