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Chicago Urban Resiliency Building (CURB): An Internet-Based Depression-Prevention Intervention for Urban African-American and Latino Adolescents

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Early preventive interventions for depressive disorders in racial/ethnic minorities may help to reduce lifetime depression outcome disparities by improving developmental trajectories and social outcomes. We describe the development process, intervention and evaluation plan for a culturally adapted, low-cost, primary care/Internet-based depression-prevention intervention (CURB, Chicago Urban Resiliency Building). CURB is culturally adapted for socio-economically disadvantaged African-American and Latino adolescents according to the PEN-3 model of health promotion programs (Airhihenbuwa in Health and culture: beyond the Western paradigm, Sage Publishers, Thousand Oaks, 1995). Based on the idea that health behavior is rooted in culture, the PEN-3 model contains three interdependent dimensions that influence health beliefs and behaviors. Within each dimension are factors (using the acronym PEN) that must be considered about the target culture. Application of the PEN-3 model occurred in 3 phases. In each phase, a dimension of the model was explored and subsequent changes were made to the intervention so as to be more culturally suitable. In the CURB clinical trial, adolescents ages 13–17 will be recruited from wait-lists for mental health services at community health care provider organizations and screened for risk of future depressive disorder in the primary care sites. Adolescents screening positive for persistent depressed mood will be randomly assigned to either the CURB intervention group or the wait-list control group. The study aims are to determine if participants in the CURB intervention group will have lower levels of depressive symptoms and/or a lower cumulative incidence of depressive episodes.
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1 23
Journal of Child and Family Studies
ISSN 1062-1024
Volume 22
Number 1
J Child Fam Stud (2013) 22:150-160
DOI 10.1007/s10826-012-9627-8
Chicago Urban Resiliency Building
(CURB): An Internet-Based Depression-
Prevention Intervention for Urban African-
American and Latino Adolescents
Alexandria Saulsberry, Marya E.Corden,
Karen Taylor-Crawford, Theodore
J.Crawford, Mary Johnson, Jennifer
Froemel, et al.
1 23
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ORIGINAL PAPER
Chicago Urban Resiliency Building (CURB): An Internet-Based
Depression-Prevention Intervention for Urban African-American
and Latino Adolescents
Alexandria Saulsberry Marya E. Corden Karen Taylor-Crawford
Theodore J. Crawford Mary Johnson Jennifer Froemel Ashley Walls
Joshua Fogel Monika Marko-Holguin Benjamin W. Van Voorhees
Published online: 14 August 2012
ÓSpringer Science+Business Media, LLC 2012
Abstract Early preventive interventions for depressive
disorders in racial/ethnic minorities may help to reduce
lifetime depression outcome disparities by improving
developmental trajectories and social outcomes. We
describe the development process, intervention and evalu-
ation plan for a culturally adapted, low-cost, primary care/
Internet-based depression-prevention intervention (CURB,
Chicago Urban Resiliency Building). CURB is culturally
adapted for socio-economically disadvantaged African-
American and Latino adolescents according to the PEN-3
model of health promotion programs (Airhihenbuwa in
Health and culture: beyond the Western paradigm, Sage
Publishers, Thousand Oaks, 1995). Based on the idea that
health behavior is rooted in culture, the PEN-3 model
contains three interdependent dimensions that influence
health beliefs and behaviors. Within each dimension are
factors (using the acronym PEN) that must be considered
about the target culture. Application of the PEN-3 model
occurred in 3 phases. In each phase, a dimension of the
model was explored and subsequent changes were made to
the intervention so as to be more culturally suitable. In the
CURB clinical trial, adolescents ages 13–17 will be
recruited from wait-lists for mental health services at
community health care provider organizations and
screened for risk of future depressive disorder in the pri-
mary care sites. Adolescents screening positive for persis-
tent depressed mood will be randomly assigned to either
the CURB intervention group or the wait-list control group.
The study aims are to determine if participants in the
CURB intervention group will have lower levels of
depressive symptoms and/or a lower cumulative incidence
of depressive episodes.
