Adaptations of evidence-based interventions for diverse families: Cultural competency from conception to implementatio

1. Adaptations of evidence-based interventions for diverse families: Cultural competency from conception to implementation (and beyond) Stephanie I. Coard, Ph.D.Associate Professor Human Development and Family Studies, UNCG Workshop presented at the 26th Statewide Conference on Child Abuse and Neglect Winston-Salem, NC ~ March 17, 2008

2. Workshop Purpose The translation, implementation and testing of clinically efficacious interventions into community settings Specifically, Culturally adapting and testing those interventions to ensure successful dissemination within urban and inner-city communities with economically disadvantaged African American families

3. Workshop Learning Goals: 1. Gain knowledge of cultural competence and cultural relevancy and its importance in prevention programming. 2. Gain knowledge of racial socialization as a key culturally-based theoretical model for understanding African American families and developing programs targeting them. 3. Learn how to bridge culturally-specific content/processes with generic evidenced-based practices to optimize program efficacy and effectiveness.

4. “We all should know that diversity makes for a rich tapestry. We must understand that all the threads of the tapestry are equal in value, no matter their color, equal in importance, no matter their texture.” -- Maya Angelou

5. Defining Ourselves HOW DO YOU IDENTIFY YOURSELF? Racially Ethnically Culturally

6. Definitions cont’d Race: A concept that refers to a presumed classification of all human groups on the basis of biological or visible physical traits (e.g., skin color, physical features), behavioral patterns, and, in some cases, language.

7. Definitions cont’d Ethnicity: Refers to a group with a specific national origin, religious affiliation, or other type of socially or geographically defined group. In the U.S., ethnicity has been used as a euphemism for race when referring to people of color and as a nonracial designation for Whites (Betancourt & Lopez, 1993)

8. Definitions of diversity constructs Culture: The transmission of knowledge, skills, attitudes, behaviors, and language from one generation to the next, usually within the confines of a physical environment. According to this viewpoint, culture is a learned behavior (Smedley, 1993).

9. Total Population Comprised of Different Groups(in millions/percentage of total population) Populations 1996 2050____ • Hispanics 27.8(10.5%) 96.5(24.5%) • African American 32.0(12.1%) 53.6(13.6%) • Asian/Pacific Isl. 9.1(3.4%) 32.4(8.2%) • American Indian 2.0(0.7%) 3.5(0.9%) • White 194.4(73.3%) 207.9(52.8%) • Total 265.4(100%) 393.9(100%) Source: U.S. Bureau of Census, 2000. Hispanic can be of any race; data for all other groups are non-Hispanic.

10. U.S. Diversity • The United States has become increasingly diverse in the last century.  • Approximately 30 percent of the population currently belongs to a visible racial or ethnic minority group.  • By the year 2100, non-Hispanic whites will make up only 40 percent of the U.S. population. -- U.S. Census (2000)

11. "The future health (and mental health) of the nation will be determined to a large extent by how effectively we work with communities to reduce and eliminate health disparities between non-minorityand minoritypopulations experiencing disproportionate burdens of disease, disability, and premature death." ~ Guiding Principle for Improving Minority Health, Centers for Disease Control

12. Healthy People 2010 • Healthy People 2010 is designed to achieve two overarching goals: 1) Increase quality and years of healthy life; 2) Eliminate health disparities. • The second goal of Healthy People 2010, to eliminate health disparities, includes differences that occur by gender, race, ethnicity, education, income, disability, geographic location, or sexual orientation. • Compelling evidence indicate that race and ethnicity correlate with persistent, and often increasing, health disparities among U.S. populations in all these categories and demands national attention.

13. MENTAL HEALTH: CULTURE, RACE, AND ETHNICITY: A Supplement to Mental Health: A Report of the Surgeon General Probe more deeply into mental health disparities affecting racial and ethnic persons. Three purposes: To understand better the nature and extent of mental health disparities; To present the evidence on the need for mental health services and the provision of services to meet those needs; and To document promising directions toward the elimination of mental health disparities and the promotion of mental health.

14. Theory and Research:Help-seeking Behavior • Intercultural differences in parental “distress thresholds” • Financial resources • Variation in the presentation of emotional/behavioral illnesses • Language

15. Reducing Barriers • Recruitment • Engagement • Retention • Participation • Overall Effectiveness • Satisfaction

16. Mental Health Service and Utilization among Racial/Ethnic Groups People of African Descent: • Drop out of services at a significantly higher rate than white populations • Use fewer treatment session for their mental health problems than white populations • Enter mental health treatment services at a later stage in the course of their illness than do white populations • Under-consume community mental health services of all kinds • over-consume inpatient psychiatric care in state hospitals at twice the rate of corresponding white populations • Are more often diagnosed by mental health practitioners than white populations • are more often diagnosed as having severe mental illness than white. Source: Substance Abuse and Mental Health Administration (SAMHSA), Center Mental Health Service(CMHS).

