Introduction to Multi-Level Community Based Culturally Situated Interventions

This introduction to a special issue of the American Journal of Community Psychiatry is the result of a symposium at the Annual Meeting of the Society for Applied Anthropology, 2006, that brought together anthropologists and psychologists involved in community based collaborative intervention studies to examine critically the assumptions, processes and results of their multilevel interventions in local communities with local partners. The papers were an effort to examine context by offering a theoretical framework for the concept of “level” in intervention science, and advocating for “multi‐level” approaches to social/behavioral change. They presented examples of ways in which interventions targeted social “levels” either simultaneously or sequentially by working together with communities across levels, and drawing on and co‐constructing elements of local culture as components of the intervention. The papers raised a number of important issues, for example: (1) How are levels defined and how should collaborators be chosen; (2) does it matter at which level multilevel interventions begin; (3) do multilevel interventions have a greater effect on desired outcomes than level‐specific interventions; (4) are multilevel interventions more sustainable; (5) are multilevel interventions cost effective to run, and evaluate; (6) how can theories of intervention be generated and adapted to each level of a multilevel intervention; (7) how should intervention activities at each level coordinate to facilitate community resident or target population empowerment? Many of these questions were only partially addressed in the papers presented at that time, and are more fully addressed in the theoretical papers, case studies and approach to evaluation included in this collection.     

Consumer engagement and the development, evaluation, and dissemination of evidence-based parenting programs

A consumer perspective can contribute much to enhancing the "ecological fit" of population-level parenting interventions so they meet the needs of parents. This approach involves building relationships with consumer groups and soliciting consumer input into the relevance and acceptability of interventions, clarifying the enablers and barriers to engagement and involvement of parents, and clarifying variables that influence a parent's program completion. The adoption of a more collaborative approach to working with consumers is important if meaningful population-level change in the prevalence of serious social, emotional, and behavioral problems in children and young people is to be achieved. Parents seeking assistance for their children's behavior come from a diverse range of socioeconomic backgrounds, educational levels, cultures, and languages. This paper examines consumer engagement strategies that can be employed throughout the process of program development, evaluation, training, and dissemination, and in "scaling up" the intervention. We argue that a multilevel public health approach to parenting intervention requires a strong consumer perspective to enable interventions to be more responsive to the preferences and needs of families and to ensure improved population reach of interventions. Examples from large-scale dissemination trials are used to illustrate how consumer input can result in an increasingly differentiated suite of evidence-based parenting programs.     

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.     

From ��Water Boiling in a Peruvian Town�� to ��Letting them Die��: Culture, Community Intervention, and the Metabolic Balance Between Patience and Zeal

While the concept of culture has long been central to community psychology research and intervention, it has most frequently referred to the communities in which such work occurs. The purpose of this paper is to reframe this discussion by viewing community interventions as instances of intercultural contact between the culture of science, reflected in community intervention research, and the culture of the communities in which those interventions occur. Following a brief discussion of the complexities of culture as a concept, two illustrative stories of failed community interventions are provided to highlight the centrality of cultural and contextual understanding as prelude to community intervention. These stories, set 50 years apart, reflect the depth and pervasive influence of both the culture of science and the culture of communities. Next, a series of propositions about the culture of social science as a partial reflection of the broader culture of the United States are offered, and their implications for the conduct of community interventions drawn. The paper concludes with a series of recommendations which, together, provide an ecological mind-set for taking culture seriously in community interventions. Central to this mind set are the importance of focusing on communities rather than programs and emphasizing the intervention goal of choice over change.     

Towards an Ecological Understanding of Resilience in Trauma Survivors

Abstract

The ecological perspective of community psychology offers needed understanding of diverse sources and expressions of resilience among trauma survivors. Investigations by community psychologists into the nature of wellness-enhancing interventions and empowering social change can inform trauma-focused interventions at individual, community, and societal levels. Here, works by selected community psychologists are reviewed. The ecological view of trauma, recovery, and resilience guiding work at the Victims of Violence (VOV) Program, the range and reach of VOV's clinical and community interventions, and elements of its trauma recovery and resiliency research project illustrate the implications and relevance of these works. Five premises of an ecological understanding of resilience in trauma survivors are discussed.     

