The Seven County Study

As a significant first step towards eliminating disparities through culturally competent practices responsive to California’s cultural communities, the California Institute for Mental Health (CiMH), through the Center for Multicultural Development (CMD), conducted the Seven County Study with funding from The California Endowment. This study was designed to document strategies implemented by California’s mental health system in promoting cultural competence. Our aim was to identify and evaluate the breadth and effectiveness of specific cultural competence activities in seven counties in order to advance policy and help operationalize culturally competent practices. The Seven County Study yielded significant information towards understanding the implementation of cultural competence activities in working with cultural, ethnic, racial and linguistic communities throughout California.

Four specific main themes emerged from the culturally competent strategies implemented within these seven counties:

1. The conceptualization of cultural competence (policy, organizational and clinical levels);
2. Best practices including ethnic-specific clinics, outreach programs and training;
3. Key challenges or barriers to addressing cultural competence;
4. Strategies to overcome such barriers in order to further culturally competent practices with consumers and diverse community stakeholders.

Extensive, in-depth interviews were conducted and analyzed, yielding 152 indicators of cultural competence. In order to prioritize the multiple indicators of cultural competence and identify best practices, the indicators were categorized into 18 clusters of activities that most likely promote culturally competent practice. These 18 best practices represent the most prominent themes of cultural competence across the seven counties.

To further guide our data analysis, we utilized a conceptual framework for cultural competence presented by the Lewin Group in a report prepared for the Health Resources and Services Administration of the U.S. Dept. of Health and Human Services in 2002. We used the seven components or domains of cultural competence identified by the Lewin Group, and specific focus areas for each domain, to help analyze and organize the evidence gathered by the Seven County Study. The 18 best practices identified in the study corresponded to three of the Lewin Group domains and six of the focus areas. The best practices were organized according to these domains and focus areas and are presented with examples from the seven counties in the following table:

Table I: Seven County Study Cultural Competence Best Practices.

Several specific community-based clinics with services tailored to meet the needs of cultural communities were also identified and described. These clinics and county agencies within the seven counties carry out discrete practices and programs that can be considered emerging practices or practices with practice-based evidence of effectiveness. These practices and programs were identified and are listed as follows:

1. Proyecto Radionovelas
2. Hmong Outings
3. Native American Liaison
4. Los Niños Bien Educados
5. Cena Con Sus Hijos
6. Multicultural Assessment Intervention Process Model

Further work that could be carried out to build upon these findings would be to promote, formulate and evaluate promising practices to build their levels of evidence so they can be more widely disseminated. This would involve manualizing and researching the discrete practices listed above, as well as formulating new practices based on the practices listed in Table I: Cultural Competence Best Practices from the Seven County Study and manualizing and evaluating these new practices.

Beyond the Seven County Study: A Multi-Stage Approach to Furthering Practices Towards Eliminating Disparities

Having completed the Seven County Study, the CMD has now taken a two-pronged approach in seeking to promote practices effective in working with ethnic, racial and linguistically diverse communities to help eliminate disparities in care. The first has been to identify practices with an existing body of research evidence indicating their effectiveness at addressing disparities. The second prong to our approach is to support the development of a research base for community-based practices so that practices that are considered effective in communities will get supported and replicated.

Adopting Culturally Competent Practices (ACCP)

In taking up the first prong of our approach, the Adopting Culturally Competent Practices (ACCP) Project, also funded by The California Endowment, was effectively implemented to further the findings from the Seven County Study by specifically looking to identify practices with research evidence indicating their potential towards increasing access and quality of care for unserved and underserved ethnic populations. To this end, a carefully constructed process was utilized to identify practices (i.e. clinical interventions, outreach, engagement and retention strategies) that hold promise for reducing disparities in mental health care for ethnically and culturally diverse populations.

The first phase of the ACCP Project contributed to efforts seeking to address the need for culturally competent practices in order to reduce disparities by researching, analyzing and synthesizing available literature on evidence-based practices relevant to ethnic populations. These practices are identified and organized in the following matrix:

Matrix I: Summary of Psychosocial Interventions for Ethnic Populations of Children/Adolescents and Adults.

Upon the completion of Matrix I, a second process was initiated to present specific dimensions of psychosocial interventions critical for identifying appropriate practices that meet the needs of ethnic populations, and also to indicate evidentiary levels of research for the identified practices. Directly referencing information gathered in the initial phase, this important supplementary information is carefully summarized and appears in Matrix II.

