Advances Vol. 1, No. 2 CCuullttuurraall SSeennssiittiivviittyy iinn AATTOODD AAggeenncciieess:: AAddmmiinniissttrraattoorr aanndd SSttaaffff PPeerrcceeppttiioonnss iinn tthhee HHiissppaanniicc HHeeaarrttllaanndd David R. Hodge Paul Cardenas Harry Montoya Abstract: Administrator and staff perceptions (N = 72) of alcohol, tobacco, and other drugs (ATOD) agency cultural sensitivity were explored in a predominantly Hispanic rural area with elevated levels of acculturation and high ATOD usage. While providers generally agreed that a relatively moderate need existed for training related to cultural issues, a more nuanced picture emerged in the purview of cultur- ally-related barriers. Administrators viewed the lack of appropriate interpreters and language as a greater barrier than did the staff. Administrators also held higher per- ceptions of agencies’ cultural competency. The overall high assessment of cultural sensitivity may result from the substantial number of Latino providers. Keywords: Alcohol, drugs, culture sensitivity, Hispanic, Latino, prevention, administration, ATOD agencies Hispanics are projected to surpass African Americans in the next few years as the nation’s largest minority group (Castex, 1994; Perez & De La Rosa, 1993) due to their relative youth, high fertility rates, and high documented and undocumented immigration. Although long-range projections are problem- atic, one census estimate predicts the Hispanic/Latino population will reach 128.3 million by 2050 (Castex, 1994). Castex (1994) highlighted four social indexes as par- ticularly salient in illuminating the Hispanic context (1992 figures): High poverty levels (26.2% vs. 10.3% for non-Hispanic families, a high ratio of single-parent fam- ilies (30% vs. 20% for non-Hispanics), low levels of median income ($22,848 vs. $33,388 for white households), and a low median age (26 vs. 33.5 years). While it is commonly assumed that such social indicators presage high levels of alcohol, tobacco and other drugs (ATOD) usage (Austin & Gilbert, 1989), studies exploring ATOD use and related issues have produced inconsistent results (Warheit, Vega & Khoury, 1996). For example, the US Department of Health and Human Services’ (1997) latest National Household Survey on Drug Abuse (NHSDA) data revealed overall Hispanic ATOD use and abuse as significantly below that of whites and frequently less than African Americans. It is noteworthy 137 David R. Hodge, M.C.S., M.S.W. is a Rene Sand Doctoral Fellow at the George Warren Brown School of Social Work, Washington University, St. Louis, Missouri, USA. Paul Cardenas, M.S.W. is President, National Multicultral Associates, Denver, Colorado. Harry Montoya, M.A. is President, Hands Across Cultures, Española, New Mexico, USA. Copyright© 2000 Advances in Social WorkVol. 1 No. 2 (Fall 2000) 137-147. Indiana University School of Social Work. that the NHSDA is the most extensive source of national information on ATOD usage patterns among members of the civilian, non-institutionalized population age 12 and over in the United States. Conversely, other observers (Austin & Gilbert, 1989; Caetano, 1983, 1994; Carrasquillo, 1991; Casas, et al., 1998; Deren et al., 1997; Rodriguez & Brindis, 1995; Warheit, Vega & Khoury, 1996; Weeks et al., 1996) have found a more nuanced pic- ture. These authors cite, in at least some contexts, higher rates of ATOD usage and related problems as compared to the general population. Numerous methodological factors may underlie the difference in the results obtained. Possible causes for the lack of consensus have been credited to sample size and location, non-random sampling, differences in operationalizing the con- structs measured, underreporting of certain groups due to fear of deportation, undercounting youth due to the high Hispanic drop-out rate, and confounding due to the disproportionately higher rates of abstinence among Latina females (Austin & Gilbert, 1989; Casas et al., 1998; Warheit et al., 1996). As Parker, Weaver, and Calhoun (1995) noted, despite the recent interest in exploring ATOD issues among minority populations, few studies of Latinos have been conducted. Another critical element in the disparate findings may be the relative degree of acculturation. In aggregate, ATOD use tends to increase with acculturation (Austin & Gilbert, 1989; Caetano, 1994; Casas et al., 1998; Deren et al., 1997; Warheit et al., 1996). For example, Warheit, Vega, and Khoury (1996) found in their longitudinal study a generally linear trend between length of time in the United States and increased substance use among all four