17. Mental Health Service and Utilization among Racial/Ethnic groups Latino populations: • Insufficient access to health care insurance. • Often perceive U.S. mental health models as unnecessary, unwelcoming, or not useful. • Disproportionately less access to the full range of mental health services normally expected. • They do not have comparable rates of use of ongoing outpatient services • Have lower rates of voluntary hospitalization • Use crisis and other higher-cost services at higher rates that other populations. Source: Substance Abuse and Mental Health Administration (SAMHSA), Center Mental Health Service(CMHS).

18. Mental Health Service and Utilization among Racial/Ethnic groups Asian and Pacific Islanders: • convergent evidence that Asian/Pacific Islanders underutilize mental health services, regardless of service type. • more likely to drop out after initial contact or terminate prematurely from mainstream service settings. • Underuse linked to shame, stigma and other cultural factors that influence symptom expression and conceptions of illness, as well and to limited knowledge about the availability of local mental health services, and a tendency to seek more culturally congruent care (e.g., herbalist, acupuncturist, and other forms of indigenous healing) • When they do seek care, they are more likely to be misdiagnosed as "problem-free" Source: Substance Abuse and Mental Health Administration (SAMHSA), Center Mental Health Service(CMHS).

19. Mental Health Service and Utilization among Racial/Ethnic groups American Indian, Native Alaskan, and Native Hawaiian Populations: • In 1955 the Public Health Service via the Indian Health Service and Bureau of Native Affairs assumed primary responsibility for providing health care. • 60% of Indian population is currently served by IHS (Johnson, 1995), • Of great concern is the high prevalence of depression, anxiety, substance abuse, violence, and suicide. source: Substance Abuse and Mental Health Administration (SAMHSA), Center Mental Health Service(CMHS).

20. Cultural Constructs Defined • Cultural Sensitivity • Knowing that cultural differences as well as similarities exist, without assigning values, i.e., better or worse, right or wrong, to those cultural differences (National Maternal and Child Health Center on Cultural Competency, 1997). • Cultural Awareness • Developing sensitivity and understanding of another ethnic group.  This usually involves internal changes in terms of attitudes and values.  • Awareness and sensitivity also refer to the qualities of openness and flexibility that people develop in relation to others.  • Cultural awareness must be supplemented with cultural knowledge(Adams, 1995). • Cultural Knowledge • Familiarization with selected cultural characteristics, history, values, belief systems, and behaviors of the members of another ethnic group (Adams, 1995).

21. Cultural Competency A set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables that system, agency, or those professionals to work effectively in cross-cultural situations (Cross, Bazron, Dennis, & Isaacs, 1989).   Emphasizes the idea of effectively operating in different cultural contexts.  Knowledge, sensitivity, and awareness do not include this concept.   

22. Cultural competence is … • A developmental process • Occurs along a continuum.  • There are six possibilities: • 1) cultural destructiveness • 2) cultural incapacity • 3) cultural blindness • 4) cultural pre–competence • 5) cultural competency • 6) cultural proficiency

23. What is Cultural Competency? The acceptance and respect for difference, continuing self-assessment regarding culture, attention to the dynamics of difference, ongoing development of cultural knowledge and resources, and flexibility within service models to work towards better meeting the of needs of racial/ethnic populations. (Coard, 1999)

24. Elements of Cultural Competence(Coard, 1999) 1. Requires a commitment Believing that all cultures are equal with and none are inherently superior to others. 2. Acknowledge and value diversity Recognizing that cultural differences are real and play a major part in the care of individuals and families. 3. Develop cultural awareness An awareness of one’s culture and how it shapes beliefs and behaviors. and understand the dynamics of difference.

25. Elements of Cultural Competence cont’d 4. Recognize and understand the dynamics of difference • subtle and overt differences • interaction patterns • influence of past experiences with racism, stereotyping on level of trust, etc. 5. Acquire Cultural knowledge General knowledge about cultural groups is good but individualization is critical 6. Adapt to Diversity Adapt practice behaviors to meet needs of individuals/families.

26. Determining where you stand along the continuum of cultural competence in order to choose what steps to take next in professional development. Considerations if you work directly with clients: • How do you react when confronted with a "new" client situation that does not fit your expectations? Does the situation provoke feelings of anxiety and discomfort? Are you able to assess what is going on within yourself as well as within the client? • Do you have strategies to use to gain clarification of a puzzling situation, and to enhance both your own and your client's understanding? • Are you able to support and help clients to understand that they are impacted by the same factors as you, regarding cultural differences in beliefs, expectations, behaviors?

