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Volume 9
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Aging |
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In this Issue Special Issue: Aging Work of “Retired” Farmers Over Age 50 Other Original Research
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Applying a Model of Program Adaptation to the Familias Fuertes Parent/Adolescent Educational Intervention for Latino Immigrant Families in the Rural South Cecilia Azziz-Baumgartner, BSN, MS Lynda Law Wilson, RN, PhD, FAAN School of Nursing ABSTRACT There is increasing recognition of the importance of adapting interventions to ensure that they fit unique needs of diverse populations such as Latino immigrant families. The Strengthening Families Program: For Parents and Youth 10-14 (SFP 10-14) is a parent, youth, and family educational intervention that has demonstrated effectiveness in prevention of teen substance abuse and other behavior problems, and in enhancing parenting and family strengths.1 The SFP 10-14 program has been adapted and translated into Spanish by the Pan American Health Organization and has been found to be effective in several small studies in Latin America, but has not been evaluated with Latino immigrant families in the United States. This article describes issues to consider and discusses application of a process to adapt the Familias Fuertes (FF) intervention for Latino immigrant families. Nominal group technique focus groups were conducted with 7 adolescents and 10 parents who participated in the 7-week FF program to identify their recommended program adaptations. Although the findings of this study are limited by the small sample size, the findings provide direction for adapting the FF program to address specific and unique needs of Latino families in the United States. Keywords: Cultural Adaptation, Latino, Family Education Program Applying a Model of Program Adaptation to the Familias Fuertes Parent/Adolescent Educational Intervention for Latino Immigrant Families in the Rural South Acknowledgements: This study was funded in part by a pilot study grant from the National Institute of Occupational Safety and Health through the Southern Coastal Agromedicine Center at East Carolina University (Award # U50OH07551-05). Support for the FF facilitator training was provided in part by the Pan American Health Organization Office of Family and Community Health. The authors would also like to express appreciation to Father Bruce Bumbarger, the community partners who served as facilitators, and the parents and adolescents who participated in the Familias Fuertes program. Providing parenting education and support can strengthen families and thereby prevent problems such as physical and mental health problems, sexually transmitted diseases, early pregnancies, substance abuse, involvement in gangs, and family violence.2,3 For example, interventions focused on increasing parental monitoring of children’s behavior have been associated with lower levels of risky sexual behaviors in adolescents.4 The findings from several recently published meta-analyses have indicated that parental support programs can also reduce risks that are associated with child abuse and neglect,5 and with conduct disorders or antisocial behavior in children.6,7 There are many different types of parenting education and support programs, ranging from short-term educational programs to more multi-component long term interventions. Short-term educational programs have been found to be effective for families with low levels of risk, whereas more complex programs may be indicated for higher risk families.8 Parent education programs are especially important for Latino immigrant families in the United States who face multiple challenges including economic stressors, acculturation stressors, and fear of being caught by immigration authorities.9 Previous studies indicate that Latino adolescents in the United States are overrepresented among youth with problems of risky sexual behaviors, substance abuse, and depression.10,11 For example, Latino adolescents are more likely than White adolescents to have had more than four sexual partners and to have initiated sexual activity before the age of 13, and are less likely than White adolescents to use condoms.11,12 Findings from the 2005 Youth Risk Behavior Survey also indicated that Hispanic adolescents are more likely than White or Black adolescents to report having felt sad or hopeless, seriously considered suicide, or made a suicide plan.13 Latino adolescents also report higher lifetime or current alcohol use and current alcohol use, lifetime and current marijuana use, and lifetime methamphetamine use than White or Black adolescents.13 The Strengthening Families Program: For Parents and Youth 10-14 (SFP 10-14) is a seven-session parent, youth, and family skills-building curriculum designed to prevent teen substance abuse and other behavior problems, strengthen parenting skills, and build family strengths. The program was evaluated in a randomized controlled trial that involved random assignment of 33 Iowa public schools. Outcome evaluations involved use of multiple methods and data were collected 6, 18, 24, 30, 48, and 72 months after the pretest. A total of 161 families participated in 21 intervention groups at 11 different schools, with group sizes ranging from 3-15 families. A total of 94% of the families participated in five or more of the seven sessions. Findings indicated that parents in the intervention group demonstrated significantly improved parenting behaviors (communicating specific rules and consequences for using substances, controlling anger when communicating with the child, and increased positive involvement and communication