Differential Cultural Adaptation Designs :

1. A relevant methodological approach to empirically test the differential implementation feasibility and efficacy of culturally adapted interventions Gabriela López-Zerón, M.S. Ruben Parra-Cardona, Ph.D. Cris Sullivan, Ph.D. Deborah Bybee, Ph.D. Differential Cultural Adaptation Designs: Society for Implementation Research Collaboration Seattle, Washington September 9, 2017

2. Background and Context • NIMH Cultural Adaptation Study • Relevance and Implications • Acknowledgements Overview

3. 55.4 million Latinos/as in the United States make up for 17.6% of the total population (US Census, 2015). Latinos/as experience widespread health and mental health disparities, with foreign-born Latinos/as more likely to experience the most intense contextual adversity (Alegría et al., 2012; National Research Council, 2006). Why Latinos/as?

4. Listening and understanding • Exploring mutual interests and needs (parenting research and community needs) • Negotiating and establishing mutual goals Building a Program of Research According to CBPR Principles

9. Selecting a parenting intervention…

10. Parent Management Training—The Oregon Model (Generation PMTOR) Marion Forgatch & Gerald Patterson

12. Cultural Adaptation Cultural adaptation refers to “the systematic modification of an evidence-based treatment (EBT) to consider language, culture, and context in such a way that it is compatible with the client’s cultural patterns, meanings, and values.” (Bernal, Jimenez-Chafey, & Domenech Rodriguez, 2009, p. 362)

13. Latinos/as in Detroit

15. Implement small randomized controlled trial (RCT) with two culturally adapted interventions to empirically test: a) Differential implementation feasibility b) Differential cultural acceptability c) Differential initial efficacy Specific Aims

16. Generation PMTO: Evidence-based parenting intervention aimed at improving parenting skills and reducing problematic behaviors in children • 1. Positive Involvement • 2. Skill Encouragement • 3. Limit Setting • 4. Monitoring/Supervision • 5. Family Problem Solving

17. Bernal, G., Bonilla, J., & Bellido, C. (1995). Ecological validity and cultural sensitivity for outcome research: Issues for the cultural adaptation and development of psychosocial treatments with Hispanics. Journal of Abnormal Child Psychology, 23, 67-82. Domenech Rodríguez, M. M., Baumann, A. A., & Schwartz, A. L. (2011). Cultural adaptation of an evidence-based intervention: From theory to practice in a Latino/a community context. American Journal of Community Psychology, 47, 170-186 Ecological Validity Modeland CAPAS Intervention 1. Language 5. Concepts 2. Persons 6. Goals 3. Metaphors 7. Methods 4. Content 8. Context

18. Method

19. CAPAS vs. CAPAS-ENHANCED Immigration and Biculturalism Concepts and Examples

20. Advocacy - Access to various resources (e.g., immigration clinic, food pantry, job training, funeral assistance, etc.). • Interventionists - One team for each condition, each integrated by one male community organizer and one female clinical MSW. • Active case management for IPV and specialized mental health services Both Adapted Interventions

21. Prevention Design Screening: Latino/a immigrant families with children ages 4-12; mild to moderate child behavioral problems • Parenting groups format • Randomized Controlled Trial (a) CAPAS-Original, (b) CAPAS-Enhanced, (c) Wait-list control • Multiple Assessment Points Quantitative: BL (T1), Intervention Completion (T2), 6-month follow-up (T3) Qualitative: Intervention Completion (T2) Design

22. 103 Families (189 individual parents) randomly assigned: [1] CAPAS (n=36) [2] CAPAS-Enhanced (n=35) [3]Wait-list Control (n=32) • Participant Demographics: Latino immigrant families with one target child per family Child 4-12 years old, exhibiting mild to moderate behavior problems 84.47% compromised of two-parent families 62% reported annual family income lower than $30,000 Participants

24. Satisfaction Ratings All Parenting Waves (Scale 1-5)

25. Results • Overall, CE and CA were both significantly different from control group • Comparisons of linear slopes indicate: • Significant differences between CE and control on overall means and all parenting measures • Significant differences between CA and control on all parenting measures but skill encouragement

26. Parenting Skills

27. Child Outcomes

28. Parent Reported Child Behavior • Significant Gender Effect Observed: • Mothers reported significant improvements of child internalizing behaviors only • Fathers reported significant improvement of child internalizing and externalizing behaviors

29. Qualitative Findings “My neighbors starting calling my daughter “little Black girl”…and then she started dating a White boy who would say to her “you are not Black, you are Brownish.” This is hard…I just wish we all could teach our children that we can live without being racists to one another.” (CE mother) “You grow as a person by being an immigrant. You also struggle if you do not have basic services like health insurance. Without an education, you cannot grow professionally in this country. It was important for me being able to talk with other parents about the limitations we experience in this country as immigrants.” (CE mother)

