Differential Designs: A Relevant Methodological Approach in the - - PowerPoint PPT Presentation

Differential Designs: A Relevant Methodological Approach in the Cultural Adaptation Field

9th Annual Conference on the Science of Dissemination and Implementation in Health Washington, D.C., December 2016

Rubén Parra-Cardona Michigan State University

Funding Support:

• National Institute of Mental Health (NIMH), Division of Services and

Intervention Research, Grant #R34MH087678

• Michigan State University, Office of Vice-President for Research and

Graduate Studies (OVPRGS), the MSU College of Social Science, and the Department of Health and Human Development

• National Institute on Drug Abuse (NIDA), Grant # K01DA036747

Acknowledgements

Co-Investigators, Consultants, and Research Staff:

• Co-Investigators: Cris Sullivan, Deborah Bybee, Melanie

Domenech-Rodríguez, Guillermo Bernal, Lisa Tams,

• Research Consultants: Marion Forgatch, Hiram Fitzgerald,

James C. Anthony (K01 Sponsor)

• Interventionists: Efraín Zamudio, Mónica E. Villa, & Florys

Meredith-Gonzáles

• Project Managers: Gabriela López-Zerón, Ana Rocío Escobar-

Chew, Kendal Holtrop, David Cordova

• Data Collectors: Ana Romo-Huerta, Idali Sancen, Juan José

Arredondo

• Community Partners: Southwest Solutions (Brian Dates), MSU-

Extension Detroit, Holly Redeemer

• Curriculum Development: Ana Baumann, Nancy Amador

Buenabad

• Ethnic minorities continue to experience widespread

health and mental health disparities in the US.

• Empirical research indicates that ethnic minority

populations can benefit from culturally adapted (CA) interventions (Smith et al., 2011).

Background

Cultural Adaptation

Cultural adaptation refers to “the systematic modification of an evidence-based treatment (EBT) or intervention protocol to consider language, culture, and context in such a way that it is compatible with the client’s cultural patterns, meanings, and values.

(Bernal, Jimenez-Chafey, & Domenech Rodriguez, 2009, p. 362)

A Comparative Design

Latino/a immigrants in Detroit

Method

Specific Aims

Implement small RCT with the two culturally adapted interventions aimed at testing differential: a) Implementation feasibility b) Initial efficacy

• 1. Positive Involvement
• 2. Skill Encouragement
• 3. Limit Setting
• 4. Monitoring/Supervision
• 5. Family Problem Solving

METHOD OF DELIVERY - Role play & focus on parents

PMTOR: Evidence-based parenting intervention aimed at improving parenting skills and reducing problematic behaviors in children

Ecological Validity Model

(Bernal & Sáez-Santiago, 2006)

• According to the EVM model, all research activities

and procedures must be culturally adapted according to the following dimensions:

• 1. Language
• 5. Concepts
• 2. Persons
• 6. Goals
• 3. Metaphors 7. Methods
• 4. Content
• 8. Context

Both Adapted Interventions

• Interventionists
• One team for each condition, each integrated by one

male community organizer and one female CSW

• Advocacy
• Immigration services, IPV services, mental health

services job training, funeral assistance and repatriation of remains, etc.

Culturally Adapted Versions of PMTO

• CAPAS Intervention
• Exclusively focused on the culturally adapted core

PMTO parenting components.

• Cultural adaptation led by Domenech-Rodríguez with

NIMH funding support. CAPAS-Enhanced Intervention

• Two culture-specific sessions focused on biculturalism,

immigration stress, and discrimination.

• All PMTO sessions, especially role-plays, informed

according to narratives of parents.

