Service utilization in high-crime communities: Consumer views on supports and barriers

Abstract

This study uses qualitative methods to investigate perceived supports and barriers to social and health service utilization among minorities residing In high-crime and violent communities. Focus groups were conducted with African Americans, Asian Americans, and Hispanics/Latinos (N= 64) who reside In these communities within a moderately sized Midwestern city. Both convergent and divergent themes were Identified across the groups. Implications of these findings for research and practice are discussed.

VIOLENT CRIME ACROSS the country declined 10% in 1999, reaching its lowest level in the history of the National Crime Victimization Survey (NCVS) (Bureau of justice Statistics, 2000). A similar decline was reported for property crime, which showed a 20-year decline (Bureau of Justice Statistics, 2000). Indeed, it is good to see a decrease in homicides, forcible rapes, robbery, assaults, and theft (Federal Bureau of Investigation, 2000). However, despite this encouraging news, residents from poor and depressed sections of urban communities, where a significant number of these offenses occur, still feel that crime and violence in their communities are routine and commonplace, and that their communities remain unsafe and unresponsive to their needs (Rapp & Wodarski, 1997; Osofsky, J. D., Wewers, S., Hann, D. M., & Fick, A. C. (1993). In African American communities the rates of victimization by violence remained static from 1998 to 1999 (Bureau of justice Statistics, 2000).

The daily occurrence of crime, random acts of violence, and concerns raised about safety, have resulted in inner-city communities and neighborhoods being characterized as war zones (Garbarino, J., Dubrow, N., Kostelny, K., & Pardo, C. (1992); Garbarino & Dubrow, 1989; Shihadeh & Steffensmeier, 1994). Similarly, Green (1993) notes that "violence is a frequent phenomenon in most of the poor sections of our urban centers" (p. 106), and acts of violence are as varied as the communities in which they occur. How individuals and families living in these communities respond to the daily challenge of life in these unsafe environments depends on their own inner resources and their ability to seek help, to identify the source of the problem, and then identify and utilize the needed service in order to resolve the problem. This help-seeking process is a multifaceted concept that has social, emotional, and environmental components to understanding it's complexities (Andersen & Newman, 1973; Kulka, Veroff, & Douvan, 1979; Gary, L., Leashore, B., Howard, C., & Buckner-Dowell, R. (1983); Neighbors, 1985; Andersen, 1995). For example, help-seeking involves decision-making wherein a person defines a problem, decides to seek help, and then selects a particular source of help to resolve the problem (Sussman, 1996). Yet, people typically categorize, label, and interpret problems according to the "cultural lens of their families and community" (Sussman, 1996). However, since many of these violent urban communities are racially and ethnically mixed, help-seeking is as varied as the racial and/or ethnic groups. For example, depending upon the location of the community, it is usual for poor Caucasians, African Americans, Asians, Bosnians, Russians, Hispanics, Native Americans, and Ethiopians, to live in the same community and sometimes in the same city block. Problems that arise because of this mixture of people and cultures make help-seeking and service utilization difficult to fully understand.

Yamashiro & Matsuoka (1997) for example, posit that attitudes of Asian Americans toward mental health and help-seeking are instrumental in understanding their underutilization of formal mental health services. According to the authors, "Asian Americans would rarely endorse emotional and interpersonal problems as their central problem" (p. 177). Consequently, despite the need, Asian Americans might underutilize formal mental health services. In analyzing national data, Matsuoka and colleagues (1997) found that Asian Americans/Pacific Islanders were three times less likely than their Caucasian counterparts to use available mental health services.

McMiller & Weisz (1996) found after examining the full pattern of parents' help-seeking for 192 clinic-admitted African American, Latino, and Caucasian children for mental health care, that "compared to Caucasian parents, African American and Latino parents were less likely to contact professionals when seeking advice or help regarding their children's problems" (p. 1090). Tran, Dhooper, and McInnis-Dittrich, (1997) came to a similar conclusion, in using the 1988 National Survey of Hispanic Elderly, the authors concluded that community-based health and social services are routinely underutilized by elder Hispanics (Cubans, Mexicans, and Puerto Ricans) who were born outside the United States.

Similarly, Biegel, Farkas, and Song (1997) found in their study of barriers to the use of mental health services among African American and Hispanic/Latino elders, that a number of system, staff, and individual barriers prevent these elderly people from utilizing mental health services. System barriers identified by the authors include: a lack of staff knowledge in geriatrics, physicians who do not refer minority elderly for mental health services, staff's lack of specialized knowledge about or sensitivity to cultural differences, and limited outreach agencies and services. Agency/staff barriers included attitudes that minority elders were untreatable and unwilling to change behaviors. Individual and family barriers identified include the perceived stigma of mental illness among minority elderly and their families. The authors concluded that system-- level barriers were the greatest barrier to service utilization for individuals and their families.