27. Adapting to Diversity • Program marketing • Program content • Program delivery • Program evaluation

28. Marketing • Meals • Transportation • Childcare • Local community involvement • use of focus groups • advisory boards • interviews  • Advertising simplifications • - educational level • Inclusion of cultural experts • Strong community partnerships and presence • Labeling considerations • program title • program goals • participants

29. Content • Language translations • Inclusion of people of color in manuals and videotapes • Translation versions • Language expression and common language • Race related factors (e.g. oppression, racism, prejudice) • Ethnic/racial development • Culturally defined parental norms

30. Delivery • Cultural specific delivery strategies • (e.g., common language, Proverbs, affirmations, storytelling; emphasis on cultural values) • Community member “aids” • cultural value and model incongruence • Use of a collaborative approach • Diverse or racial/ethnic matching participants w/staff • Use of community members as “aids”

31. Evaluation • instruments translated in different languages • Empirical validity for children of color • Behavioral observations • racial bias • culture/learning style • Behavioral assessments • Extended family/kinship networks • spirituality

32. Cultural Competency: Take home message We need to unravel the challenges, in inter- and intra-racial and ethnic interactions . . . Multicultural competence in research and service delivery true value of diversity (on an individual and larger societal level) are crucial to the prevention, and treatment of mental health issues in diverse children and families.

33. INTERVENTION DEVELOPMENT AND ADAPTATION

34. Mission The prevention and treatment of child mental health problems and the promotion of emotional and behavioral health –with particular emphasis on Black/African American children, adolescents and their families. What does that mean?…

35. Remaining at the forefront of research in prevention and comprehensive treatments for/with African American youth and facilitating awareness of the importance of examining and understanding the role of race, ethnicity and culture in the conduct of research. • Elucidating roles of race/ethnicity in development • These factors contribute to the complexities of psychological processes, and are of vital importance to the understanding of culturally diverse populations.

36. 2. Integrate existing and new knowledge on culture, ethnicity and race with intervention efforts aimed at preventing and treating child mental health problems and fostering competence and well being. • As evidenced-based interventions are applied to children within diverse families, schools and communities, the understanding of culture and how specific culture-related factors influence implementation, acceptance and outcome become paramount.

37. Outline Research Overview • Rationale and limitations Racial Socialization Overview • Definition and Importance Intervention Development Phases • Cultural adaptation process • Intervention components Pilot Findings Conclusions and Future Directions

38. K01 Award:Cultural Strategies for Preventing Conduct Problems • Pursue research on translation, implementation and testing of clinically efficacious interventions into community settings; and in culturally adapting and testing those interventions to ensure successful dissemination within urban and inner-city communities. • A primary focus of this research has been the development and testing of culturally-relevant strategies to assist African American parents in preventing and managing common behavioral problems in children. Funded by National Institute of Mental HealthK01 MH-01881-012000-2005

39. Limitations of Parent Training Interventions Increase in contextually focused evidenced-based preventive intervention, BUT… • Focus on “surface” modifications rather than the consideration of “deeper” structural cultural adaptations. • Consideration to critical values and traditions of a particular ethnic group, the unique historical, present, and future conditions of the group have largely been ignored. • Do not consider the unique parental challenges that African American families experience and unique parenting practices that are culturally, ethnically, racially-based, valued and influenced by the societal realities that exist (e.g., racism, prejudice, discrimination).

40. Racial Socialization Defined • The process by which messages are transmitted inter- and intra-generationally regarding the significance and meaning of race and ethnicity. • Involves teaching children values and norms associated with race/ethnicity, and problem-solving skills that enable children to be flexible in their approach to race-related situations, without losing a core sense of self. Coard, S. & Sellers, R. African American families as a context for racial socialization. (2005) In V. McLoyd, N. Hill and K. Dodge, (eds.) Emerging Issues In African-American Family Life: Context, Adaptation, and Policy. New York: Guildford Press. Stevenson, H., Winn, D.M., Walker-Barnes, C. & Coard, S.Style Matters: Towards a culturally relevant framework for interventions with African American families (2005) In V. McLoyd, N. Hill and K. Dodge, (eds.) Emerging Issues In African-American Family Life: Context, Adaptation, and Policy. New York: Guildford Press.