Matrix II identifies the research status of interventions along three levels of evidentiary criteria: a) effective, b) efficacious and c) promising. Additionally, the matrix identifies and catalogues aspects of the intervention that are attuned or have been accommodated or adapted for ethnic populations according to the following eight dimensions: 1) language, 2) persons of intervention, 3) metaphors of intervention, 4) content, 5) concepts, 6) goals of treatment, 7) methods and 8) context.

Matrix II: Dimensions of Culturally-Relevant, Evidence-Based Interventions for Ethnic Populations.

A subsequent multi-step decision-making process involving multiple counties and stakeholders identified one specific practice to implement and study as an evidence-based practice with scientific evidence of positive outcomes with cultural populations. The practice they identified for implementation is Multidimensional Family Therapy (MDFT). This practice has yielded positive results for utilization in racial, cultural and linguistic communities as well as those that are poor or with limited resources. Training towards certification of therapists and community linked therapist assistants has been positive for engaging marginalized families, including African American and Latino families, in which there are mental health issues, related substance abuse issues, and multiple clinical at-risk issues for adolescents and young adults, involving their families. Early data indicates that the implementation sites are serving a multi-ethnic clientele, with Latinos in the majority, followed by Caucasians, African-Americans, Asian/Pacific Islanders and non-specified others.

Furthering Lessons Learned from the Seven County Study and ACCP: Sustaining and Expanding a Potential Evidence-Based Practice

As the ACCP Project enters its final phase, the CMD is at an interesting crossroads of research and information dissemination towards eliminating disparities. Given the evidence of MDFT’s positive impact on diverse communities, there is now great potential for MDFT through ACCP to be: a) sustained and even expanded in those communities where it has been piloted and b) to have the training, implementation and practice of MDFT as a culturally relevant and responsive practice expanded to other geographic areas in California. Each of these paths would lead to further understanding and strengthening of culturally competent practices in contributing significantly to addressing disparities. CiMH is hoping to have support to further the ACCP identified practice of Multidimensional Family Therapy.

Going Beyond the Seven County Study and ACCP: Identifying, Evaluating and Manualizing Promising Practices Specific to Ethnic, Racial and Linguistic Communities

In addition to sustaining and expanding the implementation of MDFT as an established evidence-based practice, there is a next step which has clearly arisen providing a highly significant next opportunity in partnering with cultural communities. In the context of ongoing debate on the generalizability of evidence-based practices and the potential value of pursuing practices supported by practice-based evidence, the CMD proposes to help further the research on practices arising from cultural communities themselves and the providers that work directly with them. Embarking on this process can serve to help empower communities thereby enhancing possibilities for true partnership and collaboration with mental health systems.

As part of the second prong of our approach in seeking to promote practices effective in working with ethnic, racial, and linguistically diverse communities, CiMH, through the Center for Multicultural Development, proposes a project to identify and promote cultural practices that arise from communities and are being used in everyday practice. We will work alongside and assist cultural communities in manualizing their practices, determining different research methodologies that might work well for demonstrating and evaluating the effectiveness of these practices and linking the communities with researchers or resources to conduct the research.

By asking questions such as: What practices are being used by your community? What have elders or credible holders of cultural knowledge considered to be effective approaches and practices in mental health or health care for your communities? What would services look like in your home country, and have they been adapted here in California? Practices such as the use of promotores, indigenous healers, traditional Chinese medicine, spiritual healing and already manualized promising practices or adaptations of evidence-based practices, will be identified, categorized and carefully described.

Five core areas of description needed for consideration of use by counties include the following: 1) primary purpose of the ethnic/cultural practice; 2) target population including risk factors and protective factors addressed; 3) level and types of evidence supporting the practice; 4) practice implementation needs (including staffing requirements, training, costs of the program, funding, implementation timeline and 5) additional important considerations in working with and partnering with cultural families and communities in implementing the culturally responsive practice.

We will widely disseminate our findings to counties, throughout California and in national venues. The CMD could also conduct more in-depth examination and research on one or two select practices.

CiMH, the CMD, will then conduct trainings, provide technical assistance, develop a peer support network and evaluate and facilitate processes of continuous inquiry towards furthering practices responsive to and effectively used by cultural communities. This project will be a significant contribution towards eliminating disparities in mental health care by raising effective culturally responsive practices to public awareness.