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From “soul calling” to calling a therapist: meeting the mental health needs of Hmong youth through the integration of spiritual healing, culturally responsive practice and technology

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From “soul calling” to calling a therapist: meeting the mental health needs of Hmong youth through the integration of spiritual healing, culturally responsive practice and technology

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Content Running head: HMONG YOUTH MENTAL HEAL TH
From "soul calling" to calling a therapist: Meeting the mental health needs of Hmong youth
through the integration of spiritual healing, culturally responsive practice and technology
by
Kimiko Vang
Capstone Project for
Doctor of Social Work
Suzanne Dworak-Peck School of Social Work
University of Southern California
Dr. Annalisa Emile
SOWK 722
August 2020
1
HMONG YOUTH MENTAL HEALTH
Dedication
To the many great Hmong women who have paved the way for me to have the opportunity to
boldly go into the world and take risks to live a life that is my own. I stand on your shoulders
today, as I wish for future generations to stand on mine tomorrow.
Acknowledgement
With gratitude, I would like to thank my husband, Pao, and son, Estin, for your patience and
support during the completion of this capstone project. A heartfelt appreciation to my parents,
Aline and Simon, for your continued support of my educational endeavors. Much gratitude to
my mother and father in-law, Xee and CherJeng, for your care and support. I am extremely
grateful to have an entire village of family, friends and colleagues who provided encouragement
during this process. I especially would like to thank Kit Chang, May-Ci Xiong and Palee Moua
for the clinical and Hmong cultural expertise you have provided me during the development of
this capstone. Finally, I am indebted to my DSW professors and cohort who have provided
unconditional support and encouragement for the successful completion of this capstone project.
2
HMONG YOUTH MENTAL HEALTH 3
Table of Contents
1. Executive Summary 5
2. Conceptual Framework 10
a. Grand Challenge 10
b. Statement of the Problem 11
C. Literature Review 12
d. Applied Implication 16
e. Innovations in the Topical Area 16
f. Theory of Change and Logic Model 17
3. Problems of Practice and Innovation 19
a. Innovation and Contribution to the Grand Challenge 19
b. Innovative Solution 19
C. Multiple Stakeholder Perspectives of the Problem 21
d. Analysis of the Broader Landscape 24
e. Consideration of Existing Opportunities for Innovation 25
f. Project's Likelihood of Success 26
4. Project Structure, Methodology, and Action Component 27
a. Prototype 27
b. Analysis of the Market 28
C. Project Implementation 28
d. Financial Plans 32
e. Methods for Assessment of Impact 34
f. Stakeholder Involvement 36
HMONG YOUTH MENTAL HEALTH 4
g. Communications Plan 36
h. Ethical and Diversity Considerations 37
5. Conclusions, Actions, and Implications 37
a. Implications 37
b. Future Decisions and Actions 38
C. Limitations and Risks 39
d. Conclusion 39
6. References 41
7. Appendices
a. Appendix A: Logic Model 49
b. Appendix B: Mental Health Training for Hmong Shaman 50
Curriculum
C. Appendix C: Understanding Hmong Cultural and Spiritual 54
Beliefs: A Training for Mental Health Providers Training
Curriculum
d. Appendix D: Hmong Mental Health Providers Directory 58
e. Appendix E: Storyboard 59
f. Appendix F: Exploration, Preparation, Implementation, 63
Sustainment (EPIS) Chart
g. Appendix G: Gannt Chart 64
h. Appendix H: Start-Up Budget 65
1. Appendix I: Pre/Post Survey for Shamans 66
J.
Appendix J: Infographics 67
HMONG YOUTH MENTAL HEALTH 5
Executive Summary
The United States is a nation of immigrants, a mosaic of peoples with unique cultural and
language heritage that, with each new generation of fresh perspective and ideas landing on its
shores, reinvigorates our economic and social landscape. While this country' s diversity certainly
constitutes one of its strengths, the complex systems put in place to meet the needs of its
constituency have remained unpliable in their approach to serving ethnic minority communities.
McCarthy (2001) found that the mental health system has failed ethnic minorities in providing
them with proper access and culturally competent services. This has resulted in disparities
among racial and ethnic populations such as Hmong youth who, as an Asian American ethnic
group, experience a high prevalence of untreated mental health issues (Ferris, Hane & Wagner,
2014).
The Grand Challenge of Ensure the Healthy Development for All Youth demands
solutions for intractable problems such as the pervasive, unaddressed, and often time invisible,
mental health needs of Hmong youth. Asian Americans, including Hmong youth, have the most
mental health needs nationally among all racial groups, and yet are the most under-represented in
the children's mental health system (Ferris et al., 2014). This is especially concerning when
research has found Hmong youth to report a higher rate of depressive symptoms, self-harm, and
suicidal ideation than the average youth (Minnesota State Epidemiological Outcomes
Workgroup, 2017). Those engaged in services are forced to do so when unmanageable
symptoms become acute and the youth find themselves in crisis (Collier, Moua & Munger,
2012). This has led to a high rate of suicides and unaddressed mental illness (Ellis, 2002; Thao,
Leite, & Atella, 2010).
HMONG YOUTH MENTAL HEALTH 6
For centuries, the Hmong have maintained an understanding of health and illness that is
associated with spiritual health (Moua, 2019). The concept of mental health, as the Western
world understands it, does not exist in the Hmong culture. Mental health symptoms and
disorders are viewed as a spiritual incongruence and an issue that a shaman is able to address
through a spiritual healing ceremony. The majority of Hmong in the U.S. still consult with
shamans who hold ceremonies such as a "soul calling" to heal a person. Research, interviews
with families and mental health providers, and journey mapping reveal that many Hmong
families consult with a shaman when their child struggles with a mental illness, sometimes for
years, until it is necessary to bring the child to the mental health system as a last resort (Thao et
al., 2010; Collier et al., 2012). The mental health stigma that exists within the Hmong
community and a mental health system that does not offer linguistically appropriate and
culturally competent services contribute to this intractable problem. This situation has left many
Hmong youth suffering from mental illness with no proper resources and interventions. For
Hmong youth under the age of 18 who constitute 40% of an estimated 296,890 Hmong
Americans, a solution to this intractable problem could mean the difference between life and
early death (Hmong National Development, 2013).
KaShia, which means "at peace" in Hmong, is the non-profit organization that will
implement the capstone project. The innovation consists of a culturally responsive approach to
connecting Hmong youth and their family to mental health services through support from
shamans, as well as the use of telehealth for more accessible services provided by bilingual and
bi cultural clinicians. The innovation is composed of two interconnected program models that are
culturally sanctioned and that address Hmong youth's barriers to access and utilization of
services. The first program model provides a mental health training to shamans to educate them
HMONG YOUTH MENTAL HEALTH 7
on Western mental health, benefits of mental health services and resources. This program model
seeks to combat mental health stigma and provides an opportunity for an early intervention with
shamans referring youth to services, while also preserving and supporting cultural and spiritual
beliefs. The second program model provides Hmong youth and families virtual access to
bilingual and bicultural clinicians through the use of Telehealth, increasing access and utilization
of mental health services for Hmong youth regardless of where they may be located. Together,
the program models create an early intervention that is seamless and scalable for Hmong youth
to receive needed mental health services within a culturally sanctioned milieu. The integration
of cultural and spiritual beliefs along with components that address the primary issues of the
intractable problem results in an innovation that will disrupt the social norms of mental health
stigma and a "one size fit all" mental health system. Currently, most mental health programs
targeted towards the Hmong community only serve adults. The very few programs for Hmong
youth are school based, limiting the number of youth who can be served. This innovation, set in
the disruption and sustaining arenas, will facilitate emerging new behaviors creating a
breakthrough that will increase access to mental health services for Hmong youth, and build a
better culturally relevant model for utilization of services for this particular population.
The pilot project will offer the mental health training to shamans who will be attending
the Spiritual Healer training at Dignity Health Mercy Medical Center, a nationally recognized
cross-cultural Western health care training for Hmong shamans in Merced, California. The
short-term outcome, based on a pre and post-survey, is for 80% of participant shamans to
increase their understanding of mental health concepts, diagnoses, treatment and benefits of
services by the end of the training session. The long-term outcome is for 80% of Hmong
shamans to be willing to refer youth to mental health services one year post completion of the
HMONG YOUTH MENTAL HEALTH
training. The short-term outcome objective for the telehealth mental health services is that 70%
of Hmong youth will experience a decrease in mental illness symptoms by the end of the
treatment period. The long-term outcome is to increase utilization of mental health services
among Hmong youth into services by 25% by the 5
th
year of the program. A summative
evaluation using a quasi-experimental design will be conducted to determine whether the
programs have successfully met their intended goals and objectives to guide decisions to
maintain, expand or scale programs.
8
Using the Exploration, Preparation, Implementation and Sustainment (EPIS) model, steps
have been identified to leverage existing resources and successfully move the capstone project to
fruition. These includes comprehensive analysis of the market, political climate, development of
the organization including hiring of staff, securing and management of funding, launch of a
marketing plan, program evaluation and continuous quality improvement. A start-up budget for
the pilot year will be presented, along with a budget narrative. It is anticipated that for this start
up budget, funding will be primarily secured from Mental Health Services Act (MHSA),
foundation grants, MediCal and private insurance reimbursement, and fundraising. During the
COVID-19 pandemic which limits in-person interventions, the pilot mental health training for
shamans may be offered online through social media groups such as the "neeb of the 21
st
Century" or "shamans of the 21
st
Century." The telehealth component will not be affected and
might, actually, be better accepted as the world has slowly switched to a virtual interface for
everything from school, work and primary care physician' s visits.
The prototype for this innovation consists of a storyboard, a mental health curriculum for
shamans, a Hmong cultural and spiritual curriculum for mental health providers, and a directory
of Hmong mental health providers. The storyboard helps stakeholders understand how the
HMONG YOUTH MENTAL HEALTH 9
innovation will work from the perspective of a Hmong family who is seeking help for their child.
It illustrates a journey mapping that leverages the new opportunities offered by the innovation
and demonstrates the benefits of engaging in services. The mental health curriculum will help
shamans have a better understanding of mental health, mental illness and the benefits of
treatment. It includes information and approaches to educating shamans about Western mental
health, mental illness, diagnoses and treatment in a manner that is culturally competent. The
Hmong cultural and spiritual curriculum will provide the necessary cultural and spiritual