41. Complexities of Racial Socialization • Synergistic and dynamic • Bi-directional process • Deliberate and unintended • Transmission and reception • Moderated by family and ecological characteristics

42. Racial Socialization and Child Outcomes: Empirical Findings Racial Competence Academic Achievement Self-Efficacy Self-Esteem Behavioral Competence Delinquency Drug Abuse

43. Why is Racial Socialization Important? • It influences a children’s beliefs about the way the world works. • It informs children’s beliefs and attitudes regarding ‘the self’. • It helps shape children’s repertoire of strategies and skills for coping with and navigating racism. • It impacts the nature of the child’s’ inter- and intra-racial relationships and interactions.

44. Race and/or Ethnicity Black and/or African American Biracial Multiracial Race of parent and/or race of child Race of grandparent and/or race of parent and/or child And the answer is… Barbershops/hairdressers Nail salons Resource/drop in centers Schools (drop off/dismissal) Housing projects Playgrounds/Parks Block Parties/Festivals Restaurants/Take-outs Community Centers YMCA Churches/mosques DMV Street vendors Caretakers/nannies Who am I Targeting?A quest to define Blackness

45. Intervention Development Phases 1. Qualitative Study: Further elaborate the key aspects of racial socialization through qualitative methods and review of historical, sociological, and psychological literatures. 2. Program Adaptation: Develop an intervention for African American parents of 5 – 7 year old socio-economically disadvantaged children that encourages parents use of racial socialization practices. 3. Assessment Battery: Develop an assessment battery that is sensitive to changes in racial socialization practices and related constructs. 4. Open Pilot : Pilot the racial socialization intervention as an adjunct to a standard parent training intervention. 5. Randomized Controlled Pilot: Test the enhanced parent training intervention in a randomized controlled trial (waitlist control).

46. Model of Racial Socialization Processes (Coard, 2003) Frequency of Message Frequently Used Routine aspect of parenting Moderated by family characteristics Content of Messages Racial Preparation (83%) Racial Pride (93%) Racial Equality (86%) Racial Achievement (67%) Racial Socialization Mode/Delivery of Messages Active Responsive Passive Coard, S. & Wallace, S., & Stevenson, H. & Miller Brotman, L. (2004). Towards culturally competent preventive interventions: The consideration of racial socialization in parent training with African American families. Journal of Child and Family Studies, 13 (3), 277-293.

47. Content: Black child development Using proactive racial socialization strategies Talking to your child about race Knowledge of African American history Encouraging culturally affirming attitudes and behaviors Coping with race-related conflicts Race-related advocacy in school settings *informed by qualitative findings and existing literature Delivery Strategies: Use of AA language expression, common language Physical expression Emphasize AA values about collective responsibility, cooperation and interdependence. Use of African proverbs, sayings/affirmations, poems, quotes, symbols, pledges African American perspective use of (“we”) Prayer Role-playing Storytelling/testimonies Extended family participation Humor Setting/Motif- representative of population (e.g., books, magazines, pictures) Other Culturally-Specific Considerations*

48. Program Overview: A culturally- and strengths-based parenting program for the prevention of conduct problems of young children grades K-2. Weekly session (12 weeks) Two hour sessions Meals and childcare/tutoring Ticket system Attendance (on time) Homework completion Binder Program goals: STRENGTHEN parenting skills IMPROVE parental involvement EMPOWER parents to advocate and access GUIDE parents in preparing African-American children for success So we can…. INCREASE positive behaviors in children DEVELOP self-image and self-esteem BUILD their confidence in school PROMOTE positive racial discussions ENHANCE problem-solving skills Culturally Enhanced Version:Black Parenting Strengths and Strategies (BPSS)

49. Parenting the Strong-Willed Child (Long & Forehand, 2002) • Evidence-based behavioral parent training program, recognized for its general effectiveness. • Designed to improve the parent-child relationship and increase desirable child behaviors. • Teaches skills that assist parents in dealing with and preventing noncompliance and other problematic behavior. • Skills: Attending, Rewards, Ignoring, Effective directions, Time Out

50. BPSS Parent Group Sessions: 1- 6 1Welcome and Introduction Parenting in Context: Yourselves as Black Parents Self –Reflection 2 Black Discipline: Stickin’ To, Watchin’ Over and Gettin’ With* Affection, Protection and Correction 3Young Children and Racial-Ethnic Matters Racial/Ethnic Development and Competence Racial Socialization: Talking about Race 4Understanding Child Behavior and Identifying BehaviorProblems Attending 5 Creating a Positive Homeplace** and Homespace*** Spirituality and Family Traditions Rewards 6Improving Communication Skills Ignoring *Based on Stevenson, Davis & Abdul-Kabir (2001) **Term conceived by L. Burton *** Term conceived by J.V. Ward