Hispanic subgroups. Thus, high rates of recent immigration may have produced a relatively favorable portrayal of current ATOD usage in the NHSDA data set. Furthermore, this depiction may be substan- tially altered in the future, as a relatively young, unacculturated population is exposed to acculturating influences. Corporate America’s (Roslow & Nicholls, 1996) recent discovery of the Hispanic market has exacerbated the acculturation effect. Alcohol and tobacco companies are leaders in employing psychologically sophisticated advertising to penetrate the Latino market (Nuiry, 1997). Examples of the manifestation of this targeted marketing effort (Rodriguez & Brindis, 1995) are Spanish cigarette brands and the predominance of liquor outlets in Hispanic neighborhoods. Accordingly, it seems probable that ATOD use and related issues will increase among the Latino population in the immediate future. ATOD problems are likely to grow significantly due to a high percentage of the Hispanic population reaching adolescence, an anticipated increase in the level of acculturation, and the stepped-up use of psychological marketing techniques by alcohol and tobacco advertisers. In fact, studies employing smaller sample sets of highly acculturated Hispano subjects may be more representative of the future than the extensive NHSDA study. While consensus has not yet been reached concerning the prevalence, extent, or antecedents associated with ATOD use, a widespread agreement exists regarding the importance of developing culturally sensitive methods for delivering services to Hispanos. In addition to the importance of culture sensitivity in agency settings 138 ADVANCES IN SOCIAL WORK (Applewhite, Wong & Daley, 1991; Colon, 1996; Gant & Gutierrez, 1996; Santiago- Rivera, 1995; Weeks et al., 1996), it has been cited as a critical component in a number of diverse areas. For example, assessment and prevention of aggressive behavior (Delva-Tauili’ili, 1995), health care interventions (Bird, Otero-Sabogal, Ha & McPhee, 1996), caregiving for elders (Delgado & Tennstedt, 1997), community organization/practice (Kahn, 1997; Weil, 1996), as well as ATOD programs (Austin & Gilbert, 1989) have all been mentioned as areas where an awareness of Latino cultural issues is crucial. Yet, as Gant and Gutierrez (1996) noted, the empirical investigation of agencies’ cultural sensitivity is still in its infancy. While a growing body of literature that delineates the cultural characteristics significant for the delivery of services in Latino settings exists, to the best of the authors’ knowledge, the cultural issues in ATOD agencies have not been empirically explored. This is a significant oversight given the growing prevalence of ATOD problems in Hispano communities. Accordingly, this study examines cultural sensitivity issues in ATOD agencies in a predominantly Hispanic area that has experienced a high degree of accultura- tion. In line with Gant and Gutierrez’ (1996) observations that provider percep- tions of the agency environment are often more significant than the actual char- acteristics of the agency, administrator and staff perceptions are explored in three areas: Culturally-related training needs, culturally-oriented barriers that inhibit access to ATOD services and programs, and an overall assessment of agency cul- tural competency. METHOD As suggested above, it may be especially salient to examine perceptions in rela- tively acculturated environments, as such contexts may presage the future for a substantial segment of the relatively unacculturated Hispanic population. Accordingly, the geographic area surrounding the town of Española in northern New Mexico was selected. This catchment area includes the counties of southern Rio Arriba, northern Santa Fe, and southern Taos. In total, this sparsely populated district comprises an area approximately the size of Massachusetts. In this tri-cultural area, 70% are Hispanic, with the remaining 30% equally divided between Native Americans and Anglos or non-Hispanic whites (1998 U.S. Census). Hispanics or Hispanos have been the dominant population in the area for almost 400 years. In fact, with a history of settlement stretching back to 1598, the region is the center of the nation’s oldest continuous European settlement and proudly self- identifies as the nation’s Hispanic Heartland. Despite becoming a United States possession in the mid-19th century, until rel- ativey recently, acculturating influences have been minimal. The relative geo- graphic and linguistic isolation, combined with the strong Spanish/Latin culture (the area was under Spanish rule for 213 years and Mexican for 25 years) and main- stream oppression (Wright, 1994), has limited acculturation. However, wide rang- ing societal changes dating from the end of WWII, including such factors as mass communication, increased access to transportation, and a growing influx of Anglos, have fostered a high level of acculturation in the past few decades. 