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A Call to Action for Delaware:

When Sister Theresa Elitz, OSF, LPCMH became a Licensed Bilingual Counselor, she had already worked for three decades as a nurse in Latin America. As a bilingual health care worker serving vulnerable patients with few resources, Sister Theresa was deeply acquainted with the intersections of poverty, discrimination, abuse, lack of access to care, and trauma rooted in oppression that too often had been passed from generation to generation for hundreds of years. As a newly licensed bilingual counselor in Wilmington in 2003, Sister Theresa could count on one hand the number of other licensed bilingual clinicians available to serve the behavioral health needs of the rapidly growing Latin@ population in the State of Delaware and surrounding areas.

its mission "to see Latinos health grow and thrive, by providing behavioral health and resources that empower individuals and families."

Delaware's Latin@ Population and Social Determinants of Health
The health of Delaware's Latin@ population is influenced by an intersection of multiple social determinants of health. The population is subject to a disproportionately high degree of marginalization, which simultaneously increases stressors and decreases access to services. Latin@s in Delaware have been vulnerable to multiple adverse health outcomes due to many factors, including multi-generational family histories of complex trauma, poverty, exposure to community violence, and limited access to public benefits due to immigration and language accessibility issues.

Multigenerational Trauma
Many of those seeking services at Amanecer have survived crimes that have never been reported. Some have come to the United States as refugees fleeing war, community violence, torture, abuse, and deprivation of fundamental resources needed for survival. People we serve have often experienced multiple traumatic events during their lives, and have grown up in families and communities with multigenerational exposures to trauma. Many have "normalized" these experiences as part of their expected life course.

Poverty
Latin@s in Delaware experience higher rates of poverty than non-Latin@s. They live in communities with a higher concentration of poverty (22% with median income of $28,000 according to the 2019 US Census Bureau American Community Survey). 2 In the Westside Wilmington "Hilltop" neighborhood in which Amanecer's office is located, 50% of the population is Latin@. 2 In this census tract, 64% of people live at or below 50-75% of the median family income (MFI) and 31% live at or below 30-50% of the area median income (AMI) poverty level. 2

Exposure to Violence
Latin@s in Delaware are exposed to higher rates of violent crime. Gun violence has continued to rise in the state of Delaware and in the City of Wilmington. According to data gathered by the

Inaccessible Services
US political rhetoric, especially over the past few years, has often led to pervasive fear among Latin@ immigrants that impacts their ability to access government-sponsored supports. Lowincome immigrants without citizenship are not able to access public benefits for which they would otherwise qualify and are less likely to seek protection from law enforcement and other government authorities for fear they could be detained or deported. When immigration policy changes target those with a history of accessing public benefits, such as the "public charge" rule promoted by the Trump Administration, are announced, there is a chilling effect. This already vulnerable, underserved, and underinsured population is now less likely to access available social services due to fear that a record of applying for public benefits their family is eligible to receive could negatively impact a petition for immigration status. 4 Another factor that limits accessibility to behavioral health treatment is access to health insurance. The 2018 Delaware Behavioral Risk Factor Survey (BRFS) revealed that -even with the expanded coverage of the Affordable Care Act (ACA) -46.5 percent of Latin@ residents between the ages of 18 and 64 did not have any form of health care coverage or health insurance. 5

The Connection between Language Access and Trauma-Sensitive Care
While all the social determinants mentioned above play a role in worsening health outcomes and limiting access to care for Latin@s in Delaware, Amanecer's workforce development program focuses on addressing access to linguistically appropriate and culturally humble behavioral health care. What does language accessibility have to do with trauma-sensitive care? When individuals call Amanecer seeking information about services, it is often the first time they have spoken about the experiences that happened to them and the feelings they have about it. Establishing a sense of trust is vital throughout the therapeutic alliance. A National Academy of State Health Policy article from December 2021 referenced a study that linked ethnic matches between clients and clinicians with improved working alliances in treatment with individuals with severe mental illness. 6 In 2014, the Substance Abuse and Mental Health Services Administration (SAMHSA) named six key principles of a Trauma-Informed Approach to behavioral health care 7 : The quality of communication between clinician and client directly impacts the ability of behavioral health providers to implement trauma-informed care in each of the above areas. However, linguistic competency alone is not enough to establish a sense of safety and trustworthiness. This is where the importance of cultural humility comes in. For a client to rediscover their voice and to heal, it must be established in interactions with professionals that the client is the expert in their own life -in what has happened to them, what has worked to help them, what has re-traumatized them, what they believe may help them to heal.
Advocacy and support from trauma-informed, culturally humble and linguistically responsive professionals establishes the safety and trust that is necessary for survivors of trauma to build a greater sense of safety and stability for themselves and their families.