Keywords Adolescent depression Prevention and
intervention Primary care Internet Cultural adaptation
Introduction
The lifetime prevalence of major depressive disorder in
adolescents is estimated to be 20 % by age 17 (Kaufman
et al. 1996) and has considerable long-term morbidity and
mortality (Brent et al. 1993,1988; Georgiades et al. 2006;
Harrington et al. 1990; Lewinsohn et al. 1994; Weissman
A. Saulsberry M. E. Corden M. Marko-Holguin
B. W. Van Voorhees (&)
Section of General Pediatrics, Adolescent Medicine and
Education, Children’s Hospital of the University of Illinois,
College of Medicine, University of Illinois, 840 South Wood
Street, Chicago, IL 60612, USA
e-mail: bvanvoor@uic.edu
K. Taylor-Crawford A. Walls
Institute of Juvenile Research Department of Psychiatry,
University of Illinois Chicago, Chicago, IL, USA
T. J. Crawford
Positive Influence, Chicago, IL, USA
M. Johnson
Corazon Community Services, Cicero, IL, USA
J. Froemel
Family Service and Mental Health Center of Cicero, Cicero, IL,
USA
J. Fogel
Department of Finance and Business Management, Brooklyn
College of the City University of New York, Brooklyn, NY,
USA
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DOI 10.1007/s10826-012-9627-8
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et al. 1999). However, as compared to Caucasian adoles-
cents, more African American adolescents experience a
depressive episode (Van Voorhees et al. 2009b). Also,
Latino and African American adolescents report
significantly higher levels of depressive symptoms than
non-Latino white adolescents, even when controlling for
adolescents’ age, gender, family structure and household
income (Wight et al. 2005).
African American and Latino adolescents of low socio-
economic status appear to be even more vulnerable for a
depressive episode. In addition to the specific mental health
concern of depression, both minorities and low-income
populations underutilize mental health services (Cardemil
et al. 2002). Chronic life stressors, such as exposure to
neighborhood violence, occur more often among low-
income minority urban children than among middle-class
white urban children (Stein et al. 2003) and chronic life
stressors are associated with higher rates of depressive
symptoms (Barreto and McManus 1997). Minority ado-
lescents and their parents may perceive stigma related to
treatment for mental health problems. For example, among
African Americans, this perceived stigma may be influ-
enced by a historical mistrust of the medical profession,
provider bias in diagnosis and treatment of mental illness,
and the cultural perception of psychiatric illness as a social
construct rather than a medical disorder with biologic
underpinnings (Breland-Noble et al. 2006). Additionally,
publicly funded mental health services for adolescents do
not provide a full range of community-based models of
care, which is more effective than hospitalization and
emergency room treatment. (New Freedom Commission on
Mental Health 2003) Without choice and the availability of
acceptable treatment options, adolescents with mental ill-
ness are less likely to engage in treatment or to participate
in appropriate and timely interventions. These unique
vulnerabilities point to the need for early preventive
interventions in the development of depressive disorder to
reduce lifetime disparities in depressive outcomes for eth-
nic minority adolescents (Van Voorhees et al. 2007).
Racial/Ethnic Differences in Risk Factors
for Development of Depressive Episodes
In addition to racial/ethnic disparities in the development of
depressive disorders, there appear to be differences in the
patterns of vulnerability for depression between Caucasian
and African American adolescents, even among adolescents
of similar socio-economic status. In our earlier published
research, we demonstrated differences between Caucasian
and African American adolescents in vulnerability factors
predicting depressive episodes (Van Voorhees et al. 2009b).
Univariate analyses showed that some risk factors were
shared by both groups of adolescents (such as low family and
peer connectedness and lack of parental completion of high
school). One marker of low-income, family receipt of public
assistance, significantly predicted a depressive episode in
Caucasian adolescents, but not in African-American ado-
lescents. In a multivariate analysis in which variables sig-
nificant in the univariate model were included, lack of
parental completion of high school was a predictor of a
depressive episode in African-American but not Caucasian
adolescents. This may indicate that even among adolescents
with certain markers of low socio-economic status, cultural
factors may influence an adolescent’s self-perception of that
marker in such a way that it may or may not be associated
with depression. These findings suggest that a culturally
adapted approach to depression prevention that also
addresses unique vulnerabilities caused by socio-economic
disadvantage may be more effective for some ethnic
minority adolescents from low-income backgrounds.
