Prevention Science, Vol. 3, No. 3, September 2002 (C ?2002)
Cultural Sensitivity and Adaptation in Family-Based
Karol L. Kumpfer,1,4Rose Alvarado,1Paula Smith,2Nikki Bellamy3
Because of the substantial impact of families on the developmental trajectories of children,
family interventions should be a critical ingredient in comprehensive prevention programs.
Very few family interventions have been adapted to be culturally sensitive for different ethnic
groups. This paper examines the research literature on whether culturally adapting family
interventions improves retention and outcome effectiveness. Because of limited research on
the topic, the prevention research field is divided on the issue. Factors to consider for cul-
effectiveness of the generic version of the Strengthening Families Program (SFP) compared
to culturally-adapted versions for African Americans, Hispanic, Asian/Pacific Islander, and
American Indian families suggest that cultural adaptations made by practitioners that reduce
dosage or eliminate critical core content can increase retention by up to 40%, but reduce
positive outcomes. Recommendations include the need for additional research on culturally-
sensitive family interventions.
KEY WORDS: cultural issues; parent training; family therapy; substance abuse prevention; outcome
Strong families and wise parents are key to rais-
ing pro-social, socially competent, and healthy chil-
parents skills to effectively praise, supervise, disci-
ical ingredient in any effective approach to the pre-
Most drug prevention programs are delivered to
1Department of Health Promotion and Education, University of
Utah, Salt Lake City, Utah.
Salt Lake City, Utah.
3Center for Substance Abuse Prevention, Division of Knowledge
Development and Evaluation, Rockville, Maryland.
4Correspondence should be directed to Karol L. Kumpfer, PhD,
Associate Professor, Department of Health Promotion and Edu-
cation, University of Utah, 1850 East 250 South, Salt Lake City,
Utah 84112; e-mail: email@example.com.
5Dr. Karol Kumpfer developed the Strengthening Families Pro-
gram. The program materials are disseminated by the University
the program through his company, LutraGroup.
not involve parents or family members. In our expe-
rience, ethnic families and staff prefer family-focused
rather than youth-only focused prevention services.
Mock (2001) believes that family interventions are
popular with traditional ethnic families because of
their collective “we” family identity as opposed to an
individual “I” self-identity, which is stressed in many
family interventions are more culturally-appropriate
for ethnic families than individualistic intervention
Unfortunately, even when family programs are
offered in schools and communities, ethnic families
are often difficult to recruit and retain, particularly
if the program is not culturally appropriate. For in-
stance, generic universal parenting programs attract
only about 33% of parents when offered in schools
(Weinberger et al., 1990). That figure drops to 20–
25% if families are asked to participate in research
(Coie et al., 1991) and as low as 10% for ethnic fami-
lies (Biglan & Metzler, 1999).
1389-4986/02/0900-0241/1 C ?2002 Society for Prevention Research
Kumpfer, Alvarado, Smith, and Bellamy
REASONS FOR THE LACK OF CULTURALLY
Most universal prevention programs are generic
youth culture, which is heavily influenced by White,
middle class values. Professional training has stressed
“the melting pot” model of American culture, result-
ing in few culturally-specific models (McGoldrick &
Giordano, 1996). The theoretical constructs, defini-
tions of protective or risk factors, appropriate inter-
vention strategies, and research evaluation strategies
have all been influenced by mainstream American
values (Turner, 2000). Commercial developers seek
to develop generic programs culturally acceptable by
diverse families; thus, making their products widely
Early attempts at revising prevention programs
typically only considered surface structure or “first
cut” modifications, by hiring ethnically matched staff
tural adaptations should consider critical values and
traditions for within-race cultural subgroups defined
by geographic location (rural, suburbs, urban, reser-
tus, language, acculturation level, and the individ-
ual’s own interpretation and identity with their race,
ethnicity, and culture. It would be better to develop
culturally-specific family programs addressing deep
structure cultural values and practices (Resnicow
et al., 2000) including sensitivity to diverse cultural
values of relational orientation, human nature, a per-
son’s relationship to nature, activity orientation, and
time orientation (Santisteban et al., 2001). Unfortu-
nately, even culturally-specific prevention programs
are sometimes based more on practitioners’ percep-
tions of ethnic community needs than empirically
tested theories. Research evidence suggests substan-
tial similarity in the major causal precursors of drug
use across racial groups (Newcomb, 1995), with slight
variations in the strength of the relationships in risk
or protective factors (Kumpfer & Turner, 1990/1991).
