Cultural Competency in Peer-Run Programs: Results of a Web Survey and Implications for Future Practice

Cultural Competency in Peer-Run Programs: Results of a Web Survey and Implications for Future Practice

Jessica A. Jonikas University of Illinois at Chicago

Stephen Kiosk National Alliance on Mental Illness, Support, Technical Assistance, and

Resources Center, Arlington, VA

Dennis D. Grey and Marie M. Hamilton

University of Illinois at Chicago

James McNulty Depression and Bipolar Support

Alliance, Chicago, IL

Judith A. Cook University of Illinois at Chicago

Acknowledgements: This project was funded by the U.S. Department of Education, National Institute on Disability and Rehabilitation Research, and the Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, under Cooperative Agreement H133B050003B. The project was also funded by grant number #sm056675 (via the NAMI Star Center) from SAMHSA. The views expressed do not reflect the policy or position of any Federal agency.

Objective: The study explored perceptions of adults with psychiatric disabilities regarding cultural competency of peer-run mental health support groups and pro- grams. Methods: Web survey respondents were recruited via mental health list- servs, web sites, newsletters, emails, and word of mouth. A total of 527 peers were surveyed about cultural competency barriers facing peer-run programs; com- mon reasons for not using peer services; and strategies to engage diverse com- munities. Results: Both multicultural and Caucasian respondents agreed that lack of funding and staff education about diversity were barriers to cultural competen- cy in peer programs. Multicultural respondents were more likely than whites to feel that both the recognition of the need for and interest in attending cultural competency training is lacking in peer programs, as well as information about the diverse composition of peer program memberships. Among those who had never participated in peer support, people of color were more likely than whites to endorse feeling they would not belong and believing their languages would not be spoken in peer programs. Whites, on the other hand, were more likely to cite a preference for professional over peer support, while nearly half of both groups indicated that the main reason for non-attendance is a lack of knowledge about peer programs. Qualitative results highlighted successful outreach and engage- ment strategies. Conclusions: Study findings informed development of a cultural competency tool that was pilot-tested among peer-run programs. Given the importance of peer support in recovery, these findings suggest the need for additional research on cultural competency in peer programs.

Keywords: peer support, cultural competence, diversity, self-help groups

Introduction

During the past twenty years, land- mark legislation and several influential reports have promoted meaningful community participation and attain- ment of a fulfilling life for people with disabilities. Within this context, recov- ery and self-determination have in- creasingly been promoted as the

guiding vision for transformed mental health services and systems (Anthony, 1993; Cook & Jonikas, 2002; Davidson, Tondora & O’Connell, 2007; Deegan, 1988; Jacobson & Curtis, 2000; Onken et al., 2007). This trend is bolstered by the growing emphasis on the value of peer support and mutual self-help as both alternatives and complements to traditional services, with one study showing nearly 535,000 users of con-

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2010, Volume 34, No. 2, 121–129 Copyright 2010 Trustees of Boston University

DOI: 10.2975/34.2.2010.121.129

special section

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sumer-operated programs in the year surveyed (Goldstrom et al., 2005). In spite of these promising develop- ments, however, disparities continue to exist between Caucasians and peo- ple of color regarding access to and quality of mental health care (US DHHS, 2001). Additionally, although multicultural individuals use self-help services and peer support (US DHHS, Office of Applied Studies [OAS], 2009), little research has been published to date on how peer program member- ship feels about and manages their own and others’ diversity within the context of mutual support. Therefore, this article describes a national web survey of adults with psychiatric dis- abilities to assess their views on cultur- al competency within mental health self-help groups and peer-run pro- grams. Described are the survey, pre- liminary quantitative and qualitative results, survey limitations, and implications for future research and programming.