Description of the Existing Original Intervention
To address the need for a preventive intervention in the
primary care setting which would be widely acceptable to
diverse adolescents, we developed CATCH-IT (Competent
Adulthood Transition with Cognitive-behavioral Human-
istic and Interpersonal Training). CATCH-IT is a primary
care/Internet-based behavioral ‘‘vaccine’’ intended for
adolescents at elevated risk for depression. The interven-
tion consists of 14 modules based on Behavioral Activa-
tion, Cognitive-Behavioral Therapy (CBT), Interpersonal
Psychotherapy and a community resiliency concept model
(Landback et al. 2009; Van Voorhees et al. 2009a). During
phase 2 clinical trials of CATCH-IT, adolescents were
screened during primary care visits for risk of depressive
disorder. Those screening at risk for depression were
invited to participate in the study. Participants received a
physician interview encouraging them to use the CATCH-
IT program, followed by the Internet intervention (Van
Voorhees et al. 2008). Participants in phase 2 clinical trials
of CATCH-IT had declines in depressive symptom scores
6 weeks after the intervention. These declines were sus-
tained 3 and 6 months following the intervention.
CATCH-IT also demonstrated potential efficacy in reduc-
ing future incidence of depressive episodes (Hoek et al.
2011; Van Voorhees et al. 2009a).
Cultural Adaptation and Improved Outcomes
Several studies demonstrate the effectiveness of culturally
adapted mental health interventions. For example, Cardemil
et al. (2002) developed a cultural adaptation of the Penn
Resiliency Program for low-income minority middle school
children. Following the program, Latino children reported
lower rates of depressive symptoms, automatic negative
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thoughts and hopelessness, and higher self-esteem compared
to their peer controls. These results were maintained
6 months following the intervention, and benefits continued
to be demonstrated 2 years following the intervention.
However, similar findings were not found among African
American participants (Cardemil et al. 2007). An adaptation
of the Beardslee Preventive Intervention Program for
depression was used in predominantly low-income Latino
families (D’Angelo et al. 2009). Families could receive the
intervention in either English or Spanish, and contextual
experiences of Latino families and a strengths-based family
approach were included in the intervention. When compared
to a pilot study of the original intervention, parents reported
higher levels of satisfaction, with similar results. Jacob et al.
(2011) also report positive findings from a case series in
which behavioral activation (BAC) was used for the treat-
ment of depression in low-income African-American ado-
lescents, with decreased severity of both clinician-rated
depressive symptoms and impairment for all participants at
the end of treatment.
Previous studies also use motivational interviewing
along with cultural adaptation for depression treatment
interventions. For example, Breland-Noble et al. (2006)
reports the multi-phase development of a motivational
interviewing intervention to improve treatment engage-
ment for African-American adolescents with depression
and their families. Prior to the adolescent’s treatment,
families participated in one phone clinician session and two
face-to-face clinician sessions (one involving the adoles-
cent only, the second involving both adolescent and par-
ent), with the aim of increasing readiness for engagement
with psychiatric treatment. A pilot intervention demon-
strated higher rates of initiation of treatment for depression
as compared to delayed group controls (Breland-Noble and
AAKOMA Project Adult Advisory 2012).
Increasing Effectiveness by Increasing Socio-cultural
Relevance
Participants’ beliefs about the relevance of our original
CATCH-IT intervention predicted their adherence to the
intervention. For example, both the belief that an inter-
vention like CATCH-IT was important and the attitude that
benefits of the intervention would outweigh any difficulties
significantly predicted total time spent online in the inter-
vention (Marko et al. 2010). Also, the way in which ado-
lescents interpreted the program was highly contextual. A
review of adolescents’ comments typed into the CATCH-
IT website during the intervention revealed that many
participants applied lessons of the intervention to their own
life situations. For example, in their online comments,
adolescents suggested behavioral changes they could make
in the areas of health, school, and communication with
family and friends (Iloabachie et al. 2011). Given these
findings, it is likely that an intervention that is more rele-
vant to participants will be more meaningful to them. By
making an intervention more culturally relevant, we
believe that it can also become easier to personalize, thus
increasing participant motivation to adhere to the inter-
vention and resulting in behavioral change.