with the child). Youth who participated in the program had lower levels of substance use, problem conduct, school problems, affiliation with antisocial peers, and better peer resistance. Some of the group differences actually increased in favor of the intervention group youth over the 6 year follow-up (source: http://www.extension.iastate.edu/sfp/inside/research.php). Long-term follow up data indicated that at 10 years after the intervention there is a two- to threefold reduction in overall mental health problems in adolescents who participated in the SFF 10-14 program, including reduced levels of depression, anxiety, phobias, and personality disorders.14 In a review of longitudinal studies evaluating substance abuse prevention programs published in the International Cochrane Collaboration Reviews, Foxcroft and colleagues concluded that the SFP 10-14 demonstrated “striking and important” effectiveness with increasing and large effect sizes at 2 and 4-year follow up.1 The SFP 10-14 program has been translated into Spanish by the Pan American Health Organization (PAHO) and is called Familias Fuertes (FF). Although the FF program has been pilot tested and evaluated in El Salvador, there have been no controlled scientific evaluations or experimental studies evaluating the program with Latino immigrant families in the United States (V. Molgaard, personal communication, July 30, 2007). There is increasing recognition of the importance of adapting interventions that have been found effective in controlled evaluations prior to implementing them in the broader community to ensure that they fit special and unique needs of diverse populations such as Latino immigrant families. Several authors have described the importance of balancing the tension between these program adaptations and maintaining fidelity with the core components of the original intervention.15,16 The purpose of this article is to (a) describe issues to be considered when adapting validated model interventions to ensure that they are culturally relevant for specific populations and that they also maintain fidelity to the core components of the original intervention; (b) discuss a six-step approach to program adaptation; and (c) illustrate the application of this approach to modification of the Familias Fuertes (FF) parent/adolescent educational intervention to address unique needs of Latino immigrant families in the rural southern United States. Balancing Program Fidelity and Adaptation Fidelity refers to the “the degree of fit between the developer-defined components of a …program and its actual implementation in a given organizational or community setting.”17p7 Although there is general recognition of the importance of maintaining program fidelity, Dane and Schneider reported that only 24% of 162 studies evaluating primary and secondary prevention programs assessed fidelity.18 Dusenbery et al. noted that studies that have assessed fidelity reported a high incidence of program modification, although few of these studies described methods used to assess fidelity or the validity and reliability of measures used.19 Most evidence indicates that program effectiveness is enhanced if core components of the original intervention are maintained, but few programs have identified core components.20 In order to address this problem, the United States Substance Abuse and Mental Health Administration (SAMHSA) has developed a website that lists core components and other information about model intervention programs that have been evaluated as effective in preventing or treating substance abuse ( http://www.modelprograms.samhsa.gov/). Such initiatives will make a significant contribution to helping to ensure an appropriate balance between fidelity to the original intervention and appropriate fit for diverse community groups. Program adaptation may be either deliberate or accidental and may include program deletions or additions, modifications of program components, changes in the manner or intensity of administration, and cultural modifications.17 Resnicow, Soler, Braithwaite, Ahulwalia and Butler described two categories of cultural modifications to interventions: surface structural or deep modifications.21 Surface structural modifications involve matching materials and messages to superficial characteristics of population (e.g., language, music, clothing). Deep structural modifications are more extensive and involve the cultural, social, historical, environmental and psychological forces that influence the target health behavior. Turner identified specific factors that should be considered when making cultural adaptations to interventions: (a) sensitivity to influence of specific cultural risk and protective factors; (b) level of acculturation and acculturation differences; (c) family migration patterns; (d) socioeconomic factors; (e) language preferences and dialects; (f) geographic and regional differences; and (g) intragroup heterogeneity.22 This latter factor is particularly important when adapting programs for Latino immigrants in the United States, because there are many different ethnic groups that comprise the panethnic Latino group and it is essential to recognize differences among different immigrant Latino subgroups when designing, adapting, and evaluating family intervention programs.23 Kumpfer, Alvarado, Smith, and Bellamy suggested that cultural adaptations of programs for Latino immigrant families should incorporate recognition of the importance of extended family relationships, the influence of metaphysical and supernatural forces, spirituality and religious practices, and the importance of social networks or clubs.24 These researchers reported results from a series of studies evaluating adaptations of the original Strengthening