Introduction

The Latino older adult population is one of the fastest growing segments of elderly Americans (U.S. Census Bureau 2003; Min 2005). The number of Spanish-speaking individuals residing in the United States is also increasing rapidly. Approximately 90% of Latino older adults (age 65 and older) speak Spanish in their homes (Beyene et al. 2002). As the population of Latino older adults increases, we will see a concomitant increase in the number of Latino patients who will need psychiatric and rehabilitative care. Epidemiological studies have repeatedly shown that Latino adults in need of mental health treatment are less likely than non-Latino Whites to access or receive care (USDHHS 2001; Cabassa et al. 2006; Vega et al. 1999). For example, one study reported that among Mexican Americans with a diagnosed mental disorder, only about one-fourth had used services in the past year (Vega et al. 1999). For Mexican immigrants the degree of underutilization was even lower at two-fifths of that of U.S.-born Mexican Americans (Vega et al. 1999). Several studies have documented that Latino older adults are undertreated for mental health problems and that when they receive treatment, the overall quality of care is less than optimal (Arean and Unützer 2003; Damron-Rodriguez et al. 1994; Ell 2006; Virnig et al. 2004).

Current programs delivering mental health services, based on Western behavioral models, often lack cultural relevance for Latinos seeking treatment (Sue 2003; USDHHS 2001), especially for low-acculturated Spanish-speaking immigrants (Barrio 2000; Telles et al. 1995). Latino older adults are more likely to be less acculturated to American cultural values and more likely to adhere to traditional worldviews of health, mental health, and treatment (Lau and Gallagher-Thompson 2002; Min 2005). As such, several researchers have noted that there is a mismatch between the goals and assumptions of existing program services and those held by ethnic minority older adults and their families (Abramson et al. 2002; Barrio 2000; Lau and Gallagher-Thompson 2002; Min 2005; Valle et al. 2004).

Several studies have identified sociocultural and health issues that have implications for meeting the mental health needs of Latino older adults. Epidemiologic investigations have documented that Latinos have more favorable health and mortality profiles, and mental health outcomes relative to the non-Latino White population (Markides and Eschbach 2005; Vega et al. 1998). These findings are counter-intuitive because most Latinos in the United States are socioeconomically disadvantaged compared to non-Latino Whites (Escobar 1998; Markides and Eschbach 2005; Markides and Coreil 1986). This phenomenon is particularly evident for Latino older adults of Mexican origin, especially men (Markides and Eschbach 2005). However, the evidence also suggests that living longer for Latinos is accompanied by more disability, poorer health, and, overall, a worse quality of life (Markides and Eschbach 2005). Other factors that impact the mental and physical health of Latino older adults are a lack of formal education and high rates of illiteracy (Harris 1998; Wykle and Musil 1993). Even when assessed in Spanish, older Spanish-speaking Latinos have a high prevalence of inadequate or marginal health literacy, which is associated with less illness knowledge and poorer physical and mental health (Gazmararian et al. 1999; Wolf et al. 2005). Limited English proficiency among Latinos is associated with lower use of services (Barrio et al. 2003), increased risk of lower quality of care, and worse health and emotional health outcomes (Ponce et al. 2006). Findings from a large population-based study indicate that the prevalence and risk for depression was higher for older Mexican immigrants than for U.S.-born Mexican Americans (Gonzalez et al. 2001). A complicating factor is that Latino immigrants tend to seek mental health care in health care settings where they are less likely to have mental disorders detected or adequately treated (Marin et al. 2006).

Recent national reports have prioritized the importance of understanding the insider perspectives of patients and their families in developing culturally responsive service programs to better meet the needs of ethnic minority groups (DHHS 2003; USDHHS 1999, 2001). However, only a few studies have qualitatively examined the perceptions and experience of mental healthcare and services among Latino older adults. One study of Latino older adults in an East Coast community in the U.S. (Rosental-Gelman 2002) uncovered the following areas of unmet need: transportation, communication with providers, social and recreational activities, and safety. The study findings also indicated negative perceptions of aging, and complaints of anxiety, depression, and boredom. Similarly, in an investigation in Northern California, Latino older adults were most concerned about loneliness and the prospect of living in nursing homes (Beyene et al. 2002).