139Hodge et al./CULTURAL SENSITIVITY IN ATOD AGENCIES Interestingly, the area’s current poverty rates, incidence of single-parent families, income levels, and median age among Hispanics approximate Castex’s (1994) national averages for Latinos (New Mexico Department of Health, 1996). However, ATOD use and related problems are generally significantly higher than state or national averages (Lewis, 1997; New Mexico Department of Health, 1996). As sug- gested above, the rates of ATOD usage may be related to the extended accultura- tion process the area has experienced during the preceding 50 years. In light of the existing ATOD problems, a number of agencies have developed programs to address the area’s concerns. As part of a previous project undertaken by Hands Across Cultures—an Española-based prevention agency—an exhaustive list of the area’s community agencies had been compiled. From this schedule, 52 agencies were identified as having the potential for providing ATOD services. Phone interviews with the respective organizations yielded 29 agencies involved with ATOD issues in some form (e.g., education, counseling, prevention). After confirming ATOD services, permission was sought from each agency’s executive director, CEO, or in their absence, an administrative assistant for author- ization to mail surveys to the appropriate personnel. Twenty-six agencies agreed to participate. In organizations with fewer than five staff involved with the direct pro- vision of services, every individual was mailed a survey. In agencies with 5 to 10 employees, every second staff member was sent a survey. Executive directors and when warranted by agency size, department heads or their equivalents, were sent administrator surveys. In addition to the survey, the mailed package included a personalized cover let- ter, postage-paid return envelope, and a $2.00 bill as an incentive. One week after the mailing a phone call was placed to ensure the package had arrived and to offer assistance in facilitating the return of the survey. Three weeks after the mailing a second follow-up call was placed to those individuals who had not returned com- pleted surveys. Thirty-two of the administrator surveys were sent to identified personnel at the 26 agencies. Twenty-four were returned, for a response rate of 75% among execu- tive directors and department supervisors. Seventy-eight staff surveys were sent and 48 were returned, resulting in a 61% return rate by staff involved in the direct provision of ATOD services. Survey Instrument The instrument explored cultural issues from three angles. Administrators and staff were asked to assess their agencies in two domains: Training needs that would enhance ATOD services, and barriers that inhibit the utilization of programs and services. The questionnaire utilized a series of Likert-type scales (1=Not at all, 5=Extremely) to operationalize perceptions in the 10-question training domain (see Table 2) and the 9-question barriers domain (see Table 3). Providers were also asked to choose the best statement from a choice of four that most accurately depicted the cultural stance of their agency—the one that most accurately reflected different levels of cultural orientation (see Table 4). Researchers specializing in minority studies at Arizona State University (Castro, 1997) pretested and refined the instrument on a prior sample of administrators and staff. 140 ADVANCES IN SOCIAL WORK FINDINGS Sample Characteristics Table 1 reveals that provider characteristics are generally reflective of the surrounding community, although Native Americans are noticeably under- represented. This finding sug- gests the need for further empir- ical exploration. The lack of Native American representation is particularly notable in light of the high percentage of Latino providers. In fact, among admin- istrators, 71% were Hispanic (vs. 55% of staff and 70% of the catchment’s general popula- tion). However, chi-square tests revealed no significant differ- ences among provider charac- teristics, with the exception of professional status (χ2=19, df=3, p<.001). There were, for exam- ple, substantially more social workers among staff (34%) than administrators (8%). Training Needs