Literature Review

Mental Health Mutual Support. For many decades, people with psychiatric disabilities have come together to offer one another practical, social, and emo- tional support, as well as a vision of hope and recovery (Campbell, 2005; Chamberlin, Rogers & Ellison, 1995; Cook & Jonikas, 2002; Davidson et al., 1999). Peer support has been defined as giving and receiving help based on respect, shared responsibility, and mu- tual agreement of what is helpful (Mead, Hilton & Curtis, 2001), and is used as both a complement to and a supplement for traditional mental health services (Goldstrom et al., 2005). Consumer-operated programs, or those managed, staffed, attended, and evaluated entirely by people with psychiatric disabilities (Swarbrick, 2007; Van Tosh, Ralph & Campbell, 2000), have gained momentum through the years as an empowering

likely than whites to delay or avoid seeking traditional mental health treat- ment (Kessler et al., 1996; Sussman, Robins & Earls, 1987; Zhang, Snowden & Sue, 1998).

There appear to be many reasons for the tendency to avoid Western treat- ment, including cultural variation in how psychiatric distress and help- seeking are viewed, discouragement of the sharing of personal problems out- side of one’s family, lack of linguistic competence in many mental health set- tings, and enduring lack of diversity in the mental health workforce (Cook, Razzano & Jonikas, 2009). The stigma that surrounds having a diagnosis of mental illness also can inhibit multicul- tural individuals’ willingness to access and engage in services (U.S. DHHS, 2001). As a result, many experts have called for the development of cultural competency within behavioral health care systems, which would require providers and supporters to exhibit the knowledge, attitudes, and skills neces- sary to help people from many diverse backgrounds achieve recovery (Whaley & Davis, 2007). When systems become culturally responsive, services and sup- ports will be tailored toward people’s unique backgrounds, thereby facilitat- ing access, engagement, service reten- tion, and positive recovery outcomes across cultures (Sue & Torino, 2005).

Certainly, peer services are included in this call for cultural competency and, as demonstrated by the National Survey on Drug Use and Health, multi- cultural individuals who have received traditional treatment during the past year participate in mutual support groups and peer programs at rates generally greater than that of their white counterparts, with the exception of Asian Americans (US DHHS, OAS, 2009). Specifically, when considering people surveyed who received both past year traditional treatment and

option for both the givers and receivers of care (Corrigan, 2006; Rappaport, Resichl & Zimmerman, 1992; Segal, Silverman & Temkin, 1993).

A growing body of literature addresses the positive outcomes of peer support services, both for the providers and re- cipients. As described by Solomon (2004), a number of studies have shown that, as a result of offering oth- ers mutual support, peer providers ex- perience reduced reliance on psychiatric hospitalization, and in- creased self-esteem, confidence, em- powerment, hope, and quality of life, as well as enhanced social support, productivity, and career skills. Studies also reveal many similar benefits of peer services to recipients, although findings must be interpreted with cau- tion due to the less rigorous designs of most studies to date. Specifically, peo- ple who receive peer support are re- ported to have reduced psychiatric symptoms and psychiatric hospitaliza- tions, improved social functioning, en- hanced social support, recovery, hope, self-esteem, and quality of life, and less formal service utilization (Campbell, 2005; Cook, Copeland et al., 2009; Salzer & Shear, 2002).

Mental Health Treatment Disparities. Widespread disparities between multi- cultural groups and their white coun- terparts persist in mental health treatment settings. In general, people of color have less access to psychiatric services (due to factors such as lack of convenient locations; lack of insur- ance), are less likely to remain en- gaged in treatment, are more likely to suffer from improper dosing of psychi- atric medications, and their psychiatric care is less likely to be based on cur- rent standards of evidence than that of their white counterparts (Atdjian & Vega, 2005; McGuire & Miranda, 2008). Moreover, it has been shown that multicultural individuals are more

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past year peer support, 8.1% were black or African American, 7.9% were Hispanic/Latino, 5.1% were white, 3.8% were Asian American, and 5.6% were two or more races.