For instance, family protective factors influence
youth of color more than White youth (Turner et al.,
Another challenge is that there are many cul-
tural subgroups with differing dialects and languages
within races. There are more than 50 Hispanic/
Latino groups, 60 distinct Asian or Pacific Islander
groups, more than 500 American Indian tribes and
sub-clans, and many mixed race people of color
with differing levels of acculturation to the White
This article addresses the question of whether
culturally-adapted or specific programs are more ac-
ing existing evidence-based programs are presented
based on the primary author’s experience with devel-
oping culturally-tailored versions of the Strengthen-
ing Families Program. In this article, the authors use
the terms culturally-adapted, (appropriate, tailored,
sensitive, or modified) in which culture refers to the
sum total of ways of living of a group (e.g., tradi-
tions, rituals, values, religion). The terms ethnically-
sensitive or racially-sensitive are not employed. Eth-
nicity refers to a person’s identification with a group
and race is a biological and genetic concept (Turner,
2000). Hence, culture is the focus of the discussion
rather than ethnicity or race.
Each culture has its own traditional worldviews
of healing approaches. Traditional ethnic families ap-
pear to prefer family systems change approach com-
pared to individual change approach to prevention,
because of the emphasis on interconnection, reci-
procity, and filial responsibility. Research supports
this traditional wisdom. Meta-analyses indicate that
family approaches have effect sizes on average nine
times larger than youth-only interventions in reduc-
ing youth conduct problem behaviors for both tradi-
tional and acculturated minority families (Tobler &
Kumpfer, 2000; Tobler & Stratton, 1997). Changes in
the child will not likely continue if the family system
remains unchanged regardless of ethnic orientation.
According to Mock (2001), in close traditional ethnic
families, individual change that is not sanctioned by
ARE CULTURALLY-ADAPTED FAMILY PROGRAMS
Limited research makes it difficult to answer
this question because there are no randomized con-
trol trials comparing a culturally-adapted version to
a generic version. The prevention field is divided
on the issue as the theoretical and empirical ev-
idence is equivocal (Dent et al., 1996). Some re-
searchers of ethnic descent believe that culturally-
sensitive programs are essential for the success of
family-focused prevention (Kumpfer & Alvarado,
1995; Turner, 2000) and advocate for culturally-
appropriate, population-based family interventions.
Cultural Adaptation in Family-Based Prevention
This position is based more on direct observations,
limited quasi-experimental research, and a desire to
be respectful of ethnic family values, rather than on
Research does suggest that behavioral family
interventions are more effective with diverse eth-
nic families than affective-based family approaches
(McMahon, 1999; Taylor & Biglan, 1998), possibly
because many ethnic groups, particularly Asian and
American Indian, expect elders (group leaders or
therapists) to provide wisdom and concrete sugges-
tions rather than use reflective techniques. Family in-
terventions that require sharing personal feelings are
often culturally inappropriate in cultures where this
is discouraged (Wong & Mock, 1997).
formation. Sanders (2000) says “there is an ethical
imperative” to ensure that interventions developed
for the dominant culture do not negatively impact
a child’s own cultural values, competencies, or lan-
guage. He cites the need to identify factors such as
“family structure, roles and responsibilities, predom-
inant cultural beliefs and values, child raising prac-
tices and developmental issues, sexuality and gender
roles” within the context of developing culturally-
sensitive family interventions. These efforts must be
balanced against the context of the considerable het-
et al. (1993) note that in addition to cultural adapta-
tions, which may aid program utilization and reten-
tion, it may also be necessary to adapt recruitment
1993) have argued there is little empirical support
for the superiority of culturally-specific prevention
programs, which would justify the additional cost.
Harachi et al. (1997) found that culturally-adapted,
but equivalent dosage versions of a family program
were more locally acceptable, and slightly more ef-
fective for the ethnic families involved (e.g., African
American, Latino, Native American, and Samoan).