Families Program (SFP), a 14-session program designed for substance-abusing parents of 6-10 year-old children. The program was adapted for different groups including rural and urban African-Americans, Asian/Pacific Islanders, Hispanics, and American Indians. Kumpfer et al. reported that although the adapted versions resulted in a 41% improvement in recruitment and retention of program participants, the unmodified versions of the programs were generally more effective.24 The researchers acknowledged that the design of the comparison studies made it difficult to determine the reasons for the differences in program effectiveness, although these findings illustrate the importance of finding the right balance between program fidelity and adaptation. A Six-Step Approach to Program Adaptation Backer published a review of existing program adaptation strategies and proposed a model for program adaptation that includes six steps: (1) identify and understand the theory base behind the program, what ideas were the precursor for the creation of the program, which population was the main target, which problems is trying to prevent; (2) identify core components of the program, what are the main ideas behind the program, which is the intend approach and style, and which are the expected goals; (3) assess fidelity/adaptation concerns for the particular implementation site, discuss what are the things or elements that are going to be adapted or changed from the original design; (4) consult as needed with program developer, verify if any change or adaptation will compromise the theory or core components of the program; (5) consult with community in which implementation will take place, identify a community leader or several leaders that understand and explain the program, thoroughly explain the original and adapted version of the program until all leaders fully understand; and (6) develop an implementation plan based on these inputs, with a team approach among the main investigator and community come up with a strategic plan to implement the program.17 Once the implementation has been accomplished successfully, the community leaders and participants should be consulted to evaluate program outcomes. This reevaluation will give valuable insight to ensure that the core components have not been distorted or overlooked along the implementation. The remainder of this paper describes the application of this model to planning for a cultural adaptation of the Familias Fuertes (FF) intervention for Latino immigrant families in the rural southern United States. Applying the Model to the Familias Fuertes (FF) Intervention Step 1: Identifying the Theoretical Base of the FF Intervention The FF program is an adaptation of the SFP 10-14 program that was developed by Molgaard as an adaptation of the original 14-session Strengthening Families Program (SFP) developed by Karol Kumpfer for substance-abusing parents and their 6-10-year-old children. The original SFP program was guided by theoretical underpinnings from developmental theory, the biopsychosocial vulnerability model, and from other models related to resiliency, stress, and family processes.25 The SFP 10-14 program was an adaptation of the original SFP program for young adolescents and their parents (SFP 10-14) who were not identified as having problems such as substance abuse. The SFP 10-14 program incorporates protective processes associated with youth resiliency and includes instruction in life skills including emotional management skills, interpersonal social skills, reflective skills, academic and job skills, ability to restore self-esteem, planning skills, and problem-solving ability. (www.extension.iastate.edu/sfp/) The curriculum for both SFP programs was also based on social learning theory to encourage a parenting style that is authoritative (providing consistent discipline within a nurturing environment) rather than authoritarian or permissive. Parents and youths participate in experiential activities as they learn skills in communication that are designed to enhance relationships and understanding of one another’s perspectives and dreams. It is important to understand the theoretical base of the original program to ensure that any adaptation is consistent with this base. Step 2: Identifying Core Components of the FF Intervention The original SFP 10-14 program includes seven weekly 2-hour sessions. Parents and youths meet separately during the first hour and together as families during the second hour to practice skills, play games, and do family projects. Both youth and parent groups are led by trained group facilitators who promote active involvement, role-playing, discussions, learning games, and family projects among group participants. The original SFP 10-14 program has been translated and modified slightly by the PAHO. The revised program is entitled Familias Fuertes (FF) and it has been used with Latino families in Latin America and to a limited extent in the United States. The FF program was modified slightly from the original SFP 10-14 program by incorporating additional content related to gender issues, helping youth develop independence and promoting parental advocacy on youth issues based on suggestions of a focus group of professionals who met in 2001 in Costa Rica to make recommendations on adaptations of the program needed for Latin American families (V. Molgaard, personal communication, July 30, 2007). Molgaard acknowledged the need to make modifications in the original SFP 10-14 program to fit special needs, interests and experiences of program participants, but identified core elements in the parent, youth, and family sessions that must be maintained in order to ensure fidelity with the original program (V. Molgaard, personal