Purpose of Intervention
We describe in this publication the development of the
CURB intervention and the plans for evaluation and dis-
semination. We are not aware of any culturally adapted
interventions to prevent depression for socio-economically
disadvantaged African American and Latino adolescents in
primary care settings. To address this need, we developed
four aims or steps: (1) CURB development, (2) final
intervention design, (3) evaluation and (4) dissemination.
Our first aim (CURB development, including cultural
adaptation) was to adapt a ‘‘standard’’ Internet-based
depression prevention intervention to meet the needs of
low-income urban African American and Latino adoles-
cents. The second aim (final intervention design) was to
construct the intervention that would be implemented
within a primary care setting. This includes the culturally
adapted Internet component and parent component, along
with a motivational component to be completed by the
primary care provider. The third aim (evaluation) is to
describe the planned evaluation study that would determine
if CURB is superior to wait-list control for urban African
American and Latino adolescents with respect to depres-
sion-related outcomes (i.e., depressed mood, depressive
disorders and presence of vulnerability and protective
factors). Our fourth aim (dissemination) is to determine the
ways in which the intervention might be disseminated
effectively once an evaluation study is completed.
Methods
Overview
We developed a culturally adapted version of CATCH-IT
called CURB (Chicago Urban Resiliency Building). Like
CATCH-IT, CURB targets the multiple etiological ele-
ments of depression that act either in concert or in com-
bination, including negative cognitions (Lewinsohn et al.
1995,1997), poorer social skills (Lewinsohn et al. 1994;
Liu 2002), stressful events, subsyndromal depressive
symptoms (Lewinsohn et al. 1994; Van Voorhees et al.
2008), and the absence of protective factors (e.g., high self-
esteem, coping skills). Additionally, CURB engages both
parents and adolescents with distinct behavior change
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programs to address person- and family-level barriers
(Compas et al. 1995; Garber 2006; Hankin 2006; Lewin-
sohn et al. 1994; Reinecke and Simmons 2005). Below, we
describe four key elements of the cultural adaptation and
implementation of the CURB intervention: (1) CURB
development (including cultural adaptation framework),
(2) final intervention design, (3) evaluation, and (4)
dissemination.
CURB Development
Parent and Adolescent Advisors
Two adolescent advisory groups were convened to aid with
cultural adaptation of the intervention. We gathered 12
adolescents (six African-American and six Latino), both
male and female, ages 15–18) with the help of a local
community service center and a local community member.
For their participation, adolescents were paid $20 each,
served two meals, and provided reimbursement for trans-
portation costs, for spending 6 h evaluating the interven-
tion in the computer lab of a local community service
center in November 2010. Adolescents all provided assent
and also permission was received from their parents for
participation. Adolescents were first given a demographic
questionnaire. They were then given 1 h to navigate
through the public website of the original CATCH-IT
intervention. They were advised to pay attention to details
such as language, navigation on the site, and pictures/
media. They were told that their opinion was going to help
build a better site to help teens in need of improved mental
health and wellbeing. After adolescents completed navi-
gation of the site, they were given a second questionnaire
to capture their immediate self-reported response to the
website. Then adolescents were separated by ethnicity and
escorted into two separate rooms where advisory sessions
took place (the African-American group was facilitated by
a local African-American community member, and the
Latino advisory group was facilitated by a social worker
with extensive experience working with Latino adoles-
cents). The five main areas discussed with adolescents
were: (1) ease of navigation and use, (2) clarity and ease of
understanding (3) level of engagement (i.e., elements par-
ticipants found interesting or boring), (4) motivation (i.e.,
elements participants felt motivating or non-motivating),
and (5) pictures/media (i.e., what pictures and other media
elements participants found boring or exciting). During the
discussions, screenshots of specific pages of the interven-
tion, such as the home page and rewards page, were also
shown and participants were asked for general impressions
and suggestions for improvement. Several months later, the
adolescent advisor group then re-convened to view the final
design.
Four parents (two African-American and two Latino),
all local community members, were recruited to be parent
advisors for the CURB intervention. They were given
copies of the parent program and discussed individually
with one of the study’s principal investigators their general
impressions and suggestions for improvement. An experi-
enced psychotherapist with extensive experience working
with African-American and Latino communities also pro-
vided feedback on the developing parent program.