The purpose of the present study was to explore peers’ perceptions of cultur- al competency at both the peer provider and the organizational levels within peer-run programs/groups. Perceptions of multicultural and white peers who do and do not attend peer- run programs were obtained. For this study, the definition of cultural compe- tency was comprised of the standard components: 1) attitudes towards race, ethnicity, and culture; 2) knowledge about cultures that differ from one’s own; and 3) skills to interact and com- municate effectively across cultures (Whaley & Davis, 2007). At the provider level, cultural competency is demon- strated when staff (in this case, peer providers) have the attitudes, knowl- edge, and skills to interact comfortably and effectively with clients (in this case peer members) from a variety of cultur- al backgrounds. At the organizational level, cultural competency is demon- strated when programs develop a mis- sion statement, program policies, hiring practices/staffing patterns, and services or supports that promote cul- tural diversity and competence among the staff and clientele. The current study also explored perceptions of the cultural diversity of peer programs, de- fined as whether or not people from non-majority groups were present and active in these programs.

This research was one component of a project run collaboratively by the University of Illinois at Chicago National Research and Training Center (UIC NRTC) and the Support, Technical Assistance, and Resources (STAR) Center at the National Alliance on Mental Illness. Research questions in- cluded the following. First, what com-

mon cultural competency barriers are reported by those attending peer pro- grams/groups and do perceptions of these vary by race/ethnicity? Second, what reasons do peers have for not at- tending peer-run programs and do these vary by race/ethnicity? Third, what challenges and successes have peers had in promoting cultural diversity and competency within peer programs?

Methods

Sampling Strategy. A convenience sam- ple of adults self-identifying as having had mental health problems was ob- tained through national outreach. Announcements in both English and Spanish were posted to a dozen mental health listservs and web sites, with special emphasis on sites operated by mental health peers and people of color. Flyers were distributed at nation- al conferences, especially peer confer- ences, and the study was advertised in relevant newsletters. The authors also used their national networks of peer leaders and cultural competency ex- perts to distribute the announcement at local/state meetings and to peer-run programs directly. The announcement explained the purpose of the survey, described eligible respondents, and provided a secure web address where people could complete the survey on- line with full anonymity. Contact infor- mation for the UIC NRTC was provided for people who had questions or to re- quest a paper copy of the survey for those who did not have computer ac- cess or preferred to complete it by hand.

Sample. A total of 527 participants completed the survey. The majority (n=328, 62.2%) was Caucasian; 13.1% (n=69) were African American; 10.6% (n=56) Hispanic/Latino, 4.9% (n=26) Native American/Alaska Native; 1.5% (n=8) Asian/Pacific Islander; 3.6%

(n=19) multi-racial/ethnic; and 4.0% (n=21) “other.” At the beginning of the survey, respondents were asked to identify themselves as belonging to one of four groups: 1) racially/ethnical- ly diverse people who had participated in peer-run groups or programs (n=119); 2) racially/ethnically diverse people who had never participated in peer support (n=57); 3) white people who had participated in peer support (n=235); and 4) white people who had never participated in peer support (n=116). While 62.2% said they were Caucasian when responding to the question about their race/ethnicity, 66.7% classified themselves as “non- minority” when responding to the four group question. This common inconsis- tency in self-reported ethnicity has been documented in other surveys, in- cluding the U.S. Census (McKenney & Bennett, 1994). For the remainder of this article, participants are classified according to the four group question. There were no significant differences between peer support participants and non-participants in terms of their racial or ethnic background. As shown in Table 1, respondents were primarily women, their average age was early to mid-forties, the large majority had a high school education, and most lived in urban or suburban areas. Half or more were employed, and fairly low proportions reported incomes of less than $10,000 per year.