Bui & Takeuchi (1992) in their examination of the use of community mental health care services by ethnic minority adolescents (African Americans, Asian Americans, Mexican Americans, and Caucasians), found that such use actually parallels the service utilization patterns among adults. In other words, sporadic service use by African American adults results in a similar sporadic service pattern among African American adolescents. Padgett and her colleagues (1994) found that differences in service use also existed among poor African Americans, Hispanics, and Caucasians who were insured. Finally, investigation of patterns of service use among low-income pregnant and parenting African American adolescents revealed that patterns of service utilization are not alike, but were correlated with rates of victimization experienced by the woman (Rhodes, Fischer, & Meyers, 1993).

A host of themes about service utilization among racial and ethnic minority populations emerged from these studies. Two of these themes provided a starting point for the present study. First is the reality that in some inner city communities, accessing and utilizing a needed service is dependant upon its availability (both in terms of quantity and quality) and the threat of violence one might encounter in accessing the service (Garbarino et al., 1992). Many of these communities have high levels of poverty, elevated rates of unemployment, single-parent households, teen pregnancies, welfare dependency, high crime, and drug use and trafficking (Garbarino et al., 1992). To be mobile in these communities requires having to watch one's back at all times (Kotlowitz, 1991; Anderson, 1999). One consequence of this threat of danger is that community services like banks, grocery, drug, and department stores have either abandoned some inner city communities entirely or dramatically reduced their services, thus further alienating its residents from mainstream society.

Secondly, many communities in central cities that were once racially and ethnically homogeneous enclaves of stable, middle and working class individuals and families, are now more heterogeneous and tend to contain multiple ethnic groups (Reiss, Jr. & Roth, 1993). Given this situation, service providers may often experience considerable difficulty designing and implementing programs and services that address the needs of minority clients in violent communities. For example, to ensure that the various ethnic and racial groups in a given community are targeted, an infrastructure must be in place with substantive, culturally relevant materials. Unfortunately, this is a challenge many service providers find labor intensive, cumbersome, and fiscally taxing. These and other issues must be resolved if service providers and their staff are to maximize the benefits of social and health services to all in need.

Recognizing these complexities, the present study explored the perceived barriers to social and health service utilization by minorities (African Americans, Hispanics/Latinos, Asian Americans) residing in high crime and violent communities in a moderate sized Mid-- western city. Individuals in this study were residents of communities defined and mapped by the urban community planning office. The mapping of these communities are based on traditional historical boundaries.

The most current crime data for the city is 3.45 violent acts (i.e., homicide, forcible sexual assault, robbery, aggravated assault) per 100 residents (9,651 violent crimes). The violent crime rate among residents of two African American communities who participated in the study were 7.0 and 4.5 per 100 residents (1,728 violent crimes). Approximately 18% of all violent crimes for the city were perpetrated in these African American communities. The rate of violent crime among residents in the Hispanic/Latino community was 3.0 per 100 residents (517 violent crimes), representing approximately 5% of violent crimes for the city. The violent crime rate among residents in the Asian American community was 4.5 per 100 residents (972 violent crimes), representing approximately 13% of the violent crime rate for the city (Project Respond, Vision for Children at Risk, 1997). These data would suggest that when comparing these communities, the African American and Asian American communities are more exposed to violence and crime than the Hispanic/Latino community.

Methods

Design

Seven 90-minute focus groups were conducted with various community residents, all of whom lived in distinct ethnic and racial communities. Of these seven groups, three were African Americans, two were Asian Americans, and two were Hispanics/Latinos. Three of the seven focus groups were conducted by the first and second authors. The remaining four groups-two of which were Asian American, and two were Hispanic. Latino-were conducted by individuals known by the authors to have the ability to speak the participant's language of origin. The sample was recruited from community-based agencies in high crime/violent communities using a snowball sampling procedure. Content for the focus groups was generated from the literature on violent communities and concentrated on the following areas: (a) resident's overall perception of their community, (b) precipitating factors prompting service use, (c) reasons for service use, (d) barriers to service usage, and (e) levels of satisfaction with community services.

