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Are cultural adaptations of evidence-based programs sufficient to address disparities?

Despite decades of research, behavioral health disparities continue to negatively affect ethnic and racial minority populations, including immigrant populations. To reduce disparities, behavioral health programs need to be successful in reaching and influencing subcultural groups while also demonstrating effectiveness in improving targeted outcomes (Barrera et al., 2013). Indeed, for the last several decades, the behavioral health field has emphasized the use of evidence-based practices (EBPs). These dynamics led practitioners to favor evidence-based models that have been shown to be effective through outcome studies. While the concept that EBPs would be the most effective intervention seems sound in theory, the reality is that implementing EBPs with diverse populations yields many challenges. Because of these challenges, some practitioners advocate for practice-based models or promising practices. These include locally developed intervention programs, many of which demonstrate practice-based or community-defined evidence but that often have not been subjected to empirical evaluation. Practice-based programs (PBPs) involve local practitioners designing interventions based on an unmet need specific to their service population and that often places culturally specific values, beliefs, and sociohistorical perspectives at the center of the treatment model (Lyon, Pullmann, Walker, & D’Angelo, 2017). PBPs are therefore ideal for use with specific populations; however, without the evidence base, adoption and dissemination will remain limited compared to EBPs. This phenomenon speaks to the disconnect that exists between research and practice. Often, practitioners choose not to use evidence-based programs despite the high reputation they may have in the research literature. Usually this is because of the irrelevance they hold to ethnic and racial minority populations. There is a need to translate research into practice and vice versa. This has led to an emergence of the field of implementation science that is focused on “the study of methods to promote the adoption and integration of EBPs, interventions and policies into routine health care and public health settings” (Bauer et al., 2015). Within this field there is a growing body of knowledge focused on the need for attention to cultural diversity and cultural adaptation of EBPs.

Cultural adaptation and program fidelity. Among researchers, there is controversy over whether programs should be culturally adapted. The most salient problem with EBPs used with any ethnic and racial minority population is that most were developed by and for white middle-class Americans. The theory and methodology do not necessarily apply to racial and ethnic minority populations. In an effort to make EBPs more culturally relevant for use with racial and ethnic minority populations, practitioners deviate from the curriculum in ways that were not intended by those who developed the program, compromising its integrity. For example, research that has tested effective family interventions has revealed that only 10% of practitioners implement evidence-based family intervention programs, and only 25% are implemented with fidelity (Kumpfer & Alvarado, 2003). Researchers argue that cultural adaptation actually compromises the original evidence-based research, limiting it to such a specific population that it cannot be widely used and thus is not worth the effort to develop a structured program (Martinez & Eddy, 2005). It is often agreed that fidelity requires only implementation of the core components of the tested intervention. However, the problem is that it is rarely ever clear what those core components are (Elliot & Mihalic, 2004). Fidelity is believed to be related to effectiveness, and thus, deviations from this will compromise the program. Others claim that implementing research-based programs outside the original context has continued to yield disappointing results. For example, Gottfredson et al. (2006) found this to be true in testing effectiveness of the Strengthening Families Program with a substantially different population than the one it was initially tested on and under much more rigorous conditions.

Varying degrees of cultural adaptations. Some attempts to make programs culturally appropriate include mere surface structure modifications. Surface structure cultural adaptations are those that match program materials to observable superficial materials (e.g., food, music, clothing, language, people), and some of the more culturally specific programs are even based more on practitioners’ perceptions of community needs. Deep structure adaptations refer to cultural, social, historical, environmental, developmental, and psychological influences on behavior. One resolution to the fidelity-adaptation controversy is to create a new breed of intervention described as hybrid interventions that would have a core components program with the flexibility to have a preintervention adaptations phase that would allow for adjustments to be made based on the target population (Holleran Steiker et al., 2008). This is a good idea in theory, but the reality is that it is based on assumptions that core components of a program have been identified, that enough is known and understood about the target audience as it relates to the program, and that all analysis and adjustments are being kept within the guidance of the original theoretical framework that was used in designing the program. Others posit that fidelity is important in terms of dosage and that adaptation should simply include recognition and use of cultural practices (e.g., adding songs, blessings, stories; Kumpfer et al., 2002). There is an argument for cultural adaptations to follow a well-thought-out iterative adaptation process, involving considerable trial and error until the best changes are made as documented by the evaluation (Holleran Steiker et al., 2008). There are researchers, especially among those who value PBPs, who believe that the most culturally relevant program is one that is built from the bottom up and question whether a program like that can even be applied to another group (Marsiglia & Waller, 2002). However, the reality is that behavioral interventions operate within a resource-limited world, and cultural adaptation tends to be more cost effective and timely, but it should be done before delivering the intervention.