An Ethical Imperative: Effectively Reducing SGM Disparities Utilizing a Multi-Level Intervention Approach

Health disparities for sexual and gender minority (SGM) populations are well documented and manifest systemically. Mental health professionals have begun working to address these disparities, demonstrating efforts to more effectively define and increase competency in SGM health and by adapting existing evidence-based interventions to more effectively target the unique needs of the SGM community. While such efforts are necessary, they inadequately address the systemic nature of the problem, placing an unnecessary burden on SGM individuals to tolerate systemic discrimination, injustice, and inequality. The current special series attempts to address this gap by featuring papers that describe multilevel (e.g., micro, mezzo, macro) intervention approaches to reduce SGM health disparities. We argue that advocacy is inherent to the work, and we hope that this special series will empower mental health professionals to engage in multilevel, systemic interventions as an ethical imperative.     

The Multilevel Relationships of HIV‐Related Stigma to Child and Caregiver Mental Health among HIV‐Affected Households in South Africa

HIV/AIDS‐related (HAR) stigma is still a prevalent problem in Sub‐Saharan Africa, and has been found to be related to mental health of HIV‐positive individuals. However, no studies in the Sub‐Saharan African context have yet examined the relationship between HAR stigma and mental health among HIV‐negative, HIV‐affected adults and families; nor have any studies in this context yet examined stigma as an ecological construct predicting mental health outcomes through supra‐individual (setting level) and individual levels of influence. Multilevel modeling was used to examine multilevel, ecological relationships between HAR stigma and mental health among child and caregiver pairs from a systematic, community‐representative sample of 508 HIV‐affected households nested within 24 communities in KwaZulu‐Natal, South Africa. Two distinct dimensions of HAR stigma were measured: individual stigmatizing attitudes, and perceptions of community normative stigma. Findings suggest that individual‐level HAR stigma significantly predicts individual mental health (depression and anxiety) among HIV‐affected adults; and that community‐level HAR stigma significantly predicts both individual‐level mental health outcomes (anxiety) among HIV‐affected adults, and mental health outcomes (PTSD and externalizing behavior scores) among HIV‐affected children. Differentiated patterns of relationships were found using the two different stigma measures. These findings of unique relationships identified when utilizing two conceptually distinct stigma measures, at two levels of analysis (individual and community) suggest that HAR stigma in this context should be conceptualized as a multilevel, multidimensional construct. These findings have important implications both for mental health interventions and for interventions to reduce HAR stigma in this context.     

Parental Personality,Relationship Stress,and Child Development: A Stress Generation Perspective

This study aimed to investigate associations among the parental personality dimensions of self‐criticism and dependency, parental relationship stress, and child development from a stress generation perspective. Data from 79 first‐time parents and their children aged 8–13 months, who were followed up in a two‐wave, 1‐year longitudinal study, were analysed within a multilevel structural equation modelling framework in order to account for within‐couple interdependence. Results revealed that, as hypothesised, both parental self‐criticism and dependency were associated with increased levels of relationship stress, which in turn were negatively related to child development. Hence, parental personality features in combination with relationship stress may be an important target in couple and family‐based interventions. Implications for further research on family dynamics and interventions are discussed. Copyright © 2015 John Wiley & Sons, Ltd.     

Toward a culturally anchored ecological framework of research in ethnic-cultural communities

Proposed a research framework (the “cube” model) in which community psychologists working in ethnic-cultural communities can make appropriate decisions on conceptual and methodological issues from a culturally anchored, ecological-contextualist perspective. The intent of the model is to articulate ethnic-cultural heterogeneity in community research by elucidating three metamethodological issues: (a) definition of an ethnic-cultural community, (b) applicability of cross-cultural theories and methods to ethnic-cultural community research, and (c) geographical or ecological stability of an ethnic-cultural community. The model posits that ethnic-cultural community research can be conceptualized as a three-dimensional structure that represents an interaction among research questions, methods, and cultural complexity (referring to the extent to which an ethnic-cultural group is defined in a larger ecological context or community both at the individual and collective levels). Future directions for research were discussed in terms of the utility and the limitations of the proposed research model.     