The present study was a part of a larger qualitative investigation of the unmet needs for mental health services among older adults in San Diego County, California (Palinkas et al. 2007). The larger study examined the perspectives of multicultural participants representing three stakeholder groups: older adult consumers and potential consumers of mental health services, family members/advocates of consumers, and front-line clinicians and program administrators. The overarching objective was to identify specific concerns and unmet needs for mental health services of older adults, and to determine the extent to which older adults in these communities faced challenges or required solutions to challenges common to culturally diverse older adults, as a reflection of their status as a minority group, or a consequence of their unique sociocultural circumstances. The present study focused on the qualitative findings from the insider perspectives and experiences of Latino stakeholders to develop a comprehensive picture of the problems and solutions related to the need for or use of mental health services for the largest older adult ethnic minority group in the region. In contrast to previous qualitative studies which described unmet needs for mental health services among Latinos from the perspective of older Latino consumers or potential consumers of services (Beyene et al. 2002; Rosental-Gelman 2002), we also included the perspectives of caregivers and providers of services as these may affect both process and outcomes of service delivery as well as complicate efforts to address unmet needs (Fischer et al. 2002; Palinkas et al. 2007).

Methods

Study Participants

The methods and procedures are more fully described elsewhere (Palinkas et al. 2007). Briefly, study participants were recruited in two phases. Phase I participants who served as “key informants” for the in-depth semi-structured interviews included 14 Latinos from three stakeholder groups: healthcare and social service providers (n = 4), community-dwelling (i.e., non-institutionalized) pubic sector outpatient consumers (i.e., County Mental Health) and potential consumers (i.e., receiving services from programs or providers outside the public mental health system of care) of public sector (i.e., County Mental Health) outpatient services (n = 5), and caregivers (family members and patient/consumer advocates), most of whom were also older adults, who volunteered their time and efforts as promotoras to assist consumers with transportation, in-home services, and peer counseling and support (n = 5). Phase II consisted of five focus groups, one comprised of 6 Latino consumers, three comprised of 16 Latino caregivers, and one comprised of 6 providers of services to Latino consumers. The majority of the participants identified themselves as Latinos of Mexican origin, which corresponds with the demographics of the Latino population in San Diego County.

Recruitment was conducted by the County of San Diego Adult and Older Adult Mental Health Services (AOAMHS) and University of California, San Diego (UCSD) staff using a purposive sampling strategy designed to obtain “representative” viewpoints by stakeholder group and region in a nonrandomized fashion (Johnson 1990). A recruitment letter was disseminated widely among ten AOAMHS community based agencies providing mental health and support services (e.g., senior centers) serving predominately Latino populations throughout San Diego County. Potential study participants were identified by AOAMHS staff or members of the AOAMHS Community Advisory Board and invited to participate in semi-structured interviews or in focus groups for their respective stakeholder group. Three focus groups of caregivers were conducted to accommodate the large number of family members and consumer advocates who volunteered to participate. Two-thirds (66.6%) of the study participants were female. Almost all of the consumers and potential consumers (85%) were 60 years of age and older. The study was approved by the UCSD Institutional Review Board and the County of San Diego Mental Health Services Research Committee. Informed consent was obtained from each participant after the study objectives and data collection procedures had been fully explained.

Data Collection

Interviews and focus groups were conducted by trained Latino bilingual–bicultural Master’s-level providers and research staff.