Cultural Adaptation Framework
The CATCH-IT intervention was culturally adapted
according to the PEN-3 model of health promotion pro-
grams, as described by Airhihenbuwa (1995), between
August 2010 and January 2012. The PEN-3 model is based
on the idea that health behavior is rooted in culture, and
that consideration of cultural factors can foster the devel-
opment of successful health programs. The model contains
three interdependent dimensions that influence health
beliefs and behaviors. Within each dimension are factors
(using the acronym PEN) that must be considered about the
target culture: (1) Persons, Extended family, and Neigh-
borhoods, (2) Perceptions, Enablers, and Nurturers, and (3)
Positive, Existential, and Negative behaviors. The PEN-3
model has been widely applied to develop culturally
adapted versions of health programs for target audiences
(see Fig. 1; Erwin et al. 2005; James 2004; Matthews et al.
2009). Application of the PEN-3 model to CATCH-IT
occurred in 3 phases. In each phase, a dimension of the
model was explored and subsequent changes were made to
the intervention so as to be more culturally suitable.
Phase 1: Persons, Extended Family and Neighborhoods
In Phase 1, we identified whether the target of the inter-
vention would be the person, extended family or neigh-
borhood. In our study, we focus on individuals living in
urban communities in Chicago, IL and Cicero, IL with high
concentrations of low-income African American and
Latino adolescents. We first had to determine for pre-
ventive interventions whether the vulnerability and pro-
tective factors for ethnic minority adolescents differed
meaningfully from those of American adolescents as a
whole or of Caucasian adolescents in particular.
To determine the unique vulnerability factors for ethnic
minority adolescents as compared to Caucasian adoles-
cents, we conducted a literature review with regard to
Latino adolescents and incorporated our own work com-
paring vulnerability and protective factors for depressive
episodes between African American and Caucasian ado-
lescents (Van Voorhees et al. 2009b). We identified salient
vulnerability factors including stigma, socio-economic
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hardship, immigration stress, sexual activity, substance
abuse, emotional trauma and physical trauma. Similarly,
we identified strengths such as family closeness and con-
nection to community that may be particularly protective.
Phase 2: Perceptions, Enablers, and Nurturers
In Phase 2, we identified beliefs (perceptions) and systemic
factors (enablers) that may hinder or promote depression
prevention in each ethnic minority group, and the extent to
which cultural beliefs are influenced by an individual’s
family and community (nurturers). After identifying the
relevant perceptions, enabling and nurturing cultural factors,
we adapted the intervention to maximize acceptance and
potential efficacy. To make the Internet intervention and
program materials more culturally appropriate, we utilized
the approach described by Kreuter et al. (2003) to achieve
cultural appropriateness in health programs. This approach
includes the use of: (A) peripheral strategies, (B) evidential
strategies, (C) linguistic strategies, and (D) constituent-
involving strategies. Each is further explained below.
A. Peripheral strategies: The program was changed to
increase visual appeal to the target group. We solicited
input from adolescent and parent advisors to make the
appearance of the intervention more engaging to our
targeted audience. Based on their comments, pictures
of urban African American and Latino adolescents
were included on the website and thematic elements
were used that appealed to African American and
Latino adolescent advisors. Adolescent advisors
reported that the initial colors and design appeared
too ‘‘boring’’ for them, so we selected a hip-hop theme
and earth tone colors, which adolescents found quite
appealing (see Fig. 2).
B. Evidential strategies: The program was changed to
make the health issue of depression prevention more
personally relevant for African-American and Latino
adolescents. We re-wrote text and stories used within
the intervention to reflect the feedback from the parent
and teen advisors. In particular, themes for stories
were developed to reflect the unique vulnerability and
protective factors experienced by ethnic minority
Fig. 1 CURB cultural adaptation method
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adolescents. Stories also featured African American or
Latino cultural and family contexts including names,
idioms and other cultural elements.