Web Survey Instrument. In developing the survey, common themes and fea- tures across published cultural assess- ments were identified (for example, Association of University Centers on Disabilities, 2004; National Center on Cultural Competence, n.d.; Siegel, Haugland & Chambers, 2004; US DHHS, HRSA, 2002). Additionally, lis- tening sessions and individual inter- views with peers at two national conferences were conducted to ascer- tain cultural themes unique to peer

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programs. The resulting survey was comprised of 4 sections. First was a se- ries of check-off items for peer support attendees related to problems their programs may have faced in meeting the needs of multicultural people. Sample items included: “The program or group lacked education about the needs and beliefs of people from di- verse cultures”; and “The program or group lacked translation services for people who speak different lan- guages.” Second was a series of open- ended questions for peer support attendees to describe their own experi- ences with cultural competency barri- ers, peer program success stories in supporting diversity, awards for diver- sity that their program may have re- ceived, and strategies their peer programs used to engage and support diverse membership. The third survey section contained a series of check-off items describing reasons for not at- tending peer services, such as “Peer- run programs don’t respect my race, ethnicity, or culture” or “I don’t know of any peer-run programs or groups.” The survey concluded with a set of demographic questions for all respondents.

encryption. Neither Internet Protocol (IP) addresses linked to the device used to complete the survey nor any other identifying information about the respondents was collected. The survey was posted from January 2008 to April 2009. All research procedures were ap- proved by the UIC Institutional Review Board.

Use of a Web-Based Format. Careful consideration was given to the best for- mat for a survey of diversity and cultur- al competency (a sensitive topic for many reasons) among self-help and peer programs nationally. Although a detailed discussion of the advantages and disadvantages of interactive web- based surveying is beyond the scope of this paper, some of the benefits of a web format include: broader and more affordable national access to survey re- spondents; the documented ability to engage difficult-to-reach participants with computer-mediated surveys, es- pecially those who do not wish to iden- tify themselves or their disability to researchers (Braithwaite, Waldron & Finn, 1999; Cook et al., 2007); ability to ensure strict anonymity, especially when addressing a highly sensitive topic; reduced pressure on respon- dents to provide socially desirable an- swers; and the ease and accuracy of automated data collection (Wright, 2005). Some of the drawbacks to the web format include: concerns about representativeness of and self-selec- tion bias in the sample; and the validi- ty and accuracy of the data collected. Since these same drawbacks can be present in mail and in-person surveys (Wright, 2005), a web-based format was chosen for the present study.

Data Analysis

Frequency distributions and descrip- tive statistics were computed for all study variables. Chi-square analysis was used to determine associations between respondents’ minority status

Web Survey Procedures. The instru- ment was written at the 7th grade read- ing level to be inclusive of individuals with lower literacy. Programming in- volved automated skip patterns, imme- diate range and error checks, forced responses to applicable items, a series of open-ended items, and respondent- generated data submission. The survey was available to anyone with Internet access (or to those who requested paper copies from the UIC NRTC). Upon visiting the survey web site, peers were provided with the choice of completing the survey in English or Spanish. They were then taken to an overview of the survey and instructions for completion. The survey began with a set of ques- tions for respondents to identify whether or not they had mental health problems, were white or a person of color, and had ever attended mental health self-help or a peer-run program. Skip patterns then led them to a set of survey questions that took 10 to 20 minutes to complete. At the end, re- spondents were thanked for their time and encouraged to pass the web sur- vey address on to a peer. The web site and secure database were hosted by Vovici, and all transmitted data were encoded using Secure Sockets Layer

Table 1–Demographic Characteristics of Survey Respondents

Racially/Ethnically Diverse Caucasian

Participant Non-participant Participant Non-participant

N 119 57 235 116

Female 68.9% 80.7% 73.2% 80.2%

Avg Age*** 45.7 40.4 48.8 40.3

HS+ Educ* 93.3% 96.5% 98.7% 97.4%

Working 50.4% 59.6% 57.8% 54.3%

Urban** 51.3% 36.8% 35.3% 26.7%

Suburban* 32.8% 42.1% 43.0% 52.6%

Rural 16.0% 21.1% 21.7% 20.7%

<10K/Year 24.4% 12.3% 16.6% 15.5%

***=p<.001, **=p<.01, *=p<.05

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(20% vs. 10%), and feeling they al- ready had adequate levels of support in their lives (18% vs. 9%). A higher proportion of racially/ethnically di- verse respondents were concerned that they would not feel at home in peer-run programs (28% vs. 16%). However, these differences were not statistically significant and only trended toward significance.