Although it is not a family-centered program, Botvin
et al. (1995) reported slight improvements at the 2-
year follow-up (but not the 1-year follow- up) for a
culturally-modified version of his Life Skills program
compared to the generic, standard version. These re-
searchers concluded “tailoring interventions to spe-
cific populations can increase their effectiveness with
inner-city minority populations” (p. 188). One solu-
tion is hiring culturally-matched facilitators who are
amples, language, etc.) of generic programs without
FACTORS TO CONSIDER FOR CULTURAL
Kazdin (1993) recommends deriving principles
to guide cultural adaptations of existing model pro-
Ethnic researchers (Turner, 2000) recommend that
these principles include sensitivity to the following
elements: (a) sensitivity to the degree of influence
of specific cultural family risk and protective factors,
(b) level of acculturation, identity, and lifestyle pref-
erences, (c) differential family member acculturation
leading to family conflict, (d) family migration and
relocation history, (e) levels of trauma, loss, and pos-
sible posttraumatic stress disorder (PTSD) related to
war experiences or relocation, (f) family work and fi-
nancial stressors, and (g) language preferences and
impediments due to English as a second language,
and level of literacy in native language. Each spe-
cific ethnic group will have special issues to consider
when adapting programs. Generally, special issues to
consider with Latino families include (a) extended
family relationships, (b) influence of metaphysical
or supernatural forces, (c) spirituality and religious
practices, (d) and the role of social clubs (Cervantes,
1993). Adaptations for African American families
should consider their value of (a) education, (b) strict
discipline, (c) religion, (d) extended family support,
(e) adaptability of family roles, and (f) coping skills in
hard times (Boyd-Franklin, 1989; Turner, 2000).
CASE EXAMPLE OF CULTURAL ADAPTATION: THE
STRENGTHENING FAMILIES PROGRAM
The Strengthening Families Program (SFP) is a
that was developed in 1982 on a NIDA grant. The
program has three components namely: parent, child,
and family skills training courses. In the first hour
of the program, the parents and children meet sepa-
as positive playtime, communication, family meet-
ings, planning, and effective discipline. SFP has been
tested in 27 studies with diverse families in a variety
of settings by independent researchers including: five
NIDA grants (multiethnic Utah, American Indians,
African Americans), two NIAAA grants (African
Americans and Canadians), five CSAP High Risk
Kumpfer, Alvarado, Smith, and Bellamy
Youth Grants (described below), 10 CSAP Family
Strengthening grants (five American Indian commu-
nities), three CSAP Children of Substance Abusing
Parents (COSAP) grants, and one SAMHSA grant),
on CD-ROM (Kumpfer & Whiteside, 2000). A junior
high school version of SFP was developed (Kumpfer
et al., 1996) and found cost-effective ($9.60 saved in
hol and drug initiation within Project Family at Iowa
State University (Spoth et al., in press). Because of
these positive results, SFP has been recommended
for dissemination by a number of federal and state
funding agencies (Texas, New Jersey, North Carolina,
Deleware, Virginia, Tennessee, and Florida).
The original research on SFP involved 218 fami-
lies with 6–11 year old children of substance abusers.
A randomized 4-group dismantling design tested
three alternative interventions: (a) a behavioral par-
enting program (PT), (b) PT plus a children’s skills
training program (CT), and (c) both PT & CT, plus a
family relationship and practice program, compared
to a no-treatment control group. The parenting pro-
gram reduced children’s negative behaviors, the chil-
dren program improved social competencies, but the
combined intervention significantly improved more
parent, child, and family risk factors and drug use in
1985). SFP is the combined intervention (Kumpfer
et al., 1989).
RESEARCH RESULTS OF THE CULTURALLY-SPECIFIC
VERSIONS OF THE STRENGTHENING FAMILIES
Results are presented from five studies compar-
ing the generic SFP version implemented in the first
2 years to a culturally-modified SFP version imple-
mented in the last 2 years. Generally the generic ver-
sion had slightly better outcomes, but recruitment
and retention of attending families was 41% bet-
ter with the culturally-adapted versions (Kumpfer &
designs employed made it difficult to disentangle rea-
sons for the lack of more positive outcomes in the
culturally-adapted versions. Staff might have imple-
mented SFP with less enthusiasm in the last 2 years,
but appeared to be more experienced and commit-
but analyses didn’t suggest this. The major factor ap-
peared to be that the dosage was reduced in three
of the five studies. Longer dosage alone, however,
did not necessarily equate to better outcomes as the
Hawaii SFP version lengthened SFP to 20-sessions.