Semi-structured Interviews

Semi-structured interviews were conducted with the use of a guide developed in collaboration with the investigators representing AOAMHS and the Older Adult Task Force. The following five questions were asked of all the participants, with appropriate follow-up probes: (1) For those presently involved in mental health care, please narrate your experience with the mental health service systems in San Diego County; (2) From your perspective, what are the most important needs of older adults in San Diego County? (3) Are those needs being met? (4) If not, why not? and (5) Do you have suggestions on how those needs could be met? However, the interviews were designed to also be sufficiently open-ended to enable the informant to elaborate on issues relevant to service delivery. The average interview was about 1 h long. Interviews were tape recorded and transcribed or notes were taken, according to participant preference.

Focus Groups

Focus groups were conducted to examine opinions resulting from group discussion rather than individual introspection. Each group was asked to comment on the perspectives that emerged from the semi-structured interviews of members of their respective stakeholder groups only, specifically addressing the following questions: (1) Do you agree with the findings presented? (2) Which findings do you feel to be most relevant to your experience with obtaining or providing mental health services? (3) Which findings do you feel to be least relevant? (4) Are there any aspects of your experience with obtaining or providing services to older adults with mental illness that you feel were not included or given adequate emphasis? (5) Do you believe any of these features are likely to affect your willingness or ability to change the way you obtain or deliver mental health services? (6) Can you describe specific instances where any of these features affected your willingness or ability to obtain or provide mental health services? While the predetermined probes listed above were used to guide the discussion, the bilingual–bicultural moderator was trained to elicit all relevant opinions related to the unmet needs of Latino older adults with mental illness, and allowed the group members to present their own model of these issues.

Data Analysis

Using a methodology of “Coding Consensus, Co-occurrence, and Comparison” outlined by Willms et al. (1992) and rooted in grounded theory (i.e., theory derived from data and then illustrated by characteristic examples of data) (Glaser and Strauss 1967), individual interview and focus group audiotapes were analyzed as follows. The first author and two research staff members (all bilingual and of Mexican heritage) reviewed the audiotapes and independently conducted a content analysis to condense the data into analyzable units. Provisional categories of emergent themes were developed to facilitate further coding. The results of the content analysis produced by each reviewer were discussed and through constant comparison, different categories were condensed further into broad summary themes.

The process of axial coding (Strauss and Corbin 1998) was then used by the investigators to generate a series of categories, arranged in a tree-like structure connecting transcript segments grouped into separate categories or “nodes,” with the assistance of the computer program QSR NVivo (Fraser 2000). These nodes and trees were used to create a taxonomy of themes that included both a priori and emergent categories and new, previously unrecognized categories. The number of interviews and focus groups in which these categories appeared was recorded, and specific examples of co-occurrence of categories illustrated with transcript texts. Through the process of constantly comparing these categories with one another, the different categories were further condensed into broad themes that were organized to illustrate linkages across categories (e.g., types of mental and physical disorders experienced by older adults, mental health services, social support, housing, transportation) and within specific categories (e.g., access, quality and utilization as subcategories of mental health services). These themes were further examined to determine which were identified by all three stakeholder groups and which were identified by only one or two groups. However, unlike our earlier study (Palinkas et al. 2007), no attempt was made to prioritize these themes or provide quantitative assessment of their salience based on the percentage of participants or focus groups who identified or endorsed a particular theme because of the small sample of participants (n = 14) and focus groups (n = 5).

Results

The unmet needs identified in our analysis of interview and focus group transcripts fell into two categories: mental health services and services related to factors that either placed Latino older adults at increased risk for mental illness or compromised the effectiveness of mental health services. Specific illustrative unmet needs within each of these categories, along with an indication of whether the need was addressed by members of each stakeholder group, are presented in Table 1.

Table 1 Unmet needs for mental health and other services for Latino older adults identified by one or more stakeholder groups
Full size table

Mental Health Services

Limitations to accessing existing services included organizational or administrative factors, financing of services, logistics of access, and source of access. The primary organizational barriers to accessing services as reported by members of all three stakeholder groups were language and cultural barriers, specifically a lack of translators, followed by a dearth of information on which services were available and how to use them. According to one family member, “We need to educate providers to learn the language. Although there are doctors that speak the language [Spanish], but to find them [is difficult].” The lack of information about the availability of services or about mental illness, especially in Spanish, was noted by one family caregiver who stated: “I think there is very little information that we have available about mental health. It is important to educate ourselves and to receive the information in Spanish. There is a lot of information in English, but not in Spanish.” The solution, according to a promotora, is for more outreach in the Spanish-speaking community.

