The Role of Culture in Prevention Science
Past Progress and Future Challenges
2013 Bennett Lecture
Bennett Pierce Prevention Research Center
Nancy A. Gonzales
Prevention Research Center
Arizona State University
Demographic Changes in U.S.
International migration is a large and growing GLOBAL phenomenon
Global Migration Trends
• Increasing Scale
230 million projected in 2050
Global Migration Trends
Involving wider diversity of ethnic and cultural groups
Global
Migration Trends
Global Migration Trends
Permanent migration being replaced by circulation
• Emergence of transnationalism Global Migration Trends
• Social networks have proliferated and increased in significance
Global Migration Trends
• Increasing polarization or bifurcation in migration
Goals of Talk:
 Describe historical forces that have shaped the role of culture in prevention science
 Summarize major contributions of research on cultural adaptation over the past 3 decades
 Highlight limitations of current strategies to address culture in prevention
Research on Culture ASU Prevention Research Center • 20 years of research spanning the Prevention Research Cycle • Ongoing developmental studies of risk and protective processes
• Intervention design, efficacy, effectiveness, implementation
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Bridges to High School REACH
New Beginnings Program Family Bereavement Program
Dissemination of Family Check‐Up Parenting for Resilience in Military Families
Evidence‐Based approach to Parent Engagement Gonzales, N.A., Lau, A., Murry, V.M., Pina, A., Barrera, M.Jr. (in press). Culturally Adapted Preventive Interventions for Children and Youth. Chapter to appear in D. Cicchetti (Ed.) Developmental Psychopathology, Third Edition. Hoboken, NJ: John Wiley & Sons.
Historical Forces (Science, Ethics, Pragmatics, & Services) 2009
2001 NRC/IOM Report Health Preventing Disparities Disorders of Report (U.S. 1994 Young People
Dept of Health NIH policy and Human requiring 2013 Services)
inclusion of 2005 Spoth,Rohrbach, ethnic Greenberg et al. Standards of minorities in (2013) Core Evidence funded (Flay et al., Challenges for Type research
1998 2005). 2 Translation
Guidelines for APA Task Empirically Force on Supported Evidence Treatments Early 1990s
Based (Chambless & Practice
Emergence of Hollon, 1998).
Cultural and Cross‐Cultural Psychology
Emergence of a New Field:
Underlying Tensions
Underlying Tensions
• Etic vs. Emic
• Fidelity vs. Adaptation • Top Down vs. Bottom Up
Cultural Adaptation of Evidence Based Interventions …
Became the predominant focus for Prevention Science
Aimed at increasing ecological validity and the congruence between the client’s experience and the elements of the intervention
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Preserve core components Increase reach (access & engagement)
Increase cultural compatibility & sensitivity
Promote community buy‐in
CONTENT AND PROCESS MODELS OF CULTURAL ADAPTATION
1995
1999
2004
2006
2006
2006
2008
2008
2008
2012
Ecological Validity Model (Bernal et al)
Cultural Sensitivity Model (Resnicow)
Cultural Adaptation “Process” Model (Domenech‐Rodriguez)
Selective and Directed Treatment Adaptation Framework (Lau)
Heuristic Framework for the Cultural Adaptation of Interventions (Barrera & Castro)
Culturally Specific Prevention Model (Whitbeck)
Adaptation for International Transport of SFP (Kumpfer et al) International Implementation of MST (Schoenwald et al)
ADAPT‐ITT (Wingood & DiClemente)
Planned Intervention Adaptation Protocol (Ferrer‐Wreder et al)
Consensus on Effective Practices • Integration of participatory research methods
• Focus on community partnerships
– Stakeholders; Advisory Boards, Consumers
• Qualitative and quantitative methods
– Iterative design and pilot testing
– Test effects on engagement & outcomes
Goals of Cultural Adaptation:
• Move from efficacy to effectiveness
• Maximize sensitivity and responsiveness to values, preferences, needs, contexts of diverse cultural groups • Engaging to diverse families • Appropriate for delivery in multicultural contexts
(family courts in 5 counties in Arizona). This research was supported by NIMH grant 5-P30-MH39246-13 and 1R01DA026874
Moving to Effectiveness
Efficacious
Program
Effective
Service
Steps in transition:
•Select community partner
•Develop community-based systems for recruitment and service delivery
•Redesign NBP so it can be delivered with fidelity in community settings
•Adapt NBP to fit diverse families and fathers
Cultural Adaptations of NBP
Cultural Advisory Board
Researchers with experience working with African American,
Mexican American, and Asian American families reviewed
NBP and recommended strategies for cultural broadening.