As Table 2 demonstrates, inde- pendent two-tailed t-tests revealed no statistically significant differences between administrators and staff in any of the areas surveyed. The resulting scores of the two groups were basically congruent. The general parity is also demonstrated by the fact that administrators recorded marginally higher assessments on seven queries, while staff had slightly higher scores on the other three questions. Table 2 is organized in descending order of perceived training need in terms of the provider mean. In other words, when administrator and staff scores are averaged together, the question concerning how to involve community members in the planning of ATOD programs received the highest score. Thus, in aggregate, providers perceived this to be the area reflecting the greatest need for training. Accordingly, it is listed first on the table. However, it should be kept in mind that there was minimal variation between the areas requiring the most and the least training. In short, providers gave all areas an essentially moderate score in terms of culturally oriented training needs. Barriers to ATOD Services As Table 3 reveals, there was more variation between administrators and staff in the purview of barriers. Independent two sample t-tests disclosed statistically sig- 141Hodge et al./CULTURAL SENSITIVITY IN ATOD AGENCIES Characteristic % Gender Male 51 Female 49 Ethnicity Hispanic 61 Anglo 31 Native American 4 Other 4 Birthplace New Mexico 60 Southwest 14 Other 26 Fluency in Spanish Excellent 31 Good 22 Fair 39 None 8 Social Work Degree 25 Education High School or < 11 Associates 7 Bachelors 37 Masters 35 Doctorate 10 Table 1: Characteristics of ATOD providers (N = 72) nificant differences in the areas of access to appropriate interpreters and lack of congruence between clients’ language capabilities and those of providers. In both cases administrators perceived the obstacle to be of greater consequence than did the staff. However, in the remaining insignificant areas, administrators and staff were evenly split, with each assessing three areas as marginally more of an impediment. Table 3 was also arranged in descending order based upon provider means, with the greatest obstacle listed first. Unlike training needs, which demonstrated little variation, there were marked differences in how the various barriers were rated. Client transportation was cited as the most prominent obstacle to clients receiving ATOD services, perhaps an expected finding given the poverty and lack of trans- portation networks in the region. Lack of advertising agency services and restrictive scheduling policies, followed by eligibility criteria, which limit some clients, were also listed as important barriers. At the other end of the continuum was the issue of appropriate interpreters and having a significant number of minority providers with whom minority clients can identify. Agencies’ Cultural Competency Respondents were given a choice of four cultural orientations and asked to select the perspective that best embodied their agency’s orientation towards cultural issues. Providers were asked to consider both program development and service 142 ADVANCES IN SOCIAL WORK Administrators Staff M SD M SD t-score How to involve community members 3.42 1.04 3.21 .93 .86 in program planning Evaluating programs designed to help 3.50 .72 3.24 1.05 -1.07 clients from diverse backgrounds Learning about community resources 3.20 .83 3.38 1.05 .71 (e.g., churches, traditional healers) Understanding ATOD services barriers 3.42 .83 3.23 .96 -.79 various clients face Helping clients become more involved 3.25 .85 3.17 1.11 -.31 in meeting their own health needs Understanding the health-related beliefs, 3.25 .79 3.17 1.01 -.34 behaviors, and traditions of clients How to provide cultural sensitivity 3.15 1.01 3.12 .61 .12 training to others Understanding how to communicate 3.21 1.06 3.17 1.01 -.15 and work more effectively with minorities Learning how to make the agency more 3.29 .86 2.98 1.03 -1.28 sensitive and responsive to diverse clients Understanding the major health needs 3.12 .85 2.87 1.13 -.96 of minorities Table 2: Agency Training Needs (N = 72) delivery. As can be seen by the choices delineated in the Agency Cultural Competency Scale presented in Table 4, a higher score represents a greater degree of cultural awareness. Independent two sample t-tests revealed a significant difference in perceptions. Administrators rated their agencies as more culturally competent than did staff (M=3.72, SD .57 vs. M=3.18, SD=.90; t=-2.32, p<.05). Although on balance, both