The primary financial barrier to accessing mental health services was a lack of money or insurance to pay for services or medications. According to one promotora: “What I see is that people do not go to the [mental health] clinics because of the expense and the families do not have the means to pay for it. The families go to the community clinics but they limit themselves.” A Latino consumer further stated that, “I’ve had to tell my doctor that I cannot pay for three or four medications.” Generally the comments from all stakeholders indicated that Latino older adults were especially vulnerable because of a history of employment in jobs that provided no health insurance or retirement benefits and difficulty applying for government benefits (Medi-Cal, which is Medicaid in California, and Medicare) due to a lack of information about available programs and inability to speak English.

The legal status of some Latino older adults or their children and other relatives was also perceived by all three groups of stakeholders as an important barrier to accessing mental health care. According to another caregiver, “I think there is a fear of going into buildings that are government buildings, especially the ones who don’t have the documentation...because they’re afraid of being deported. Or if they have somebody in their house, they don’t want you to go into their house. If they have a nephew or niece or somebody that’s undocumented they don’t want any strangers there.”

Finally, the limited availability of providers and services were cited by members of all three stakeholder groups. As noted by one consumer, “Qualified personnel are lacking in the offices. They do not give appropriate treatment to the client.” The scarcity of mental health care providers and clinics was noted in the areas of the county where Latino older adults were most concentrated. Many Latino consumers are required to travel considerable distances to obtain mental health services. Providers, consumers and caregivers cited the lack of available transportation or reliance on public transportation as a significant barrier to accessing services.

The cultural barriers that restrict access to services also limit use of services because older adults are unwilling to use services that are not culturally responsive. Caregivers and providers noted that Latino older adults also preferred to deal with mental illness on their own or within their families. Even when services were available, there was agreement among all three stakeholder groups that Latino older adults were reluctant to use them, mainly because of a fear of being labeled as mentally ill. According to one Latino consumer advocate, “The word clinic itself scares them, especially if it’s mental, because then they say ‘I do not wish to be called crazy’ (no quiero que me digan loco).” Latino consumers and family members also noted the reluctance of Latino older adults to ask questions or to ask for help and to work with younger adults who lack an understanding of growing old. These barriers were not mentioned in any of the service provider interviews or focus groups.

To reduce the stigma associated with seeking mental health services, one Latina promotora suggested “using bilingual and culturally informed providers to educate people and educate the community.” Another caregiver called for “outreach in the person’s own language.” One family member recommended placing information on local Spanish language television programs. The implementation of age- and culturally-appropriate services was also recommended. Specific suggestions from family members for the implementation of culturally competent services included involving members of the Latino community with a reputation for being informal mental health services providers (promatoras, consejeras), hiring more bilingual staff at mental health clinics, providing additional Spanish language training to existing providers, and educating the larger community in the culture and diversity of the Latino population.

The primary barrier to quality of services was poor understanding of the needs of Latino older adults by primary care physicians and inappropriate provider attitudes toward Latino older adults. The inability to communicate with Latino older adults and the lack of sufficient time spent with consumers during clinic visits were also cited as important barriers to service quality. Insufficient time with a provider violated consumer expectations of the patient–provider relationship according to Latino consumers and caregivers; however, this barrier was not identified by any of the providers. In regard to services, the Latino stakeholders noted that existing services were not age-appropriate, focusing more on younger than on older adults. As described by one promotora: “It has not happened to me, but other people tell me that they are treated with disrespect (con falta de respeto). An older gentleman told me that he went to see his doctors complaining about aches and sorrows. His doctor told him ‘que quieres con la edad que tienes?’ (what do you expect at your age)? I also heard that they do not receive attention or are disrespected and the doctors are young.” A scarcity of culturally competent services was also thought by the Latino community to affect the quality of mental health services provided to Latino older adults.

