The University of Texas at El Paso

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1 P204 The University of Texas at El Paso Felipe González Castro, Ph.D., M.S.W. Theodore Cooper, Ph.D. Department of Psychology University of Texas at El Paso Presentation at: the American Psychological Association meeting:.strengthening Psychology s Role in Reducing Tobacco Health Disparities. December 10 th, Hyatt Regency Capital Hill, Washington, DC.

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3 Key Terms and Concepts * An EBI refers to an Evidence-Based Intervention (Castro, Barrera, Holleran Steiker, 2010) * This is a broader term that includes prevention and treatment as types of interventions * Interventions must be validated empirically as being efficacious using a well-designed randomized controlled trial (Flay, Biglan, Boruch et al., 2005) * Castro, F. G., Barrera, M., & Holleran Steiker, L. K. (2010). Issues and challenges in the design of culturally-adapted evidence-based interventions. Annual Review of Clinical Psychology, 6, * Flay, B., Biglan, A., Boruch, R. F., Castro, F. G., Gottfriedson, D., Kellam, E. K. Moscicki, E. K., Schinke, S.,Valentine, J. C., & Ji, P. (2005). Standards of evidence: Criteria for efficacy, effectiveness and dissemination. Prevention Science, 6,

4 Key Terms and Concepts * Ideally, a tested-and-effective intervention is also replicated to confirm the robustness of the observed efficacy effect (Valentine, Biglan, Boruch et al., 2011) * In the adaptation field, replication is rare, partly because it is difficult to conduct a truly equivalent replication trial * Valentine, J. C., Biglan, A., Boruch, R. F., Castro, F. G., Collins, L. M., Flay, B. R., Kellam, S., Moscicki, E. K., & Schinke, S. P. (2011). Replication in prevention science. Prevention Science, 12,

5 Theory: Assumptions and Perspectives * Diversity of Need - One size does not fit all. In any society, there exists considerable withinpopulation and between-population diversity on several cultural and other factors (Resnicow, Soler, Braithwaite, Ahluwalia, & Butler, 2000) * Universal Interventions Universality assumes that a single intervention is equally relevant and thus if an EBI is validated, it will be efficacious with all (or most) members of a population * The universality assumption is often not true Resnicow, K., Soler, R., Braithwait, R. L., Ahluwalia, J. S., & Butler, J. (2000). Cultural sensitivity in substance abuse prevention. Journal of Community Psychology, 28,

6 Basic Issues in EBI Adaptations * What factors must be considered in developing an appropriate adaptation of an evidence-based intervention? 1. Linguistic mismatches Participants cannot understand the content of the protocol 2. Comprehension mismatches Participants cannot comprehend the content 3. Cultural mismatches Conflicts or challenges in intervention contents that differ from the cultural values, beliefs, attitudes, expectations of the participating subcultural group (Barrera, Castro, Martinez, 2004) Castro, F. G., Barrera, M., & Martinez, C. R. (2004). The cultural adaptation of prevention interventions: Resolving tensions between fidelity and fit. Prevention Science, 5,

7 Sources of Mismatch in Program and Client Needs Castro, F. G., Barrera, M., & Martinez, C. R. (2004). The cultural adaptation of prevention interventions: Resolving tensions between fidelity and fit. Prevention Science, 5,

8 Sources of Mismatch in Program and Client Needs Castro, F. G., Barrera, M., & Martinez, C. R. (2004). The cultural adaptation of prevention interventions: Resolving tensions between fidelity and fit. Prevention Science, 5,

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10 Evidence Regarding Efficacy of Cultural Adaptations * Meta-analysis of 76 published and unpublished studies (Griner & Smith, 2006) 1. Types of adaptation activities: * Cultural values and concepts * Matching by native language or ethnicity * Treatment in culturally-responsive clinics 2. Culturally-adapted interventions were moderately effective; weighted average effect size: d= Effect for same-race participants (d= 0.49) versus for mixed-race participants (d= 0.12) Griner, D., & Smith, T. B. (2006). Culturally adapted mental health interventions: A meta-analytic review. Psychotherapy : Theory, Research and Practice 43,

11 Evidence on Efficacy of Cultural Adaptations 4. Client-therapist language matching: * Same language (not English), e.g. Spanish language matching (d= 0.49), vs. * No language matching (d= 0.21) 5. Level of acculturation of Latino clients on average effect sizes: * Low-acculturated > moderately-acculturated * Low-acculturated benefit more from intervention adaptation 6. Effect size for age of group receiving adaptation: Older > Younger Griner, D., & Smith, T. B. (2006). Culturally adapted mental health interventions: A meta-analytic review. Psychotherapy : Theory, Research and Practice 43,

