What is the problem that needs to be addressed? Please describe how it is related to mental health.
Homicide is the second leading cause of death among Latino youth ages 10-24 (CDC, 2012), and Latino youth experience high rates of dating violence (Cuevas, Sabina, & Bell, 2014). Importantly, exposure to violence in the community or in the context of family and romantic relationships has long-term impacts on mental health, heightening risk for a wide range of deleterious outcomes, including depression, anxiety, and substance use disorders (e.g., Amar & Gennaro, 2005; Lee, 2012; Trocki & Caetano, 2003). Indeed, within the last decade, evidence regarding the impact of toxic stress on the developing brain has rapidly accumulated, suggesting there is an urgent need to prevent community and family violence (Shonkoff et al., 2012). To date, relatively few prevention programs for adolescents exist that target multiple types of youth violence perpetration and victimization, and even fewer programs have been implemented and evaluated for youth growing up in low-income, primarily immigrant Latino communities. Youth in these communities often face a range of adverse childhood experiences such as high levels of violence exposure, single parent households, higher levels of responsibility to their parents (due to language and/or immigration-based barriers), overcrowded housing, and lack of support services, underscoring the need for effective violence prevention and mental health promotion programs. Further, low-income urban communities face challenges implementing strict manualized programs with little flexibility, high costs, and requiring a highly professionalized staff (Backer & Guerra, 2011). Consequently, it is critical to develop and test novel, flexible interventions for youth and their families, and that utilize culturally sensitive and cost-effective delivery methods to promote uptake and enhance sustainability beyond the intervention trial. Once youth and their families have become engaged in violence prevention and health promotion efforts, developing and implementing strategies to keep them meaningfully involved in this work is integral in transforming communities with high crime rates into healthy environments in which youth can prosper.
Why is this a concern for Orange County? What can Orange County and other counties learn from this project?
Orange County is the seat of extreme opulence and abject poverty. Among the communities living in poverty in Orange County are the recent immigrants from Latin America residing in Santa Ana, recently named by the Nelson A. Rockefeller Institute of Government as the nation’s “most difficult place to survive.” This community demonstrates a great need for youth violence prevention and mental health promotion programming as serious youth violence disproportionately affects Latino families. Santa Ana’s population is over 80% Latino and over 50% first-generation immigrant, and has a poverty rate of 16.5% compared to the county rate of 9.5%. Further, only 50% of adults over age 25 have a high school diploma or equivalent; and 81% of children in the school district are eligible for free or reduced price meals. By all metrics, this is a community in need of support. These statistics regarding Santa Ana’s population in conjunction with the above-mentioned statistics regarding risk for serious violence among Latino youth raise concern for the well-being of the youth and families residing there. However, Santa Ana also has tremendous community resources in the form of non-profit organizations poised to address these challenges. For instance, our partner agency, Latino Health Access (LHA), has provided prevention and health promotion services in these impoverished neighborhoods for over two decades. LHA trains individuals and families affected with a physical or mental health condition to gain control of their health and lives. Participants that demonstrate leadership are recruited and trained as community health workers (promotoras) who teach others to develop similar competencies. These full-time, paid promotoras work in the neighborhoods where they live; as such, they are experts in the areas they serve and know these places from the inside. They have learned to gain access to and navigate the health care system; manage chronic conditions; and assist others in managing their health and wellness and the living conditions that influence health. LHA’s unique model of community engagement has resulted in many awards and both national and international recognition. In 2013, The New England Journal of Medicine mentioned LHA among three examples of their selected community model organizations using the Community Health Worker model. LHA’s strong ties with the community and welcoming space mirror the resiliency and strength of Latino families. Latino families boast strong family ties and impressive loyalty. Parenting practices in Latino families are often embedded in the cultural values of familismo (strong family cohesion), warmth, respeto, and cariño (Leidy, Guerra, & Toro, 2010 Livas-Dlott et al., 2010). The emphasis on promoting closeness and valuing familial ties is a source of strength for these communities, an asset that can be harnessed in order to ameliorate problems in surrounding neighborhoods.
What is currently being done to resolve this problem in our county and throughout the United States? If applicable: Is it working; why or why not?
