Transcript Document

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
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
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.
“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
Defining Ourselves
HOW DO YOU IDENTIFY YOURSELF?
Racially
Ethnically
Culturally
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.
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)
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).
Total Population Comprised of Different Groups
(in millions/percentage of total population)
Populations
Hispanics
African American
Asian/Pacific Isl.
American Indian
White
Total
1996
27.8(10.5%)
32.0(12.1%)
9.1(3.4%)
2.0(0.7%)
194.4(73.3%)
265.4(100%)
2050____
96.5(24.5%)
53.6(13.6%)
32.4(8.2%)
3.5(0.9%)
207.9(52.8%)
393.9(100%)
Source: U.S. Bureau of Census, 2000. Hispanic can be of any race; data for all
other groups are non-Hispanic.
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)
"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-minority and
minority populations experiencing
disproportionate burdens of disease,
disability, and premature death."
~ Guiding Principle for Improving Minority Health, Centers for
Disease Control
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.
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.
Theory and Research:
Help-seeking Behavior
Intercultural differences in parental “distress
thresholds”
Financial resources
Variation in the presentation of
emotional/behavioral illnesses
Language
Reducing Barriers
Recruitment

Engagement
Retention

Participation
Overall Effectiveness

Satisfaction
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).
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).
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).
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).
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).
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.
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
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)
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.
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.
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?
Adapting to Diversity
• Program marketing
• Program content
• Program delivery
• Program evaluation
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
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
Delivery
• Use of a collaborative
approach
• Diverse or racial/ethnic
matching participants
w/staff
• Use of community
members as “aids”
• Cultural specific delivery
strategies
– (e.g., common
language, Proverbs,
affirmations,
storytelling; emphasis
on cultural values)
• Community member
“aids”
– cultural value and
model incongruence
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
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.
INTERVENTION DEVELOPMENT
AND
ADAPTATION
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?…
1.
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.
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.
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
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 Health
K01 MH-01881-01
2000-2005
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).
Racial Socialization Defined
The process by which messages are
transmitted inter- and intragenerationally 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 racerelated 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.
Complexities of Racial
Socialization
Synergistic and dynamic
Bi-directional process
Deliberate and unintended
Transmission and reception
Moderated by family and ecological
characteristics
Racial Socialization and Child
Outcomes: Empirical Findings
Racial Competence
Academic Achievement
Self-Efficacy
Self-Esteem
Behavioral Competence
Delinquency
Drug Abuse
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.
Who am I Targeting?
A quest to define Blackness
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
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).
Model of Racial Socialization
Processes (Coard, 2003)
Frequency of Message
Frequently Used
Routine aspect of parenting
Moderated by family characteristics
Content of Messages
Racial
Socialization
Racial Preparation (83%)
Racial Pride (93%)
Racial Equality (86%)
Racial Achievement (67%)
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.
Other Culturally-Specific Considerations*
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)
Culturally Enhanced Version:
Black Parenting Strengths and Strategies (BPSS)
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
Program goals:




So we can….

Ticket system
•
Attendance (on time)
•
Homework completion
•
Binder
STRENGTHEN parenting skills
IMPROVE parental involvement
EMPOWER parents to advocate
and access
GUIDE parents in preparing
African-American children for
success




INCREASE positive behaviors in
children
DEVELOP self-image and selfesteem
BUILD their confidence in school
PROMOTE positive racial
discussions
ENHANCE problem-solving skills
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
BPSS Parent Group Sessions: 1- 6
1 Welcome 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
3 Young Children and Racial-Ethnic Matters
Racial/Ethnic Development and Competence
Racial Socialization: Talking about Race
4 Understanding Child Behavior and Identifying Behavior Problems
Attending
5 Creating a Positive Homeplace** and Homespace***
Spirituality and Family Traditions
Rewards
6 Improving Communication Skills
Ignoring
*Based on Stevenson, Davis & Abdul-Kabir (2001)
**Term conceived by L. Burton
*** Term conceived by J.V. Ward
BPSS Parent Group Sessions: 7 - 12
7
Building Positive Self-Esteem and Self-Image
Effective Directions
8
Developing More Patience and Respect
Time-Out
9
Black Children and the School Experience
Racial Achievement
10 Teaching Children to Problem Solve
Chit chats and Race–Related Problem Solving
11 Integrating Parenting/Behavior Change Skills
Addressing Specific Behavior Problems
12 Advocating for Your Child
Addressing specific race/ethnic matters (at home and in the
community)
13 Graduation Ceremony
Child Domains and Measures
Child Behavior Problems
Child Social Competence

Behavioral Assessment System
for Children (BASC- P/T)

Behavioral Assessment System
for Children (BASC- P/T)
Social Skills Rating
Scale(SSRS-P/T)

Child Racial Competence
 Attitudes
 Coping
 Racial Preference

Preschool Racial Attitude
Measure(PRAM)
Racial Stories Task II

Color of My Skin

Parent Domains and Measures
Parenting Practices



Parent Racial Socialization


Parent Racial Identity
Parent Functioning
Parent Practice Interview (PPI)
Involve Parent Questionnaire (IPQ)
Parent Experience of Racial
Socialization (PERS)
Parent-Child Race-related
Observational Measure (PC-ROM)
Afro-centric Home Environment
Inventory

Multidimensional Inventory of
Black Identity (MIBI)

Parent Stress Index (PSI)
Inventory of Race Related Stress
(IRRS)

Means for Parenting Practices and parent-rated child behavior for control and
intervention: Parenting Practices
4
3.5
3
2.5
2
1.5
1
0.5
0
H
sh
ar
e
lin
ip
sc
Di
g
in
nt
re
Pa
Post control
e
tiv
si
Po
g
rin
ito
on
M
Baseline control
Baseline Intervention
Post Intervention
Means for Parenting Practices and parent-rated child behavior for control and
intervention: Parents Experience of Racial Socialization
25
20
15
10
5
0
Total Score
Baseline control
Baseline Intervention
Post control
Post Intervention
Means for Parenting Practices and parent-rated child behavior for control and
intervention: Child Conduct Problem
56
54
52
50
48
46
Conduct Problems
Baseline control
Baseline Intervention
Problem Behavior
Post control
Post Intervention
Means for Parenting Practices and parent-rated child behavior for control and
intervention: Child Social Competence
120
110
100
90
80
70
60
50
40
30
20
10
0
Responsibility
Cooperation
Baseline control
Baseline Intervention
Self-Control
Post control
Post Intervention
Conclusion

BPSS is a model for incorporating culturally relevant
content and processes into established evidence-based
interventions.

BPSS is a promising preventive intervention with
encouraging preliminary data.
 The feasibility as been established.
 A preliminary evaluation of BPSS via a randomized
wait list control pilot is complete.
 Significant results in positive changes in parenting,
including reduction in harsh discipline, increase in use
of positive racial socialization strategies, and positive
changes in social and racial competence in African
American children.
Coard, S., Foy-Watson, S., Zimmer, C., & Wallace, A. (2007). Considering culturally relevant parenting practices in intervention
development and adaptation: A randomized control trial of the Black Parenting Strengths and Strategies (BPSS) Program. The
Counseling Psychologist 36(6). 797-820.
THANK YOU!!
Contact Information:
Stephanie I. Coard, Ph.D
University of North Carolina - Greensboro
[email protected]
(336)334-4666