groups had very positive assessments of their agencies’ level of cultural competency. DISCUSSION As an exploratory study examining providers in one geographic region, the results cannot be generalized to other contexts. Further, in light of the diversity intrinsic to the Hispanic classification (Castex, 1994), the applicability of results obtained from one group to others has been questioned (Austin & Gilbert, 1989). Since a sin- gle homogeneous Hispano culture does not exist, replication with other Latino populations is clearly warranted. Despite their diversity, there tends to be a number of shared cultural values among the discrete populations that comprise this group (Rodriguez & Brindis, 1995). For example, familismo, the understanding that family is central to one’s personal ontology, is a widely held value (Munoz, 1997; Rodriguez & Brindis, 1995). Indeed, Madison Avenue’s success in targeting the Latino market testifies to numerous points of congruence among discrete Hispanic groups. 143Hodge et al./CULTURAL SENSITIVITY IN ATOD AGENCIES Administrators Staff M SD M SD t-score Clients’ limited transportation 3.33 1.00 2.96 1.22 -1.29 Lack of advertising of agency services 2.71 .91 2.41 1.21 -1.06 in clients’ communities Agency’s scheduling policies that don’t 2.42 1.21 2.56 1.16 .48 offer evening or weekend service Eligibility criteria that limit access of 2.36 1.25 2.21 1.12 -.50 ATOD services for some groups Cultural differences between 1.96 .98 2.00 .94 .18 clients and providers Clients’ language skills (speaking only 2.29 .80 1.73 .78 -.80** Spanish or other language) Providers’ negative attitudes towards 1.83 .92 1.91 1.00 .32 clients Too few minority staff with whom 1.83 .76 1.78 1.06 -.23 minority clients can identify Lack of appropriate interpreters 1.96 .98 1.51 .76 -2.01* (having to use children, cleaning staff, etc.) Table 3: Barriers to ATOD Services (N = 72) *p<.05. **p<.01. Furthermore, there is evidence that similarities may also exist in the purview of ATOD issues, as well. For instance, ATOD usage patterns show more symmetry than dissimilarity among diverse Hispanic populations (Warheit et al., 1996). In fact, Warheit, Vega, and Khoury (1996) have suggested the similarities are of such magnitude in this area that one can generally place Latinos in a single category without violating the integrity of their individuality. Similarly, as noted in the introduction, widespread agreement exists that cultural sensitivity issues have broad applicability. In addition, acculturation tends to fos- ter increased ATOD usage among numerous Latino subgroups. Indeed, in light of the acculturation effects seen in this geographic area, as well as other settings (Caetano, 1994; Casas et al., 1998; Deren et al., 1997; Warheit et al., 1996), this study may have particular salience for Hispanic-area ATOD agencies. The high level of Hispano presence among providers was an unexpected finding. As mentioned above, the percentage of Latinos among administrators slightly exceeded the proportion within the surrounding population. This suggests accultur- ation may be a double-edged sword for Hispanics. While it may foster increased ATOD use, it may also facilitate higher levels of education and ATOD agency involvement. Interestingly, Munoz (1997) has posited that the Hispano sense of familismo is not limited to the immediate family but is often generalized to the community. Correspondingly, individual identity development is intertwined with community development. In other words, as wholeness in the community is achieved, it is achieved in the individual. This dynamic may foster increased Hispanic involve- ment in ATOD agencies as a means to achieve community development. While some qualitative evidence supports this theory (Lazzari, Ford & Haughey, 1996), further research with other samples of highly acculturated Latinos is required to confirm this hypothesis. In terms of the cultural issues explored, providers perceived their agencies as needing only average amounts of training. There is little doubt that provider char- acteristics played a substantial role in this assessment. Providers were well edu- cated, exhibited high levels of Spanish fluency, and perhaps most importantly, incorporated minority representation on a par with the surrounding community. There was a noticeable pattern in both the training and barriers domains, although more pronounced in the latter. In questions that addressed cultural sen- sitivity issues at the interpersonal level, agencies were rated with more proficiency 144 ADVANCES IN SOCIAL WORK 1. Attention to cultural issues is seen as totally unnecessary in ATOD programs and serv- ice delivery. 