Design

• Prevention Design

Screening: Families with children ages 4-12; mild to moderate child behavioral problems

• Parenting groups format
• RCT:

a)

CAPAS-Original, b) CAPAS-Enhanced, c) Wait-list control

• Multiple Assessment Points

Quantitative:

• BL (T1), Intervention Completion (T2), 6-month follow-up

(T3) Qualitative:

• Intervention Completion (T2)

Assessment

• Parental Self-Report:
• Parenting Practices

Skill Encouragement Monitoring & Supervision Positive Involvement Problem Solving Limit Setting

• Child Behavior (CBCL), Internalizing and Externalizing

RCT Demographic Data

Family Characteristics

CAPAS-Original CAPAS-Enhanced Control

Participating Families 36 35

32

Annual Family Income $20,000 or less 41.7% 22.9% 25.0% $21,000-30,000 25.0% 34.3% 37.5% $31,000-40,000 11.1% 22.9% 15.6% Greater than $40,000 13.9% 11.4% 12.5% Average Age of Children

9.44 (±3.35) 8.66 (±2.85) 9.16 (±3.18)

Average Number of Children in Household

2.69 (±0.98) 2.63 (±1.11) 3.10 (±1.08)

Individual Characteristics

Participating Individuals 66 64 59 Mothers 36 35 32 Fathers 30 29 23 Country of Origin: Mexico 59 57 27 Average Parent Age 35.97 (±4.83) 36.97 (±6.48) 36.52 (±5.29) Average Years Living in US 15.04 (±4.88) 14.11 (±5.48) 14.80 (±5.72)

Feasibility and Initial Efficacy Findings

Retention and Dosage

At 6-month follow-up: Retention Families = 87% Retention Fathers = 85%

n = 119 parents

CAPAS-Original CAPAS-Enhanced Fathers Mothers Fathers Mothers Number of Sessions 12 19% 29% 32% 27% 10-11 39% 48% 28% 60% 7-9 42% 23% 36% 13% 6 0% 0% 4% 0%

Satisfaction Ratings All Parenting Waves (Scale1-5)

CAPAS-Original Mean Rating CAPAS-Enhanced Mean Rating 1 Introduction 4.63 Being a Latino Immigrant Parent 4.69 2 Giving Good Directions 4.51 Giving Good Directions 4.57 3 Encouragement I 4.45 Encouragement I 4.53 4 Encouragement II 4.43 Encouragement II 4.56 5 Booster 4.47 Setting Limits I 4.51 6 Setting Limits I 4.60 Setting Limits II 4.64 7 Setting Limits II 4.50 Setting Limits III 4.52 8 Setting Limits III 4.52 Booster 4.58 9 Booster 4.58 Monitoring 4.52 10 Monitoring 4.56 Problem Solving 4.56 11 Problem Solving 4.51 Parenting Between Two Cultures 4.60 Average 4.52 Average 4.57* *t (6) = -.670, p = .528

Parenting Skills

CAPAS & CAPAS-Enhanced sig higher than Control 6-months

1 2 3 4 5 6 7 8 9 10 11 12 2.7 2.8 2.9 3.0 3.1 3.2 3.3 3.4 3.5

Months after pre-intervention Parenting Practices (Mean)

Control CAPAS adapted CAPAS enhanced

Limit Setting

CAPAS & CAPAS-Enhanced sig higher than Control at 6-month follow-up

2 4 6 8 10 12 3.05 3.25 3.45 3.65 3.85 4.05 4.25

Months Discipline - Limit-setting

Control Mother Control Father CA Mother CA Father CE Mother CE Father

Preliminary Effect Size Results

(Feingold, 2009; Raudenbush & Lui, 2001)

Between-condition differences at 6-month FU CE vs Control CA vs Control CE vs CA Outcome Variables d p d p d p Skill Encouragement 0.815 <.001 0.505 0.002 0.308 0.103 Supervision 0.948 <.001 0.659 0.002 0.286 0.131 Family Problem Solving 0.832 <.001 0.706 <.001 0.124 0.483 Positive Involvement 0.520 0.001 0.706 <.001 0.187 0.168 Discipline - Limit Setting 1.122 <.001 0.807 <.001 0.316 0.089

Child Internalizing and Externalizing

CAPAS Enhanced sig higher than CAPAS and Control 6-months

4.5 5.5 6.5 7.5 8.5 9.5 10.5 11.5 12.5

Child Behavior (Mean)

1 2 3 4 5 6 7 8 9 10 11 12

Months after pre-intervention

Control CAPAS adapted CAPAS enhanced

Parent-Reported Child Behavior Internalizing

CAPAS-Enhanced, main effect sig lower than Control at 6-month follow-up

2 4 6 8 10 12 1.16 1.36 1.56 1.76 1.96 2.16 2.36 2.56 2.76

Months CBCL Internalizing (Log)

Control Mother Control Father CA Mother CA Father CE Mother CE Father

Preliminary Effect Size Results

(Feingold, 2009; Raudenbush & Lui, 2001)

Between-condition differences at 6-month FU CE vs Control CA vs Control CE vs CA Outcome Variables d p d p d p CBCL Internalizing Main Effect

• 1.447

0.016 -0.878 0.154 -0.573 0.330

Parent-Reported Child Behavior Externalizing

For fathers only, CAPAS-Enhanced significantly lower than CAPAS & Control at 6-month follow-up

2 4 6 8 10 12 1.12 1.32 1.52 1.72 1.92 2.12 2.32 2.52 2.72

Months CBCL Externalizing (Log)

Control Mother Control Father CA Mother CA Father CE Mother CE Father

Preliminary Effect Size Results

(Feingold, 2009; Raudenbush & Lui, 2001)

Between-condition differences at 6-month FU CE vs Control CA vs Control CE vs CA Outcome Variables d p d p d p CBCL Externalizing Main Effect

• 0.409

0.261

• 0.396

0.221

• 0.011

0.971 CBCL Externalizing Fathers

• 1.075

0.011 0.074 0.827

• 1.155

0.007

Summary: Qualitative Findings

Intervention Satisfaction:

Positive Involvement & Skill Encouragement

“I learned that I was the one who had to change, rather than expecting my child to change. Before, my son would approach me and I would evade him. Now, he approaches me and I express my love to him.” (CA mother) “I always had problems with my daughter doing her homework. From giving 25 orders at once. Now, with the incentive chart, it is only five steps. It has helped me a lot.” (CE father)

I was not close to my children. I would only yell at them, “Do this!” “Do that!” I learned here that one thing is respect and another fear…they were afraid of me (CE mother)

“Learning how to discipline my kid has

helped me because I can use authority but without hurting him” (CA father)

Limit Setting

Culture-Specific Sessions Immigration Challenges/ Racial Socialization

CE Participant: “I need to learn how to talk to children about racism because in many occasions my children have suffered racism…Just because they have Hispanic accent, they have experienced racism.”

Culture-Specific Sessions Biculturalism

“We need to teach our children recognize the

• pportunities they have here, like being bilingual

…We also have to make sure that they adapt to our Latino culture. We need to help them to live between two cultures, because by having two cultures, they will have many opportunities in life.”

Discussion

• The value of differential CA research designs,

particularly if fathers are retained.

• Hypotheses associated with differential child
• utcomes:
• Context associated with immigration experience
• Common and differential impact for mothers and

fathers

• The high relevance of integrating implementation

science and cultural adaptation, particularly as it refers to underserved diverse populations.

Differential Designs: A Relevant Methodological Approach in the Cultural Adaptation Field

9th Annual Conference on the Science of Dissemination and Implementation in Health Washington, D.C., December 2016

Rubén Parra-Cardona Michigan State University

1 Introduction Being a Latino Immigrant Parent 2 Giving Good Directions Parenting Between Two Cultures 3 Encouragement I Giving Good Directions 4 Encouragement II Encouragement I 5 Booster Encouragement II 6 Setting Limits I Setting Limits I 7 Setting Limits II Setting Limits II 8 Setting Limits III Setting Limits III 9 Booster Booster 10 Monitoring Monitoring 11 Problem Solving Problem Solving

CAPAS vs CAPAS-ENHANCED

Pilot Study

ESSENTIAL Role of Interventionists

“The interventionists knew how to present these topics to us as Latinos. Even with a good program, without good facilitators, the program will not work. Thanks to them, the program was excellent.”

“I thought that my children were going to grow and think like I do, as a Mexican. But then I realized that they are growing up here...Their minds are

• different. If I only teach them what I learned in

Mexico, I will not offer them a good education. I need to learn how to raise them in a new way by also adapting to this culture.”

Culture-Specific Sessions