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.     

Community, Culture and Sustainability in Multilevel Dynamic Systems Intervention Science

This paper addresses intertwined issues in the conceptualization, implementation and evaluation of multilevel dynamic systems intervention science (MDSIS). Interventions are systematically planned, conducted and evaluated social science-based cultural products intercepting the lives of people and institutions in the context of multiple additional events and processes (which also may be referred to as interventions) that may speed, slow or reduce change towards a desired outcome. Multilevel interventions address change efforts at multiple social levels in the hope that effects at each level will forge synergistic links, facilitating movement toward desired change. This paper utilizes an ecological framework that identifies macro (policy and regulatory institutions), meso (organizations and agencies with resources, and power) and micro (individuals, families and friends living in communities) interacting directly and indirectly. An MDSIS approach hypothesizes that change toward a goal will occur faster and more effectively when synchronized and supported across levels in a social system. MDSIS approaches by definition involve “whole” communities and cannot be implemented without the establishments of working community partnerships This paper takes a dynamic systems approach to science as conducted in communities, and discusses four concepts that are central to MDSIS—science, community, culture, and sustainability. These concepts are important in community based participatory research and to the targeting, refinement, and adaptation of enduring interventions. Consistency in their meaning and use can promote forward movement in the field of MDSIS, and in community-based prevention science.     

Achieving Population-Level Change Through a System-Contextual Approach to Supporting Competent Parenting

The quality of parenting children receive affects a diverse range of child and youth outcomes. Addressing the quality of parenting on a broad scale is a critical part of producing a more nurturing society. To achieve a meaningful population-level reduction in the prevalence rates of child maltreatment and social and emotional problems that are directly or indirectly influenced by parenting practices requires the adoption of a broad ecological perspective in supporting families to raise children. We make the case for adopting a multilevel, whole of population approach to enhance competent parenting and describe the essential tasks that must be accomplished for the approach to be successful and its effects measurable. We describe how a theoretically integrated system of parenting support based on social learning and cognitive behavioral principles can be further strengthened when the broader community supports parental participation. Implications for policy and practice are discussed.     

Ethical Considerations in Psychotherapy Effectiveness Research: Choosing the Comparison Group

The primary purpose behind effectiveness research is to determine whether a treatment with demonstrated efficacy has utility when administered to the general population. The main questions these studies are meant to answer are these: Can the typical patient respond to treatment? Is the treatment acceptable to the typical patient? Can the treatment be administered safely and in its entirety in the typical treatment setting? Is the treatment under study significantly better than the community standard of care both from a cost and outcome perspective? Answering these questions is meant to provide sufficient information to providers and policymakers so that effective interventions can be adopted and become the new community standard.

For this research to make a meaningful impact on a provider and policymaker's decision to change the status quo, study interventions should be compared to the existing community standard of treatment, often referred to as treatment as usual (TAU). From an ethical perspective, this decision may not always be the safest choice. In some populations, TAU may mean no treatment at all, and in others TAU may be worse than withholding treatment. The effectiveness researcher is then caught between the pull to do no harm and the need for research to have an impact on change. The purpose of this article is to highlight certain conditions when TAU is ethically acceptable and to discuss alternatives when TAU may be an unethical treatment condition. For purposes of precision, we focus exclusively on psychotherapy effectiveness research rather than system-intervention research or medication-intervention research.     