Physical Health and Social Services

As in the larger study (Palinkas et al. 2007), respondents discussed a second category of unmet needs that appeared both to increase the risk of mental illness and affect access to services or service effectiveness. These included: physical health, socialization and social support, transportation, housing, financial assistance, legal assistance, and caregiver support.

Physical Health

Latinos often present with physical concerns or somatic complaints as culturally sanctioned expressions of psychological distress (Castillo 1998; Chaplin 1997; Escobar 1995). Consistent with this literature suggesting that Latinos perceive mental health problems as on a continuum of health and illness, consumers and family members often referred to physical health when probed about unmet needs for mental health services. Latino consumers and family members/advocates frequently cited chronic diseases, especially diabetes and hypertension, as significant challenges impacting the mental health of older adults. In many instances these individuals present with comorbid conditions because the mental illness is seen as a consequence of the physical disease, as one provider explained: “Well, it’s no secret that in our older population, two things stand out—the increasing chronic illness the older we age. We’re enjoying longer lifetimes, but that means we also have to sustain the illnesses that we carry with them into these older years—but secondly if you look at some of the indicators in our community, mental health issues rank as one of the top issues for that older population. And, indeed, it’s false to separate the two, because many of our chronic illnesses carry with it a great deal of depression.” In other instances, providers and caregivers acknowledged that despite often being stereotyped as somaticizers, somatic complaints in Latino consumers were often related to depressive symptoms.

Concerns were also raised about medication adherence, especially when patients were often unable to afford all the medications they required, and had limited functional ability and had increased risk of accidents due to frailty. As one provider to Latino older adult consumers noted: “Well, very many of them do have chronic diseases, which they don’t always manage very well, because you get into the medication adherence again, which is a big deal. Sometimes, they can’t afford the medications. Sometimes, they can’t get there; sometimes they forget or they don’t think they need it. Or pick and choose; they don’t like to take that one, but they may take that one, because it’s for your thyroid, you know, and they’re okay with that. But they don’t like some of the others, and then that can cause other problems. There are side effects with all those medications...I see a fair amount of prescription drug abuse. You know, they’ll start taking all of their painkillers and their anti-anxiety medications and their sleeping pills, and on and on and on.”

The perspectives of consumers and family members/advocates indicated that the treatment of comorbid conditions like depression and diabetes is complicated by the lack of a regular provider with consequential disruption in the continuity of care. According to one consumer, “I have no primary care doctor...there is limited access to a doctor. The employees treat you poorly—with my illness, I had difficulty finding help.” As with access to mental health services, members of all three stakeholder groups suggested that access to primary care was limited by a lack of health insurance, the high cost of services, and the undocumented status of some Latino older adults, or the legal status of their younger family members. Other reported challenges included poor nutrition due to an age-related decrease in appetite and poor respect accorded to older adults by primary care physicians. However, providers and caregivers but not consumers mentioned the need for adequate nutrition while consumers and caregivers but not providers mentioned the need for respect. Providers of services to Latino older adults recommended an establishment of age-appropriate programs to address prevention and health behavior (e.g., smoking, physical activity, diet, immunizations) and supervision of older adults with physical disabilities. Latino consumers and caregivers recommended more dental, vision, and hearing care and more time spent with patients during clinic visits pointing to the need for comprehensive centralized care that attends to health and the mental health care of this population in an age-appropriate manner.