Cultural Competency Barriers Perceived by Peer Support Participants. Respondents who said they attended peer-run programs were asked to se- lect from a list of barriers to cultural competency that are commonly en- countered by social service organiza- tions. As shown in Table 3, there was a high level of agreement between multi- cultural and white respondents about common challenges in this area. Among the three most often selected barriers by each group there was agreement on two: lack of funding to reach out to diverse communities, and lack of information about the program members’ cultures. On the other hand, racially/ethnically diverse participants were more likely than white ones to feel that peer staff was unwilling to learn about different cultures, that staff failed to recognize their own need for

and different reasons for not attending peer programs, and perceptions of multicultural barriers in peer programs. In addition, respondents were asked to describe in their own words their reasons for not attending peer-run programs, and barriers to cultural com- petency in these programs. These writ- ten responses were analyzed using the method of Constant Comparative Analysis (Glaser & Strauss, 1967), in- volving coding each statement and then grouping them into similar con- cepts from which themes were derived.

Results

Differences by Race/Ethnicity and Peer Program Participation. As shown in Table 1, in both racially/ethnically di- verse and Caucasian groups, partici- pants in peer-run programs were significantly older than non-partici- pants. Participants were also more likely to live in urban areas, and less likely to reside in suburban areas than non-participants. Among racially/eth- nically diverse respondents only, peer- program participants had significantly less formal education than non-partici- pants. However, there were no signifi-

cant differences by gender, employ- ment status, or income status.

Differences in Reasons for Not Attending Peer-Run Programs. Those respondents who said they had never participated in peer-run programs were asked to select from a list of reasons for non-participation. As shown in Table 2, the most frequently cited rea- son for non-attendance was lack of knowledge about peer-run programs in their local area, endorsed by about half of both multicultural and white respon- dents. The next most frequently en- dorsed reasons were concern that they would not feel a sense of belonging, and preferring professional over peer- run programs. Multicultural respon- dents were also significantly more likely than Caucasians to be concerned that peer programs would not respect their race, culture, or ethnicity; and that their preferred language would not be spoken at peer programs. A signifi- cantly higher proportion of white re- spondents said they preferred professional over peer-run services as compared with racially/ethnically di- verse respondents (34% vs. 19%). Finally, higher proportions of white re- spondents reported feeling uncomfort- able with the idea of peer support

Table 2–Reasons for Not Attending Peer-Run Programs as Reported by Respondents Who Had Never Attended

Reason Caucasian Respondents Multicultural Respondents

N % N %

Don’t know of programs 53 46 29 51

Not open when convenient 13 11 9 16

Not comfortable with idea of peer-run programs† 23 20 6 10

Programs don’t respect race, ethnicity, culture** 1 1 6 10

My preferred language not spoken* 0 0 3 5

Don’t feel like I belong or I’m at home 19 16 16 28

Prefer getting help from professionals* 39 34 11 19

I already have all the support I need† 21 18 5 9

Don’t like seeking help outside family† 4 3 6 10

** p≤.01, * p≤.05, † p≤.10

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cultural competency training, and that staff lacked information about the di- verse cultures of their current member- ship. Finally, there was a trend toward a higher proportion of white partici- pants than multicultural ones reporting lack of bilingual staff as a barrier in their programs.

Qualitative Findings. The web survey allowed respondents to reflect upon the cultural competency of peer servic- es in their own words. Participants’ re- sponses reflected several themes, including struggles peer programs/groups have in being cultur- ally responsive, strategies that suc- cessfully engage multicultural groups, and things that would make peer sup- port non-attendees more likely to try a peer program. First, in terms of chal- lenges in being culturally competent, respondents reflected upon the lack of knowledge, attitudes, skills, and re- sources among their peer programs to effectively support multicultural peo- ple. These included lack of transporta- tion, lack of time to do effective outreach, and lack of written materials specific to racial, cultural, or ethnic minority groups.

Many respondents reflected on the shortage of training among peers to meet one another’s culture-specific needs. In some cases this was due to

to the African American community’s churches, pastors, and women’s groups to let them know about the pro- gram’s existence and what services were available.

