A qualitative study of cultural congruency of Legacy for Children™ for Spanish-speaking mothers

https://doi.org/10.1016/j.childyouth.2017.06.022Get rights and content

Highlights

  • Results indicate positive aspects of the Legacy program including content, approach, topics, social engagement, and straightforward curriculum language.

  • Themes from qualitative data include best practices in identifying, recruiting, and approaching Hispanic mothers, and key engagement strategies.

  • Recommended revisions of the adapted Legacy curriculum focus on enhancing supplements, lowering reading level, and reducing attendance barriers.

Abstract

In recognition of the need to reach more families, the Legacy for Children™ (Legacy) program was translated and culturally adapted for Spanish-speaking Hispanic mothers and their infants. This study examined the cultural adaptations and logistical supports needed for successful implementation with Spanish-speaking mothers. The research team used purposive techniques to sample Hispanic bi-lingual providers (N = 14) and supervisors (N = 5) of local home-based parenting programs (Healthy Families, Parents as Teachers, and SafeCare®). The goal of the study was to determine from providers and supervisors the social validity (satisfaction, relevancy, importance, and acceptability of the intervention) and cultural congruency of the adapted Legacy curriculum. Researchers conducted a qualitative analysis of the transcriptions using a template approach within NVivo 10 software to identify broad themes within focus group data. Overall, results indicated many positive aspects of the Legacy program including content, approach, pace, topics, structure, social engagement, and straightforward curriculum language. Emergent themes from the focus groups included best practices in identifying, recruiting, and approaching Hispanic mothers, as well as key engagement strategies. Recommended revisions of the adapted Legacy curriculum focused on enhancing visual and auditory supplements, making minor improvements to lower the reading level, and reducing barriers to attendance. Implications for cultural adaptation of parenting programs are discussed.

Introduction

Poverty in childhood is associated with significant disparities in physical, mental, and academic health (AAP Council on Community Pediatrics, 2016, Duncan et al., 2010, Evans and Kim, 2012, Hall et al., 2006). These disparities disproportionately affect Hispanic/Latino families (Flores et al., 2002, Wright et al., 2011). For example, between 2004 and 2006, almost twice as many Hispanic children (28.7%) lived in low-income households compared to non-Hispanic children (15.7%) and the inequality gap within Hispanic families was higher than that reported among non-Hispanic families (Gennetian, Rodrigues, Hill, & Morris, 2015). Although Hispanic families are the largest and the fastest growing racial/ethnic minority group, Hispanic children are less likely to receive a well-child visit, have health insurance, or enter school with the necessary academic skills (Murphey, Guzman, & Torres, 2014).

Parenting programs designed for families experiencing poverty have established evidence supporting improved health and developmental outcomes (Morris et al., 2016). However, parenting programs are rarely evaluated with a diversity of racial/ethnic groups and are often only available in English. With an increased recognition of racial disparities in the access and availability of social services, recent literature has focused on reducing barriers by both increasing access to evidence-based programs for minorities and ensuring that services are culturally congruent (Atkinson et al., 2001, Bernal and Scharron-Del-Rio, 2001, Whaley and Davis, 2007). A 2016 report by the National Academies of Sciences, Engineering, and Medicine highlighted these gaps in services by recommending culturally relevant parenting programs to increase engagement and effectiveness of these programs for racial and ethnic minorities (NASEM, 2016).

Culturally congruent services refer to those that are adapted to meet the unique cultural needs of families and communities (Whaley & Davis, 2007). Culturally congruent approaches may be particularly important for acceptability, initial engagement, and retention in services. Services that have utilized culturally adapted engagement strategies have found improved recruitment and retention rates (Botvin et al., 1999, Harachi et al., 1997, McCabe et al., 2005, McKay et al., 1998). Further, there is an accumulation of meta-analyses indicating the importance of culturally adapted treatments (Benish et al., 2011, Griner and Smith, 2006). For example, Griner and Smith (2006) found that culturally adapted psychotherapy effectively addressed mental health and substance abuse with ethnic and racial minorities. Additionally, Benish et al. (2011) found that after conducting a “multilevel-model, direct-comparison meta-analysis” of both published and unpublished research studies, culturally adapted treatments had greater treatment outcome effect for the primary target of treatment (e.g., depression, anxiety, social skills, etc.) as compared to treatments that did not imply cultural adaptation.

