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.     

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.     

Youth Action Research for Prevention: A Multi-level Intervention Designed to Increase Efficacy and Empowerment Among Urban Youth

Youth Action Research for Prevention (YARP), a federally funded research and demonstration intervention, utilizes youth empowerment as the cornerstone of a multi-level intervention designed to reduce and/or delay onset of drug and sex risk, while increasing individual and collective efficacy and educational expectations. The intervention, located in Hartford Connecticut, served 114 African-Caribbean and Latino high school youth in a community education setting and a matched comparison group of 202 youth from 2001 to 2004. The strategy used in YARP begins with individuals, forges group identity and cohesion, trains youth as a group to use research to understand their community better (formative community ethnography), and then engages them in using the research for social action at multiple levels in community settings (policy, school-based, parental etc.) Engagement in community activism has, in turn, an effect on individual and collective efficacy and individual behavioral change. This approach is unique insofar as it differs from multilevel interventions that create approaches to attack multiple levels simultaneously. We describe the YARP intervention and employ qualitative and quantitative data from the quasi-experimental evaluation study design to assess the way in which the YARP approach empowered individual youth and groups of youth (youth networks) to engage in social action in their schools, communities and at the policy level, which in turn affected their attitudes and behaviors.     

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.     

Multilevel Community-Based Culturally Situated Interventions and Community Impact: An Ecological Perspective

The purpose of this paper is to apply an ecological perspective to the conduct of multilevel community-based culturally-situated interventions. After a discussion of the emerging consensus about the value of approaching such interventions ecologically, the paper outlines a series of questions stimulated by an ecological perspective that can guide further theory development in conducting multilevel interventions. These questions all derive from the importance of assessing the local community ecology where the intervention occurs. The paper concludes with a series of topics which, taken together, provide a roadmap for further conceptual development of multilevel interventions as vehicles for long-range community impact.     

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.     

Peer support telephone dyads for elderly women: The wrong intervention or the wrong research?

Reaction to the intervention paper by Heller et al. (1990) places their work into a larger framework of social support interventions to make explicit the assumptions underlying the project. It is suggested that the intervention was constrained by the experimental design of the evaluation research and overlooked important features in the process of relationship development among dyads. In developing interventions designed to impact personal relationships, it is recommended that community psychologists (a) consider the context in which personal relationships are formed, maintained, and terminated; (b) use the power of their scientific inquiry to create, strengthen, or legitimize new social roles for people who are disenfranchised; (c) promote the use and legitimacy of research methods that compliment rather than dictate the nature of interventions.     

Indigenizing CBPR: Evaluation of a Community-Based and Participatory Research Process Implementation of the Elluam Tungiinun (Towards Wellness) Program in Alaska

The process that community based participatory research (CBPR) implementation takes in indigenous community contexts has serious implications for health intervention outcomes and sustainability. An evaluation of the Elluam Tungiinun (Towards Wellness) Project aimed to explore the experience of a Yup'ik Alaska Native community engaged within a CBPR process and describe the effects of CBPR process implementation from an indigenous community member perspective. CBPR is acknowledged as an effective strategy for engaging American Indian and Alaska Native communities in research process, but we still know very little about the experience from a local, community member perspective. What are the perceived outcomes of participation in CBPR from a local, community member perspective? Qualitative methods were used to elicit community member perspectives of participation in a CBPR process engaged with one Yup'ik community in southwest Alaska. Results focus on community member perceptions of CBPR implementation, involvement in the process and partnership, ownership of the project with outcomes observed and perceived at the community, family and individual levels, and challenges. A discussion of findings demonstrates how ownership of the intervention arose from a translational and indigenizing process initiated by the community that was supported and enhanced through the implementation of CBPR. Community member perspectives of their participation in the research reveal important process points that stand to contribute meaningfully to implementation science for interventions developed by and for indigenous and other minority and culturally diverse peoples.     

Using ethnographic methods for development of culture-specific interventions

Cultural specificity is considered important in developing effective school- and community-based interventions. This article illustrates the use of ethnographic research to enhance understanding of students' cultural experiences and facilitate the development of culturally specific interventions. Ethnographic data were collected during formative and intervention phases of a school-based mental health promotion project. Data were coded using an interactive deductive-inductive process. Culture specificity was defined as the integration of etic (universal) and emic (culture-bound) perspectives. Four culture-specific themes were identified: adult-sanctioned behaviors and practices, adolescents' perspectives about the present and aspirations for the future, and societal factors. These themes encompassed code categories reflecting cultural attitudes, beliefs, customs, expectations, norms, and values; and reflected the ecological framework that guided the research. Future research is needed to address the use of combined etic-emic conceptualizations of culture in the development of culture-specific interventions.     