communication, March 6, 2008). Space limitations preclude listing these elements in this article, but they can be obtained from Dr. Molgaard. These core elements were maintained in the development of the FF program as an adaptation of the original SFP 10-14 program, and should also be maintained in any adaptations of the FF program for Latino immigrant families in the United States. Step 3: Assess Fidelity/Adaptation Concerns for the Particular Implementation Site Given the significant diversity among Latino immigrant families in the United States, it is critical to involve program participants in plans for adapting and implementing family interventions. Many states in the southern United States have not previously had a significant Latino population and often are lacking in educational, health, and social service programs that can help families adapt to the pressures of raising adolescent children. Alabama is among the top six “emerging” Latino states in the United States.26 The present study was conducted is in a rural county in Alabama which had not had a large Latino presence until relatively recently. Most of the Latino families are of Mexican or Guatemalan origin. A total of 16.1% of the population in the community where the study was conducted is Latino.27 One of the co-authors of this paper ( Harrison) had been working in this county for 2 years as a founding member of a Latino Health Community Partnership, and thus had strong community connections that facilitated the process of implementing and adapting the FF program. In order to assess the fidelity and adaptation concerns of the FF program, we trained a group of Latino community volunteers to be program facilitators, and three of these volunteers subsequently implemented the program with a group of 10 Latino families in the community. Following the sixth of the seven sessions we sought informed consent from the parents and adolescents who attended the seven-session program to participate in a study to identify fidelity and adaptation concerns. The study was approved by the Institutional Review Board of the University of Alabama at Birmingham. All adolescents and parents assented or consented to participate in the study which involved collection of data related to demographic characteristics and acculturation, and participation in a nominal group technique (NGT) focus group to share ideas about adaptations that would enhance the program. The NGT is a method that involves collecting quantitative and qualitative data from participants in small groups to identify perceptions related to specific issues or topics. The technique involves four steps: (1) a silent generation of ideas by each participant, (2) recording of ideas generated by the group members, (3) structured time-limited discussion of ideas, and (4) selection and ranking of ideas by voting.28-30 Although often all four of these steps are conducted during one group meeting, we modified the process slightly in order to minimize the length of time that family members would need to meet in the focus group. At the end of the sixth FF session, after signing consent or assent forms, parents and adolescents completed instruments that included demographic information, a shortened version of the Acculturation Rating Scale for Mexican Americans (ARAMSA),31 and answered a question that asked them to identify additional topics that should be included, or changes that should be made in the FF program. The instruments were available in both English and Spanish and participants were able to complete the instruments in the language of their choice. The ARAMSA is a standardized questionnaire used to quantify participants’ levels of Latino and Anglo Orientation, as well as Linear Acculturation Scores. We used 17 of the original 20 questions of this scale (deleting several questions to avoid redundancy based on pilot work with the adolescents in the community where we conducted this study). Each question has a scale of 1-5. Average scores are calculated to represent Latino Orientation (closer to 5) or Anglo Orientation (closer to 5). A Linear Acculturation score is calculated by subtracting the Latino Orientation score from the Anglo Orientation score. The investigator collected the instruments and the lists of suggestions for program adaptations that parents and adolescents had generated. Prior to the seventh FF session, the investigators developed separate lists of the different topics, themes, and suggestions for adaptation that had been generated by the parents and the adolescents so that these lists could be shared with the parents and adolescents. Following the seventh session, the two investigators met separately with the parents (Azziz) and the adolescents (Harrison), and gave each participant a list of the themes that had been identified the previous week. Consistent with the NGT process, group members discussed each theme to clarify the meaning of the theme. Group members were also invited to identify other topics or suggestions for program adaptation. At the end of the discussion, participants were asked to rank the five most important additional topics or adaptations on their list, and to submit their responses to the investigator. Findings from NGT Focus Groups A total of 7 mothers, 3 fathers, and 7 adolescents participated in the focus groups. The mean age of the parents was 34 (sd 4.37) and the mean age of the adolescents was 12 years (sd 0.74). The country of origin of the parents was Mexico (90%) and Colombia (10%). The participants reported that they had lived in the United States from 4.5-15 years (mean = 10.01, sd 3.9). Half of the parents reported that they had completed elementary school, but the other half had not completed elementary school. Most of the