Specific to the cultural adaptation of parenting interventions for Latino immigrants, Ruben Parra Cardona et al. (2012) explored the impact of two culturally adapted evidence-based interventions and found high levels of satisfaction with both interventions, further confirming the importance of culturally adapting programs for Hispanic families. Additionally, within the context of home-based parenting programs, it was found that researchers found strong acceptability and cultural congruency of a prevention program (SafeCare) adapted for the Hispanic community (Beasley et al., 2014). The extant literature indicates the importance of cultural adaptation of treatments; therefore, the current study was designed to understand the social validity and cultural congruency of an adapted prevention program for Hispanic families that takes place within a community setting.

The Legacy for Children™ (Legacy) program is a group-based prevention program designed to promote child development by supporting sensitive, responsive mother-child relationships, building maternal self-efficacy, and fostering peer networks of support among mothers living in poverty (Perou et al., 2012). Legacy is designed to prevent child developmental delays associated with poverty and is built on the philosophy that parents have a direct impact on their children's development. The Legacy program focuses on five goals: (1) promote maternal responsibility, investment, and devotion of time and energy; (2) promote responsive, sensitive mother-child relationships; (3) support mothers as guides to their children's behavioral and emotional regulation; (4) promote each mother's facilitation of their children's verbal and cognitive development; (5) and promote mothers' sense of community.

The original Legacy prevention program was evaluated with a pair of randomized controlled trials (ClinicalTrials.gov registry #: NCT00164697) at two intervention sites (Los Angeles and Miami). The two sites developed and implemented their own curricula based on both their distinct community and population characteristics as well as the Legacy model, resulting in the University of California at Los Angeles (UCLA) and University of Miami (UM) versions (Perou et al., 2012). While the UCLA and UM curricula differ on some implementation-specific factors, such as target child age range (prenatally through three years or birth through five years, respectively), total sessions offered, and session composition, they both adhere to the five Legacy goals and include the same core model components. Using a non-didactic approach, the Legacy model posits there are many positive ways to parent a child and a sensitive, responsive parent-child relationship is more important than any single parenting behavior. The developmentally timed curricula are implemented in a group-based format with the group leader facilitating the curriculum discussion rather than teaching it. Groups meet weekly (or weekly with breaks in between curriculum blocks) over the years. The curricula are designed for three different types of session components: mother-only time to discuss curriculum material and build connections between mothers, mother-child time to practice session material with one targeted “Legacy child,” and one-on-one time with the group leader to reinforce curriculum content.

The Legacy program was originally implemented and evaluated with mothers from a range of ethnic backgrounds, including English-speaking Hispanic mothers. At baseline in the LA sample, 44.9% of mothers identified as Non-Hispanic Black and 41.1% identified as Hispanic. The baseline sample at the Miami site identified primarily as Non-Hispanic Black (69.2%), Haitian (17.0%), and Hispanic (9.0%). Although participation in Legacy required that participants speak and read English, many of the mothers enrolled in the program were bilingual or multilingual; 42.3% reported speaking a language other than English in the home (Perou et al., 2012). Results from randomized clinical trials (RCTs) found that compared to mothers in the “usual care” comparison group, children of mothers randomized to the intervention group had fewer socio-emotional and behavior problems in the Miami sample, and fewer hyperactive behavior symptoms in the LA sample (Kaminski et al., 2013). Forthcoming analyses are examining program impacts on child cognitive outcomes, the mother-child relationship, and child maltreatment risk.