foundational knowledge to mental health providers for a culturally responsive practice. It
supports the need for clinicians to partner with shamans whenever possible to provide a more
effective holistic treatment. Together, the curricula support cross-cultural practice. The Hmong
mental health providers directory will be provided to shamans as an incentive for completing the
training and as a resource to make referrals. All components of the prototype are ready to be
shared with stakeholders. Additionally, a robust communication plan consisting of an
infographic detailing the problem and solution, and a series of two short films introducing the
audience to the target population, problem and innovation will be shared on social media
platforms and the KaShia website. The summative evaluation of the innovation will be shared
through conference presentations and published articles.
KaShia is an innovative solution to a problem, long ignored, that will disrupt the social
norms of mental health stigma and a rigid mental health system to redefine how and where
Hmong youth access and utilize mental health services. This innovation also has the potential to
help other underserved populations access mental health services using the same principles of
culturally responsive and language appropriate practices, and a technology-aided scalable
approach.
HMONG YOUTH MENTAL HEALTH
Conceptual Framework
Grand Challenge
The Grand Challenge of Ensure the Healthy Development for All Youth is a call for
action to find solutions to social ills that threaten the well-being of youth and that, ultimately,
could lead to their premature death (Jenson & Hawkins, 2018). Youth mental health is an area
within this Grand Challenge that has been emphasized due to staggering data demonstrating an
increasing number of youth struggling with mental illness, along with the exorbitant financial
and human cost to society (Youth, n.d.). Jenson and Hawkins (2018) indicate that two of the
goals of this Grand Challenge is to decrease the incidence and prevalence of behavioral health
and the racial disparities found in this problem by 20% within the next decade. Labeled an
epidemic, the current youth mental health problem is one that is connected to complex risk
factors such as poverty, high crime rates, poor health and substance abuse (Annie E. Casey
Foundation, 2018). At an annual cost of $247 billion, one in every four to five youth suffers
from mental illness such as anxiety, depressive disorder, and attention deficit hyperactivity
disorder (Youth, n.d; Allegria, Vallas & Pumariega, 2010). Within this Grand Challenge,
minority populations such as Hmong youth continue to be grossly underserved, putting them at
further risk for devastating psychological issues (Thao et al., 2010).
Mental health Issues Among Hmong Youth
10
With a population of 296,890, the Hmong grew by 40% between 2000 and 2010 making
it one of the fastest growing communities in the country, with major hubs in California,
Minnesota and Wisconsin (U.S. Census, 2016; Southeast Asia Resource Action Center, 2020;
Hmong National Development, 2013). In 2002, the Fresno Bee reported a disproportionately
high rate of suicide for Hmong youth in the county. While they represented only 3% of the
HMONG YOUTH MENTAL HEALTH 11
adolescent population, Hmong youth had committed more than 50% of all teen suicides in the
county (Ellis, 2002). Additionally, research found a higher rate ofreported suicidal ideation for
Hmong youth at 12.7% compared to 11.8% of the average youth. An estimated 18% of Hmong
youth reported self-harm compared to 15.6% of youth. Furthermore, about 29% of Hmong
youth reported depressive symptoms compared to 22% of the average youth (Minnesota State
Epidemiological Outcomes Workgroup, 2017).
Studies have found that Asian American youth, including Hmong youth, are the most
underrepresented in our children's mental health system in spite of having the most unmet needs
(Ferris et al., 2014). Studies confirmed that very few Hmong youth are engaged in mental health
services (Allegria et al., 2010; Thao et al., 2010). In Merced County, home to one of the largest
Hmong communities in the U.S. where the Hmong represent the majority of the Asian American
population, the County Behavioral Health and Recovery Department served 0. 7 % of all eligible
Asian American youth (Hmong National Development, 2013; Merced County Behavioral Health
and Recovery Services, 2017). In Fiscal Year 2018-2019, only 11 Hmong youth out of a
community of 7,254 were served at the Department (B. Hoskins, personal communication,
February 19, 2019; Hmong National Development, 2013). In addition, studies confirmed that
the usual point of entry into mental health services for Hmong youth occurs when their mental
health symptoms have become severe and parents have exhausted other options (Thao et al.,
2010; Collier et al., 2012).
Statement of the Problem
At the core of Hmong youth's high mental health needs, inadequate access to and
underutilization of mental health services lies a mental health system and clinical practice that
have been unresponsive to the specific cultural and language needs of this population. A
HMONG YOUTH MENTAL HEALTH 12
complex nexus of cultural and language factors, mental health stigma and inequity in the mental
health system contribute to this intractable problem. With over 40% of its population under the
age of 18, this young population is at high risk of further social ills if this problem remains
unaddressed (Southeast Asia Resource Action Center, 2020). This intractable problem will
exponentially affect Hmong youth' s ability to live a healthy life, thus affecting the future of the
Hmong community and society. Addressing this problem requires a thoughtful innovation that
leverages culturally defined social norms as strengths and introduces a deviant intervention that
supports new behaviors for a healthy future for Hmong youth.
Literature Review
Hmong Historical and Cultural Background. From a systems theory perspective, the
experiences of Hmong youth do not occur in a vacuum as they are influenced by their families'
cultural and spiritual worldviews, acculturation and biculturalism challenges, socioeconomic
situation and experienced historical trauma. Systems theory highlights the inherent connection
and interdependency between different subsystems within the same system, affecting each
other's outcome (Michaelakis & Schirmer, 2014; Moeller, 2006). It is through this theoretical
perspective that the following information is presented for a fuller understanding of the context
of the problem.
War and Refugee Trauma. The Hmong are an ethnic group from Laos who came to the
United States over 40 years ago in the aftermath of the American Central Intelligence Agency
(CIA) involved Secret War there (Hamilton-Merritt, 1993). The Hmong who fought alongside
Americans lost about 30% of its population to the conflict (Pfaff, 1995). When the war ended,
the Hmong endured a perilous and traumatic journey to reach Thailand for safety (Donnelly,
1997). Westermeyer (1988) found that many Hmong refugees suffered from psychological
HMONG YOUTH MENTAL HEALTH 13
distress caused by the war and traumatic escape and that the prevalence of mental health issues is
at least twice as high in Hmong adults as in the mainstream society, especially with diagnoses
such as major depression, post-traumatic stress disorder, and anxiety disorder. Thao (2019)
found that years of surviving atrocities of war and experiencing life and death situations for this
first generation of Hmong have created a historic oppression mindset, resulting in current mental
health disorders and social issues. This provides a significant context to understanding today's
Hmong youth's mental health issues. Sangalang and Vang (2017) found that Hmong youth's
mental health is impacted by intergenerational trauma experienced by their parents and
grandparents long before they were even born.
Socioeconomic Context. While some Hmong individuals have achieved professional and
personal success, the majority of Hmong still struggle (Yang, 2001 ). Studies found a 27.4%
poverty rate among this population compared to 11.3% for overall U.S. families (Hmong
National Development, 2013). According to systems theory, the poverty level among the
Hmong is a contributor to poor access to mental health services leading to Hmong youth being
underserved (Ferris et al., 2014).
Hmong Cultural and Spiritual Beliefs. An estimated 70% of Hmong still practice animism,
the belief that all things have a spirit, and shamanism, the spiritual practice to heal individuals
and families. The Hmong believe that the cause of an illness is due to spiritual incongruence
such as the loss of one of a person's three souls, a curse inflicted upon the individual or family,
or an angry spirit (Moua, 2019; Fadiman, 1997). It is culturally sanctioned to seek out herbal
remedies or spiritual soul healing ceremonies to heal the person (UC Davis, 2009). A shaman, a
spiritual leader within the Hmong culture, performs these ceremonies. Shamans are highly
respected and regarded as the intermediary between the physical world and the spiritual world
HMONG YOUTH MENTAL HEALTH 14
(Lemoine, 1986). Shamans are neither trained nor educated to serve in this position. They
cannot self-select or be selected by other people to become a shaman. Rather, they are selected
by the "Neeb" spirits who come to them in the form of serious illnesses, either physical or visual
and auditory hallucinations (Moua, 2019). Once the selected individual accepts his or her path
as a shaman, the symptoms subside, and they are able to resume a normal daily life while
performing the duties of a shaman to the community (Lemoine, 2011 ). While the Hmong have
accepted Western medicine, the majority of them still rely on centuries-old shamanism for
spiritual well-being, which researchers have argued could be a complimentary practice to
medical treatment (Helsel, Mochel & Bauer, 2004; Plotnikoff, Numrich, Wu, Yang & Xiong,
2002).
From a holistic perspective, spiritual practices such as animism and shamanism were
found to have positive effects on mental health and well-being when treating the person (Weber
& Pargament, 2014). Clinically, studies found that trained mental health clinicians were able to
engage in spiritually competent practice with their clients, leading to positive outcomes (Rogers,
Wattis, Stephenson, Khan & Curran, 2019). These researchers indicated that a holistic approach
comprised of spirituality and Western health care approaches could improve a person's mental
health. While this is a gap in the current practice, a systems theory and client-centered approach
favor an innovation that utilizes the Hmong spiritual beliefs as strengths when providing mental
health treatment. The cultural influence of Hmong families affects how Hmong youth navigate
the Western world they are a part of and the traditional beliefs of their parents. Research shows
that Hmong youth who are acculturated prefer to engage in counseling services (Thao et al.,
2010). However, Hmong youth also reported they would comply with their parents' preference
for shamans' spiritual ceremonies as a remedy (Vang, 2014; Thao et al., 2010).
HMONG YOUTH MENTAL HEALTH
Mental Health Stigma
15
Due to divergent beliefs about health and the nature of illness, Western mental health
concepts do not exist in Hmong culture. The absence of Western mental health concepts also
means that there is no direct translation for diagnoses, symptoms, and general mental health
language, further perpetuating mental health stigma within this community (Moua, 2019). For
example, the Mental Health Department is loosely translated as "the crazy house." Vang (2011)
and Ly (2016) found that shame and stigma of mental health, along with a lack of family support
and cultural beliefs about symptoms and treatment all result in Hmong individuals not seeking
mental health services. The innovation introduces new behaviors by leveraging the unique
authority figure and role of shamans within the Hmong culture.
Inadequate Mental Health System
Research found that the current mental health system does not support culturally
competent practices, nor does it honor Hmong beliefs (Thao et al., 2010). This discourages
Hmong parents from having their child engage with this system. Language barriers were found
to have a profound impact on the access, engagement and utilization of mental health services for