Socialization and Social Support

The Latino participants agreed that older adults in general and those with mental illness in particular were socially isolated. Consumers and caregivers asserted that much of the depression and negative thinking experienced by Latino older adults were a result of this isolation. These stakeholders also thought that Latino older adults were even more isolated than most non-Latino older adults because of their inability to speak English. However, it was also suggested that many Latino older adults spent much of their day alone in the house because their children worked long hours and were often absent. Related to a lack of interaction with younger family members was an absence of a valued role within the family and, hence, within the larger community, and inadequate support from family members for immediate physical and functional needs. Several consumers complained of intergenerational tensions related to feelings of loneliness and disconnection. As stated by one Latino consumer, “I had to put my foot down and remind my family that I am still in charge, the ‘Jefe de la familia.’ They were not taking into account my opinion and I considered leaving my home, and thought about going to a place where nobody knew me...My children are already grown. I say what goes. I have my opinion. They cannot ignore me.”

Underlying the loneliness and social isolation expressed by Latino consumers was a cultural expectation that family members should meet their needs for companionship in line with the “customs of our culture.” Consequently many Latino older adults felt abandoned by their children; this abandonment led to psychological distress, and in turn, increased the risk of mental illness and limited access to mental health services. This sentiment was in contrast to the perspective of service providers who viewed the Latino family as cohesive and supportive of the needs of older adults. Latino participants also complained of a great need for more community resources that provided socialization and social support. Support groups for Spanish-speaking Latino older adults and respite services for caregivers were perceived as sorely lacking.

To address these challenges, Latino participants recommended use of peer counselors and the implementation of a promotora model and support groups specifically to draw out isolated Latino older adults. Latino participants also recommended that existing in-home supportive services be improved and expanded. Also recommended were the creation of more senior centers and community groups, more recreational and social activities, and programs that linked Latino older adults with the younger generation of Latino community members. Participants also asserted that programs that addressed age discrimination and the stigma attached to growing old were important and could facilitate increased social contact within the Latino community, as well as improve access to and use of existing mental health services.

Transportation

A predominant theme concerned an absence of available, appropriate, and affordable transportation services, which contributed to social isolation and restricted access to mental health services for Latino older adults. Some public transportation was not accessible to Latino older adults due to schedule inflexibility and cost. Another family member noted that older adults of color were more likely to be stopped and fined for driving without a license. As this segment of the community was especially limited in getting to and from clinic visits, there was some concern that some providers might deliberately fail to schedule appointments due to an expectation that consumers would be unable to keep them. To address these concerns, the Latino participants recommended making appropriate and free or low-cost transportation available to older adults.

Housing

Latino participants also expressed concern over the scarcity of adequate housing for Latino older adults. In part, this was attributed to age and racial discrimination. As described by one Latino consumer, “Where I live, I think there is discrimination...I was told on the phone that there were three apartments. When I went to the place and spoke to the apartment manager, with my limited English I understood that they had none available. Then I was told that there were apartments, but not for me. I had to return to the HUD office, speak with the HUD supervisors and bring the interpreter along before my application was accepted.”

Many interviewees complained that existing housing was substandard and that senior housing would not allow relatives to live with older adult residents. On the other hand, one consumer stated “I would like to have my own home. I need housing and privacy.” Participants recommended designing housing for older adults with on-site services like food, transportation, primary care, and social services.

Financial Assistance

Other unmet needs identified by Latino participants included adequate financial support to cover the high cost of living, employment assistance and opportunities, and affordable legal services. Many Latino older adults would prefer to work, if only part-time, in order to supplement their income and maintain their role as head of the household. However, a number of them reported having difficulty finding such employment. As stated by one consumer, “You want to work when you are old, but they don’t want to use you...They don’t want to give me work. My daughter says I am too old, ‘muy grande’.”

Legal Assistance

Obtaining legal assistance has been a challenge for Latino older adults. According to one Latino consumer, “We need people to help with the legal papers (naturalization). We have no money to pay an attorney.” Latino consumers and providers of services to Latino consumers but not caregivers also raised the issue of domestic violence and the need for programs to assist victims of interpersonal violence.

Caregiver Support

The need to provide support and supervision to caregivers to prevent stress and burnout was also cited by this group of participants. Related to the need for more social support services for older adults, one Latino advocate noted, “There is much stress for the families that care for the elderly at home. The Latino family has no help at all. This is also a priority.”