Interfaith Relations in the United States: Toward a Multilevel Community Psychology Approach

Interest in religion within the field of community psychology has steadily emerged within the last three decades. This interest has focused almost exclusively on the social benefits of religion, glossing over the often‐contentious nature of religious life and the ways in which religious individuals and institutions can disrupt healthy human and community development. Considering the recent surge of interfaith conflicts and discriminatory practices targeting religious minorities in communities across the United States, it is imperative that community psychologists begin to examine relevant trends in interfaith relations and potential directions for action research and intervention. This paper serves as the beginning point of just such an examination, proposing a multilevel model for addressing the microsystemic, mesosystemic, and macrosystemic levels of interfaith phenomena. More specifically, I present interfaith contact, congregation‐based community partnerships, and theological belief systems as particularly relevant to interfaith community research and intervention. Finally, I detail an interfaith organization that embodies these dimensions of interfaith relations and provides a concrete example of how a multilevel action research model may be effectively employed. Copyright © 2012 John Wiley & Sons, Ltd.     

Doing Community Research Without a Community: Creating Safe Space for Rape Survivors

This paper describes how the values of a feminist research team influenced methodological decisions in a study of rape survivors. Building upon concepts from community psychology and urban sociology, the authors created a community-based research design that respected the emotional needs of rape survivors without sacrificing methodological rigor. We developed relationships with community members in diverse settings, such as nail and hair salons, child care centers, churches, and bookstores, to advertise the study and recruit participants. Consistent with feminist approaches to interviewing, our goal was to create a safe setting for survivors to tell their stories. Although the purpose of this study was research rather than intervention, most survivors reported that participating in these interviews was healing. Our experiences in this project suggest that allowing values to influence the process of research may have beneficial outcomes for both researchers and participants.     

Community Readiness for Change and Youth Violence Prevention: a Tale of Two Cities

This case study identifies a situation in which there exists a set of preconditions for the successful application of evidence based practice to bear on the community based problem of youth violence. The concept of readiness to change and its impact on the success or failure of interventions designed to change harmful or dangerous behavior among individuals is well established and understood in intervention research. In recent years this concept has been discussed and developed in the community intervention and harm reduction literatures. The current study is one of a community where an attempt was made to identify community levels of harm, develop a strategic plan to reduce the source of harm, and develop, implement, and evaluate youth violence prevention interventions. Over more than 5 years of involvement by university based researchers and community partners, the effort was largely unsuccessful. The events of this project are discussed within the context of the Community Readiness Model Edwards et al. (J Community Psychol 28(3): 291-307, 2000) and we present a narrative that helps to highlight the reasons for the relative lack of success of the effort. We suggest additional strategies and actions that might have helped to overcome the lack of readiness of this particular community to reduce the harms associated with youth violence. Suggestions that may improve chances for a more successful set of outcomes for other communities in similar states of readiness to change and with similar challenges are given.     

Positive aspects of caregiving as a moderator of treatment outcome over 12 months

The authors examined the influence of positive aspects of caregiving (PAC) as a moderator of treatment outcome across 12 months in 1 of the original sites of the Resources for Enhancing Alzheimer's Caregiver Health I project. They used multilevel random coefficients regression analysis to predict time-varying PAC, depression, behavioral bother, and daily care burden in Alzheimer's caregivers (N = 243; mean age = 60.89, SD = 14.19). They found that time-varying PAC was predicted by time-varying daily care burden. They also found significant effects of time-varying PAC for depression, behavioral bother, and daily care burden. Notably, a PAC x Phase x Treatment effect was found for daily care burden, such that individuals who endorsed less PAC benefited most from the intervention across 12 months. The tendency to positively appraise the caregiving experience (i.e., PAC) in response to chronic stressors such as Alzheimer's caregiving may affect individuals' responsiveness to, and benefit from, interventions, whereas only daily care burden affected the tendency to find enjoyment in caregiving across 12 months. Future intervention research should assess individual PAC in order to better tailor interventions to caregiving needs.     

Building cardiovascular disease competence in an urban poor Ghanaian community: A social psychology of participation approach

This paper describes conceptual, methodological, and practical insights from a longitudinal social psychological project that aims to build cardiovascular disease (CVD) competence in a poor community in Accra, Ghana's capital. Informed by a social psychology of participation approach, mixed method data included qualitative interviews and household surveys from over 500 community members, including people living with diabetes, hypertension, and stroke, their caregivers, health care providers, and GIS mapping of pluralistic health systems, food vending sites, bars, and physical activity spaces. Data analysis was informed by the diagnosis‐psychosocial intervention‐reflexivity framework proposed by Guareschi and Jovchelovitch. The community had a high prevalence of CVD and risk factors, and CVD knowledge was cognitive polyphasic. The environment was obesogenic, alcohol promoting, and medically pluralistic. These factors shaped CVD experiences and eclectic treatment seeking behaviours. Psychosocial interventions included establishing a self‐help group and community screening and education. Applying the “AIDS‐competent communities” model proposed by Campbell and colleagues, we outline the psychosocial features of CVD competence that are relatively easy to implement, albeit with funds and labour, and those that are difficult. We offer a reflexive analysis of four challenges that future activities will address: social protection, increasing men's participation, connecting national health policy to community needs, and sustaining the project.     