this community (Ly, 2016). With 37% of Hmong being considered Limited English Proficient or
monolingual, an effective solution will need to include appropriate language for Hmong families
(Southeast Asia Resource Action Center, 2020). Thao et al. (2010) found that Hmong youth and
parents preferred bilingual Hmong service providers with the cultural understanding and
communication ability to effectively serve them. Studies also showed that Hmong clients had a
higher rate of effective mental health treatment when their clinicians were bilingual and
bicultural (Xiong, Fang, & Vang, 2017). Ngo (2017) found that as Hmong youth struggled with
identity issues and biculturalism, they needed to engage with service providers who had a deep
HMONG YOUTH MENTAL HEALTH 16
understanding of these acculturation issues (Ngo, 2017; Lee, 2009). These studies indicate the
need for the innovation to include bilingual and bicultural providers.
In spite of these issues, the mental health system has remained status quo, a situation that
critical race theory attributes to racism and the effort of the White majority to maintain power
(Delgado & Stefancic, 2001). McCarthy (2001) found that the mental health system has failed to
provide adequate access and culturally competent practices to minority groups in the U.S.
Studies indicate that race-related inequalities reflected in the experiences of Hmong youth, such
as acculturation and identity issues, may lead to mental illness (Brown, 2008; Zapata, 2020). In
other words, racism is a tool utilized to maintain a mentally oppressive environment and a mental
health system that sustains inequities.
Applied Implication
In spite of the alarming increase in number of youth with mental illness in the nation,
Hmong youth still have a very low engagement rate with services (Allegria et al., 2010; Annie E.
Casey Foundation, 2018). Considering that Asian Americans are the fastest growing minority
group in this country, the Hmong youth population will continue to rapidly expand (Ferris et al.,
2014). Without strategic interventions, mental illness will continue to impact this young
population, effectively threatening the well-being of these youth. For an estimated 114,538
Hmong youth, finding a solution to this intractable problem could be the difference between life
and early death.
Innovations in the Topical Area
In spite of the severity and prevalence of mental health issues within Hmong youth, there
have been limited efforts and innovations to address this problem. As a response to the high rate
of Hmong youth suicides in Fresno in 2002, the Fresno Unified School District (FUSD)
HMONG YOUTH MENTAL HEALTH 17
implemented a prevention program for middle school and high school aged Hmong youth
provided by bilingual Hmong clinicians (Xiong & Jeselow, 2008). However, the program ended
several years later due to lack of funding (X. Moua, personal communication, October 17, 2018).
In Minnesota, the Wilder Foundation provides a school-based therapeutic program to Hmong
students in several elementary, middle school and high schools in the St. Paul area, (Wilder
Foundation, n.d.; Hmong National Development, 2013). These programs have been school
based and serve a limited pool of Hmong students.
Theory of Change and Logic Model
The goal of the innovation is for Hmong youth to be emotionally and mentally healthy
and lead a productive life. The theory of change for this capstone contends that shamans, who
have a better understanding of the benefits of mental health services, will be accepting of said
services and will be more willing to refer Hmong youth and families to services. This, in turn,
will lead to increased engagement of Hmong youth into mental health services that are culturally
responsive and linguistically appropriate.
The logic model in Appendix A describes the theory of change leading to the desired
short-term and long-term outcomes, resulting in an impact in the innovation areas of disruption
and sustaining. The innovation introduces new behaviors that will disrupt social norms that have
prevented Hmong youth from receiving mental health services and increase access to needed
services. The innovation is also developing a more effective program model that is adapted for
the Hmong youth population.
The logic model includes resources such as cultural and clinical expertise, clinicians,
trainers, a program coordinator and administrative staff. A telehealth platform and online case
management system will be required to provide virtual mental health services. Collaboration is
HMONG YOUTH MENTAL HEALTH 18
essential to any successful project, and a long list of community partners will be a significant
resource. Primary activities will include a mental health training for Hmong shamans and the
provision of outpatient mental health services for mild to moderate symptoms by bilingual and
bicultural clinicians via a telehealth platform. Other activities include a Hmong cultural and
spiritual training for mental health providers, clinical supervision and consultation. The theory of
change for both program models are described below.
Program Model 1: Mental Health Training for Shamans
A Mental Health training will be delivered to bring awareness and education of mental
health to Hmong shamans. Since the Hmong culture does not view health in the same way as
Western society, through this training shamans will learn about mental health, benefits of mental
health services and resources available. This theory of change has proven successful with
Hmong shamans who through the Spiritual Healer training at Dignity Health Mercy Medical
Center in Merced, California, have improved their understanding of Western medical procedures
and alleviated Hmong families' fear of medical procedures while increasing their medical
compliance (Moua, 2019). This cross-cultural training series has been widely successful, having
trained over 120 shamans. Likewise, trained shamans will be able to explain mental health
concepts and services to patients whose issues are neither of spiritual nor physical nature.
Shamans have confirmed that they are able to distinguish between spiritual and mental health
issues (M. Thao, personal communication, February 12, 2019). As respected authority figures,
shamans will have the ability to bring this issue to light, thereby fighting the stigma associated
with mental health.
Studies and journey mapping show that shamans are often time the first point of contact
with families when Hmong parents seek their assistance when their child demonstrates
symptoms congruent with a mental disorder (Helsel et al., 2004). Because consultation with a
HMONG YOUTH MENTAL HEALTH 19
shaman can continue for months and even years until families have to resort to utilizing the
mental health system, there is an opportunity to intervene upstream to prevent progression of the
mental health disorder and disrupt this social norm (Collier et al., 2012).
Program Model 2: Bilingual and bicultural Mental Services via Telehealth
Holm-Hanson (2006) reported that while ethnic minorities are less likely to self-refer to
mental health services, they tend to do so more frequently when agencies serving their specific
population are available to provide services. Furthermore, Hmong youth and parents prefer
bilingual and bicultural Hmong service providers (Thao et al., 2010; UC Davis, 2009). Using a
telehealth platform, Hmong youth and their family will be able to connect with bilingual and
bicultural Hmong mental health clinicians regardless of their location. Telehealth has been
effective in reaching clients in remote areas and providing them with mental health services,
while scaling service providers' services in an efficient manner (Kressley, 2019; Myers, 2019).
For these reasons, telehealth is the vehicle that will make this innovation accessible and scalable.
Problems of Practice and Innovation
Innovation and Contribution to the Grand Challenge
KaShia, which means "joyful heart" or "peaceful heart" in Hmong, is the organization
that will be developed to implement the innovation which will introduce a set of new behaviors
within a culturally accepted milieu, disrupting the upstream progression of mental illness in
Hmong youth and resulting in greater positive outcomes for Hmong youth' s mental health. The
innovation blends culturally and spiritually held beliefs with Western mental health services that
are optimized by technology for a scalable approach, improving access and engagement into
services.
HMONG YOUTH MENTAL HEALTH
Innovative Solution
20
Hmong Shaman Mental Health Training. A training curriculum covering the concepts
of Western mental health and illness, symptoms, diagnoses, treatment and benefits of clinical
services will be provided to Hmong shamans. While this is a stand-alone training, for the pilot
the training will be offered to shaman participants in the Spiritual Healer training series at
Dignity Health Mercy Medical Center in Merced. The mental health training will help shamans
encourage individuals to engage in mental health services. Upon completing the mental health
training, each shaman will receive a certificate of completion and a directory of Hmong bilingual
mental health providers and organizations that are available to serve Hmong youth and their
family. This program model integrates an important cultural and spiritual aspect of the traditional
Hmong culture, and leverages the role of shamans as gatekeepers while supporting a holistic
approach to treating a Hmong youth. Trained shamans will have the basic knowledge to explain
mental health concepts and refer families to therapeutic services provided by KaShia.
Bilingual and Bicultural Mental Health Services via Telehealth. The second program
model provides Hmong youth and their family virtual access to bilingual and bicultural Hmong
mental health providers. A Telehealth platform will be utilized to provide therapeutic services to
youth with mild to moderate symptoms. This leverages the existing limited bilingual clinical
workforce available to serve this population and allows services beyond a limited setting or
geographical area. It also may reduce mental health stigma as youth and their family will be
meeting with the clinician in the comfort of their own home, thereby avoiding having to go to the
"crazy house." Since the Hmong community is close knit, seeing a clinician who resides in a
different area of the state may provide the family a certain sense of anonymity. In addition, as
license-eligible bilingual clinicians provide this service, they will be able to earn clinical hours
HMONG YOUTH MENTAL HEALTH 21
towards licensure. This capacity building facet of this program model creates a viable supply for
a bilingual licensed workforce over time. Consistent with a cross-cultural approach, these
clinicians will receive a training on Hmong cultural and spiritual beliefs prior to commencing
providing services to families to cement their cultural competency. It is expected they will
consult and collaborate with shamans. Altogether, the two program models that constitute the
innovation will increase access to a new culturally responsive mental health sub-system and
improve engagement and utilization of mental health services. This innovation will increase
Hmong youth's mental health and well-being within the area of the Grand Challenge.
Multiple Stakeholder Perspectives of the Problem
The complex issue of the mental health needs of Hmong youth interfaces with many
groups and organizations. The individuals who are directly affected by the problem include
Hmong youth, their parents and families, including extended families such as clans, and the
Hmong community. The issue of mental health in Hmong youth has become more public
recently on social media, more so than in other public forum, since mental health stigma is very
high (S. Vang, personal communication, February19, 2019). Recently, there have been efforts
such as student-led conferences to bring awareness to this issue and there is an increasing
demand to find viable solutions (Hall, 2018). Based on interviews, Hmong youth, parents and
the community have confirmed to be open to the innovation ideas (Vang, 2019). Some have
been seeking mental health services with no avail and they are looking forward to the
opportunity of utilizing telehealth to connect with a clinician who speaks their language and
understands their culture.
Hmong youth and young people view mental health as a serious issue. They have