Throughout the United States, concern about youth violence and mental health in affected areas has grown, resulting in the development of a large number of manualized programs for violence prevention. However, the majority of these youth violence prevention programs are didactic in nature and skills-based. Such programs, developed by researchers and initially tested in controlled laboratory environments, often fail to achieve their promise when implemented in communities facing multiple forms of intersecting risk (e.g., poverty, discrimination, immigration-related stress, crime exposure, etc.). One reason for their failure is that these programs may not adequately address the contextual determinants of violence, such as the erosion of trust within the community. Evidence-based programs (EBPs) cannot easily be exported to settings with different and unique needs and challenges. As Dodge (2011, p.2) notes, “The traditional model of translation from basic laboratory science to efficacy trials to effectiveness trials to community dissemination has flaws that arise from false assumptions that context changes little or doesn’t matter.” Further, programs tend to focus on a specific type of violence, for instance, serious assaultive behavior versus teen dating violence, rather than testing whether a comprehensive program can address multiple types of youth violence and victimization for both boys and girls—an approach that would be more useful for broader implementation. In addition, violence prevention programs rarely involve parents, which is a serious oversight given that parents are significant influences in adolescents’ lives and well-being. The prominent role of parents in promoting adolescents’ health may be even stronger among Latino families. However, in general, most parenting programs for Latino/a parents fall short of their promise. In fact, a recent report (Parra Cardona et al., 2009, 2012) indicates that, while Latino/a parents express a strong desire to improve their parenting, existing programs are not culturally sensitive (Parra Cardona et al., 2012), or are costly and difficult to implement in community settings (Parra Cardona et al., 2009). Programs may alienate Latino families if they fail to incorporate cultural values and interveners present as experts on optimal parenting, recapitulating experiences of discrimination. Thus, there is a general need for the development of culturally-sensitive and sustainable parenting programs for Latino/a parents, including those that have a focus on adolescent violence prevention and mental health promotion. Previous work conducted by members of our team with our community partner, Latino Health Access (LHA) as part of the CDC-funded Academic Center of Excellence on Youth Violence Prevention (ACE-UCR (2000-2010) highlighted the difficulty of not only translating EBPs from one cultural setting to another but also sustaining them beyond the research project. Specifically, we conducted a multi-cohort evaluation of the Families and Schools Together (FAST) program for mothers and their elementary school-aged children. Although the FAST program had demonstrated effectiveness in over 40 different studies across different ethnic groups, the program was not effective in preventing immigrant Latino children’s aggression. Families in our program faced challenges not addressed by available programs, such as “parentification” (children have to translate for parents because parents only speak Spanish) and low levels of efficacy in dealing with agencies and institutions such as schools and the justice system. The FAST program also was too costly and difficult to implement for our partner agency to sustain. To address these concerns, we developed a targeted child development parenting program delivered by promotoras (lay health workers who were parents themselves) specifically for Latino parents of young children. We had initially targeted mothers and fathers, but fathers were reluctant to participate; and mothers preferred to meet with other mothers to develop their support networks. This Madres a Madres program had positive impacts on elementary school children’s aggression and mental health. It has been replicated in over 10 sites in the U.S. and around the world. It also has been featured on TV specials such as Bill Moyers Journal (http://www.pbs.org/moyers/journal/10162009/brachoexcl_flash.html). In follow-up focus groups, mothers noted that they also faced considerable challenges parenting teenagers, particularly given the difficulties they had monitoring and supervising their older children, combined with the lack of opportunities and the lure of gangs. They underscored the importance of providing youth with skills to counteract negative peer influences and structured opportunities for positive community engagement (consistent with the literature on peer and community risk factors for youth violence), as well as the importance of maintaining strong bonds of trust and support in the family (consistent with the Latino cultural value of familismo). Our new work with an attachment-based savoring intervention allows us to further strengthen this approach to working with Latino families, address their concerns, and go beyond skill provision to address a set of risk factors associated with attachment and relationship quality that are often overlooked in standard cognitive-behavioral youth violence prevention programs, and that have potential to bridge across youth violence prevention and dating violence prevention programming. Our attachment-based or relationship-focused intervention can prevent not only youth violence but also dating violence, whereas cognitive-behavioral interventions are not set up to address relationship violence. Thus, we have a unique opportunity to address an unmet need in low income immigrant Latino families who have previously been receptive and responsive to our community-embedded intervention efforts.