Latinx Mental Health Scholars' Experiences with Cultural Adaptation and Implementation of Systemic Family Interventions

An increasing number of culturally adapted family-level interventions address mental health disparities with marginalized populations in the United States. However, with these developments many barriers have arisen, such as challenges with degree of cultural fit, engagement, and sustainability. We conducted 12 elite phenomenological interviews with mental health scholars involved in prevention and intervention family research with various Latinx communities within and outside of the United States. These scholars discussed their experiences of overcoming barriers in their research. We used thematic analysis to code and analyze participant responses, and our findings support the gaps in previous literature and highlight potential pathways to overcoming barriers in cultural adaptation research. Themes included the need for: (a) better understanding of the intersection between culture and context; (b) community-centered approaches to addressing implementation challenges; and (c) structural changes within institutional, governmental, and political levels. We discuss implications for researchers and practitioners working with Latinx families.     

HIV/AIDS and immigrant Cape Verdean women: Contextualized perspectives of Cape Verdean community advocates

This research explored Cape Verdean community advocates’ understandings of the structural and social realities that contribute to the increased HIV/AIDS risk of Northeastern U.S.-based immigrant Cape Verdean women. A community perspective informed the analysis of the multi-layered contextual barriers that these advocates identified as limiting the effectiveness of individual-level HIV/AIDS prevention and intervention models. Qualitative content analysis of interviews with nine community advocates revealed several thematic clusters including challenges to (1) perceived institutional and community realities; (2) traditional gender relations; and, (3) traditional ways of thinking. These findings challenge universalist cognitive-behavioral change models of HIV/AIDS prevention and intervention and are critically discussed to better understand the complex realities faced by Cape Verdean immigrant women. A liberatory community psychology perspective framed the research process and contributed to reconceptualizing HIV/AIDS risk as a community problem that requires interventions not simply at the individual and relational levels, but also at the structural level.     

A Pilot Study Implementing Coping Power in Italian Community Hospitals: Effect of Therapist Attachment Style on Outcomes in Children

The study presented the initial report of a project regarding the implementation of the Coping Power Program in Italian community hospitals, and the program’s ability to reduce externalizing behavioral problems in children with a Disruptive Behavior Disorder diagnosis. Usually, interventions for children are implemented by a number of therapists with different personal characteristics, which therefore influence the implementation quality of an intervention. That said, the present study aimed to establish whether the insecure attachment styles of therapists predict unfavorable outcomes for children treated with the Coping Power Program. The sample included 80 children with a Disruptive Behavior Disorder diagnosis and 16 therapists. The results showed that the change in children’s aggressive behavioral problems was significantly related to the levels of the therapist’s preoccupation with relationships. Higher levels of change in aggression (where a higher value means that the aggression at the end of the treatment is higher than aggression at the baseline evaluation) are associated with higher levels of therapist’s preoccupied attachment style (anxious attachment style). This study provided some preliminary evidence that therapists need to be sensitive to their own attachment experiences when delivering therapy for children.     

The Cooperative Research Centre for Living with Autism (Autism CRC) Conceptual Model to Promote Mental Health for Adolescents with ASD

Despite an increased risk of mental health problems in adolescents with autism spectrum disorder (ASD), there is limited research on effective prevention approaches for this population. Funded by the Cooperative Research Centre for Living with Autism, a theoretically and empirically supported school-based preventative model has been developed to alter the negative trajectory and promote wellbeing and positive mental health in adolescents with ASD. This conceptual paper provides the rationale, theoretical, empirical and methodological framework of a multilayered intervention targeting the school, parents and adolescents on the spectrum. Two important interrelated protective factors have been identified in community adolescent samples, namely the sense of belonging (connectedness) to school and the capacity for self and affect regulation in the face of stress (i.e. resilience). We describe how a confluence of theories from social psychology, developmental psychology and family systems theory, along with empirical evidence (including emerging neurobiological evidence), supports the interrelationships between these protective factors and many indices of wellbeing. However, the characteristics of ASD (including social and communication difficulties, and frequently difficulties with changes and transitions, and diminished optimism and self-esteem) impair access to these vital protective factors. The paper describes how evidence-based interventions at the school level for promoting inclusive schools (using the Index for Inclusion) and interventions for adolescents and parents to promote resilience and belonging [using the Resourceful Adolescent Program (RAP)] are adapted and integrated for adolescents with ASD. This multisite proof-of-concept study will confirm whether this multilevel school-based intervention is promising, feasible and sustainable.     

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.