A qualitative approach was chosen because of the lack of understanding regarding the effects of community crime and violence on service utilization patterns among minority individuals and their families. Focus groups have an extensive history as an effective method of collecting this type of exploratory data (Krueger, 1988; Morgan, 1988, 1993; Patton, 1990; Strauss & Corbin, 1990). Qualitative research is particularity appropriate when gathering such sensitive and difficult data such as residents' perceptions of their high crime communities and understanding the contextual effects crime and violence have on service utilization. When investigating the effects of crime and violence on a community, the focus group format affords individuals in the community an opportunity to meet other neighbors and share a common experience. Focus groups also are useful in developing survey questions that truly capture the cultural specifics of the residents in the community.

Data analysis was conducted in several steps. First, impressions formed from earlier groups were validated with the later groups. All sessions were audio taped and transcribed verbatim, checked for accuracy, and edited for identifying information. The transcriptions were then carefully read by all of the authors. All readers independently identified themes that emerged from the transcriptions and then met to discuss the themes. Only those themes that were agreed upon by all readers were included.

Participants

Participants were individuals who resided in various ethnic/racial communities in the urban core of a moderate sized Midwestern city. These participants were recruited through a collaborative effort between the project's investigators and key individuals employed in several community-based agencies. Each participant in the African American and Asian American groups received a small financial incentive for their participation. Participants in the Hispanic/Latino groups requested a dinner in lieu of cash payment for their participation. Seven focus groups consisting of 64 adult participants were held in different communities of the city. Of the 64 participants, 45 were female and 19 were male. Thirty-one of the participants were African Americans (20 females, 11 males), 15 were Asian Americans (10 females, 5 males), and 18 were Hispanics/Latinos (15 females, 3 males). The imbalance in the overall numbers of females to males may be indicative of service use patterns noted in the literature (Gary et al., 1983; Husaini, Moore, & Cain, 1994), social networks, or availability. Age range of the participants was 18-80 years, with a mean age of 43.79 (SD = 13.25). The respondents lived in their respective communities for 57.33 months (the mean), SD = 86.37. The Asian Americans and Hispanics/Latinos had lived in the United States for 10.19 years (the mean), SD = 11.00. Eighty-four percent of the participants had an annual income of less than $20,000, with 55% having annual income of less than $10,000. Thirty-one percent of the participants had less than a high school education and 26% were college graduates. The marital status of the participants ranged from 38% who reported being married, 27% who reported to being single, and 33% who reported to being either divorced, widowed, or separated.

Results

Discussion

Several important themes stand out from the results of this study: (a) the general concern regarding the lack of safety in the communities and the participants' feeling of powerlessness to address the causes for this lack of safety, (b) the attribution of the problem with safety to African Americans by the other minority groups in the study, (c) the language and cultural barriers to accessing services, and (d) the importance of churches as service providers.

Focus group participants reported that safety was the most important issue related to their community. The importance of personal safety is consistent with previous community assessments (Rapp & Wodarski, 1997; Garbarino et al., 1992; Garbarino & Dubrow, 1989). These results suggest that an individual's sense of how safe their community is affects their mobility and may have an impact on how they access and use services.

Another area that became apparent was the uniformity with which Asian Americans and Hispanic/Latinos attributed the crime and violence in their communities to African Americans. The majority of non-African American participants attributed the primary cause for the lack of safety in their communities to African Americans; they also felt that African Americans held all of the political power Anecdotal stories and information regarding the mistrust and animosity across racial groups/ethnic groups have been very topical in the popular electronic and print media.

The results also clearly point out how language and cultural barriers impede service utilization. All participants from the Asian American and Hispanic/Latino groups agreed that lack of translation services and culturally aware personnel in agencies had a profound effect on how comfortable they felt in using services. These results are consistent with previous studies indicating that system-level barriers and attitudes were instrumental in determining service utilization (Bui & Takeuchi, 1992; Tran et al., 1997).

In contrast, all of the group participants found the churches to be the most positive aspect of their communities. This is also consistent with other research that has explored the role of religion and churches in minority communities (Levin, Taylor, & Chatters, 1995; Scandrett, 1994; Levin, Chatters, & Taylor, 1995). It is apparent that participants in the focus groups view churches as a service provided and a stabilizing affect on the community. This was especially true for the Asian Americans and Hispanic/Latino members.

Given the results of this study, it is important to note its limit. Males were underrepresented as participants in the focus groups and many of the participants were individuals who had relationships with community-based agencies and were more likely to attend the focus groups. Given these limitations readers should interpret results with caution when attempting to generalize the findings to other communities and populations.