What is new or different about this project idea? Please describe how this differs from what is already being done (Question 6). Please list any research that was done on this topic.
To address the gap in efficacious programming for the prevention of youth violence and the promotion of mental health in low income Latino families, with the support of a grant from the Centers for Disease Control (CDC), we have developed, implemented, and are currently evaluating an innovative youth and caregiver-engaged, community-based approach to preventing multiple forms of youth violence among low-income urban, Latino boys and girls. Importantly, this program capitalizes on the strengths already existing within these Latino families, as well as the strengths of our partner organization, LHA, to prevent youth violence and promote youth mental health by reinforcing strong family bonds. We work with LHA to expand their youth promotora (lay health worker) network into a comprehensive Youth Engaged for Action (YEA) program, and to extend and broaden our effective Madres a Madres promotora-led family engagement program to focus on adolescents and their caregivers, including building in a new component designed to strengthen attachment relationships. We are currently conducting a randomized controlled trial (RCT) of the integrated YEA/Madres program embedded in a larger 10-year Building Healthy Communities (BHC) initiative funded by the California Endowment (2010-2020) in six Santa Ana neighborhoods with violence rates approximately six times the national average. We are delivering the YEA/Madres program in three of these neighborhoods, with the other three neighborhoods serving as comparison sites. As part of this CDC-funded project, we will serve a total of 300 families of teenagers residing in the most impoverished neighborhoods of Santa Ana, evaluating the impact of this program on adolescents’ and mothers’ mental health (depression, anxiety, substance use), relationship quality, and exposure to and perpetration of aggression. Below we describe in greater depth the violence prevention programs we have developed to provide a better context for the project we propose be supported by the Innovation OC MHSA grant. Specifically, the youth component (YEA) engage participants in an 8-session series of structured group discussions led by an adult or young adult promotora. These sessions leverage empirically supported, manualized techniques to strengthen attachments to significant others (via a novel technique developed by the lead researcher, “relational savoring”), increase self-efficacy, and promote prosocial/anti-violence norms. After the completion of the program, youth channel their new skills into action by leading “hope, energy, and action” projects (e.g., anti-bullying campaigns) and becoming positive agents of change in their own lives and their communities. The 8-session parent component builds on our Madres a Madres program, updated to recent standards of care and modified to focus on adolescents and to add a community engagement component. This program also was adapted using the relational savoring method drawn from attachment theory, and emphasizes how to build caregivers’ and youth attachment security, self-efficacy and anti-violence norms, as well as parenting skills. After completing the program, mothers support their youth’s efforts to complete neighborhood action projects targeting positive engagement and violence prevention. Taken together, the two components of the intervention reflect a positive, hopeful, strengths-based and agentic approach to engagement and action. We hypothesize that the comprehensive YEA/Madres program, with a focus on cognitive and affective skills, attachment relationships, parenting, and community engagement will contribute significantly to preventing youth violence and dating violence among participants By implementing the program in three of six neighborhoods that are part of a broader community development initiative, we also can conduct exploratory analyses to determine whether the YEA/Madres program influences neighborhood-level indicators of violence and perceptions of safety in our target vs. matched comparison neighborhoods, and whether this impact is mediated by neighborhood-level constructs of collective efficacy and prosocial/anti-violence norms. Results of this study will be significant in advancing science and practice in several ways including: (a) expanding the evidence-base of effective prevention programs for Latino youth and their families; (b) providing a cost-effective model that is easy to implement and can be sustained in low-resource communities; (c) testing whether a comprehensive program can be effective in preventing both youth violence and dating violence, highlighting common mechanisms of risk and also advancing practice by addressing multiple outcomes with a single program; and (d) assessing hypothesized youth and family mediators of change in order to determine the precise mechanisms that impact multiple types of violence, providing direction for evidence-based practices that can be adapted across settings. In this manner, we are evaluating empirically the impact of the YEA/Madres program on individual and neighborhood-level outcomes. With this proposed Innovation OC MHSA project we seek to extend the reach of this innovative, strengths-based program in terms of its impact on the community and the families involved in the study. Specifically, we use this OC MHSA Innovation mechanism as an opportunity to identify and evaluate ways of promoting continued youth and parent engagement of the 300 families receiving our YEA/Madres program, by supporting their continued involvement at LHA and their positive engagement with their communities. In so doing, the project builds upon a strong foundation of collaborative effort between LHA and UCI researchers in developing a program that will be appealing to families and efficacious in strengthening family ties, reducing serious youth violence, and promoting mental health. In the section below, we outline the methods we will use to accomplish these goals of harnessing the assets of this community to further strengthen the community.
