Evidence Based Practice

1. Immigrants/Refugees and mental health in Louisville Evidence Based Practice

3. Mental Health: Policies and Procedures Mental health screenings are not required by resettlement agencies (C. Young personal communication, October 29, 2007) -Is this population getting diagnosed and treated? Title VI requires all agencies receiving federal funds to provide information in a language understandable by patients (Bryan 2007; Executive Order 13166, 2000) -How well is Title VI being implemented in Louisville?

4. Evidence Based Practice �Conscientious, explicit and judicious use of current best evidence in making decisions about the care of individuals [clients]� (Sackett, Richardson, Rosenberg & Haynes, 1997; cited in Gibbs & Gambrill, 2002) Four Cornerstones of EBP: -Research and theory -Practice wisdom -Professional values - Client preference and opinion (Gilgun, 2005) Five Steps of EBP: - Convert needs into answerable question - Critically appraise the evidence for its validity and usefulness - Applying the results of this appraisal to policy/practice decisions - Evaluate outcomes (Gibbs & Gambrill, 2002)

5. Best Practices Inquiry COPES Question Client Oriented Practical Evidence Search What are the special needs of immigrants/refugees within the mental health system and what are implications for providers based on these needs?

6. Methodology Interviewed 5 Stakeholders in Louisville concerned with mental health delivery to the immigrant and refugee population: Edgardo Mansilla- Director, Americana Community Center Carol Young- Director, Kentucky Refugee Ministries Christy Elliott-Gonzalez, Nurse Practitioner, Americana Health Center Susan Rhema, LCSW, Contract worker for Seven Counties Mari Mujica, President, Diversity Consultants LLC Appraised over 20 academic articles for literature review -Emphasis on generalizability, trustworthiness, and validity of results Supplemented Consumer Interviews due to lack of relationship and stigma associated with this topic, with 5 qualitative articles summarizing this population�s experience with the mental health system.

7. Results

8. Qualitative Quantitative Belief that only a �higher� power, (i.e. God, can heal) Different perceptions in the causes of mental illness Belief that Western doctors have an over-reliance on prescription medication and display a �dismissive attitude� Stigma associated with illnesses Knowing where to seek help Discrimination Costs of services Language barriers Lack of collaboration amongst providers Pre-occupation with post-migration stressors including housing/income and immigration status Lack of transportation Language barriers Costs of services Literature Review 

9. Primary Themes Secondary Themes Lack of cultural competence by provider -insensitivity, lack of knowledge about culture and treatment preferences Alternative coping mechanisms -rely on family, religion, church and self to persevere through hard times Different perceptions in the causes of mental illness Somatic Complaints vs. Mental Problems -physical expression vs. emotional or psychological Need for outreach programs Language barriers Lack of Trust Difference in cultural norms Stigma Gender differences Depression Difficulty seeking help -are unfamiliar with system and how to access help, where to go, etc. Family Reputation/Confidentiality -do not wish to shame family with illness �Hiding Up�/Isolation-wait until the last minute to receive care -Might explain why many immigrants and refugees end up in ICU in Louisville hospitals Consumer Wisdom(Gong-Guy et al, (1991), Whitley et al, (2006), Palmer (2006), Wynaden et al, (2005) & Bernstein (2007). 

10. Primary Themes Secondary Themes Differences in the perceptions of mental health (i.e. causes & treatment) Lack of cultural competence by provider Language barriers Lack of Trust/Confidentiality towards providers and system Stigma PTSD Assimilation issues Cost of obtaining services Difference in cultural norms Lack of culturally appropriate treatment Lack of knowledge about system Stakeholder InterviewsE. Mansilla, C. Gonzalez, C. Young, M. Mujica & S. Rhema, Personal Communication October-November, 2007

11. Difference in Perceptions of Mental Health Refugee/immigrants may not conform to our understanding of physical or mental health, and therefore, they define their �sickness� in other ways that are culturally appropriate. Mental health is a Western concept that is a social construction. Other refugee and immigrant populations may tend to have: No concept of mental health; Express themselves physically rather than mentally/emotionally; Not understand the importance of mental health in our culture. As a result, stigma associated with mental health increases since it is a foreign idea that remains unfamiliar amongst numerous cultures.

12. Need for Culturally Appropriate Treatment Language Barriers Many refugees believe that many American doctors are over-reliant on pharmaceuticals Unfriendly and hurried Refugees/Immigrants may believe in different causes of mental illness (i.e. God�s will, curse, kharma, etc.) Mental health only accepts Western values and our pre-existing cultural ideas Based on these facts, many will not want a prescription, understand the diagnosis of their illness, disagree with doctors as to why they are or are not �sick�, etc. Title VI is not being implemented in Louisville Many refugees are being asked to bring an interpreter/translator with them to see health providers Children are being used to fill these positions. Some languages (Maay )are only spoken languages which magnifies hardship Interpreters/Translators are also not necessarily able to interpret body language/appearance, etc. Stakeholder Interviews�.cont�d��

13. Implications for Social Work Practice Incorporate mental health screenings into existing health exams administered by resettlement agencies: -Lessens stigma -Economically sustainable -Routine measure Create Culturally Appropriate /Meaningful Treatment Plans -Combination of both Western and Native values/preferences, client driven treatment -Hire or take in volunteers who practice mental health in other countries, applicable to Louisville�s demographics, to aid our health care providers -Refer clients to appropriate treatment, acupuncture, church services, local community leaders/healers Mandate Continuous Cultural Competency Training for Health Professionals -Once is never enough -Life-long learning/world view -Requires deep respect of all cultures and a desire to learn Improve Language Services - Hire bi-lingual leaders within different cultural communities -Support local council-members to implement Title VI as a city ordinance

14. References Abner, C. (June/July 2005). Finding Refuge. �State News�. The Council of State Governments. Available at http://www.csg.org/pubs/documents/sn0507FindingRefuge.pdf. Bryan, Jenessa. (2007). Voices from the Bluegrass: A Portrait of Kentucky�s Children in Immigrant Families. Kentucky Youth Advocates. Executive Order 13166 (August 2000) requiring all federally funded recipients to provide language access and ensure persons with limited English Proficiency can meaningfully access those services. Available at http://www.frwebgate.access.gpo.gov/cgibin/getdoc.cgi?dbname=2000_register&docid-fr16au00-137.pdf. Gilgun, J.F. (2005). The four cornerstones of evidence based practice in social work. Research on Social Work Practice, 15 (1), 52-61. Migration Policy Institute (2007). �Kentucky factsheet on the foreign born: Demographic and social characteristics. Available at www.migrationinformation.org/datahub/state.cfm?ID=KY. Sackett, Richardson, Rosenberg & Haynes. (1997). Cited in Gibbs, L., & E. Gambrill (2003). Evidence based practice: Counterarguments to objections. Research on Social Work Practice, 12 (3), 452-476.