Micro, Mezzo & Macro Levels of Implementation: An Examination of Minnesota’s Cultural and Ethnic Minority Infrastructure Grant Program

Abstract

Using Minnesota’s Cultural and Ethnic Minority Infrastructure Grant (CEMIG) program as a case study, this dissertation, using a multi-paper format, analyzes how race, ethnicity, and culture interact with large-scale, system-wide implementation projects at the micro, mezzo, and macro levels. CEMIG funded 21 agencies over $8.83 million in workforce development efforts (e.g., assist individuals in obtaining mental health licensure) for 281 individuals, clinical and ancillary services, and EBP training for cultural and ethnic minority populations from 2008-2017.Data used for these papers was varied, including 62 online survey responses from clinical trainees, over 1000 grant documents gathered and maintained by Minnesota’s Department of Human Services (DHS), and 23 interview transcripts from 27 participants collected between summer 2017 and fall 2018. While the primary method of data analysis was qualitative content analysis, multiple regression was used to assess the relationship between challenges and supportive services among clinical trainees who participated in the CEMIG program and responded to the online survey. Micro-level findings indicate that while there was no statistically significant relationship between clinical trainees and their demographics, education debt amount, or perceived level of graduate training for the mental health licensure exam, in comparison, services and supports, specifically financial assistance with test fees, were found to be beneficial. The qualitative component of the survey found that clinical trainees experienced the exams as culturally biased and were warned that the licensure exams are challenging and required code-switching behaviors to be successful. Mezzo-level findings separated grantee agencies into four types: sovereign, legacy, transitional, and grassroots; themes generated described the differential need, based on agency typology, to create internal infrastructure, attend to hidden bias, and maintain autonomy during the grant contract process. Macro-level findings demonstrate the participants perceived that the grant program perpetuated inequities by neglecting to promote the program, advocate for clinicians of color, and coordinate isolated policy ecology systems. Findings from these studies highlight the complexities of racial and cultural identity in the implementation process. At the micro level, the need for clinical trainees to engage in codeswitching behaviors to succeed, questions the role of the licensure exam in assessing competence or cultural assimilation. At the mezzo level, findings suggest that when including non-legacy agencies, more technical assistance and funding for data reporting and contract management should be included. Further, government or private funders should engage in conversations that uncover hidden biases that affect relationships and implementation processes with sovereign, transitional, and grassroots agencies. Last, at the macro level, suggestions for process improvement included enhanced data collection, innovation cross-fertilization, and stakeholder advocacy involvement. Especially within policies engaging with disparate communities, including ethnicity-specific mental health provider advocacy groups in the stakeholder advisory board and collaborating with these advocacy groups for grant program development and data collection efforts are critical for project enhancement and sustainability. Further research is needed to describe differences in implementation based on culture and ethnicity within mental health settings, as well as examining institutional norms, such as licensing exams that clinicians of color may experience in discriminatory ways.