Felipe González Castro

Standards of Evidence: Criteria for Efficacy, Effectiveness and Dissemination

Ever increasing demands for accountability, together with the proliferation of lists of evidence-based prevention programs and policies, led the Society for Prevention Research to charge a committee with establishing standards for identifying effective prevention programs and policies. Recognizing that interventions that are effective and ready for dissemination are a subset of effective programs and policies, and that effective programs and policies are a subset of efficacious interventions, SPR’s Standards Committee developed overlapping sets of standards. We designed these Standards to assist practitioners, policy makers, and administrators to determine which interventions are efficacious, which are effective, and which are ready for dissemination. Under these Standards, an efficacious intervention will have been tested in at least two rigorous trials that (1) involved defined samples from defined populations, (2) used psychometrically sound measures and data collection procedures; (3) analyzed their data with rigorous statistical approaches; (4) showed consistent positive effects (without serious iatrogenic effects); and (5) reported at least one significant long-term follow-up. An effective intervention under these Standards will not only meet all standards for efficacious interventions, but also will have (1) manuals, appropriate training, and technical support available to allow third parties to adopt and implement the intervention; (2) been evaluated under real-world conditions in studies that included sound measurement of the level of implementation and engagement of the target audience (in both the intervention and control conditions); (3) indicated the practical importance of intervention outcome effects; and (4) clearly demonstrated to whom intervention findings can be generalized. An intervention recognized as ready for broad dissemination under these Standards will not only meet all standards for efficacious and effective interventions, but will also provide (1) evidence of the ability to “go to scale”; (2) clear cost information; and (3) monitoring and evaluation tools so that adopting agencies can monitor or evaluate how well the intervention works in their settings. Finally, the Standards Committee identified possible standards desirable for current and future areas of prevention science as the field develops. If successful, these Standards will inform efforts in the field to find prevention programs and policies that are of proven efficacy, effectiveness, or readiness for adoption and will guide prevention scientists as they seek to discover, research, and bring to the field new prevention programs and policies.

The Cultural Adaptation of Prevention Interventions: Resolving Tensions Between Fidelity and Fit

A dynamic tension has developed in prevention science regarding two imperatives: (a) fidelity of implementation—the delivery of a manualized prevention intervention program as prescribed by the program developer, and (b) program adaptation—the modification of program content to accommodate the needs of a specific consumer group. This paper examines this complex programmatic issue from a community-based participatory research approach for program adaptation that emphasizes motivating community participation to enhance program outcomes. Several issues, key concepts, and implementation strategies are presented under a strategic approach to address issues of fidelity and adaptation. Despite the noted tension between fidelity and adaptation, both are essential elements of prevention intervention program design and they are best addressed by a planned, organized, and systematic approach. Towards this aim, an innovative program design strategy is to develop hybrid prevention programs that “build in” adaptation to enhance program fit while also maximizing fidelity of implementation and program effectiveness.

Issues and Challenges in the Design of Culturally Adapted Evidence-Based Interventions

This article examines issues and challenges in the design of cultural adaptations that are developed from an original evidence-based intervention (EBI). Recently emerging multistep frameworks or stage models are examined, as these can systematically guide the development of culturally adapted EBIs. Critical issues are also presented regarding whether and how such adaptations may be conducted, and empirical evidence is presented regarding the effectiveness of such cultural adaptations. Recent evidence suggests that these cultural adaptations are effective when applied with certain subcultural groups, although they are less effective when applied with other subcultural groups. Generally, current evidence regarding the effectiveness of cultural adaptations is promising but mixed. Further research is needed to obtain more definitive conclusions regarding the efficacy and effectiveness of culturally adapted EBIs. Directions for future research and recommendations are presented to guide the development of a new generation of culturally adapted EBIs.

A methodology for conducting integrative mixed methods research and data analyses

Mixed methods research has gained visibility within the last few years, although limitations persist regarding the scientific caliber of certain mixed methods research designs and methods. The need exists for rigorous mixed methods designs that integrate various data analytic procedures for a seamless transfer of evidence across qualitative and quantitative modalities. Such designs can offer the strength of confirmatory results drawn from quantitative multivariate analyses, along with “deep structure” explanatory descriptions as drawn from qualitative analyses. This article presents evidence generated from over a decade of pilot research in developing an integrative mixed methods methodology. It presents a conceptual framework and methodological and data analytic procedures for conducting mixed methods research studies, and it also presents illustrative examples from the authors’ ongoing integrative mixed methods research studies.

Cancer Risk Reduction in Mexican American Women: The Role of Acculturation, Education, and Health Risk Factors

This article describes a two-factor schema for the development of culturally appropriate cancer risk reduction interventions for Mexican American women. Regarding this approach, risk factors for two major cancer areas are reviewed: cigarette smoking and obesity/diet. We first describe a schema that facilitates the planning of strategies associated with preferred health interventions and preventive approaches for cancer risk reduction with Mexican American and other Latino/Hispanic persons. This schema examines Acculturation and Education as key factors that should be considered in developing health education messages and interventions that are culturally and educationally appropriate to the identified subpopulations of Hispanics in terms of language and informational content of the message and in terms of psychological factors related to health behavior change. Empirical data from a community sample is presented for the purpose of illustrating the validity of this schema.

