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Title: Adaptations of evidence-based interventions for diverse families: Cultural competency from conception to implementation (and beyond)

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-Sale
m, 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

  • 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

  • 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
y Culturally
Definitions contd
  • 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 contd
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
  • 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

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
  • 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.

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
Theory and ResearchHelp-seeking Behavior
  • Intercultural differences in parental distress
  • 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

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

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
  • 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

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

  • 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
  • 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 precompetence
  • 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 ones culture and how
it shapes beliefs and behaviors. and understand
the dynamics of difference.
Elements of Cultural Competence contd
  • 4. Recognize and understand the dynamics of
  • 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

  • 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
  • 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

  • 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

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

  • 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
  • Use of community members as aids

  • 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

  • AND

  • 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?

  • 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
  • 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

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

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 childrens beliefs about the way
    the world works.
  • It informs childrens beliefs and attitudes
    regarding the self.
  • It helps shape childrens repertoire of
    strategies and skills for coping with and
    navigating racism.
  • It impacts the nature of the childs 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
  • 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
  • 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,
Frequency of Message Frequently Used Routine
aspect of parenting Moderated by family
Content of Messages Racial Preparation
(83) Racial Pride (93) Racial Equality
(86) Racial Achievement (67)
Racial Socialization
Mode/Delivery of Messages Active Responsive Passi
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
  • 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)
  • 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
  • Coping with race-related conflicts
  • Race-related advocacy in school settings
  • informed by qualitative findings and existing

Culturally Enhanced VersionBlack Parenting
Strengths and Strategies (BPSS)
  • 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
  • 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

Parenting the Strong-Willed Child (Long
Forehand, 2002)
  • Evidence-based behavioral parent training
    program, recognized for its general
  • 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
  • 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
  • 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 RaceRelated 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
  • Child Racial Competence
  • Attitudes
  • Coping
  • Racial Preference
  • Behavioral Assessment System for Children (BASC-
  • Behavioral Assessment System for Children (BASC-
  • Social Skills Rating Scale(SSRS-P/T)
  • Preschool Racial Attitude Measure(PRAM)
  • Racial Stories Task II
  • Color of My Skin

Parent Domains and Measures
  • Parent Practice Interview (PPI)
  • Involve Parent Questionnaire (IPQ)
  • Parent Experience of Racial Socialization (PERS)
  • Parent-Child Race-related Observational Measure
  • Afro-centric Home Environment Inventory
  • Multidimensional Inventory of Black Identity
  • Parent Stress Index (PSI)
  • Inventory of Race Related Stress (IRRS)
  • Parenting Practices
  • Parent Racial Socialization
  • Parent Racial Identity
  • Parent Functioning


Means for Parenting Practices and parent-rated
child behavior for control and intervention
Parenting Practices

Means for Parenting Practices and parent-rated
child behavior for control and intervention
Parents Experience of Racial Socialization

Means for Parenting Practices and parent-rated
child behavior for control and intervention
Child Conduct Problem

Means for Parenting Practices and parent-rated
child behavior for control and intervention
Child Social Competence
  • 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

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).
  • Contact Information
  • Stephanie I. Coard, Ph.D
  • University of North Carolina - Greensboro
  • (336)334-4666