contributed to its public discourse on social media and by holding public events. Professional
HMONG YOUTH MENTAL HEALTH 22
groups such as the Hmong Mental Health Network have organized on social media to serve as a
resource to Hmong clinicians. These efforts have altogether brought the issue of mental health to
light in the general Hmong community and, certainly, among Hmong youth. This signifies a
schism between the more traditional ways of practice and the ways in which mental health is
viewed by professionals and youth who are more immersed into the Western world perspective
of health and mental health.
Shamans are a critical part of the innovation since they will be receiving mental health
training to have a better understanding of the benefits of therapeutic services to further direct
youth in need of services to the appropriate resource. Based on interviews and a pilot training
with shamans, it is clear that shamans understand the concept of mental health after the training
(Vang, 2019). They also have indicated that they are able to distinguish between an issue that is
spiritual in nature and one that may be rooted in mental health. Shamans have expressed a
pressing need for mental health services for some of their clients.
Clinicians, social workers and other helping professionals who work with the Hmong
community recognize the unmet mental health needs of Hmong youth as a critical issue (UC
Davis, 2009). They understand that culturally incompetent programs and practice, in addition to
lack of bilingual staff, contribute to the issue (Thao et al., 2010). There is agreement among this
group that a solution is needed for this problem. The interviews conducted with members of this
group indicate that they find this innovation idea to be interesting and believe this will bring
additional resources for this population.
Organizations that provide mental health services, whether county department or
community-based, directly connect with this issue and this population. Even counties that are
homes to large Hmong communities, sometimes choose to dismiss the problem in spite of
HMONG YOUTH MENTAL HEALTH 23
troubling reports (P. Yang, personal communication, February 13, 2019; Ferris et al., 2014).
Reports such as the one completed by the Wilder Foundation indicate the service gaps that exist
for Hmong youth (Thao et al., 2010). In California, county departments that administer the
Mental Health Services Act (MHSA) might find the innovation idea to be interesting and worth
funding as it incorporates cultural competency and technology to serve an underserved
population, a goal of MHSA. Other advocacy and special interest organizations such as the
Valley Asian Pacific and Islander Mental Health Project in Central California and the Hmong
Institute in Wisconsin have a good understanding of this problem and its impact on Hmong
youth's lives and the community. These organizations have expressed interest in finding a
solution and a willingness to partner to address this issue.
State and federal organizations that administer mental health programs and funding most
likely are not aware of the current problem for Hmong youth. To complicate the problem, the
lack of desegregated data lumps Hmong youth within the Asian Pacific Islander (API) youth
group and gravely limits a clear understanding of the prevalence of this issue. However, the
innovative aspect of the intervention might be of interest to these organizations as this idea could
be relevant to other underserved populations. Likewise, policy makers and legislators are
generally not familiar with this issue. However, legislators whose jurisdiction includes a large
Hmong community will be at least familiar with some of the background of the Hmong. They
may find it politically beneficial to support such an issue among their constituency. The
mainstream society, along with policymakers and administrators, who have no or limited
knowledge of the issues specific to Hmong youth may find that spending limited resources on a
small population is not worthwhile. In addition, racism and other forms of discrimination may
HMONG YOUTH MENTAL HEALTH 24
affect some stakeholders' view of the problem, resulting in a lack of support for resources
necessary for the innovation.
Analysis of Broader Landscape
The impact of the traumatic experiences of the Hmong, through the war and refugee
experience, on Hmong adults' mental health issues have been well documented in a substantial
body ofresearch (Lee & Chang, 2012; Lee, 2013). These studies demonstrate the scope and
severity of mental health issues in the adult Hmong population. With the available research,
organizations have been able to successfully secure funding to provide services to Hmong adults
(Xiong & Vang, 2019; Xiong et al., 2017). While they don't generally serve youth, these
organizations might see the innovation as a threat to funding for their established programs.
The success of the different program models of the innovation rests upon funding
opportunities as well as a political climate conducive to its development and support. The
Mental Health Services Act (MHSA) provides a potential source of funding for the innovation.
MHSA has been established to serve underserved populations while supporting innovative,
culturally competent services (Department of Health Care Services of California, n.d. ). Other
potential funding courses include philanthropic foundation grants, Medicaid and private
insurance. Since the innovation will be piloted in California, these funding opportunities provide
a positive outlook for the innovation.
As the Hmong' s involvement with the American Central Intelligence Agency (CIA) in
the Secret War in Laos has become more widely known, there has been more public support
politically for the Hmong community (Hamilton-Merritt, 1993; Congressman Jim Costa 16
th
District of California, 2018). Recently, Wisconsin and Minnesota have declared May as Hmong
day in honor of the Hmong veterans who fought alongside Americans in the Secret War of Laos
HMONG YOUTH MENTAL HEALTH 25
(Herndon, 2018). These recent developments have signified a more robust political support for
the Hmong community in the U.S. Additionally, for the past 20 years Hmong Americans have
steadily made their entrance onto the local and state political arena. Hmong Americans won a
record eleven seats in the 2018 midterm election (Suab Hmong News, 2018).
This increasing political influence has brought issues specific to the Hmong community
and other immigrant communities to the forefront. This political momentum may support the
changes necessary to tackle this intractable problem. However, while the issue is certainly
feverishly debated, the national political climate has been dominated by anti-immigrant
sentiments that may negatively impact funders' support, legislation and policies in support of this
innovation. More recently, in the aftermath of George Floyd' s death in Minneapolis, a national
and global call for the end of institutional racism may be the necessary push for more inclusive
and culturally responsive practices in institutions such as mental health systems.
Consideration of Existing Opportunities for Innovation
Studies that have comprehensively researched this intractable problem have
recommended increasing Hmong culturally specific programs in school-based and primary care
settings (Thao et al., 2010; UC Davis, 2009). However, these options face several challenges,
the first one being that these are confined to specific locations and are not easily scalable. Lee
(2009) argues that Asian American youth suffer gravely from being perceived as the Asian
model minority at school, a racism-grounded belief that Asian Americans are smart and
obedient, and the ideal minority other groups should aspire to. Educators and others who
prescribe to the Asian model minority myth minimize behavioral and emotional issues that
Hmong and Asian American students may experience. For this reason, school-based
interventions are not the best solutions for this population as proper referrals may not be made.
HMONG YOUTH MENTAL HEALTH 26
In addition, research found that the screening tools, upon which schools rely on for
referrals, do not adequately evaluate mental health issues among Hmong youth and adults,
causing an under-reporting of the issues and low number ofreferrals to services (Vang, 2014).
For this reason, innovating these programs, for example in their process, did not seem to address
the most salient issues of this intractable problem.
Hmong society is organized in a patriarchal structure with leadership assigned within
clans (Donnelly, 1994 ). Since families typically consult with their clan leaders with important
decisions such as familial conflicts and major health decisions, providing clan leaders a mental
health training could potentially offer an opportunity for innovation. However, the political clan
system is not set up for social issues such as domestic violence and destigmatizing mental health.
For this reason, this idea was not pursued.
Project's Likelihood of Success
The mental health training for Hmong Shamans was piloted in April 2019 at Dignity
Health Mercy Medical Center with a group of 20 shamans. Throughout the two-hour training,
the shamans were engaged in the discussions, demonstrated interest in the topic and asked many
questions. By the end of the training, it was apparent that the shamans had a good understanding
of mental health and the benefits of treatment and services. Shamans expressed that some of the
individuals, who had come to them for help, in fact needed to receive mental health services.
The shamans in the pilot training requested resources to refer their clients to. This,
unfortunately, emphasized the critical need for access to bilingual Hmong service providers, as
there was no such service in place. The result of this pilot training demonstrates that this
program model is likely to be successful. With the program delivery limitations imposed by the
HMONG YOUTH MENTAL HEALTH 27
COVID-19 pandemic, the mental health training could be delivered online to Hmong shamans
social media groups.
Interviews with parents, young adults and shamans revealed that they are open to using
telehealth for services (Vang, 2019). With social media apps such as FaceTime and Messenger
being so popular among many Hmong, telehealth was found to be a welcome opportunity. Once
the KaShia telehealth program is available, it is anticipated that both program models will feed
off each other, making the KaShia culturally responsive mental health system much more
effective. Additionally, the circumstances of the COVID-19 pandemic have moved many facets
of work and health care online, making telehealth a much more familiar tool for mental health
services.
Project Structure, Methodology, and Action Components
Prototype
The prototype for this innovation consists of the curriculum for the mental health training
for shamans, the curriculum for the Hmong cultural and spiritual training for mental health
providers, a directory of Hmong mental health providers that shamans will receive upon
completion of their training, and a storyboard depicting how a Hmong youth and his family will
benefit from the innovation. Refer to Appendix B, C, D, and E respectively. Each element of
the prototype has a distinct purpose.
The storyboard illustrates to stakeholders how the innovation will work from the
perspective of a Hmong family who is seeking help for their child. It follows a journey mapping
that leverages the new opportunities offered by the innovation and demonstrates the benefits of
engaging in services. The mental health training curriculum for Hmong shamans includes
HMONG YOUTH MENTAL HEALTH 28
information and approaches to educating shamans about Western mental health, mental illness,
diagnoses and treatment in a manner that is culturally competent. The Hmong cultural and
spiritual curriculum will be utilized to provide necessary cultural knowledge to mental health
providers who may or may not be bilingual Hmong. While bilingual, today's educated and
trained Hmong clinicians vary in their cultural competence due to a cultural gap that has widened
with each new generation (Vang, Xiong, Xiong, Yang, & Moua, 201 7). Therefore, it is
important to provide this training as a vehicle to inform, educate or remind clinicians of the
cultural and spiritual issues that they need to be familiar with in order to incorporate them in a
culturally responsive practice. The Hmong mental health directory will be provided to shamans