Ethical considerations in psychotherapy effectiveness research: choosing the comparison group

The primary purpose behind effectiveness research is to determine whether a treatment with demonstrated efficacy has utility when administered to the general population. The main questions these studies are meant to answer are these: Can the typical patient respond to treatment? Is the treatment acceptable to the typical patient? Can the treatment be administered safely and in its entirety in the typical treatment setting? Is the treatment under study significantly better than the community standard of care both from and a cost and outcome perspective? Answering these questions is meant to provide sufficient information to providers and policymakers so that effective interventions can be adopted and become the new community standard. For this research to make a meaningful impact on a provider and policymaker's decision to change the status quo, study interventions should be compared to the existing community standard of treatment, often referred to as treatment as usual (TAU). From an ethical perspective, this decision may not always be the safest choice. In some populations, TAU may mean no treatment at all, and in others TAU may be worse than withholding treatment. The effectiveness researcher is then caught between the pull to do no harm and the need for research to have an impact on change. The purpose of this article is to highlight certain conditions when TAU is ethically acceptable and to discuss alternatives when TAU may be an unethical treatment condition. For purposes of precision, we focus exclusively on psychotherapy effectiveness research rather than system-intervention research or medication-intervention research.     

Conservation of resources in community intervention

Evaluated the applications of principles of resource conservation and management in community interventions and compared these to a more individual, perception-based psychological perspective. Conservation of resource theory suggests that promotion of well-being and prevention of disease depend on the availability and successful management of resources. When resources are lacking, lost, or when invested without consequent gain, people become vulnerable to psychological and physical disorder and debilitated functioning. Resources, in this context, are defined as those things people value or those things that may help people obtain that which they value. Conservation of resource theory further suggests that resources are to a large extent common to all people, more common within a given culture and time in the developmental cycle, and only to a small extent idiographic. Further, conservation of resource theory posits that resources operate within an ecological context where feedback, sharing, and exchange operate between the individual, social context, and environment. Given these principles, it is reasoned that community interventions must acknowledge the solid base of most problems and accept that interventions must target resources and be intensive enough to change the ecology in which resources operate.     

Community Counselling in African Contexts

This article explores community counselling as a form of professional practice for psychologists, with a particular focus on practices that are relevant in African contexts. The discussion identifies and discusses various models of practice identified in community psychology, including an ecological perspective, a public health and community mental health framework, interventions that focus on promoting a sense of community, indigenous approaches to community counselling and a critical or social action framework. Examples relating to each of these models of practice are drawn from various African settings, providing practitioners with some insights into how theory can be operationalised into practices that are relevant to African contexts. The article concludes with a discussion on community research, with a particular focus on ethical considerations relevant to a community approach in African contexts. The latter discussion emphasises the importance of working with the community as partners, and suggests the possibility of developing a Code of Ethics aimed specifically at guiding community counselling practice in African contexts.     

Children’s spiritual development in forced displacement: a human rights perspective

This article provides a synthesis of current research and theories of spiritual development in forced displacement from a human rights perspective. Spirituality, understood as a cognitive‐cultural construct, has shown positive impact on children’s development through both collective and individual processes and across ecological domains of the physical world, the community and the individual child. Findings support a human rights framework of spiritual development that privileges the child’s and the community’s own understandings of human development, and this framework may further serve as an important resource for scaffolding refugee children’s development. The study of spiritual development will enable more effective human rights protection of child development in situations of war and forced displacement.     

The increasing relevance of European rural young people in policy agendas: Contributions from community psychology

Our paper aims to provide a short guide on how community psychologists can contribute to the improvement of rural young people's prospects. After briefly introducing the demographic trends of these young people in continental Europe for the past decade, we list the current challenges faced by rural European young generations, as well as the opportunities emerging for them from the twin transition that can inspire the community psychology field. We then contextualize community psychologists' interventions in this domain according to an ecological-systemic standpoint and by embracing a Participatory Action Research (PAR) perspective on research and practice. We further detail the reasons for adopting a PAR approach in research and practice to address rural young people's challenges and opportunities. Finally, we highlight four potential intermediation missions to uphold community psychologists' rural youth development input, based on the adopted theoretical and methodological standpoint. We conclude that our short guide can facilitate community psychology professionals' complete understanding of rural young generations' prospects, in line with the expected increase in the need for rural young people's participation. Our proposal may also have long-term benefits for rural communities by contributing to the redesigning of intergenerational relationships and securing critical mass.