2. People should be treated equally in all situations; no one should receive special atten- tion. 3. Cultural issues should be examined from time to time; although cultural factors are not major issues in the development of ATOD programs and service delivery. 4. Cultural issues should be examined in depth and with respect in order to offer better ATOD programs and services. Table 4: Agency Cultural Competency Scale and barriers perceived to be less formidable. Conversely, broader, systemic, and macro issues were found at the other end of the continuum. Thus, for example, the lack of appropriate interpreters was the lowest obstacle impeding service utiliza- tion, while the lack of transportation systems was the highest. Colon (1996) has suggested that the most important aspect of cultural sensitivity is the macro dimension (cf. Gant & Gutierrez, 1996). Integrating the agency into the community through outreach, recruitment of community members, and inclusive decision making were understood to be essential to facilitating wide- spread Hispano use of services (Colon, 1996). Interestingly, even with the substan- tial numbers of locally “recruited” providers evident in this study, macro issues remained at the forefront of provider concern. It would seem that agency integra- tion with the community is a prominent issue regardless of provider characteris- tics. In other words, recruiting local community members, even at the provider level, is only part of the solution. Macro outreaches, such as strategically located advertising agency services in Spanish, are a crucial element to enhancing service provision to Latinos (Bird et al., 1996). Spanish language skills are essential in working with most Latino groups (Applewhite, Wong & Daley, 1991; Ross, 1995; Santiago-Rivera, 1995). Provocatively, this was the only area where significant differences emerged between administrators and staff in the training and barrier domains. In both cases (lack of appropriate interpreters and clients’ lack of proficiency in English), administrators, rather than staff, perceived a greater barrier existed. Although no significant differences emerged between administrators and staff in terms of birthplace, ethnicity, or Spanish linguistic ability, staff were somewhat more likely to be born outside of New Mexico, to be Anglo, and to report less flu- ency in Spanish. These factors may have resulted in administrators’ perceiving lin- guistic areas as more of an obstacle. The counterpoint to this explanation, howev- er, is that no significant differences arose in other cultural areas. For example, assessments were essentially identical in other barriers, such as too few minority staff with whom minority clients can identify, and cultural differences between clients and providers. While more research is required, perhaps the most salient point is that both sets of providers perceived language to be a relatively minor hin- drance to service. Both administrators and staff had positive overall assessments of their agency’s cultural competency in program development and service delivery. Although administrators held significantly higher perceptions of competency, this may have resulted from an enhanced sense of ownership toward their agencies. In spite of the differences, both sets of providers held very high opinions of their agency’s attention to cultural issues. CONCLUSIONS This is the first empirical exploration through the eyes of administrators and staff of ATOD agency cultural sensitivity in an acculturated Hispanic area. No out- standing culturally related training needs appeared in administrators and staff perceptions. Concurrently, with the exception of clients’ access to transportation, all culturally associated barriers received net negative scores, indicating that on 145Hodge et al./CULTURAL SENSITIVITY IN ATOD AGENCIES balance, cultural barriers were not an overriding obstacle. This positive picture was confirmed by providers’ high assessment of their agency’s cultural competen- cy in the purview of overall program development and service delivery. Additional corroboration is seen in the high degree of overlap between the results obtained in this study and the principles outlined by Gant and Gutierrez (1996) in terms of embodying their related concept of culturally sophisticated agencies. The key factor that emerged in the substantial degree of cultural sensitivity can be traced to the high percentage of Hispano providers. 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