as an incentive for completing the training and to utilize as a resource for referrals. The directory
also identifies those providers who have completed the Hmong cultural and spiritual training,
which shamans may prefer.
Analysis of the Market
Available Hmong youth programs are limited to school-based or specific geographic
areas and are currently not scalable. With mounting public discourse in social media and
conferences on the issues of mental health within the Hmong youth community, there is a
marked demand for mental health assistance and services for Hmong youth (S. Vang, personal
communication, February 19, 2019; Hall, 2018). Except for a couple of geographically based
children programs, mental health programs targeting the Hmong community are generally for
adults. The limited programs and services for this population are noticeable and the market is
ripe for this innovation.
Project Implementation
HMONG YOUTH MENTAL HEALTH 29
The Exploration, Preparation, Implementation, and Sustainment (EPIS) framework,
including barriers and facilitators for each phase, will be utilized to ensure effective
implementation of the innovation project (Moullin, Dickson, Stadnick, Rabin, & Aarons, 2019).
Please refer to Appendix F.
Exploration Phase. In the Inner Context of this phase, KaShia will be a newly
established organization, and as such, it will need to prove itself or partner with a more
established organization to obtain credibility and a sizable funding amount for its programs.
KaShia leadership has gathered data to fully evaluate the scope of the problem, current market
for the solution, as well as readiness of the Hmong community to engage in the solution.
Leadership has considered potential competitors and assessed its strengths and service gaps.
Leadership for the organization is being developed with attention to skills, knowledge and
relationships to advance the organization's mission. Leadership has selected strategies for
successful implementation with consideration to the logic model and scaling. Leadership will
create buy-in for the innovation and develop advantageous relationships for the organization.
Leadership has explored potential funding such as foundation grants, government contracts,
Mental Health Services Act (MHSA) funding and fundraising. KaShia leadership has evaluated
the political landscape, and current and upcoming policies that may affect the implementation of
the innovation.
The facilitators in the Inner Context of the Exploration phase include Hmong shamans,
who through the pilot mental health training, indicated a strong need for the training and
readiness to refer Hmong patients to mental health services. Recently, a focus on youth mental
health issues on social media has given momentum to this issue leading to public discourse and
demonstrating a readiness for change. The barriers in the Outer Context of the Exploration phase
HMONG YOUTH MENTAL HEALTH 30
include a current national anti-immigrant political climate that may prevent or reduce funding
opportunities. The facilitators in the Outer Context of the Exploration phase include local
elected officials who are knowledgeable and sympathetic to issues in the Hmong community and
will most likely support greater access to services for Hmong youth and this community. The
MHSA provides funding opportunities for programs such as KaShia' s that serve vulnerable
ethnic populations. KaShia leadership maintains a strong network within the Hmong community
and the API mental health professional community, which can be leveraged for resources and
strategic alliances.
Preparation Phase. In this phase, leadership will continue developing relationships with
stakeholders such as the Hmong community, Hmong social workers and clinicians, local formal
and informal leaders, county departments and legislators. A Board of Directors will also be
recruited to start working on the overall implementation of the programs and a 501 (c)(3) non
profit status will be filed and obtained for the organization. As a new organization, KaShia will
develop an organizational culture based on strong vision and mission statement. Leadership will
"educate" stakeholders on the nature and scope of the problem and the proposed solution. A
website and social media accounts, such as Facebook and Twitter, will be created for KaShia and
made available to the public to further educate the public on the issue.
Leadership has developed a financial plan and will submit proposals to secure funding.
Processes and procedures will be developed for a robust financial monitoring of programs. This
aligns with the "quality management" strategy of developing tools for program monitoring,
audits and a feedback loop for continuous improvement of the programs. Leadership will
develop policies and procedures in the inner context to ensure that decisions and activities align
HMONG YOUTH MENTAL HEALTH 31
with the organization's mission and vision. With this strategy, leadership positions the
organization for positive momentum for the next implementation phase within the outer context.
Implementation Phase. In this phase, the KaShia programs are initiated within the
organization and into the sociopolitical ecosystem. Flexibility will be required to review and
revise processes and problem-solve as issues arise. Funding will be secured and tightly managed
by leadership and fiscal staff. Leadership will launch a campaign using social media and the
KaShia website to bring focus to the problem and introduce the innovation to the Hmong
community and the public. Leadership will recruit and hire competent bilingual clinicians and
staff. Clinicians will receive the Hmong cultural and spiritual training, clinical supervision and
on-going training for best practice. Regularly scheduled meetings will be held to ensure accurate
and timely program implementation. Leadership will utilize tools that were developed in the
preparation phase to track data for program and fiscal monitoring. The COVID-19 pandemic has
severely impacted the economy, affecting county contracts and foundation grants. In order to
minimize fiscal impact, KaShia will diversity its revenue stream by billing private insurance and
MediCal for services.
Sustainment Phase. Leadership will utilize data to monitor programs and fiscal
information, conduct audits, and provide quality improvement feedback. Data will be utilized to
evaluate program model fidelity, efficiency of services, and whether programs are meeting
measurable outcomes. Program model fidelity and measurable outcomes will continue to be
evaluated, leading to modifications of the programs' processes as necessary. Program model and
outcomes will be disseminated to stakeholders and shared through publications, conference
presentations and TED Talks. Please refer to Appendix G for a Gannt chart, summarizing the
time line and tasks leading to successful implementation of the innovation.
HMONG YOUTH MENTAL HEALTH
Financial Plans
Operating under the auspices of the Board of Directors, KaShia will be established as a
501(c)(3) non-profit organization in California, with the mission to "holistically support
underserved youth's well-being by leaning into community cultural strengths and collaborating
with allies to create innovative solutions." KaShia will be tasked to deliver the innovation.
32
For the pilot, the start-up budget includes costs for activities required prior to the full
program launch. Personnel costs account for the majority of the total expenses of $436,000. It
is anticipated that revenue totaling $510,600 will be secured through diverse revenue streams
appropriate for the organization' s non-profit status and goals. Expenses at start-up will be
primarily driven by costs associated with personnel costs. When accounting for expenses, the
start-up budget will yield a surplus of $21,232. Please refer to Appendix G for the detailed Start
Up budget.
Personnel/Staffing Costs. With a total of $436,000 personnel costs make up most of the
start-up budget. These include several key positions: the executive director, fiscal manager, and
part-time Information & Technology (IT) staff and bilingual mental health trainer. One full time
clinician, who may be licensed, and two one part-time license-eligible clinicians will be hired to
start serving clients. The two part-time clinicians will be hired as 1099 independent contractors
who will receive free clinical supervision as part of the agreement. Many Hmong license-eligible
clinicians have expressed on social media and elsewhere how difficult it is for them to receive
the appropriate clinical supervision toward licensure. KaShia creates an opportunity for them to
earn clinical hours and supervision while providing therapeutic services via telehealth. At start
up, the KaShia executive director, who is a Licensed Clinical Social Worker (LCSW), will
provide the required weekly clinical supervision, thereby avoiding the additional cost of hiring a
HMONG YOUTH MENTAL HEALTH 33
clinical supervisor. A fiscal manager will be hired to manage the different revenue sources that
support the start-up budget and expenditures. The fiscal manager will be required to have a
minimum of a bachelor's degree in accounting or related field, and two years of experience
managing budgets and contracts for a non-profit or government entity. A part-time IT staff will
provide essential technological support for the entire personnel who will be working from home.
Additionally, a program coordinator will be hired to complete the initial coordination and
communication with clients. The bilingual program coordinator will be required to possess at
least two years of case management experience in social services. A part-time bilingual trainer
will be hired to provide the mental health awareness training to shamans four times per year.
This mental health trainer will be required to be bilingual, bicultural and have knowledge of
mental health services and system. At start-up, KaShia will employ a total of eight staff, four of
whom will be part-time. These positions will effectively develop the programmatic foundation
for all the KaShia programs and activities, positioning the organization for growth at first full
year of operation and beyond.
Other non-personnel operating costs. KaShia will utilize the doxy.me telehealth app,
or a similar user-friendly app, that can be tailored to the organization's needs. Other operating
expenses include overhead costs associated with a subscription to a HIP AA compliant software
such as "Simple Practice," computers, internet access and cell phones. There will be no cost for
an office space as all employees will be working from home. For the pilot, Dignity Health
Mercy Medical Center will be providing in-kind contribution with staff time and facility for the
mental health awareness training. This is reflected in both the revenue and expenses sections of
the budget.
HMONG YOUTH MENTAL HEALTH
Revenue strategies, funding types and plan. At start-up, it is anticipated that KaShia
will receive $100,000 from the Mental Health Services Act (MHSA). It is anticipated that
KaShia will obtain $200,000 from diverse foundations such as the Sierra Health Foundation,
California Endowment, the California Wellness Foundation, Central Valley Community
Foundation, James Irvine Foundation, and Dignity Health. KaShia will also bill MediCal and
private insurance as appropriate. Lastly, as a non-profit organization, KaShia will fundraise
$30,000 during the start-up phase. The partnership with Dignity Health Mercy Medical Center
will yield an in-kind contribution for staff time and space in the amount of $10,600. In
summary, the total revenue for the start-up budget amounts to $510,600. At the end of the pilot
year, it is anticipated that KaShia will have a surplus of $21 ,232.
Methods for Assessment of Impact
34
Mental health training for shamans. The evaluation goal for the mental health
awareness training is to improve Hmong shamans' understanding of mental health. The process
objective is to conduct a two-hour training session on a quarterly basis, with at least 20 Hmong
shamans per session. Documentation such as sign-in sheets will be utilized to verify attendance
and completion of the training. The outcome objective for this program is an 80% increase in the
shamans' understanding of mental health concepts, diagnoses, treatment and benefits of services
by the end of the training session. Using a quasi-experimental design, a pre and post-survey