To summarize, the major cultural themes that emerged from this analysis were the barriers and concerns related to limited English proficiency, inadequate transportation, and being treated with a lack of respect by physical and mental health care service staff and providers. Discussions around these themes stirred strong emotional reactions from consumers and caregivers and appeared to stress the social encapsulation and loneliness experienced by Spanish-speaking Latino older adults. Several consumers recalled that, at a younger age even though they did not speak English well, they were able to work, have great mobility, be productive, raise their families, and be self-sufficient. However, as older adults, they were faced with physical limitations, which required them to depend on adult children who were busy with their own lives, and on outside services which inadequately met their needs, and had to rely on staff members who were perceived as not showing warmth or respect in their interactions. Their narratives further indicated an overall awareness of their difficulties due to language problems and poor mobility in meeting their emotional and instrumental needs. They described their experience of seeking services as being in a vulnerable position because of the potential risk of rejection, discrimination, and maltreatment in trying to meet their needs.

Discussion

This study examined qualitatively how unmet needs for mental health services for Latino older adults were perceived and experienced by three stakeholder groups. To our knowledge, this is the first study that explored the multiple perspectives of Latino older adult consumers, family members/advocates, and providers of services to Latinos. The unmet needs identified in this study appeared to be consistent with the main findings from other studies of Latino (Rosental-Gelman 2002) and non-Latino older adults (Morano and DeForge 2004) which were based on the views of consumers. However, the findings from our study shed light on additional dimensions of the larger picture because the vantage point of family members/advocates and clinicians expands our understanding of the challenges and potential solutions in addressing the unmet needs of Latino older adults. As an example, there was consensus among consumers and caregivers that diverged from the providers’ perspective regarding the problems stemming from their lack of understanding of the needs of older adults in general. Consumers and caregivers also perceived a lack of respect accorded to them and insufficient time spent with them in the provision of services. Consumers and family members described their sense of isolation and disconnectedness due to a complex number of stressors, including lack of transportation, which limited contact with other older adults outside the household and the absence of younger household members who were at work or in school. Providers, on the other hand, perceived the Latino family as cohesive and supportive of the needs of older adults without understanding that socioeconomic conditions impose certain constraints on expressions of familial support (Golding and Baezconde-Garbanati 1990). Providers and consumers but not caregivers, many of whom were family members of consumers, noted the problem of interpersonal violence in Latino households. This is in line with prior work which identified discrepancies in the problems identified by consumers, family members, providers, and policy makers regarding preferences for treatment of schizophrenia in an ethnically diverse urban population (Shumway et al. 2003). Such discrepancies suggest the potential for miscommunication between consumers and providers, which have implications for the quality and effectiveness of services provided (DHHS 2003). Although differences in the perspectives of these various stakeholders may be attributed to their respective roles in the use and delivery of mental health services (Crane-Ross et al. 2000), they also illustrate the complex nature of the delivery of services for all older adults (Palinkas et al. 2007).

An additional contribution is that our findings elucidate the cultural context of the needs and recommendations that emerged from this investigation. Latino older adults experience many of the same challenges as older adults from other ethnic groups, including the need for improved access, use and quality of services and the need for other services such as transportation, housing, finances, and legal assistance (Palinkas et al. 2007). However, the needs of Latino older adults that stem from or are related to the intersection of language barriers and low socioeconomic status—specifically lack of formal education and illiteracy—as well as legal status (their own or that of family members), may result in culturally specific barriers to access, availability, and the acceptability of services (Valle et al. 2006). The qualitative data illustrated a great cultural distance between the participants’ unmet needs for mental health services and their experience and perception of existing services.

Our findings indicate that the range of unmet needs for mental health services requires a response in multiple areas and at the micro-, macro-, and policy level. The literature suggests several factors contribute to the growing number of Latino older adults who do not have an available support system within their family network; these include increasing life spans, female employment, a decline of two-parent families, and long-distance migration by adult children (Angel et al. 2004). As our findings have shown, there is a clear need for community-based services that attend to the particular cultural context of Latino older adults and their families (Valle et al. 2004, 2006). Therefore, at the micro-level, program designers should consider the cultural dilemma of intergenerational families regarding tensions between generations in attempting to meet the needs of older adults, and thus develop service programs that attend to the unique cultural circumstances of the older adults and family caregivers.