30. Translating Research into Practice Implications for Stakeholders • Specific intervention components had a positive impact on participants in both interventions, suggesting a cross-cultural impact of components • Differences in parental ratings may be due to contrasting levels of acculturation and parenting expectations between mothers and fathers. More research is needed in this area. • Participants’ high satisfaction with both adapted interventions indicates the need to achieve fidelity to the original PMTO core components as well as cultural relevance. • Relevance of comparative designs in cultural adaptation research, including need to examine: a) the impact of differential level of adaptation, and b) parental gender effects

31. Translating Research into Practice Implications for Research and Practice • Culturally adapted EBPs constitute a relevant alternative to reduce mental health disparities that disproportionally impact diverse populations • Engagement: • Rather than offering mental health services in traditional settings  provide services in the community and offer referrals as needed • Intervention Delivery Team: • a community organizer + a clinical MSW  key for engagement, retention, and bridging of community resources • Context: • Importance of overtly addressing discrimination (Unger, 2015)

32. Acknowledgements • Community partners • Latino/a parents • Mentors, co-investigators • Research Staff • Funding Support: • National Institute of Mental Health (NIMH), Division of Services and Intervention Research, Grant #5R34MH087678 • Michigan State University, Office of Vice-President for Research and Graduate Studies (OVPRGS), the MSU Collegeof Social Science, and the Department of Health and Human Development

33. Thank You! ¡Gracias!

34. Qualitative study (n = 83) aimed at: a) Learning from the life experiences of Latino/a parents in Michigan. b) Exploring the feasibility of disseminating parenting interventions among Latinos/as residing in Michigan. c) Identifying a target Latino/a community in high need of services. Parra-Cardona, J.R., Holtrop, K., Córdova, D., Escobar-Chew, A.R., Tams, L., Horsford, S., Villarruel, F.A., Villalobos, G., Dates, B., Anthony, J.C., & Fitzgerald, H.E. (2009). “Queremos Aprender”: Latino Immigrants call to integrate cultural adaptation with best practice knowledge in a parenting intervention. Family Process, 48, 211-231. Initial Step: Listening and Learning

35. Adversity and Discrimination • Parenting Challenges • Parenting Needs Qualitative Findings: Foreign Born Latinos/as

36. Adversity and Discrimination “Discrimination is a bitter drink that you need to swallow…you have to swallow it…because you say ‘If I get rebellious or do not behave, they can throw me into jail or they won’t help me’…So, you just have to swallow that drink.”

37. Parenting Challenges and Needs “We are Latinos and our children cannot lose their roots…We have just arrived to this culture but our roots will not be lost…So, our children will not forget how to speak Spanish because that is what we teach them at home.”

38. Parenting Challenges and Needs “We went with therapists, Anglos . . . when it went wrong is when they said, ‘you have to be this way, that way’. . . We want to learn, but there is a way to share with others that can help. . . To say something like ‘I’ll share this with you, it’s not the complete solution, but it might work for you’.”

39. Probability of Arrests by Group Average (HLM Bernoulli estimation) Group × Time ß11 = -.34, p.031 Control Group Intervention Group Forgatch, M. S., Patterson, G. R., Degarmo, D. S., & Beldavs, Z. G. (2009). Testing the Oregon delinquency model with 9-year follow-up of the Oregon Divorce Study. Development and Psychopathology, 21(2), 637–660.

40. Eligible and screened (N = 135) • Excluded (n = 32) • Declined participation (n = 6) • Schedule conflicts (n = 8) • Unable to make contact (n = 8) • Relocated: (n = 10) Randomized (N = 103)

42. Qualitative Findings “It was helpful to learn to impose my authority, but without hurting my children. Now I stop and see my children, and that pushes me to keep applying these parenting tools…Now, I motivate them more and I set my authority as a father, but with love.” (CE father) “Group helped open my eyes. I learned to recognize the good things about my daughter. This was hard for me because I used to only see what she did wrong and I would criticize her.” (CA mother) Parra-Cardona, J. R., López-Zerón, G., Domenech Rodríguez, M., Escobar-Chew, A. R., Whitehead, M., Sullivan, C., & Bernal, G. (2016). A balancing act: Integrating evidence-based knowledge and cultural relevance in a program of prevention parenting research with Latino/a immigrants.Family Process, 55, 321-337

43. Translating Research into Practice Gabriela López-Zerón lopezga3@msu.edu