available in English and Hmong will be administered by the training facilitator at the beginning
of the training and at the end of the session to evaluate this program model. Cohorts of shamans
who will attend the Spiritual Healer training at Dignity Health without taking the mental health
training will serve as the control group. The pre and post survey had to be created since no such
instrument exist in Hmong. See Appendix I for the pre/post survey.
HMONG YOUTH MENTAL HEALTH 35
Telehealth mental health services. The evaluation goal for the telehealth mental health
services is to reduce Hmong youth's symptoms and improve their daily functioning. The process
objective for the telehealth program is to conduct one hour weekly therapeutic session per youth
via telehealth for 16 weeks as indicated by agency records. The outcome objective for this
program is for 70% of youth to experience a decrease in their mental illness symptoms by the
end of the treatment period. Youth who experience depressive symptoms will complete the
Pediatric Symptoms Checklist (PSC) 35 tool during the preparation phase. This standardized
instrument was selected due to its high reliability and validity, and the fact that it is available in
Hmong and takes little time to complete (Jellinek et al., 1999). Parents will be asked to complete
the PSC 35 tool to identify psychosocial problems in their child, between the ages of 4 and 18.
The tool will be completed at intake to provide a baseline for symptoms, and then on a monthly
basis during the course of the youth's treatment. The data gathered from this instrument will be
utilized at implementation and sustainment to measure whether the outcome objective has been
met. Parents and youth will be asked to complete a program satisfaction survey, available in
English and Hmong, to provide feedback on the quality of the program. In addition, clinicians
will complete program satisfaction surveys that will provide additional qualitative feedback on
the quality of the program. The survey will be emailed to the clinicians on a quarterly basis who
will submit the result anonymously to the executive director.
Summative evaluation. A summative evaluation will occur during the sustainment
phase, about one year after program launch, to evaluate all outcome objectives of the KaShia
programs. This evaluation will help determine whether the programs have successfully met their
intended goals and objectives to guide decisions to maintain, expand or scale programs. For the
shaman mental health training, data that include pre and post test results, number of shamans
HMONG YOUTH MENTAL HEALTH 36
who completed the training, and shamans' satisfaction survey results will be cumulatively
evaluated for the year to determine whether the goal for this program was met.
Likewise, data gathered from all tools and instruments used to measure process and
outcome objectives during the implementation phase will be analyzed to evaluate whether the
organization has met its goal of improving the mental health of Hmong youth through the
telehealth mental health services program. These tools include a database that tracks the number
of sessions conducted per youth, the results from the administration of the PSC 35 instrument,
case audits and parent interview results.
Stakeholder Involvement
In order to conduct a comprehensive assessment of impact, it is critical that all
stakeholders be involved in providing feedback. Community organizations and other decision
makers will be surveyed as part of an updated needs assessment and Continuous Quality
Improvement process. Shamans, youth and parents, and clinicians will also be requested to
complete anonymous program satisfaction surveys that will help KaShia leadership better
understand gaps and areas of improvement.
Communications Plan
Branded products with KaShia key messaging will be strategically introduced in different
media platforms to gather support, interest and buy-in from targeted stakeholders. Short form
films will be released on Y ouTube and the KaShia website to bring attention to the intractable
problem facing Hmong youth to mental health organizations that are not yet aware of this
population. The goal of these short form films will be to arouse emotional connections to the
human cost of the problem and incite the audience to find out more about how to help on the
HMONG YOUTH MENTAL HEALTH
website which will have information about the innovation. An infographic has been created to
educate the public and introduce the innovation. Please refer to Appendix J for the infographic.
37
KaShia will be actively engaged on social media platforms such as Facebook and Twitter
to regularly communicate about benefits of services and success stories. Once the summative
evaluation is complete, findings will be presented at regional, statewide and national
conferences. Articles documenting the summative findings of the innovation will be submitted
for publication. Social media and the KaShia website will be leveraged to disseminate this
information. The executive director will submit for a TED Talk to share about this innovative
solution and the positive outcomes produced for Hmong youth.
Ethical and Diversity considerations
Considering the role language and culture play in this intractable problem, it is crucial
that issues of diversity be carefully and thoughtfully managed throughout the delivery of the
innovation. It is critical that the evaluation tools and surveys be available in English and Hmong.
Language access is an important piece of an overall approach that builds relationships and trust
with the Hmong community. A robust engagement with the Hmong community is required to
receive feedback for continuous quality improvement of the programs. More importantly when
attempting to bridge a cross-cultural divide, it would be unethical to only expect shamans and
Hmong families to be more accepting of Western mental health without also ensuring that mental
health providers are able to incorporate Hmong spiritual and cultural beliefs into a culturally
responsive practice. Not doing so would only perpetuate demeaning assumptions about
traditional spiritual beliefs of the Hmong.
Conclusions, Actions, and Implications
Implications
HMONG YOUTH MENTAL HEALTH 38
The complex issues contributing to Hmong youth's unmet mental health issues require a
thoughtful examination of the social norms within the Hmong culture and society and within the
mental health system that holds this intractable problem in place. Successful behavior changes
leading to the disruption of the problem will be introduced through the innovation which
validates inherent cultural strengths and spiritual practices, while leveraging technologically
driven opportunities to offer an innovation that is scalable. To address the main issues of the
intractable problem, the innovation creates a new system set apart from the current mainstream
system that was found to be unresponsive to minority populations like Hmong youth. The
implementation, impact evaluation and communication plan all illustrate a deliberate attention to
the cultural strengths that exist within the targeted population. Altogether, these capstone
components reflect a thoughtful, strength-based and systematic approach to the problem and the
Grand Challenge. Additionally, using the same principles of culturally responsive practice
provided by bilingual and bicultural mental health providers and a scalable technologically aided
service delivery system, this innovation has the potential to be replicated with other underserved
ethnic minority groups, furthering the impact on the Grand Challenge.
Future Decisions and Actions
The timeline and steps for implementation for the innovation have been detailed in the
EPIS chart and Gannt chart found in the appendix. The immediate steps will include obtaining
the 501 ( c )3 status for the KaShia organization, meeting with stakeholders to create buy-in and
start applying for funding. It is important to note that the current COVID-19 pandemic will
affect funding level as well as how timely the steps identified in the Gannt chart may be
completed. For example, with a decline in state revenue there may be less MHSA funding
HMONG YOUTH MENTAL HEALTH 39
available. KaShia leadership will need to quickly pivot to secure adequate revenue for the pilot
project.
Limitations and Risks
Shamans are a close-knit group that requires trust and credibility when interacting with
them. The level of trust and credibility KaShia and its staff members have with shamans will
determine the level of their involvement with the innovation. This is a clear limitation and
challenge for the capstone. For this reason, KaShia has identified an elder cultural expert and
liaison with the shamans who will be able to serve as a bridge for the organization. Another
limit of this project is that it is based on the evaluation of present-day Hmong culture in the
United States. Since culture is dynamic and ever-evolving, research should also be conducted to
evaluate how biculturation issues of the second and third generation of Hmong youth affect the
problem and the solutions.
While this innovation focused on developing new behaviors to facilitate new engagement
and utilization approaches, additional research is needed to develop an evidence-based
therapeutic approach that is culturally responsive. These are steps that KaShia, as an
organization, will be interested in pursuing to develop evidence-based practice. Once the
innovation has been established, KaShia will partner with the community and research
institutions to engage in these research questions.
Conclusion
Hmong youth continue to suffer from untreated mental health issues due to a myriad of
factors. However, central to the problem is the mental health system's lack of culturally
responsive programs and services that incorporate the Hmong's view on illness, and its lack of
clinical staff who are able to communicate with and understand this population. The innovation
HMONG YOUTH MENTAL HEALTH 40
is built upon the cultural resilience that has helped this community through centuries of
oppression and trauma (Thao, 2019). It validates the culturally sanctioned spiritual view of
health and illness and integrates it into a culturally responsive intervention that leverages the role
of shamans in combatting mental health stigma to connect youth and their families to mental
health services. Technology is the vehicle that allows youth and their families access to a limited
number of bilingual and bicultural Hmong clinicians for scalable culturally responsive services.
The components of the prototype for this capstone project serve a distinct purpose to
educate stakeholders, including funders, to galvanize support for the innovation and to educate
shamans and mental health providers for a culturally responsive practice. The prototype is ready
to be immediately shared with stakeholders such as Hmong families, shamans, clinicians, mental
health organizations, funders, and other decision-makers.
The innovation has a high likelihood to succeed and close the critical gaps found within
the system and community to ensure Hmong youth are, emotionally and mentally, healthy and
are given the opportunity to lead a productive life. Importantly, this project will make an impact
in the innovation areas of disruption and sustainment by generating new behaviors to increase
access and engagement of Hmong youth into mental health services and offering a more
effective model of culturally relevant practice and service for this population.
Social justice, the cornerstone of the social work profession, is the impetus, the fuel and
the foundation for this intervention. It is time to change the trajectory of so many Hmong youth
who needlessly suffer from mental illness. KaShia is an innovative idea to a problem, long
ignored, that has the potential to disrupt the system and redefine how and where Hmong youth
access and utilize mental health services, consequently ensuring the healthy development for all
youth.
HMONG YOUTH MENTAL HEALTH
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th
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w73 WmA U zfYSZk5qd9FgePjFSPvBdjq10
HMONG YOUTH MENTAL HEALTH 49
Appendix A: Logic Model
Project: KaShia
Goal: HmonQ youth are emotionally and mentally healthy and lead a productive life.
INPUTS ACTIVITIES
What we invest What we do Who we reach
Staff: bilingual, 1.Provide 1.Hmong