Despite the potential limitations of the methods used in this study, these findings suggest implications for social work practice across various levels. Micro intervention strategies (educating residents about common values of the community and ways of protecting these common values) are used to address some of the psychosocial consequences of crime and violence. Macro intervention strategies also are a key to rebuilding community infrastructures (e.g., rehabilitating housing stock, improving transportation and law enforcement services). Micro intervention strategies address the psychosocial impact of crime and violence and could provide a basis for working in these types of communities. Several themes in this study reflect the fact that in racially and ethnically mixed disorganized communities, social workers must be trained to collaborate with a variety of professionals and be able to function as generalist practitioners "who possess a holistic approach that emphasizes the environment as well as the person in environment" (Morrison et al., 1997, p. 533). Regardless of the approach, it seems clear that in order to identify and build on existing community and individual strengths, open and ongoing communication among key stakeholders is a must.

It is important to note that conceiving one strategy as a means of addressing a social ill is usually ineffective and doomed for failure. For example, to focus exclusively on public safety without addressing other factors that are interrelated with crime and violence would be taking a limited approach. Social workers should take an integrated, comprehensive, community-based approach to improving public safety. In other words, calling attention to safe streets and communities are often intertwined with other social problems (e.g., unemployment, poverty, single-parent families, inadequate housing, youth problems, inadequate services, community apathy). To address the issue of safety, as well as other problems for residents of these communities, the social worker must develop strategies that empower and motivate all residents to take action regarding their community problems. Research has shown that empowerment strategies are effective in addressing the needs of impoverished communities. Social workers can serve a key role in facilitating and implementing comprehensive community-based programs that incorporate these techniques. These types of programs are dependent on total community participation (e.g., residents, key leaders, government officials) for planning and implementation.

To bridge differences at all levels, it is important to bring various community entities together to discuss community problems, using brokering and negotiating skills to facilitate community investment and ownership. Brokering skills can be effective in facilitating collaboration and cooperation among community residents. For example, in order to address community safety, the social worker might facilitate a meeting that would include community residents, law enforcement officers and local officials to explore ways in which comprehensive community-based strategies (e.g., increasing police patrols, community-based police substations, community oriented policing programs) would address community concerns. The social worker must utilize collaboration and mediation skills in helping residents to recognize turf and power issues that may obstruct cooperation. In addressing the micro issues, it is important to help policy makers recognize the interconnectedness between community-level problems and the psychosocial impact on the well-being of its residents. On the micro level, social workers must continue to address strategies that directly intervene at the individual level. The data show that the process of help-seeking and service utilization is unique to each racial and ethnic group and even within groups. To be effective, the social worker must develop support groups across as well as within racial groups where neighbors become partners rather than competitors for needed services (Wandersman & Nation, 1998).

It is also apparent that social service staff must become more knowledgeable of various cultures and develop culturally competent skills to support various models of help-seeking behaviors. Understanding the cultural and behavioral dynamics of various ethnic groups who reside in the urban core is imperative to effectively provide and plan services.

Individuals and families, whatever their racial or ethnic background, do not live in a vacuum. The deleterious impact of community disintegration and violence on individuals and families cannot be denied. Social work practice in these communities should be based on a strength perspective where residents are empowered to take control over their own lives and the life of the community.

Finally, this study underscores the value of qualitative data in understanding service utilization in disorganized communities. This method provides consumer feedback about their community and the agencies that serve them. The qualitative approach will also provide human service administrators with data to plan their evaluation efforts. The findings from this study will be instrumental in supporting the development and administration of a survey to further explore service utilization and other components of service usage (e.g., types, amount, satisfaction, and social supports).

Authors' notes: This research was supported by a grant from the Faculty Research Fund, George Warren Brown School of Social Work, Washington University. This paper Is based on a presentation given at the 45th Annual Program Meeting of The Council on Social Work Education, in San Francisco, CA, March 1999.

The authors would like to thank Thuy Bigham, MSW, and Maria Mungula-Wellman, MSW, for their support on this project Their assistance In the recruitment of participants and conducting the focus group was instrumental in the completion of this project.

Original manuscript recieved: September 16, 1999

Revised: September 18, 2000

Accepted: September 28, 2000

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James Herbert Williams is associate professor, George Warren Brown School of Social Work Washington University, Campus Box 1196, St Louis, MO 63130, e-mail:jherbert@gwbmail.wustl.edu, Robert Pierce is associate professor, George Warren Brown School of Social Work Washington University, Campus Box 1196, St Louis, MO 63130, Nioka S. Young is program associate, Economic Development Unit The Ford Foundation, 320 East 23rd Street, New York NY, 10038, and Richard A. Van Dorn is a doctoral student School of Social Work University of North Carolina-Chapel Hill, Tate-Turner-Kuralt Building, CB# 3550, 301 Pittsboro Street Chapel Hill, NC 27599-3550.

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