12 General Conclusions about Cultural Adaptations * Huey & Polo (2008) find mixed evidence of adaptation efficacy in child treatment populations * Need for adaptation may be lower for children than for adults (Griner & Smith, 2006) * Pervasiveness of cultural adaptations * adaptations are often as effective as the original EBI, but may not be more effective * Adapted EBIs typically greater relevance for subcultural groups (Castro, Barrera & Holleran Steiker, 2010) * Castro, F. G., Barrera, M., & Holleran Steiker, L. (2010). Issues and challenges in the design of culturally adapted evidence-based interventions. Annual Review of Clinical Psychology, 6, * Huey, S. J. & Polo, A. J. (2008). Evidence based psychosocial treatments for ethnic minority youth. Journal of Clinical Child and Adolescent Psychology, 37,

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14 Maximizing Effect Size: Duration of the Intervention * How many sessions are optimal? It depends on the severity of the presenting problem and on the targeted outcome(s) * Fewer sessions tend to increase participation and program completion, but tend to reduce effect size (Kumpfer, Alvarado, Smith & Bellamy, 2002) * More sessions contribute to reduced attendance, but provide more learning opportunities, and are needed to change complex targeted outcomes * A balance in duration and depth is needed; aided by the identification of core intervention components Kumpfer, K. L., Alvarado, R., Smith, P., & Bellamy, N. (2002). Cultural sensitivity and adaptation in family-based prevention interventions. Prevention Science, 3,

15 Maximizing Effect: Motivating Attention and Involvement * Motivation - What is a most important intervention component for members of a targeted group? What do they care about, as it supports or contributes to the targeted health outcome? * Change Facilitation - What techniques can be used to produce targeted change in the shortest time, yet with empirically-based evidence of healthy effects? * Responsiveness to Diversity - Need consider existing within-group variability in lifestyles, temperaments, motivation, ecological barriers, etc.

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17 The Process of Formal Intervention Adaptation 1. Information Gathering * Conduct literature review, focus groups with participants, consultants, experts 2. Preliminary Adaptation Design * Utilize information from first phase to design a preliminary adaptation of the original EBI 3. Preliminary Adaptation Test * Pilot study of preliminary adaptation, including procedures for engagement and intervention 4. Adaptation Refinement * Utilize information from the pilot study to refine engagement procedures and adaptation content and activities to complete the adapted EBI Barrera, M. & Castro, F. G. (2006). A heuristic framework for the cultural adaptation of interventions. Clinical Psychology Science and Practice, 13,

18 Five Competing or Conflicting Imperatives 1. Knowledge Sources- Scientific evidence-based (top-down) vs. community-based participatory (bottom-up); generating evidence-based, data-driven knowledge, versus obtaining experiential wisdom from elders. Contrasting validated but imposed intervention activities, versus untested intervention activities albeit imbued with participant ownership 2. Design- Specificity/standardization vs. adjustability/adaptability: For intervention efficacy, an emphasis on consistent application of scientifically-validated evidence, versus flexible intervention activities to accommodate local and contemporary needs within a local community

19 Five Competing or Conflicting Imperatives 3. Implementation- Fidelity vs. adaptation conflict: Issues in balancing fidelity and fit (Barrera, Castro, & Holleran Steiker, 2011; Castro, Barrera & Martinez, 2004). Reframing these not as conflicting imperatives, but as two sides of the same coin. involves a stagewise application: (1) design for fidelity, (2) local adaptation, (3) fidelity in implementation 4. Engagement- Motivating participation vs. building skills: Both are needed; conflict is partially resolved by introducing motivational interviewing in Stage 1, followed in Stage 2 by program implementation * Barrera, M., Castro, F. G., & Holleran Steiker, L. K. (2011). A critical analysis of approaches to the development of preventive interventions for subcultural groups. American Journal of Community Psychology. * Castro, F. G., Barrera, M., & Holleran Steiker, L. K. (2010). Issues and challenges in the design of culturally-adapted evidence-based interventions. Annual Review of Clinical Psychology, 6,

20 Five Competing or Conflicting Imperatives 5. Dissemination- Adoption vs. Adaptation: Program publishers favor consumer adoption devoid of changes, whereas implementers favor adaptation to fit their needs. * Problem of misadaptation, when providers haphazardly make changes as they wish, which likely erodes intervention efficacy * Resolutions will require conceptual reframing, and the design of culturally-responsive intervention activities that satisfy both conditions. * Involves incorporation from the beginning cultural factors into design and intervention planning

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22 Emerging Themes 1. Sound cultural adaptation strategy involves conducing adaptive changes on the original EBI while: (1) maintaining core components, (2) increasing cultural relevance and engagement, (3) sustaining intervention efficacy * maintaining effect size on targeted outcomes, and (4) ideally increasing effect size * greater magnitude or proportion of positive change on targeted outcome variables

23 Emergent Themes 2. Abiding challenge of participant engagement and retention * issues of within-group variation in the determinants of participant engagement and efficacy * specifying efficacy effects and their limits: a program is efficacious for whom, and for whom not?