At the macro-level, service delivery systems need to address the pervasive problems caused by a lack of cultural competence or responsiveness of clinical and support staff. Administrators should prioritize comprehensive cultural training for all staff, and deploy professional staff with higher levels of formal education in the delivery of culturally responsive mental health services than exists today. Outreach programs would benefit from involving promotoras and other such community leaders for planning and conducting meaningful efforts in promoting services and addressing linguistic and other barriers to accessing care.

Another notable finding is the presence of a variety of needs related to instrumental activities of daily living that are typical across older adult populations. These common issues concerning limited transportation resources, restricted affordable and accessible housing, and few opportunities to enhance financial status may be best addressed at the organizational and policy level through aging initiatives. However, our findings suggest that for Latino older adults, these issues are compounded by linguistic barriers and the dearth of culturally specific programs to meet their needs. The fragmentation of physical, social and mental health services may be more detrimental given the limited number of bilingual bicultural service providers and the attendant demoralization experienced by older adults requires a concerted effort at the policy level to resolve these real obstacles to independent functioning and thereby promote a better quality of life and enhance the well-being of Latino older adults.

In all, our findings suggest that multi-level strategies to improve existing programs are needed to increase types of available services and to increase the quality of services provided to Latino older adults. An increase in comprehensive services would entail more service centers focused on comprehensive health, mental health and support services in more convenient locations where Latino older adults reside. In addressing the structural barriers to access, increased services should also include more availability of affordable transportation and language assistance programs to facilitate access to care, decrease dependence on family members, and decrease social isolation. An increase in the quality of services would entail more geriatric health and mental health care delivered by trained staff who are responsive to and respectful of the unique cultural, linguistic, and intergenerational needs and challenges faced by Latino older adults and their caregivers.

As a qualitative investigation, the generalizability of these findings is limited by the nonrandom selection of study participants representing the three groups of stakeholders in the San Diego area. Given that a majority of consumers, family members, and advocates were predominately Spanish-speaking immigrants of Mexican origin, any cultural inferences resulting from this investigation should be limited to this regionally specific sample of participants, and interpreted with caution. Another study limitation was the lack of a formal measure of the acculturation level of participants. Further study is needed to explore variation in the experiences and needs of Latino older adults who migrate to the U.S. as older adults to join family members versus those who have spent all or most of their lives in the U.S. (Yamada et al. 2006). A final limitation concerns the focus group methods used in this study. Even though the facilitators may have encouraged focus group participants to disagree or add new topics to the results from the semi-structured interviews, it is possible that this strategy may have artificially increased consensus within groups or artificially decreased it across groups.

Nevertheless, our findings do identify important areas of unmet need for mental health services among Latino older adults that build on those identified in the literature on Latinos older adults. Furthermore, the qualitative informant-based nature of the data provides insight into the cultural dimensions of how barriers to adequate care are experienced. A more culturally-informed assessment of needs may lead to more individualized treatment plans with improved outcomes for Latino older adults (Yamada et al. 2006). Future research on Latino older adults would benefit from exploring these cultural issues utilizing an experimental design in a larger sample of the three stakeholder groups. The results of this study also suggest that further research is required to identify the underlying causes of discrepancies in perceptions of unmet needs between Latino consumers, caregivers and providers; to determine whether these discrepancies are associated with patterns of service utilization and treatment outcomes for Latinos; and to assess the impact of limited access of Latino older adults to other physical health and social services on mental health status and use of mental health services. Notwithstanding its limitations, we believe that this study provides insight into the complex nature of linguistic and cultural issues that support and impede the health and mental status of Latino older adults as well as their effective use of community-based services.