As part of the original RCTs, twenty-one focus groups were conducted with Legacy participants (N = 166) focused on the English curriculum and intervention engagement (Fraser, 2009). Analysis of focus group data suggests cultural acceptability and parent satisfaction with the original English language program for the diverse participants. For example, one mother reported, “Our group leader, she understood that everybody comes from a different background.” Another stated, “I had a place to – to share and get support or get a hug or cry if I needed to… it was like something I looked forward to every Sunday and I was sorry that it was over.”

Given the promising data from the RCTs, inclusive of positive impacts for English-speaking Hispanic families, the Centers for Disease Control and Prevention (CDC) pursued adapting and translating the Legacy curriculum into Spanish to reach more Hispanic families. CDC assembled a team of Legacy curriculum experts and two groups of translators (CDC translators and an independent group from outside CDC). Prior to translation, the Legacy curriculum experts reviewed the full curriculum to identify any content requiring adaptation, substituting culturally relevant or traditional songs, books, and examples for the original English versions as needed. The independent translators then initially translated and the CDC staff reviewed a pilot curriculum session to ensure that word choices and tone reflected the original intent of the curriculum. After consensus was reached on the pilot session, the independent translators translated the rest of the curriculum. CDC's internal translators reviewed all translated curriculum at least twice for quality control purposes. The UCLA curriculum developers also reviewed sessions and made revisions to the translation to ensure the original session intent was preserved with the translation.

The present study used a qualitative approach to examine the social validity (satisfaction, relevancy, importance, and acceptability of the intervention) and cultural congruency of the culturally adapted Legacy curriculum, UCLA version. Further, strategies to enhance recruitment, engagement, and retention of Spanish-speaking Hispanic mothers were addressed. Qualitative methodology can be a valuable tool in the evaluation of evidence-based programs, providing insight into the implementation process and engaging program participants and other key stakeholders (Tayabas, León, & ESPINO, 2014). A qualitative approach can be especially beneficial when translating or otherwise adapting existing interventions, and ensuring programs are culturally relevant in new contexts (Cardona et al., 2012, Dumas et al., 2011). In this study, supervisors and providers of home-based parenting programs were chosen to provide this feedback as they all had experienced working with first-generation Hispanic immigrants teaching parenting to families with young children in Oklahoma. These participants were well-suited to provide broad-based insights on adaptations that would improve the cultural congruency of Legacy implementation. The Hispanic supervisors and providers participated in focus groups to review and provide feedback on the program. Focus groups were conducted with these providers to examine both the cultural congruency of the adapted program as well as address supports needed for successful implementation of the program for Oklahoma Hispanic communities.

Section snippets

Procedures

Seven focus groups ranging in length from approximately one and a half to 2 h each were conducted. The research team used purposive sampling (Hennink, Hutter, & Bailey, 2011) to recruit participants, which included Hispanic bi-lingual parenting program providers (N = 14) and supervisors (N = 5) of local home-based visitation programs (i.e., Healthy Families, Parents as Teachers, and SafeCare®). All supervisors and home visitation providers were invited to participate through presentations at

Cultural congruence of the Legacy for Children™ Spanish translation

Participant discussions overall indicated that they considered Legacy appropriate for Spanish-speaking Hispanic families. In particular, the focus group participants offered positive feedback on pace, topics, structure, engagement of mothers in social interactions, straightforward curriculum language, and incremental approach. When evaluating the structure of the program, focus group participants reported that the pace of the curriculum was appropriate, such that it does not overwhelm mothers

Discussion

Overall, focus group data provide preliminary support for the social validity, cultural congruence, and acceptability of the Legacy for Children™ program for Hispanic families. Participants provided positive feedback on the Legacy program and cultural adaptation, focusing on specific areas as mentioned in the Strengths of Curriculum section. Participants considered the program appropriate for Spanish-speaking Hispanic mothers and all agreed they would recommend the Legacy program to Hispanic

Acknowledgements

This project was supported by the Cooperative Agreement Number 5 U38 OT 000140-03 funded by the Centers for Disease Control and Prevention as a sub award from the Association of University Centers on Disabilities. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention, the Department of Health and Human Services, or the Association of University Centers on Disabilities. This research was

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