bicultural mental health shamans
clinical; bilingual training for
mental health Hmong
trainer, shamans 2.Hmong youth
Cultural and and family
clinical Hmong
expertise, community
Financial 2.Provide
resource for Hmong youth
seed money, with outpatient 3.Mental health
Community therapeutic providers
partners services for
Telehealth mild to medium
platform symptoms via Mental health &
Time telehealth. social services
Training departments
curriculum CBO's
Hospitals
3. Provide Educators
Hmong cultural
and Spiritual
training to
mental health
providers
Assumptions: Hmong shamans will be open to
learning about mental health. Hmong families are
willing to connect with a bilingual clinician through
telehealth/tech no logy.
OUTCOMES
Output/Process Short-term Long-term
Objective results results
1.four cohorts of 20 1. 80% of Hmong 1. 80% of Hmong
shamans will shamans will shamans are
receive the mental increase their willing to refer
health training per understanding of youth to mental
year. the Western health services at
mental health 1 year post
services and training.
2. One-hour benefits of
weekly therapy via treatment for youth
telehealth for 16 upon completion of
weeks per youth. the training.
2. 70% of Hmong 2. 25% increase
youth will in utilization rate
experience a of mental health
decrease in mental services among
health symptoms Hmong youth by
by the end of the the 5
th
year of the
treatment period. innovation.
External Factors: Political climate may affect support for the
project. The current economic downturn caused by the
COVID-19 pandemic may affect insurance reimbursement
and ability for in-person training.
HMONG YOUTH MENTAL HEALTH
Appendix B: Mental Health Training for Hmong Shamans
,'
1a
Healthy Hearts, Healthy Minds
Mental Health Training for
Hmong Shamans
Trainer Guide
50
HMONG YOUTH MENTAL HEALTH
Introduction
Mission and Values of KaShia:
KaShia is an organization that is dedicated to serving Hmong youth and their families, and the
broader Hmong community.
KaShia' s vision is "Youth, families and the community thrive in all core areas of health:
emotional, mental, spiritual and physical."
KaShia's mission is "to holistically support underserved youth's well-being by leaning into
community cultural strengths and collaborating with allies to create innovative solutions."
KaShia's values are:
• Cultural strengths and humility
• Respect
• Collaboration
• Inclusion
• Ethical Adherence
Purpose:
51
While many Hmong practice Christianity and other religions today, an estimated 70% of Hmong
still practice animism and shamanism in the United States (Moua, 2019). In the Hmong society,
shamans are highly respected and regarded as the intermediary between the physical world and
the spiritual world (Lemoine, 1986). The Hmong believe that the cause of an illness is due to
spiritual incongruence such as the loss of one of a person's three souls, a curse inflicted upon the
individual or family, or an angry spirit (Moua, 2019; Fadiman, 1997). It is culturally sanctioned
to seek out herbal remedies or requesting for a shaman to perform spiritual soul healing
ceremonies to heal the person (UC Davis, 2009).
From a holistic perspective, spiritual practices have been found to have positive effects on
mental health and well-being when treating the person (Weber & Pargament, 2014). These
researchers found that a holistic approach comprised of spirituality and Western health care
HMONG YOUTH MENTAL HEALTH 52
approaches could improve a person' s mental health. It is within this context that this curriculum
seeks to provide Hmong shamans with basic knowledge about Western mental health to fight the
stigma of mental health within this community and support a cross-cultural and holistic mental
health care model of Hmong youth and their family.
It should also be noted that while this training curriculum was developed specifically for Hmong
shamans for the purpose of this innovation capstone, it is also appropriate for Hmong individuals
from various religious and faith backgrounds.
Audience:
The primary audience for this curriculum is shamans who have had limited exposure to Western
mental health concepts and services. Participants may be monolingual Hmong speakers or
bilingual. Other audiences could also include Hmong community members.
Goal of this training:
The focus of this 2 hour-long training is to provide Western mental health awareness to
participants. Upon completing this training, participants will understand basic Western mental
health concepts including mental health, mental illness, diagnoses and treatment. Participants
will be introduced to the different types of mental health services.
Upon completion of the training, participants will be provided a resource directory of Hmong
bilingual mental health providers, who have completed a cross-cultural Hmong spiritual training,
and are available to provide holistic mental health treatment.
Learning objectives of this training:
• Acquire basic mental health knowledge, including understanding of mental illness,
diagnoses, treatment, types and benefits of mental health services.
• Understand the difference between mental health, spiritual health and physical health;
and how they all support an individual' s well-being and health.
• Examine how spiritual healing and mental health treatment can work hand in hand in
supporting a youth's mental and emotional well-being.
• Educate participants on available resources to help Hmong youth
Theoretical Approaches used in this curriculum:
The curriculum is based on these theoretical lenses and principles:
• Client-centered approach
HMONG YOUTH MENTAL HEALTH 53
• Cultural humility and competence
• Respect and validation of spiritual and shamanistic beliefs
• Cognitive Behavior Theory and approach
• Narrative therapy
• Trans-adaptation of mental health concepts and terminology into Hmong
Delivery methodologies
The curriculum information will be delivered using these methodologies:
• Lectures
• Discussions
• Use of case studies
• Videos
This curriculum was written to provide structure and guidance to cover essential information to
meet the goal and objectives of the training. The curriculum was purposely developed to not be
restrictive in its flow and pace in order to allow for the facilitator to be creative and flexible
during the delivery of the training. This characteristic of the curriculum supports a culturally
sensitive and client-centered approach to adult learning for this specific audience.
Assessment of learning objectives:
A pre and post-survey questionnaire will be administered at the beginning and at the end,
respectively, of the training session. The survey will measure whether there was progress made
in the participants' knowledge based on the objectives of the training upon completion of the
training.
Please contact researcher for more information at:
kmvang@usc.edu
HMONG YOUTH MENTAL HEALTH
Appendix C: Cultural and Spiritual Training for Mental Health Providers
(all)
~
1a
Healthy Hearts, Healthy Minds
Understanding Hmong
Cultural and Spiritual
Beliefs: A Training for
Mental Health Providers
Trainer Guide
54
HMONG YOUTH MENTAL HEALTH
Introduction
Mission and Values of KaShia:
KaShia is an organization that is dedicated to serving Hmong youth and their families, and the
broader Hmong community.
KaShia' s vision is "Youth, families and the community thrive in all core areas of health:
emotional, mental, spiritual and physical."
KaShia's mission is "to holistically support underserved youth's well-being by leaning into
community cultural strengths and collaborating with allies to create innovative solutions."
KaShia's values are:
• Cultural strengths and humility
• Respect
• Collaboration
• Inclusion
• Ethical Adherence
Purpose:
55
While many Hmong practice Christianity and other religions today, an estimated 70% of
Hmong still practice animism and shamanism in the United States (Moua, 2019). In the Hmong
society, shamans are highly respected and regarded as the intermediary between the physical
world and the spiritual world (Lemoine, 1986). The Hmong believe that the cause of an illness is
due to spiritual incongruence such as the loss of one of a person's three souls, a curse inflicted
upon the individual or family, or an angry spirit (Moua, 2019; Fadiman, 1997). It is culturally
sanctioned to seek out herbal remedies or requesting for a shaman to perform spiritual soul
healing ceremonies to heal the person (UC Davis, 2009).
From a holistic perspective, spiritual practices have been found to have positive effects on
mental health and well-being when treating the person (Weber & Pargament, 2014). These
researchers found that a holistic approach comprised of spirituality and Western health care
approaches could improve a person's mental health. Studies also found that trained mental
health clinicians were able to engage in spiritually competent practice with their clients, leading
to positive outcomes (Rogers, Wattis, Stephenson, Khan & Curran, 2019).
The purpose of this curriculum to provide Hmong bilingual and non-Hmong mental health
providers a basic understanding of Hmong spiritual beliefs, as it pertains to animism and
shamanism, and Hmong cultural background as a foundation for culturally competent practice
and care of Hmong youth and their family. The knowledge gained through this curriculum will
support mental health providers' holistic approach to treatment that is inclusive of Hmong
spiritual beliefs and Western mental health care.
HMONG YOUTH MENTAL HEALTH
Audience:
The primary audience for this curriculum is Hmong bilingual and non-Hmong mental health
providers who wish to increase their understanding and knowledge of Hmong culture and
spiritual beliefs. Participants may have a varying degree of exposure to the Hmong culture.
However, cultural competency and cross-cultural practice should be of interest to the audience.
Goal of this training:
56
The focus of this training is to provide mental health providers an overview of the Hmong
culture, spiritual beliefs, shamanistic practice and traditional understanding of mental illness both
in its causation and treatment. This training seeks to increase the cultural competency of mental
health providers working with Hmong consumers. An emphasis on holistic and cross-cultural
mental health practice will be made throughout the training.
Upon completion of the training, participants will receive a certificate of completion indicating
they have completed the KaShia Hmong cultural and spiritual training and have the foundational
knowledge necessary to start engaging in culturally competent mental health practice. It is
important to note that one single training, such as this one, will not be sufficient for a truly
competent practice. Mental health providers will need to continuously engage in an intentional
and thoughtful partnership with the clients they are serving and seek out consultation with
cultural experts as needed.
Learning objectives of this training:
• Understand the cultural background and traditional spiritual beliefs, including the
practice of shamanism, of the Hmong community in the United States
• Educate participants on the connection between Hmong historical trauma and the current
mental health issues among Hmong adults and Hmong youth.
• Increase cultural competency in regard to working with Hmong individuals, adults and
children
• Develop a strength-based, culturally sensitive approach to working with Hmong
consumers
• Examine how spiritual healing and mental health treatment can work hand in hand in
supporting a youth' s mental and emotional well-being.
Theoretical Approaches used in this curriculum:
The curriculum is based on these theoretical lenses and principles:
• Client-centered approach
• Cultural humility and competence
• Respect and validation of spiritual and shamanistic beliefs
• Cognitive Behavior Theory and approach
HMONG YOUTH MENTAL HEALTH
• Narrative therapy
• Trans-adaptation of mental health concepts and terminology into Hmong
Delivery methodologies
The curriculum will be delivered in two modules of 90 minutes each.
The curriculum information will be delivered using these methodologies:
• Lectures
• Discussions
• Use of case studies
• Videos
This curriculum was written to provide structure and guidance to cover essential information to
meet the goal and objectives of the training. However, it also allows for flexibility to meet the
needs of the participants during the training session.