Stress, Coping, and Mexican American Mental Health: A Systematic Review

While there has been a rapid growth in mental health research which focuses on the Mexican American population, differences in theoretical formulations and consequent research methodologies have led to a host of conflicting findings. These conflicting findings are then often difficult to translate into useful clinical applications which would make clinical services more relevant and acceptable to this growing population. One suggested solution to the problem has been to develop more systematic theoretical frameworks for guiding Mexican American mental health research. In this vein a new theoretical model was presented. The model is based upon recent concepts regarding the relationship between psychological stress and consequent physical and/or psychological illnesses. This model includes some important intervening or mediating variables which may serve to aggravate or buffer the aversive impact of exposure to potential stressors. Examination of these intervening variables is of clinical importance in promoting a better understanding of the experience of stress and its relationship to various forms of psychopathology. The model allows for critical examination of those intervening variables which are particularly relevant to Mexican Americans. In addition to presenting this stress-mediation-out-come model, an attempt was made to synthesize extant Mexican American mental health research within the framework of the proposed model. This synthesis served as a basis for identifying conceptual and methodological problems in past research, as well as for identifying current gaps in this large body of research. Finally, an attempt was made to delineate new lines of mental health research which are more consistent with the postulated stress-mediation-outcome model.

Are Clinical Psychologists Prepared for Service and Research With Ethnic Minorities? Report of a Decade of Progress

Longitudinal data on the status of training of clinical psychologists for service and research with ethnic minority populations were presented in order to assess progress. Data from an earlier survey by Bernal and Padilla (1982), which were collected in 1979-1980, were compared with similar survey data collected in 1990-1991. Results revealed a mixed picture of progress: Key aspects of minority training have improved, and there is a substantial block of programs committed to minority training. However, two changes are needed: engagement in a change process leading to training for cultural competence rather than minimal exposure to culture, and a significant increase in the numbers of minority faculty, which can occur only by a sharp increase in the numbers of minority students admitted into the educational pipeline.

Differences in cancer-risk-related behaviors in Latino and Anglo adults

METHODS. Latino (n = 358) and Anglo (n = 113) adults living in the San Diego area were surveyed on nutrition, smoking, and cancer screening behaviors. The Latino respondents were dichotomized into a low (L-Latino) or high (H-Latino) acculturation group according to a median split of an acculturation index. RESULTS. After controlling for age, years of education, gender, marital status, and income, significant cross-cultural differences were found in saturated fat/cholesterol avoidance, and fiber and high calorie food consumption. L-Latino respondents had the lowest degree of saturated fat/cholesterol avoidance, followed by H-Latinos and Anglos. A pattern of decreasing consumption with increasing acculturation was observed for fiber and high calorie foods. Significant differences were found among women in the prevalence of Pap smear exams, with L-Latinas having the lowest prevalence of ever and in the past year having had a Pap smear, followed by H-Latinas and Anglos. A similar significant pattern was observed among women 50 years of age or older with respect to the prevalence of ever having had a mammogram.

Replication in Prevention Science

Replication research is essential for the advancement of any scientific field. In this paper, we argue that prevention science will be better positioned to help improve public health if (a) more replications are conducted; (b) those replications are systematic, thoughtful, and conducted with full knowledge of the trials that have preceded them; and (c) state-of-the art techniques are used to summarize the body of evidence on the effects of the interventions. Under real-world demands it is often not feasible to wait for multiple replications to accumulate before making decisions about intervention adoption. To help individuals and agencies make better decisions about intervention utility, we outline strategies that can be used to help understand the likely direction, size, and range of intervention effects as suggested by the current knowledge base. We also suggest structural changes that could increase the amount and quality of replication research, such as the provision of incentives and a more vigorous pursuit of prospective research registers. Finally, we discuss methods for integrating replications into the roll-out of a program and suggest that strong partnerships with local decision makers are a key component of success in replication research. Our hope is that this paper can highlight the importance of replication and stimulate more discussion of the important elements of the replication process. We are confident that, armed with more and better replications and state-of-the-art review methods, prevention science will be in a better position to positively impact public health.

The Health Beliefs of Mexican, Mexican American and Anglo American Women

The health-illness beliefs in five health domains as related to level of acculturation were examined in 102 Mexican, Mexican American, and Anglo American women. The five health domains examined were Mexican folk beliefs, hot-cold theory of illness beliefs, beliefs of responsibility and control over own health, cardiovascular disease beliefs, and stress-illness beliefs. The question of interest was whether less acculturated Mexican women as compared with more acculturated and Anglo women have a significantly different conceptual system of health-illness beliefs in these five domains. A different health belief schemata in these less acculturated women might function as a barrier to their acceptance of and compliance with biomedical treatments. The Mexican-origin women expressed mild acceptance of Mexican folk beliefs, a moderate acceptance of hot-cold beliefs and a strong acceptance of biomedical beliefs (cardiovascular and stress-illness beliefs). The less aculturated women reported having a somewhat lower sense of responsibility and control over own health as characterized by a greater acceptance of powerful external agents, God, chance, the doctor, as determinants of health outcomes. These results suggest that Mexican-origin.women have a dual system of belief which tends to weaken but not disappear with increasing acculturation. This dual system however would not appear to interfere with their ability to accept and comply with prescribed biomedical health regimens.