COVID-19 Impact
The disproportionate impact of negative health outcomes on people of color during the COVID-19 pandemic has been well-documented. National data from the Centers for Disease Control and Prevention (CDC) shows that the percentage of deaths of Hispanic/Latino, non-Hispanic Black, and non-Hispanic American Indian or Alaska Native people has consistently been higher than the proportion of these populations in the overall US population. 8 In Delaware, the portion of Latin@ residents testing positive for COVID was higher than non-Latin@s almost every day during the early part of the pandemic. 9 The CDC and others continue to gather data about the disparities in COVID-19 outcomes, and the reasons are clearly complex, overlapping, and linked to social determinants of health. Infection rates early in the pandemic were higher among those who lived in households with multiple generations of family members present and living under the same roof. Infection and serious illness rates were also higher among those who worked in employment, such as meat processing plants, which continued to operate in person without options for adequate distancing or remote work. 9 Significantly, not only was race or ethnicity shown to be a factor in COVID-19 infection and mortality, but language proficiency was also a factor. A story from WBUR public radio in April 2021 reported that Brigham and Women's Hospital in Boston had tracked that non-English speakers had a 35% greater chance of death than those with English proficiency early in the pandemic. Early data showed that, by attending to the social determinant of language accessibility in health care, the hospital was able to improve outcomes among those with limited English proficiency, and learn important lessons about the importance of communication as a factor in the quality of care. 10 Another critical issue that has been laid bare throughout the pandemic is the effect of Secondary Traumatic Stress on the health care workforce. As more stress compounded on fewer providers, people began leaving health care jobs. This stress has taken a significant toll on bilingual health care workers. A Spanish-speaking client who worked as a nursing assistant in a long-term care facility throughout the early months of the pandemic witnessed multiple deaths at work, while at the same time feeling unable to talk with supervisors or other co-workers about the toll this experience was having on her because none of them spoke Spanish. The Health Resources and Services Administration (HRSA) Bureau of Health Workforce analysis highlighted how the combined issues of shortages in the behavioral health workforce and poor mental health and substance abuse indicators during pandemic increased the urgency for improved efforts to recruit and retain a diverse behavioral health workforce. 6

Efforts to Improve Behavioral Health Workforce Diversity Across the Country
The HRSA analysis also showed that 83.5% of psychologists, 64.6% of counselors, and 60.6% of social workers are white, and the majority of health care providers who are people of color are employed in non-licensed positions with limited opportunities for career advancement. 6 As the recognition of the link between accessible health care and diversity of the professional health care workforce has grown, so too have projects to address the need to recruit and retain professionals of color. Although there is a lot of research that still needs to be done in this area, learnings from these projects have highlighted key components of successful recruitment and retention efforts. In a July 2015 Report from the University of Washington Center for Health Workforce Studies, the following components were listed as promising strategies to recruit and retain racially and ethnically diverse graduate level students 11 : • Targeting recruitment with strategic outreach to underrepresented populations; • Holistic admissions processes that access an applicant's unique personal experiences alongside traditional measures of academic achievement; • Financial assistance -strategies that reduce financial barriers in education and training; • Mentoring -providing social support and networking with other supportive professionals in the field; and • Career development opportunities including intensive field training and partnerships among institutions with students at varied levels of training.
An article published in June 2020 similarly stated that best practices to improve workforce diversity in health professions are: Academic Support, Financial Support, Social Support / Mentoring, and Intensive Training in a community-based curriculum. 12

Call to Action
Addressing the behavioral health needs of Delaware's Latin@ population will require the collective involvement of community members, government leaders, and health care practitioners from all disciplines. In order to make behavioral health in Delaware more traumasensitive, culturally humble, and linguistically responsive, we need to consider the impact of social determinants of health on disparities of care and prioritize interdisciplinary collaboration, cultural and intellectual humility, and competency building in cross-cultural communication and trauma-informed care.
Amanecer is part of an innovative collaboration with Nemours Behavioral Health, Delaware State University, and Jewish Family Services of Delaware to recruit, retain, and support more behavioral health clinicians of color through graduate education to licensure and beyond. The unifying factor that drew the leaders of these organizations together is a sense of urgency about building community-based behavioral health service accessibility. The consortium has considered efforts to advance legislative advocacy, training, and mentorship with the goal of recruiting, retaining, and supporting culturally humble, linguistically responsive, traumainformed health care workers that are connected to and trusted by the community they serve throughout their careers.
We invite you to be a part of this conversation. Are you a leader of an organization that educates clinical behavioral health professionals? Are you a leader of an organization that employs clinical behavioral health professionals? Are you a community leader in Delaware that recognizes the need to make culturally responsive, trauma-sensitive behavioral health care more accessible in your community? Are you a Spanish-speaking behavioral health professional (from licensed practitioners to undergraduate students and everyone in between) in Delaware? Please reach out to me at Kathleen@amanecerde.org.