Culturally Diverse Consumers
Culturally Experienced Providers
 Delivered NBP to AA, MA, AsA mothers
 Questionnaires at multiple points
 Focus groups at end of program
Focus groups with experienced providers
who worked with ethically diverse parents
 Focus group with leaders of NBP groups
for MA and AA mothers
Synthesized “voices” and
made revisions
Pilot and Refine
Synthesizing Diverse Consumer Voices
• Increased rationales to better address concerns, values and motivations of diverse families
• Multiple models and testimonials from diverse families
• More opportunities for parents to adapt skills to meet their own needs and styles
• Numerous changes in language and examples to better reflect diversity of values and cultural styles
• Culturally insensitive material revised or eliminated
• Skills broadened to reflect differences in definition and composition of “family”
PROGRESS: FIDELITY & FIT
• Excellent at adapting language, words, reading level, metaphors (dichos, legends, stories, symbols), examples, program materials (graphics/ videos) • Excellent at adapting rationales to be consistent with differing cultural perspectives (yet NOT adapting intervention content or processes)
• Has produced culturally compatible strategies to engage and deliver interventions • Has informed the personnel and training needed to work with diverse groups
Adaptations Achieve Outcomes
• Several adaptations have been completed for diverse populations (especially African American, Hispanic)
• Culturally Adapted Interventions are effective for minority populations
• However, very few studies directly compare whether a culturally‐adapted program is more effective than a generic or multicultural program • Hecht et al. (2006
• McCabe & Yeh (2009) • Kumpfer et al (2008)
Meta‐analyses of culturally adapted interventions
Griner & Smith (2006)
• Culturally adapted psychological intervenions were moderately effective (average d = .45)
• Less effective for children than for adults
Huey & Polo (2008) • Culturally‐adapted and unadapted treatments showed comparable effect sizes for ethnic minority children
Smith et al (2011)
• Culturally‐adapted therapies showed moderate effects (average d = .46). • Participants older than 35 benefit more • The number of cultural adaptations was positively correlated (.28) with intervention efficacy.
Benish et al. (2011)
• Analyses comparing culturally‐adapted psychotherapies to unadapted
psychotherapies showed an average effect size of d= .32 Augmented Intervention Content is Less Common EXEMPLARS:
• Racial socialization (Coard et al., 2004; Myers et al., 1992; Brody et al., 2004)
• Coping with discrimination and (Murry et al., 2009 )
• Differential acculturation between immigrant parents and children (Lau et al., 2011; Martinez & Edy, 2005; Renhazo & Vignjevic, 2011)
• Parents lack of integration with U.S. schools (Gonzales et al., 2012)
Although efficacy has been established, dismantling and process studies are needed to understand whether the additional content remediates the risk processes targeted and whether those changes facilitate ultimate outcomes
Reach and Engagement
• Effects on reach and engagement not been reported as systematically
– there are a few examples of improved engagement through tailoring (e.g., Winslow et al., 2013)
– Several well‐conceived efforts were not successful (e.g., McCabe et al., 2012; Robinson et al., 2010). Subgroup Differences
(Segmented Marketing vs. Adaptive Design)
• Few models account for diversity within group or shifting cultural demands
• McCabe ( )
• Pina et al ( )
• Sue (1998) dyamic sizing = knowing when to generalize cultural and potentially stereotypical knowledge and when to individualize treatment
Advances have not kept pace with Type 2 Translational issues Are current adapted EBIs feasible for broad dissemination?
Will they be sufficient to meet future demands as cultural groups continue to change? FUTURE RECOMMENDATIONS
1. Better articulation of Core Components , including “Cultural Processes”
Future Recommendations
2. Better integration of Cultural Theory
3. Focus on dissemination and service settings to enhance interface between cultural groups, settings, delivery systems, and the intervention. • International Implementation of MST (Schoenwald et al., 2008)
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Pre‐implementation (assess needs and stakeholders; understand legal and social standards; determine staffing and consulants)
Implementation (translate and “tweak” intervention; adapt training protocols
Service delivery (consider service duration; time and caseload standards; on‐call systems; cultural advisors)
Future Recommendations
4. Increase cultural flexibility / robustness of interventions and services • To address intragroup variability, multiculturalism, constantly changing cultural dynamics
• Prepare service setting, providers and consumers to be responsive to cultural diversity and the need for tailored / adaptive program elements • Use alternative modalities and technology to achieve better fit, reach, and consumer choice
4. Culturally‐Informed Innovations vs. Adaptation of Existing Models
• New interventions based on emerging research in cultural psychology
• More focus on social determinants and strategies to reduce social and economic disparities
• Greater focus on communities as intervention targets
The Role of Culture in Prevention Science
Past Progress and Future Challenges