adolescents (71%) reported that they had been born in the United States. The findings from the Acculturation Scale indicated that parents had a higher Latino orientation (mean 3.98 (sd 0.56) than the adolescents (mean 3.44 (sd 0.72). The mean Anglo Orientation score for parents was 2.89 (sd 0.88) for adolescents 3.69 (sd 0.49). The mean Linear Acculturation score for parents was -1.01 (sd 0.80) and for adolescents it was 0.25 (s 1.01). This finding indicates that parents had a higher Latino than Anglo orientation, and adolescents had a higher Anglo than Latino orientation. One of the items on the ARAMSA scale asks about use of English and Spanish. In this sample, 70% of parents indicated that they spoke very little or no English, whereas 100% of the adolescents reported that they spoke English. Figures 1 and 2 illustrate the topics that adolescents and parents ranked as the most important topics to be added or reinforced when adapting the FF program. Figure 1 Topics Ranked by Adolescents as Most Important to be Addressed or Reinforced as FF Program Adaptations
Figure 2 Topics Ranked by Parents as Most Important to be Addressed or Reinforced as FF Program Adaptations
It was interesting to note that even though separate focus group discussions were held with parents and adolescents, the main topics that they suggested as additions or modifications in the FF program were similar. Both groups identified the need for more content related to acculturation stress including dealing with lack of support of extended family, and differences between the Latino and dominant U.S. culture. In addition, adolescents identified the need for help in dealing with language differences between parents who generally did not speak English, and adolescents who often preferred to communicate in English. Parents also identified the need for support in dealing with discrimination. These findings suggest that the FF program should be adapted for Latino immigrant families in the U.S. by adding content related to acculturation stress and helping parents and adolescents learn strategies to promote biculturalism, adapting to the positive aspects of both Latino and Anglo cultures. The concerns expressed by both parents and adolescents related to the lack of extended family support systems also suggest that it may be helpful to add content to the FF program related to mobilization and access of community support systems. Another theme that was identified by both parents and adolescents related to lack of sufficient time for family activities and communication due to pressures on both adolescents and parents. The FF program does include content encouraging families to hold regular family meetings and enjoy fun time together, and includes a number of games and other activities designed to model and stimulate this type of interaction. In fact, many of the families who participated in the program commented that this was an aspect of the program that they particularly enjoyed because they rarely found time to engage in family games at home. It may be helpful to increase the emphasis on this topic in adapting the program for Latino immigrant families. The last two topics identified (peer pressure by parents, and parent-adolescent communication by adolescents) are topics that are already addressed in the FF program. The fact that these topics were identified during the focus group discussions suggests that it may be helpful to place additional emphasis on these areas in the adapted program. Plans for Steps 4-6 in the Program Adaptation Process We have shared the findings from our NGT focus groups and suggestions for program adaptation with the original program developer (Molgaard) who has confirmed that implementing the adaptations suggested by the adolescents and parents in the focus groups would not compromise the core components of the program. We are currently seeking funding to develop and test the adapted program and plan to present our specific recommendations for program adaptation to the original program developer, as well as with the Pan American Health Organization and the 11 FF facilitators and other partners in the community where our intervention will take place to ensure that the adaptation that is ultimately developed will not compromise program fidelity. We will then work with community partners to implement and evaluate the adapted program. Summary and Conclusions The finding that there were substantial differences in the degree of acculturation between the adolescents and parents who participated in the FF pilot program and in the follow-up NGT focus groups is consistent with research describing Latino immigrant families in the United States, particularly in states that have not previously had high percentages of Latinos.32,33 The findings from the NGT focus groups provide direction for adapting the FF program to address specific and unique needs of Latino immigrant families in the United States. The findings from this study are limited by the small sample size and by the fact that we collected data in only one community in the rural South. There is a need to replicate this process with other groups of Latino immigrant families in different regions. There is also a need for ongoing work with partners in the community where this project was implemented in subsequent phases to review planned adaptations and to plan for implementation and evaluation of the revised program. Our experience supports the value of the six-step program adaptation process proposed by Backer17 as a method to ensure that interventions maintain fidelity to original core components but are modified to ensure that they are appropriate for diverse groups in diverse settings. References
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