This curriculum is flexible enough to be delivered either in person or virtually.
Assessment of learning objectives:
A pre and post-survey questionnaire will be administered at the beginning and at the end of the
training session. The survey will measure whether there was progress made in the participants'
knowledge based on the objectives of the training upon completion of the training.
Please contact researcher for more information at:
kmvang@usc.edu
57
HMONG YOUTH MENTAL HEALTH
Appendix D: Directory of Hmong Mental Health Providers
•
'
,
1a
Healthy Hearts, Healthy Minds
Directory
of Hmong Bilingual
Mental Health Providers
Please contact researcher for more information at:
kmvang@usc.edu
58
Running head: HMONG YOUTH MENTAL HEAL TH 59
Appendix E: KaShia Storyboard
1. The Chang Family
What's Happening:
Mr. and Mrs. Chang are Hmong refugees who immigrated from Laos 30 years
ago. They currently live in California. They speak some English but prefer to
communicate in Hmong. Kong is their 14-year-old son. Kong used to be an
Honor roll student but has stopped attending school this year. Kong seldom
engages in conversations with his parents and siblings and withdraws to his
bedroom most of the time. The school says Kong is just being defiant. Mr.
and Mrs. Chang are worried about Kong, but don't know what to do.
2. Seeking help from a Shaman
What's Happening:
Since there does not seem to be anything medically wrong with Kong, Mr.
and Mrs. Chang believe the issue may be of spiritual nature and they have
come to consult with Mrs. Moua, a shaman who provides protection and
healing for individuals and families. Shamans, like Mrs. Moua, can
evaluate the spiritual needs of a person. They can also navigate between
the physical and the spiritual world to guide one's wandering spirit back to
their body, which is believed to cause illnesses, thereby healing soul and
body. Mrs. Moua evaluates Kong's spiritual condition and performs a "soul
calling" ceremony. Mr. and Mrs. Chang feel relieved and are hopeful Kong
will improve.
HMONG YOUTH MENTAL HEALTH
3. A Shaman who understands Mental Health
What's Happening:
Mrs. Moua, the shaman, explains to Mr. and Mrs. Chang that based on her
spiritual evaluation of Kong and the mental health training she received, she
believes Kong may suffer from mental health issues. Mrs. Moua explains that
mental health is as important as spiritual and physical health. Mrs. Moua
explains that through the KaShia Hmong Shaman mental health training. she
learned about mental health. She spoke with a clinician who explained that
even children can be sad and depressed. She learned that people who are
receiving mental health services are not "crazy" and that there is help
available for Kong.
60
4. KaShia: A Holistic Intervention
What's Happening:
Mrs. Moua suggests Mr. and Mrs. Chang speak to a mental health
professional. Mr. and Mrs. Chang are hesitant because they don't feel
comfortable going to the Behavioral Health Department because no one
there speaks Hmong. Mrs. Moua provides Mr. and Mrs. Chang contact
information to Ms. Xiong, a clinician through KaShia Telehealth. Mrs.
Moua explains that KaShia* is an organization that helps Hmong youth and
families get connected to professionals who speak Hmong and understand
the culture. KaShia works and consults with shamans to better help
people. KaShia can help Hmong families no matter where they reside
through technology on smart phones.
*KaShia in Hmong means "happy heart."
HMONG YOUTH MENTAL HEALTH
5. Meeting with the Clinician on Telehealth
·-
What's Happening:
Mrs. Moua shows how to use the Telehealth App on her smart phone and
tells them "you press the button and then you can speak with Ms. Xiong or
another clinician." Mrs. Moua explains that Ms. Xiong speaks Hmong. Mr.
and Mrs. Chang are relieved to hear that because they don't know any
Hmong clinician in town. They connect with Ms. Xiong on their smart phone.
Ms. Xiong, the Telehealth clinician, lives in the Minnesota and is glad to meet
with Mr. and Mrs. Chang online. Ms. Xiong explains what mental health
service is and how she may be able to help. They discuss Kong's situation.
Ms. Xiong meets with Kong. He agrees to meet again. The family agrees to a
treatment plan. Mr. And Mrs. Chang feel relieved Kong can get some help
without the whole local Hmong community finding out.
61
6. Holistic Intervention with Spiritual and Mental Health Services
What's Happening:
Kong has continued to meet with Ms. Xiong via KaShia Telehealth. Ms.
Xiong has provided Mr. and Mrs. Chang some education about Kong's
diagnosis. They have a better understanding of Kong's mental health
issues and are supportive. They also consult with Mrs. Moua to ensure
Kong's spiritual health is optimal.
HMONG YOUTH MENTAL HEALTH
7. Title: Kong's Mental Health Improves with KaShia
What's Happening:
Kong is more engaged with his parents and siblings. With the assistance of
Ms. Xiong, Mr. and Mrs. Chang advocated for An Individualized Educational
Plan (IEP) and there is a plan to transition Kong back into school. Mr. and
Mrs. Chang feel like their cultural beliefs were validated through their
interactions with Mrs. Moua, the Shaman, and Ms. Xiong, the KaShia
Telehealth clinician.
62
KaShT a
Healthy Hearts, Healthy Minds
Running head: HMONG YOUTH MENTAL HEAL TH 63
Appendix F: EPIS Model
• Outer Context
• Barrier: anti-immigrnat political climate, local mental health system, lack of desegregated data.
Exploration
• Facilitator: Supportive local legislators, MHSA funding, strong network
• Inner Context
• Barrier: new non-profit, limited number of bilingual Hmong clinicians
• Facilitator: Support from Hmong shamans, Hmong community increased awareness of mental health issues
• Outer Context
• Barrier: Current local Hmong-serving non-profit
Preparation
• Facilitator: funding opportunities; Hmong bilingual professional associations
• Inner Context
• Barrier: new staff to be hired and trained; telehealth technology to be tested
• Facilitator: Strong organizational vision and mission; leadership connection
• Outer Context
• Barrier: Insufficient funding, political leadership changes, legislation not in support of immigrant populations
Implementation
• Facilitator: Strong connections to foundations; diversifying of revenue
• Inner Context
• Barrier: New processes needing refinement, staff being open minded whi le working out programmatic issues
• Facilitator: Staff believe in mission and values, deliver best practices
• Outer Context
• Barrier: Political landscape, policies at federal, state and local levels
Sustainment
• Facilitator: Hmong community focus on mental health issues; leadership and political support
• J nner Context
• Barrier: Staff turnover; cultural, language and clinical requirement of staffing
• Facilitator: Leadership has strong relationships with professional networks and local political leadership
Running head: HMONG YOUTH MENTAL HEAL TH 64
Appendix G: Gannt Chart
8/1/2020 2/17/2021 9/5/2021 3/24/2022 10/10/2022 4/28/2023 11/14/2023 6/1/2024 12/18/2024 7/6/2025
E: Analysis of the problem, market
E: Policies and political climate analysis
E: Explore Funding Opportunities
E: Select telehealth platform
P: Finalize shaman mental health training curriculum
P: Finalize Hmong cultural and spiritual training curriculum
P: Complete by-laws, file for 501(c)(3) status
P: Connect with stakeholders
P: Obtain 501 (c)(3) non-profit status
P: Recruit Board of Directors
P: Create job specifications for all positions
P: Prepare and submit grant proposals
P: Secure funding
I: Hire & train staff
I: Activate marketing materials
I: implement pilot program
I: Track data for measurable outcomes
I: Monitor fidelity of the model
I: Fiscal monitoring of programs
S: Pursue diversification of funding
S: Evaluation of program model fidelity
(j)
(j)
(j)
(j)
21
(i)
26
3
S: Analysis of measurable outcomes 81
S: Leadership sustain momentum 906
Days Into the Task Days Remaining
Running head: HMONG YOUTH MENTAL HEAL TH
REVENUE
MHSA
Category
MediCal/Private Insurance Reimbursement
Various Foundations
Dignity Health Mercy Medical Foundation
Fundraising
Consultation
Government grants
In-Kind staff time from Dignity Health
In-Kind space from Dignity Health
Total REVENUE
EXPENSES
Personnel Exp
Wages/Salaries
Executive Director
Clinicians (full time)
Fis ca I manager
IT staff
Program coordinator
Trainer
Total Wages/Salaries
Benefits(@ 30%)
Subtotal
Clinicians (part-time)
Total Personnel Expense
Other Operating Exp
doxy.me Telehealth Platform
Simple practicce telemental health software
Tech/Computers
cell phones
Comm & Mat'ls
Trng/Prof Dev
Travel & Enter.
Office Supplies
Total Other Op Exp
lnKind Expense
Dignity Health staff
Dignity Health Space
Total lnKind Exp
Total EXPENSES
SURPLUS/DEFICIT
Appendix H: Start-Up Budget
Kashia
Start-Up Budget
------------ $'s (OOO's) ------------
$100,000
$50,000
$200,000
$100,000
$30,000
$20,000
$0
$10,000
$600
$80,000
$70,000
$60,000
$40,000
$50,000
$20,000
# of Staff
1
1
1
$510,600
1 part-time
1
1 part-time
----------------Comments ---------------
$320,000
$96,000
$416,000
$20,000
$436,000
$300,000 wages & Salaries to apply beneits
$4,620
$3,948
$10,000
$7,200
$5,000
$5,000
$2,000
$5,000
$42,768
$10,000
$600
$10,600
2 part-time 1099 contractors
$489,368
$21,232
$300 initial clinic set-up+ $360/month for up to 8 clinicians
#32/month for up to 8 clinicians
computers, laptops
$100/month x 6 employees x 12 months
brochures, website maintenance
pens, papers, ink cartridge, etc.
65
HMONG YOUTH MENTAL HEALTH 66
Appendix I: Pre and Post Survey for Shamans
1. I know what mental health is.
Strongly disagree disagree neutral agree strongly agree
2. I know what a mental illness is.
Strongly disagree disagree neutral agree strongly agree
3. I know the causes of mental illnesses.
Strongly disagree disagree neutral agree strongly agree
4. I know what a mental health diagnosis is.
Strongly disagree disagree neutral agree strongly agree
5. I know what depression is.
Strongly disagree disagree neutral agree strongly agree
6. I know what mental health treatment is.
Strongly disagree disagree neutral agree strongly agree
7. I know the benefits of mental health treatment.
Strongly disagree disagree neutral agree strongly agree
8. I know about youth mental health issues.
Strongly disagree disagree neutral agree strongly agree
9. I know about resources for youth mental health.
Strongly disagree disagree neutral agree strongly agree
10. I am willing to refer youth to mental health services.
Strongly disagree disagree neutral agree strongly agree
HMONG YOUTH MENTAL HEALTH 67
Appendix J: Infographics
Mental Health Services
Can Save Mai's Life
and Other Hmong Youth Like Her
But For Hmong Youth,
The Stakes Are Much Higher
_,,
Average Youth
Depressive
Symptoms
Self-harm
Suicidal
Ideation
Hmong Youth
• Mental health stigma
• Lack of access
Why
7
• Language barriers
• Lack of culturally
competent service
providers
Innovative Solution
KaSh1a
e '"1 tU ,h I 1 !lit 5
Trained Hmong
Shamans support
spiritual healing
along with western
mental health
services
Contact Us:
KaSh1a
Heo I y rr,, H I , • •
WWW .KASHIA.COM
123-456-7890
AC0eSS to mental
health services that
are bilingual and
respectful of the
Hmong wlture
Virtual Aa:ess to
Hmong Bllingual
dinicians no matter
where the youth and
family are located

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Asset Metadata

Creator Kimiko, Vang Moua (author)

Core Title From “soul calling” to calling a therapist: meeting the mental health needs of Hmong youth through the integration of spiritual healing, culturally responsive practice and technology

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Social Work

Degree Program Social Work

Publication Date 09/11/2020

Defense Date 07/24/2020

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Asian American youth mental health,culturally responsive practice,ensure healthy development for all youth,grand challenge,Hmong youth,OAI-PMH Harvest,youth mental health

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Enrile, Annalisa (committee chair), Nguyen, Loc (committee member), Wind, James (committee member)

Creator Email kimikomv@gmail.com,kmvang@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-367486

Unique identifier UC11666140

Identifier etd-KimikoVang-8931.pdf (filename),usctheses-c89-367486 (legacy record id)

Legacy Identifier etd-KimikoVang-8931.pdf

Dmrecord 367486

Document Type Capstone project

Rights Kimiko, Vang Moua

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA