Bonnie K. Nastasi

Mixed Methods in Intervention Research: Theory to Adaptation

The purpose of this article is to demonstrate the application of mixed methods research designs to multiyear programmatic research and development projects whose goals include integration of cultural specificity when generating or translating evidence-based practices. The authors propose a set of five mixed methods designs related to different phases of program development research: (a) formative research, Qual →/+ Quan; (b) theory development or modification and testing, Qual → Quan →/+ Qual → Quan ... Qual → Quan; (c) instrument development and validation, Qual → Quan; (d) program development and evaluation, Qual →/+ Quan →/+ Qual →/+ Quan ... Qual →/+ Quan, or Qual →← Quan; and (e) evaluation research, Qual + Quan. We illustrate the application of these designs to creating and validating ethnographically informed psychological assessment measures and developing and evaluating culturally specific intervention programs within a multiyear research program conducted in the country of Sri Lanka.

Men’s Extramarital Sex, Marital Relationships and Sexual Risk in Urban Poor Communities in India

The objectives of this paper are to (1) understand the nature of men’s extramarital sexuality in three low income communities in Mumbai, India; (2) explore the associations between marital relationships and extramarital sex; and (3) assess the implications of the research results for intervention. Results are based on survey data collected from 2,408 randomly selected men from the three study communities and a matched subset of 260 randomly selected men and their wives who responded to a female version of the mens survey. These surveys produced a unique data set, which allows sociodemographic, attitudinal and behavioral variables from husband and wife and variables that are the product of husband and wife interaction to be utilized to predict mens extramarital sex through multiple sequential logistic regression analysis. Results indicate that mens extramarital sex is significantly associated with husbands and wifes age, wifes perception of domestic violence, husbands education and place of birth, husbands alcohol use, wifes willingness to engage in marital sex, and types of marital sexual acts. These results confirm the need to move from the individual to the couple as the unit of research and the need for intervention to reduce the risk of HIV/STI transmission within marriage both in India and internationally.

Meeting the Challenges of the Future: Integrating Public Health and Public Education for Mental Health Promotion

The 2002 Future of School Psychology Conference called for reform of current models of professional school psychology, including a paradigm shift toward a public health model of practice. This article explores the role of school psychologists in efforts to achieve an integrated public health and public education model for delivering comprehensive school-based mental health services. Building on expertise as psychological and educational consultants, school psychooogists can play a unique role in facilitating the necessary systemic reform and capacity building for comprehensive mental health service delivery. This revised role requires redefining school-based consultation to include consultation for capacity building, and rethinking professional preparation to ensure expertise in public health models, inter-agency and interdisciplinary collaboration, participatory action research, and comprehensive service delivery.

Challenges of Evaluating Multilevel Interventions

This article uses the Comprehensive Mixed-Methods Participatory Evaluation (CMMPE; Nastasi and Hitchcock Transforming school mental health services: Population-based approaches to promoting the competency and wellness of children, Thousand Oaks, CA: Corwin Press with National Association of School Psychologists 2008; Nastasi et al. School-based mental health services: creating comprehensive and culturally specific programs. Washington, DC: American Psychological Association 2004) model as a framework for addressing the multiplicity of evaluation decisions and complex nature of questions related to program success in multilevel interventions. CMMPE defines program success in terms of acceptability, integrity, social or cultural validity, outcomes (impact), sustainability and institutionalization, thus broadening the traditional notions of program outcomes. The authors use CMMPE and an example of a community-based multilevel sexual risk prevention program with multiple outcomes to discuss challenges of evaluating multilevel interventions. The sexual risk program exemplifies what Schensul and Tricket (this issue) characterize as multilevel intervention–multilevel evaluation (M–M), with both intervention and evaluation at community, health practitioner, and patient levels. The illustration provides the context for considering several challenges related to M–M designs: feasibility of randomized controlled trials within community-based multilevel intervention; acceptability and social or cultural validity of evaluation procedures; implementer, recipient, and contextual variations in program success; interactions among levels of the intervention; unanticipated changes or conditions; multiple indicators of program success; engaging multiple stakeholders in a participatory process; and evaluating sustainability and institutionalization. The complexity of multilevel intervention and evaluation designs challenges traditional notions of evaluation research and experimental designs. Overcoming these challenges is critical to effective translation of research to practice in psychology and related disciplines.

Multilevel Perspectives on Community Intervention: An Example from an Indo-US HIV Prevention Project in Mumbai, India

This paper explores the meaning and applicability of multilevel interventions and the role of ethnography in identifying intervention opportunities and accounting for research design limitations. It utilizes as a case example the data and experiences from a 6-year, NIMH-funded, intervention to prevent HIV/STI among married men in urban poor communities in Mumbai, India. The experiences generated by this project illustrate the need for multilevel interventions to include: (1) ethnographically driven formative research to delineate appropriate levels, stakeholders and collaborators; (2) identification of ways to link interventions to the local culture and community context; (3) the development of a model of intervention that is sufficiently flexible to be consistently applied to different intervention levels using comparable culturally congruent concepts and approaches; (4) mechanisms to involve community residents, community based organizations and community-based institutions; and (5) approaches to data collection that can evaluate the impact of the project on multiple intersecting levels.

Facilitating long-term recovery from natural disasters: Psychosocial programming for tsunami-affected schools of Sri Lanka

This article reports the findings of a school-based intervention project conducted in the Southern Province of Sri Lanka 15 to 18 months after the December 2004 Tsunami. The work responds to the need for culturally relevant programming to address long-term psychosocial recovery of children and adolescents affected by large scale disasters. Program developers used a participatory action research process to adapt and implement a school-based program previously tested with the general population of Sri Lankan students. Qualitative analysis of student products (e.g. ecomaps, stories, text) was used to determine whether the program provided a context to address both tsunami-specific stressors and non-tsunami (but developmentally and contextually relevant) stressors for students in grades 5, 7, and 9. Findings indicated that program activities differentially elicited identification and discussion of stressors related to tsunami experiences and to ‘normal’ culturally-relevant developmental challenges. The feasibility of combining a recovery focus with universal school-based mental health programming thus holds promise for extending crisis intervention and disaster response models to include long-term psychosocial recovery and for the role of school-based mental health professionals in these efforts.

Assessing Adolescents' Understanding of and Reactions to Stress in Different Cultures Results of a Mixed-Methods Approach

This article expands on an emerging mixed-method approach for validating culturally-specific constructs (see Hitchcock et al., 2005). Previous work established an approach for dealing with cultural impacts when assessing psychological constructs and the current article extends these efforts into studying stress reactions among adolescents in Sri Lanka. Ethnographic data collection and analysis techniques were used to construct scenarios that are stressful to Sri Lankan youth, along with survey items that assess their related coping mechanisms. The data were factor analysed, results were triangulated with qualitative findings, and reliability estimates of resulting scales were obtained. This in turn generated a pilot assessment approach that can be used to measure stress and coping reactions in a distinct culture. Use of the procedures described here could be replicated to generate culturally-specific instruments in international contexts, or when working with ethnic minorities within a given nation. This should in turn generate information needed to develop culturally relevant intervention work.

Validating Culture- and Gender-Specific Constructs: A Mixed-Method Approach to Advance Assessment Procedures in Cross-Cultural Settings

SUMMARY Despite on-going calls for developing cultural competency among mental health practitioners, few assessment instruments consider cultural variation in psychological constructs. To meet the challenge of developing measures for minority and international students, it is necessary to account for the influence culture may have on the latent constructs that form a given instrument. What complicates matters further is that individual factors (e.g., gender) within a culture necessitate additional refinement of factor structures on which such instruments are based. The current work endeavors to address these concerns by demonstrating a mixed-methods approach utilized to assess construct validation within a specific culture; and in turn develop culturally-specific instruments. Qualitative methods were used to inform the development of a structured self-report by gaining detailed knowledge of the target culture and creating items grounded in interview and observational data. Factor analysis techniques and triangulation with qualitative analyses validated these findings. Previous work (Sarkar, 2003) suggested a number of gender-specific perceptions of mental health constructs within the target culture and these were investigated using additional mixed-method analyses. This article demonstrates an emerging mixed-method technique for developing culturally sound assessment tools, offers guidance on how to incorporate the overall approach in assessment, and provides a basis for thinking critically about the use of existing instruments when working with diverse populations.

School-based mental health services in post-disaster contexts: A public health framework

Large scale natural disasters pose serious risks to mental health and simultaneously wreak havoc on the very systems called upon to ameliorate those risks. School-based mental health services have been identified as a potential mechanism through which gaps in service delivery systems can be addressed in post-disaster environments. We believe that a public health framework provides a useful guide for school psychologists who may be called upon to develop school-based systems of care following a disaster. In this article we discuss considerations and challenges in the application of this model in the context of our experience developing school-based mental health services in New Orleans, Louisiana, USA, following Hurricane Katrina.

Sexually transmitted infections in men in Mumbai slum communities : The relationship of prevalence to risk behavior

Objectives: The objectives of this study were to identify sexually transmitted infection (STI) prevalence, assess behavioral and symptom correlates, and develop intervention strategies. Goal: The goal of this study was to conduct one of the first community-based surveys of STI prevalence and risk behaviors among married men in India. Study Design: In 2003, 2,408 randomly selected married men, aged 21 to 40 years, were administered a survey instrument with urine and blood samples collected from a random subset of 641. Results: The most common current STI was gonorrhea (3.9%) with 6.1% of men being positive for an acute STI and 9.7% antibody-positive for Treponema pallidum or herpes simplex virus type 2. Risk behaviors were not associated with laboratory confirmed STIs, but did show an association with mens concerns about sexual performance derived from traditional Indian systems of medicine. Conclusion: Culturally based symptoms can serve as effective markers for men involved in risky sexual behaviors and provide an opportunity to engage these men as they seek care for these symptoms at community-based service points.