A group of multicultural peers who had never attended peer programs offered ideas for what might encourage them to attend. One suggested strategy was to make sure the membership already included diversity so that new mem- bers encountered “…people who look like me, have similar lifestyles, values, and cultural beliefs.” Another sugges- tion was to tailor services for the needs of specific communities versus “…some ‘canned’ stuff from people way across the country.”

Finally, a small but noteworthy group of respondents reported that cultural competency was not an issue in their peer-run programs. One woman com- mented: “As a person of color and queer identified, there have been no problems.” Another explained, “I didn’t recognize anything lacking.”

Discussion and Implications

Discussion. A large body of literature suggests that community-based men- tal health programs face a number of barriers in promoting cultural compe- tency and diversity. This study support-

lack of experience with diverse groups, and not having cross-cultural training. In other cases, the problem was lack of awareness of the need for such training due to an emphasis on treating every- one alike, as in the following example.

[Everyone] was seen as “the same” and [they] did not know about how different cultural groups see/experience mental health issues.

Others felt that some peer programs/groups were not interested in developing cultural competency. As one respondent explained: “They didn’t see the importance in reaching out to culturally diverse groups.”

In spite of these problems, however, respondents also described positive strategies used by peer programs to engage diverse individuals. One such strategy involved inviting peers from diverse cultures to give presentations about their cultural backgrounds and encouraging their membership to ask questions. Another strategy was en- couraging people to “…Just sit down and talk to [people] and listen to the stories as well.”

Others suggested the importance of outreach and education through film, music, work groups, and team building exercises to get to know one another and “…how to walk in someone else’s shoes.” One program had reached out

Table 3–Problems of Peer-Run Programs in Meeting Multicultural Needs as Reported by Participants

Nature of Problems Caucasian Respondents Multicultural Respondents

N % N %

Lack of funding to reach out to diverse communities 116 49 61 51

Failure to recognize need for cultural competency training** 65 28 49 41

Program lacked information about current members’ cultures* 74 32 52 44

Lack of willingness to learn about staff/volunteers’ different cultures ** 38 16 35 29

Lack of staff who speak different languages† 121 52 50 42

** p≤.01, * p≤.05, † p≤.10

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grams, and whether and how commu- nity outreach may be effective in over- coming them, if so.

Implications for Development of the Field. Results of this survey, and the in- sights it generated, were used by staff at the UIC NRTC and NAMI STAR Center to develop an assessment tool, admin- istration manual, and accompanying resources for use by peer programs. The purpose of this tool, called Cultural Competency in Mental Health Peer-Run Programs and Self-Help Groups, is to assist peer-run programs seeking to assess their cultural competency and implement diversity action plans. The tool presents a user-friendly, simple set of procedures for programs to use in thinking about and then rating their groups or organizations in five key cul- tural competency domains, and then, in developing an Action Plan to en- hance their diversity. Based on web survey findings, the tool helps pro- grams to consider levels of cultural competency demonstrated in their poli- cies, staffing patterns, staff and mem- bership training programs, strategies for peer outreach and engagement, the services or supports offered, the pro- gram’s atmosphere, and its language capacity. The tool also includes numer- ous training and technical assistance resources for programs seeking to im- prove their cultural competency. Working collaboratively, UIC NRTC and STAR Center staff conducted a pilot-test working with nine peer-run programs around the U.S. that used the tool to assess their programs, create Action Plans, and then, implement those plans and monitor outcomes over a 3- month period. Results revealed that the tool was user-friendly and easy to use, and that the assessment process led to the development of plans with attainable short-term program goals to achieve cultural competency. Based on the experiences and feedback of the leaders and membership in our pilot-

ed our expectation that respondents would report that peer programs also struggle to effectively outreach and serve diverse communities, as well as our anticipation that they would en- counter challenges unique to their par- ticular setting. In our survey, current and former users of peer programs identified competency barriers that are faced by many community-based men- tal health programs, including financial constraints; lack of language capacity; and shortage of materials, models, and evidence about how to best support di- verse groups (U.S. DHHS 1999; 2001). In whatever treatment or supportive settings these barriers are experi- enced, broad initiatives are necessary in order to build culturally competent traditional and peer-run mental health programs (U.S. DHHS, 2001). Nonetheless, as highlighted by our sur- vey results, improving cultural compe- tency at the program level does not necessarily have to be costly or large- scale in order to have an impact on the people served.

Current and former users of mutual support programs also identified is- sues that may be unique to peer pro- grams. For example, given the informal structure typical of mutual support pro- grams (Swarbrick, 2007), it is not sur- prising that survey respondents felt the programs lacked sufficient cultural competency training, as well as the re- sources to secure such training. Although more research is needed on the presence and impact of inadequate cultural competency training, mutual support programs may find it beneficial to tap into existing community re- sources and networks to secure cultur- al education. Additionally, that peer programs struggle to develop an orga- nizational focus on diversity (such as via committees or formal initiatives) also would be expected given their re- liance on a small staff often fully or par- tially comprised of volunteers. Mutual

support programs can address this need by first identifying one or two in- dividuals interested in focusing on di- versity issues, and then, expanding as their efforts are met with success. Finally, our survey respondents report- ed that some peer staff appeared un- able or unwilling to learn more about diverse cultures, which again might re- flect staff largely comprised of volun- teers who have not had access to formal multicultural education. Therefore, programs might start by of- fering approachable, accessible cultur- al education through cultural potlucks, cultural music festivals, or cultural reading/film clubs.

This study also provided instructive in- sights into why respondents did not at- tend peer support programs/groups. These reasons included not knowing of peer programs in their local area, feel- ing uncomfortable with the idea of peer support, not believing that the program would respect their diversity, and not expecting to feel a sense of belonging. This suggests that mutual support pro- grams might find it beneficial to en- gage with diverse community leaders to learn more about the specific beliefs and needs of various cultural groups, while simultaneously providing educa- tion about the advantages of peer sup- port. Mutual support programs and groups also might consider whether their environments are hospitable to people from diverse cultures, and iden- tify ways to help people feel welcomed through the artwork displayed, the food served, the calendar of celebrated holidays, and so forth. It should be noted, however, that these negative perceptions of peer-run programs/groups were held by respon- dents who had not participated in them, perhaps shedding light more on perceived than on actual hindrances. Further research is needed to explore whether or not these barriers are wide- ly present among mutual support pro-

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Psychiatric Rehabilitation Journal Cultural Competency in Peer-Run Programs

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test programs, the tool was refined and is now ready for distribution by con- tacting staff of the UIC NRTC http://www.cmhsrp.uic.edu/nrtc/star- center.asp or the NAMI STAR Center http://www.consumerstar.org

Implications for Research. Our results set the stage for more rigorous re- search on the strengths and challenges that mental health peer programs face in developing and maintaining cultural competency. Future research might survey a broader population of both users and non-users of peer-run servic- es, to explore these issues in greater depth. Other studies might address the efficacy of the assessment tool in a more rigorous design, involving the use of comparison groups and a longer follow-up period.

Study Limitations. Given that the re- sults are based on a non-random con- venience sample of respondents with access to the Internet, as well as the preponderance of women, those with high school or greater education, and Caucasians among the sample, caution must be used when interpreting these results since they are not representa- tive of all mental health peer pro- grams/groups or the people who staff/use them. Additionally, the sur- vey was developed for this study (given the absence of mental health peer pro- gram cultural competency surveys), and thus, was not psychometrically val- idated. Nonetheless, it should be noted that, because the cultural com- petency practices featured in the sur- vey are endorsed by many diversity experts, the items had high face validi- ty. Another weakness is the self-report nature of the data collected, and the fact that we cannot verify their accura- cy nor that the people completing the survey accurately represented them- selves. Additionally, due to the anonymity of the survey, we also can- not guarantee that the same respon-

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