Mental health and Health care
NATIONALLY, RACIAL AND ethnic minorities are projected to grow to nearly 40% of the population by the year 2030. And, although the overall health of U.S. citizens has improved over the last 2 decades, there continues to be striking disparities in the burden of illness experienced by minority individuals. Disparities in health status, illness severity, health care access, and service outcomes have been reported in a variety of conditions and settings [National Institute of Health 2000 and Institute of Medicine 2002]. The Commonwealth Fund 2001 Health Care Quality Survey [Collins et al 2002] identifies that a “substantial proportion of minorities feel they would receive better care if they were of a different race or ethnicity ( [Collins et al 2002], p. V).”
As with other areas of health care, disparities have also been clearly identified in relation to mental health care (Department of Health and Human Services [DHHS], 1999, [U.S. Department of Health and Human Services 2001]). Research has shown lower rates of mental health service (MHS) utilization by minorities and, when minority individuals use care, it is more likely to be incongruent with the needs of those using those services [U.S. Department of Health and Human Services 2001, Dixon et al 2001, Kuno and Rothbard 2002, National Institute of Mental Health 2001 and Willis 2002]. Because minority groups carry a greater burden from unmet mental health needs, it is important to understand how minority groups interface with MHS to identify unique sociocultural needs of these groups [Snowden and Hu 1997, Wang et al 2001 and Wells et al 2001]. Understanding the experiences of racial and cultural minorities is essential to the development of MHS that are more responsive to their cultural and social contexts. This article will explore the mental health care experience of one group of African Americans, their path to MHS, and the factors that enabled MHS use.
Review of the literature
African Americans occupy a unique place in American society that impacts their mental health and their interaction with MHS. History clearly illustrates experiences with racism and intolerance, exclusion from quality health care, limited economic resources and negative experiences with health care research ([Clark et al 1999]; Fox, 1995; [Williams and Williams-Morris 2000]). Many African Americans fall within populations of “high need” (homeless, incarcerated, exposed to violence, and those in child welfare systems) which indicates higher utilization of mental health safety net providers [Lewin and Altman 2000]. All of these factors serve as an important context for MHS utilization within this population.
Regardless of types of MHS that African Americans seek, there are barriers that they need to overcome at individual, environmental, and institutional levels [Hines Martin et al 2003, Miller et al 1996. P. Miller, B. Sullivan, A. Schwebel and L. Myers, Black Americans’ and White Americans view of the etiology and treatment of mental health problems. Community Mental health Journal 32 3 (1996), pp. 235–242.Miller et al 1996, Scheffler and Miller 1991, Snowden and Cheung 1990, Snowden and Thomas 2000 and Wallen 1992]. As African Americans experience mental health concerns and identify the need for MHS, the journey to successfully access those services is fraught with many potential internal and external barriers and complications [U.S. Department of Health and Human Services 2001]. Yet many do manage to successfully identify and address their needs, and use MHS. However, it is not understood how this is accomplished [National Institute of Mental Health 2001]. Questions such as “What are the decision making processes?” and “What are the important influences during the journey?” are as yet unanswered but vitally important in the development of culturally appropriate mental health care.
Theoretical framework
Because access to MHS is affected by both internal and external factors, examination of the phenomenon must be grounded in an ecological framework of health service use. One such framework is [Andersen and Newman 1973]Societal and Individual Determinants of Health Service Utilization. The model outlines a framework for viewing health service use that takes into account both environmental and individual determinants. The model was developed to facilitate understanding of how individuals use services as well as define and measure factors associated with varying degrees of access to health care. The goal of the model was also to facilitate an understanding of the extent to which a given component could be altered to influence change toward equitable health care access. This process is identified as component mutability. [Andersen and Newman 1973] identify three key constructs within this model - Societal Determinants (technology and norms), Health Services Systems (resources and organizations) and Individual Determinants. Critical components within the Individual Determinants construct were predisposing factors (demographic, social structures, beliefs), illness level (perceived, evaluated) and enabling factors (family, community).
[Andersen and Newman 1973] model is appropriate to examination of factors related to African American mental health service use. As identified in the previously mentioned literature, societal factors greatly affect the mental health of African Americans. Health systems have shown lack of congruence with the mental health needs of African Americans. Finally, many of the Individual Determinant components of the model have been identified as influential in research about African American family processes and social functioning [Chatters et al 1989, Hines-Martin 1992, Hines-Martin 1998, Hines-Martin 2002, Hines Martin et al 2003, Hines-Martin et al and McAdoo 1997]. Although [Andersen 1995] has evolved to address population based needs and other health care system issues, the effect of individual factors remains a central theme. Using the Individual Determinants aspect of the model provides a perspective for interpretation of data and provides an opportunity to evaluate the appropriateness of the model in relation to the experience of this underserved population.
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