Cultural considerations for behavioral health programs focused on immigrant families. For immigrant families, cultural adaptations of intervention programs are critical because of their unique experiences and needs in adapting to life in a foreign country. These families have challenges of migration stress and trauma, often separations and later reunifications of family members, and differential levels of acculturation that need to be addressed. Understanding the culture alone is not enough to fully explain the nature of the changes taking place within immigrant families. Immigrant families live in a multicultural context and thus need to be understood within the framework of a culturally pluralistic environment. There exists a need to enhance bicultural skills among all members of the family; in other words, there is a need for better management of the cultural differences inherent in immigrant families. The following are unique considerations for both researchers and practitioners in developing new programs or adapting existing ones for use with immigrant families:

Acculturation and migration stress: Immigrants face many challenges upon arrival to a new country. Apart from the stress of immigrating itself, they often face the daunting task of having to raise their children within the context of an unfamiliar culture. Other challenges include language barriers, financial stress, social isolation, and lack of extended family as a source of support. Parents having to face all of these obstacles are at great risk of parental disinvestment, placing their adolescents at greater risk for high-risk behaviors (Pantin, Schwartz, Sullivan, Coatsworth, & Szapocznik, 2003). The immigrant experience or the migration trauma itself often places individuals at greater risk for onset of other mental health or behavioral problems. Acculturation stress also depends upon the receptiveness of the host country to the particular immigrant population. Patterns of immigration have changed dramatically through the twentieth and twenty-first centuries, and these patterns influence the target of discrimination and oppression (Segal & Mayadas, 2005). Adding to the migration stress is the case in which families do not migrate together but rather in parts. It is not uncommon for one or both parents to go first, and after months or years, to send for the children. This dynamic incorporates the additional stress of family separations and reunifications (Chapman & Perreira, 2005). This can bring with it feelings of resentment and loss on the part of the children that can go unaddressed after reunification. It also has a direct effect on how each party experiences the immigration process. Another related instance in which parents and children may experience immigration differently involves that of how the decision to immigrate is made. For example, the hierarchy of many families places parents, specifically fathers, as the authority and decisionmakers. When a parent or parents decide to move the family to a new country, though the move is stressful for them, it is a stressor that they choose and often is a relief from stress they experienced in their home country. But for the child, it is a decision made for them and thus can be perceived as unfair, especially if the child was not exposed to stress in the home country. Related to this, Suarez-Orozco and Suarez-Orozco (2002) discuss how a dual frame of reference helps parents adjust to the new country because no matter how dire their circumstances in the native country, the immigrating process is viewed positively compared with the difficult situations that prompted the immigration from one’s home country. Children either lack that dual frame of reference because of their young age or, conversely, they were happier in their home countries as compared to the United States.

Acculturation and the family: The acculturation period is a critical time in the formation of well-adjusted families and individuals. All people face hardships in their lives, and how they negotiate these critical times depends on their coping skills. These skills depend on several factors, one of which is the individual’s social support network. When a family is displaced from its home, that larger social support network also shifts. A newly immigrated family faces an onslaught of hardships in the initial adjustment period, which is also the time that the family members are least able to cope with it because of redefining of social support networks. Acculturation, by definition, is a process, not a static variable, and there are myriad ways to measure it, thus leading to discrepancies in findings on how acculturation affects individuals and families (Martinez, 2006). Immigrant families are faced with the challenge of reconciling the differences between the two cultures and redefining themselves accordingly. This adjustment process places stress on the family unit that often translates into negative behavioral expression, most often by the adolescents. Children often experience high levels of acculturation, but their parents, who often have limited interactions with mainstream culture, do not. This difference can cause conflict, especially in terms of parent-child communication and bonding. Several researchers have found that more acculturated adolescents have more risk for externalizing behavior problems than their less acculturated peers (e.g., Gonzales et al., 2006). According to Szapocznik and Kurtines (1993), a traditional learning curve explains how youth acculturate at a more accelerated pace than their parents, who tend to hold on to traditions. This difference leads to a culturally diverse environment in the household, where youth are pushing for autonomy and parents for family unity, resulting in children’s loss of emotional and social support and parents’ loss of authority. These intergenerational conflicts are compounded by intercultural conflict (Perreira et al., 2006).

Disruption of family roles and power dynamics: For immigrant families having to make major adjustments to their new lives, there are often changes in family roles and family structure. One instance in which this occurs is when children learn the host language before their parents do and then are placed in situations where they must be the interpreters. The children in this case become the cultural broker for the parents. Parents rely on their children to help them with daily activities such as banking, doctors’ appointments, or meetings with attorneys. This language dependency disrupts the family hierarchy and places children in a leadership position, resulting in a loss of parental authority that is often contrary to traditional family values (Santisteban, Muir-Malcolm, Mitrani, & Szapocznik, 2002). This dynamic can lead to increased rigidity and discipline by the parent to overcompensate and thus creates tension and often rebellion. Another example of fluctuation in traditional family roles is that women will work outside the home, often for the first time. In some cases, because of the nature of the man’s work, the woman may at certain times be the sole wage earner, causing disruption to the traditional idea that it is the man’s duty to be the breadwinner. In some families, this dynamic can feel threatening to the father, causing negative reactions that disrupt the household.

Effective intervention programs need to address bicultural skills — teaching both parents and children how to manage their cultural differences. Programs need to address converging values and beliefs and, more specifically, help family members to recognize their shared cultural values, and programs should assist with finding common ground within the discontinuities of diverging levels of acculturation and disruption to family and community life (Holleran & Waller, 2003). The consequences of not providing culturally appropriate family intervention programs that address the special needs of the target population places families at risk. The consequences of family dysfunction leading to adolescent behavior problems are many. Certainly, it affects individual family members, but because families do not live in isolation, the consequences carry over to the broader community.


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