Only 10 of the sessions were original to SFP. Cutting
out four of the original SFP sessions eliminated some
core content and critical practice sessions.
Rural and Urban African American SFP Versions
In rural Alabama, retention of the African
American drug-abusing mothers who attended 12 of
the 14 sessions improved from 61 to 92% after mi-
nor cultural-adaptations were made (e.g., culturally
relevant examples, graphics, stories, and reduced
reading level), but outcomes were equivalent. In De-
troit the generic version had slightly better outcomes
for African American drug abusers in treatment.
However, completion rates (12 of 14 sessions) in-
creased from 45 to 85% after making cultural adapta-
tions (e.g., new local videos, sessions held in African
American churches, basic living needs addressed;
Aktan et al., 1996).
Asian/Pacific Islander SFP
Cultural consultants (without the program de-
velopers involvement) produced a longer 20-session
SFP curriculum. It included 10 sessions on Hawaiian
1996) found retention decreased from 60 to 52%
among families recruited in schools and communities
for the longer curriculum and slightly reduced posi-
tive results. Only the original more behavioral skills-
focused SFP showed significant improvements in par-
ents’ skills and depression, children’s behaviors, and
children’s substance use. The new Hawaii SFP con-
tains the original 14-session SFP, but retains the cul-
A Spanish language version of SFP was devel-
housing communities. The hallmark of this cultural
version was respect for family traditions, which re-
sulted in an increased completion rate (65–98%) by
the fifth year (Kumpfer et al., 1996). The outcome
results of versions were not as strong as prior SFP
studies, possibly because lower risk children were re-
cruited. Also, significant under reporting of problems
at the pretest due to confidentiality concerns was re-
ported by the independent evaluators.
Cultural Adaptation in Family-Based Prevention
American Indian SFP
factors, there was no statistically significant decrease
in youth substance use, possibly because of reduced
tive versus behavioral content. The researchers plan
to return to the longer, more behavioral SFP content.
CONCLUSIONS AND RECOMMENDATIONS
vention programs suggests that cultural adaptations
can substantially improve engagement and accept-
ability leading to better recruitment and retention
of ethnic families, but only slightly improve out-
comes. Better outcomes should result from cultural
adaptations that maintain fidelity rather than re-
ducing dosage, cutting core interactive elements, or
focusing on affective rather than behavior change.
Deeper understanding of cultural parenting assump-
tions leading to culturally-sensitive programs should
improve program success even more (Catalano et al.,
1993; Kumpfer & Alvarado, 1995). However, more
research is needed to determine if deeper cultural
changes will substantially improve outcomes as well
as recruitment and retention. The limited outcomes
reported justify development of culturally-adapted
versions of existing science-based family interven-
programs, a cultural emphasis is needed in all five
phases of prevention research (Institute of Medicine
[IOM], 1994), including Phase I testing of etiologi-
cal models for ethnic minorities, Phase II develop-
ment of new culturally-specific interventions, videos
and evaluation methods for ethnic families, Phase
III Randomized Control Trials to compare generic,
culturally-adapted, and culturally-sensitive versions
of evidence-based, family programs. Phase IV tests
of the new cultural versions with other similar ethnic
subgroups, and finally Phase V dissemination stud-
ies to test effectiveness when brought to scale. Cul-
turally appropriate dissemination or training systems
have not been considered, let alone evaluated, de-
spite their substantial impact on quality, fidelity and
in program design, modifications, effective recruit-
ment techniques, full-scale implementation, program
evaluation and interpretation of the results. Once re-
searchers take the critical scientific steps needed to
develop culturally-appropriate parenting and family
programs, we will be better equipped to reduce youth
problems in this country.
by CSAP grant # SPO-07926 and NIDA grant #RO1
DA10825. This article was prepared by Dr. Bellamy
ment by the Center for Substance Abuse Prevention,
U.S. Department of the Health and Human Services,
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