Health Education

Fuerte Program provides mental health education for arriving immigrant youth

[Pictured: Dr. William Martinez, UCSF Director of Pediatric Mental Health for the UCSF Health and Human Rights Initiative, is the principal investigator of the Fuerte program, a school-based group prevention program targeting newcomer immigrant youth at risk of behavioral health concerns. Photo: Anna Hoch-Kenney]

Every year, about 500 newcomer immigrants enroll in San Francisco public high schools, according to district data. Of those 500, well over half come from Honduras, El Salvador, and Guatemala. Another eight percent come from Mexico.

Among recent immigrants, linguistic, academic, social, financial, and now, pandemic stress is common. Latinx newcomer youth are at increased risk for traumatic stress and behavioral disorders, according to research done by the William T. Grant Foundation. They are also less likely than their white counterparts to have access to and use mental health care services.

Fuerte, a semester-long mental health education program for Spanish-speaking Latinx newcomer immigrants in the San Francisco Unified School District (SFUSD), seeks to change that. It has served over 350 youth since its inception in 2015, it has survived the pandemic, and its current iteration is being evaluated by UCSF researchers for impact on mental health literacy, linkage and access to mental health services, and social connectedness.

According to Dr. William Martinez, the principal investigator, the study is an opportunity to demonstrate the tangible impacts of mental health programs like Fuerte on immigrant youth. “If we can demonstrate this program is beneficial to this population, we can get funding to sustain it [and] disseminate it to other places around California,” he explained. As of now, the San Francisco program has been guaranteed funding for at least two more years, thanks to the Mental Health Services Act Innovation fund, which has been financed by a one percent income tax on annual personal incomes of over one million dollars since 2004 .

In addition to recognizing the unique mental health needs of newcomer immigrant students, Fuerte is groundbreaking in that it emphasizes the importance of preventative care. Martinez and his fellow clinicians first recognized the need for a preventive mental health program in 2013, when they began seeing “a lot of [Central American] kids coming in [to the UCSF clinic] with a lot of trauma,” he said. “Newcomers were coming in … when they were already a lot more acute, [with] a lot more behavioral health problems.” The psychological impact on immigrants of the United States’ inhumane family separation policies and detention centers, its criminalization of immigration, and its racist rhetoric at both national and interpersonal levels cannot be understated here.

Part of Fuerte’s programming, therefore, is a screening meant to identify mental health care needs and link students to services sooner. However, structural barriers to access remain. Conversations with Latinx newcomers in the program revealed that most youth were not available outside of school hours. “Most of our kids are working after school and a lot of them are working 20+ hours a week,” Martinez told El Tecolot. “We have workforce turnover … for the same reason — it’s so expensive,” he said. A shortage of Spanish-speaking mental health clinicians in San Francisco means that care is frequently delayed for patients who need bilingual services.

Erik Martinez, SFUSD focal services supervisor, said that for newcomer students “there’s a critical need for mental health [support]. There are waitlists for people to have access. Some of those waitlists are closed…[some are] minimum a month out, meaning that someone won’t be seen for a month. I think Fuerte does help — I think school-based supports do help, but I think we also have to remember that schools close for the summer.”

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What makes Fuerte great — that it is easily accessible during free periods at school — is also a reminder of the program’s limits. Ensuring access to mental health resources for newcomer students is a task that extends well beyond the limits of Fuerte and into local and state healthcare policies and priorities. No child should be waiting months for a therapy appointment. To not address the demonstrated need for Spanish-language clinicians in the city with urgency is to neglect Latinx communities.

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Further, even as Fuerte’s programming addresses literacy and linkage needs, it has also exposed new ones. For Latinx newcomers who speak Portuguese or Indigenous languages, for instance, there is a double language barrier: of not speaking English and not speaking Spanish. “We had a lot of folks being referred to us who spoke Portuguese [or] Mom,” Martinez said. One year, five Brazilian newcomers were referred to Fuerte, and the program turned them away rather than attempt to accommodate them.

A few years ago, San Francisco International High School, one of three high schools that offers Fuerte programming, approached the research team requesting an adaptation for Syrian and Yemeni newcomers. The rollout of the modified curriculum began in early 2020, but fell apart shortly after when the pandemic hit. Transitioning to Zoom and Telehealth did not inhibit the more established Spanish language program, however. In fact, even virtually, the program was able to develop students’ sense of social connectedness. One youth participant said in a focus group, “Fuerte is a great group because we share our ideas and dreams for our future, and other things about ourselves, and we share these with the group … I learned a lot of things about [the other youth participants]and they learned about me too.”

That the program is effective over Telehealth is particularly important in terms of scaling up and out to reach more newcomer populations. In more rural areas without enough Spanish-speaking providers but with substantial need, like the Central Valley, we know now that mental health education and prevention programs can happen virtually and have a substantial impact.

With regards to other future directions, the Fuerte team is discussing whether and how to involve parents in their programming. Many newcomers are “now being reunited with family members they’ve never met before, [or that] they haven’t seen in a long time, and now they need to learn to get along,” said Martinez. But again, similar barriers to implementation and access exist. Like their children, parents are often working multiple jobs and/or taking care of children. Waitlists are long. “We gotta get creative,” Martinez said.