24 Emergent Themes * Low engagement portends low or null effect size * issues of variation in preparedness to participate; motivating participation * Consider cultural segmentation (market segmentation with subcultural groups), to tailor the intervention for subcultural groups (Barrera, Castro & Holleran Steiker, 2011) * Barrera, M., Castro, F. G., & Holleran Steiker, L. K. (2011). A critical analysis of approaches to the development of preventive interventions for subcultural groups. American Journal of Community Psychology.

25 Emergent Themes 3. Importance of ongoing participant feedback to refine, adjust, and improve the intervention. * Social participatory approach (bottom up) complements the empirically-based, scientific approach (top down). * However conflict can emerge when reconciling the conflicting recommendations of local stakeholders or leaders, as these may conflict with science-based or evidence-based knowledge

26 Emergent Themes 4. Utility of rigorously applied mixed methods methodologies for detecting cultural influences and contextualizing participants perspectives, pre and post intervention (Castro, Kellison, Boyd & Kopak, 2010) * Importance of well-designed mixed methods methodologies (focus groups, key informant interviews, qualitative data gathering), as opposed to the ill-conceived or haphazard utilization of qual-quant methodologies and labeling these as being a mixed methods study * Castro, F. G., Kellison, J. G., Boyd, S. J., & Kopak, A. (2010). A methodology for conducting integrative mixed methods research and data analyses. Journal of Mixed Methods Research, 4 (4),

27 Emergent Themes 5. Reframing unresolvable imperatives requires a deep-structure (Resnicow, Soler, Braithwait, Ahluwalia & Butler, 2000) scientific and cultural analysis, and a conceptual integration, with a coherent application of both * Sound cultural adaptation, beyond the black box requires application of: * a theory or logic model, * a rationale on mechanisms of cultural adaptation and healthy behavior change * that will maximize efficacy Resnicow, K., Soler, R., Braithwait, R. L., Ahluwalia, J. S., & Butler, J. (2000). Cultural sensitivity in substance abuse prevention. Journal of Community Psychology, 28,

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29 A Light and Intermittent Smoking Cessation Intervention Dr. Theodore Cooper, PI * Funded by A Smoke Free Paso del Norte, An Initiative of the Paso del Norte Health Foundation

30 Evidence Based Cessation Intervention * StopLite was empirically and theoretically developed * A one time brief intervention (Cabriales, Cooper, Salgado-Garcia, Naylor & Gonzalez, 2012) * Empirically-derived strategies included: * health education, * motivational enhancement, * trigger management, * CO feedback * Cabriales, J. A., Cooper, T. V., Salgado-Garcia, F., Naylor, N., & Gonzalez, E. (2012). A randomized trial of a brief smoking cessation intervention in a light and intermittent Hispanic sample. Experimental and Clinical Psychopharmacology, 20,

31 Evidence Based Cessation Intervention * Both motivational enhancement and trigger management elicited motivators and triggers from the client, enabling the introduction of individual and cultural factors (Cabriales, Cooper, Salgado-Garcia, Naylor & Gonzalez, 2012) * Theoretical foundations were utilized for both assessment and intervention, focusing on motivation to change and self-efficacy based on concepts and methods from two major models: * the Transtheoretical Model * the Self-Determination Theory * Cabriales, J. A., Cooper, T. V., Salgado-Garcia, F., Naylor, N., & Gonzalez, E. (2012). A randomized trial of a brief smoking cessation intervention in a light and intermittent Hispanic sample. Experimental and Clinical Psychopharmacology, 20,

32 Results and Take Home Messages * Relative to the Delayed Intervention condition at the three month follow-up, the StopLite intervention: 1. Did not yield statistically significant group differences in the outcome measures of: * abstinence * perceived competence 2. Did produce significant increases in motivation to quit smoking. Involving quit motivation: * rate in the Intervention group: 46.0%, * rate in the Delayed group: 30.6% * Cabriales, J. A., Cooper, T. V., Salgado-Garcia, F., Naylor, N., & Gonzalez, E. (2012). A randomized trial of a brief smoking cessation intervention in a light and intermittent Hispanic sample. Experimental and Clinical Psychopharmacology, 20,

33 Future Directions - Intervention Adaptation & Enhancement * Future directions can apply adaptation approaches to: * enhance intervention intensity, * reduce attrition, * further address cultural factors * Multiple iterations with community input increased understanding of cultural adaptation needs, that: 1. Light/intermittent smokers: don t perceive themselves to be smokers ; must screen, assess, and intervene in accord with this self-concept 2. Hispanic smokers: themes included: * difficulties in sharing own smoking with their family, * Ciudad Juarez cartel violence as a factor in life activities practiced on both sides of the border * Cabrioles, J. A., Cooper, T. V., Salgado-Garcia, F., Naylor, N., & Gonzalez, E. (2012). A randomized trial of a brief smoking cessation intervention in a light and intermittent Hispanic sample. Experimental and Clinical Psychopharmacology, 20,

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