What is the project idea? Please describe how this project will operate.
In the current project spanning a five year period, we will work with the 300 youth and mothers who have previously completed our YEA/Madres program to continue to engage them in youth violence prevention. The central goal of the current project is to test whether after completing the innovative, strengths-based YEA/Madres intervention, we can engage youth and parent participants in continuing their involvement in the program and transitioning ongoing programming of YEA/Madres to these prior graduates of the program, thereby creating a model for a self-sustaining program within this community. As it currently stands, LHA does not have the resources (in terms of funding and promotora time) to devote to the continued engagement of the families who will complete the YEA/Madres program; thus, once our CDC funding ends in two years, we will have to discontinue these services. However, we believe that identifying ways to elicit continued involvement from the families who will have already completed the program, including working towards training graduates of the program to become leaders of future YEA/Madres group, offers the potential for transforming this effort into what may become a self-sustaining program at LHA. In Phase I of the study, we will offer youth and parent program graduates options from a menu of possible “continued engagement” services, all of which will be offered at LHA or community meeting spaces in the target neighborhoods (e.g., schools, parks during mild weather). At all of the in-person events, we will offer food and round-trip transportation (which will reduce commonly-cited barriers to attending these programs): 1. One-on-one sessions with promotoras or members of the research team to discuss their experiences in their communities or families and to reinforce the key principles of the intervention program. These sessions will occur will meet biweekly at first and then will taper to a monthly schedule. 2. Group sessions with promotoras or members of the research team to discuss their experiences, to reinforce the key principles of the intervention program. These groups will meet biweekly at first and then will taper to a monthly schedule. The groups will include fun/recreational components that are developmentally appropriate and promote an opportunity for group bonding. 3. Introduction and access to a mobile app developed by the researchers to assist participants in practicing the techniques they have learned during the program. 4. Involvement in a moderator-maintained group chat with interested graduates of the YEA/Madres program. This option will provide connection with the group members, who can provide support and guidance for one another, thus maintaining connections with LHA and the YEA/Madres program. 5. Training to become a group leader – both youth and parents who have demonstrated a history of strong engagement with the YEA/Madre program (e.g., by showing good attendance, strong understanding of the principles taught in the intervention, and lively participation) will be offered a chance to become leaders of the ongoing YEA/Madre groups by progressing through the following steps: Training by the promotoras, shadowing of the promotoras during a three-month group cycle, reverse shadowing (trainees lead the groups while promotoras observe and provide feedback) during a three-month group cycle, becoming leaders of groups with weekly supervision from promotoras. We will evaluate the following outcomes of these continued engagement services, which we will use as evidence of its effectiveness: 1. Total number of YEA/Madre program graduates who choose to enroll in one of the menu of options 2. Most popular options selected from the menu based on overall number of participants who use this option as well as the duration of time this option is used 3. Quality of continued engagement participation of program graduates with these continued engagement options 4. Mode of continued engagement most likely to lead to becoming a group leader 5. Evaluation of the impact of continued engagement on mental health and violence: Assessments of youth violence behavior and mental health symptoms (e.g., of substance use, depression, anxiety, sexual risk-taking) of continued engagement participants as compared to YEA/Madre participants who do not use the continued engagement options. Phase II of the study will involve prioritizing those options most frequently selected and those that prove the most likely to lead to group leadership, as each of these represent program goals. Only those options will be continued and we will devote additional efforts to strengthen their quality and ability to provide continued engagement for both youth and parents.
We are extremely excited about this work and the opportunity to see whether we can have a long-term and significant impact on the mental health and well-being of this at-risk community within Orange County.