C. Linguistic strategies: The dominant language of the
target group was used to make the program more
accessible. With regard to linguistic strategies, ver-
nacular and idioms relevant to African American and
Latino adolescents of urban Chicago were used by
African American narrators. The parent program was
translated into Spanish. We also elected, whenever
possible, to shorten the text and avoid the appearance
of a ‘‘school-like’’ experience. However, we also
added text that provided a much fuller description of
the range of affect adolescents can experience based
on comments from the advisor groups.
D. Constituent-involving strategies: Members of the
target group were involved in a substantive way in
the design of the intervention. We utilized the
experience of constituents from the target audience
by convening advisory groups of Latino and African
American adolescents and parents, and including
videos featuring mentors and parents of both African
American and Latino background.
Phase 3: Positive, Existential and Negative Behaviors
In Phase 3, we identified cultural beliefs, practices, or
behaviors that have a good impact, no impact, or a harmful
impact on depressed mood (positive behaviors, existential
behaviors, or negative behaviors, respectively). In the two
advisory groups described above, facilitators sought out
commentary that addressed knowledge deficits and benefits
of the current CATCH-IT intervention, myths about the
effectiveness of traditional depression treatment, and cul-
tural norms regarding depression treatment. Positive mes-
sages about the benefits of mental health, education on
depression and its treatment, learning about coping skills,
building resilience and changing thoughts to change
behavior were also discussed. We used this approach to
develop video elements that more fully connected the
users, parent, adolescent, physician, and office staff to the
program.
A. Adolescent: Videos in the adolescent Internet inter-
vention featured mentors, both African American and
Latino (alternating modules), describing each module,
explaining how it might help, dispelling myths and
generally extending the intervention into an African
American and Latino cultural framework. We did not
have a ‘‘matched’’ mentor on each module because the
goal of the intervention was to provide, wherever
possible, a common approach to both groups.
B. Parent: With regard to the parent intervention, we
created a video that demonstrated a process to improve
parent-adolescent communication style to enhance
connectedness to family (i.e., protective factor). The
video featured an African American family addressing
adolescent depressed mood related to the death of a
friend due to gun violence (i.e., emotional trauma
vulnerability factor).
C. Physician, medical staff and office setting: To engage
physicians and medical practices with the project, we
created an overview video that featured ethnic minor-
ity physicians and students describing the project and
the potential benefits. We created a colorful brochure
and poster to be displayed in the primary care
practices to engage adolescents and families with the
program. The brochure celebrates the concept of
building resiliency rather than focusing on ‘‘illness,’
that is, the adolescent and parent have the chance to
build on their strengths to prepare the adolescent for
the future. Similarly, the physician motivational
interview training program was revised to feature an
African American physician as well as African
American and Latino patients.
Final Intervention Design
Overview
The intervention has the same overall structure as the
CATCH-IT (2nd version) intervention. Physicians perform
initial (baseline) and follow-up (3 months) motivational
interviews for each participant to engage and follow-up
Fig. 2 CURB Internet design
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after the Internet-based program (Fig. 3). Physicians and
clinic office staff are trained using a lecture/video example
format (1 h). The adolescents also receive three motiva-
tional (or coaching) phone calls from research study staff.
The intervention includes 14 modules based on BAC, CBT
(Clarke 1994; Jacobson et al. 2001), Interpersonal Psy-
chotherapy (IPT) (Mufson et al. 2004; Stuart and Robert-
son 2003), and a community resiliency concept model (Bell
2001). These components were constructed from manuals
with demonstrated efficacy in face-to-face delivery models
using a systematic method based on principles of effective
translation of preventive interventions to community set-
tings and instructional design theory (Gagne et al. 1992;
Nation et al. 2003; Wandersman and Florin 2003). Simi-
larly, the parent program consists of three Internet- or
workbook-based modules.
Motivational Component
The CURB intervention has a motivational component,
which consists of motivational interviewing by the primary
care provider at baseline and 3 months for those receiving
the CURB intervention, and at 3 and 6 months for those in
the wait-list control group (see Fig. 3). In the motivational
interview (10–15 min duration), the physician seeks to help
the adolescent weigh the balance of positives and negatives
of undertaking the depression prevention intervention.
Coaching phone calls are made at 1, 2, 3, and 7 weeks after
exposure to the intervention. Coaching calls will be con-
ducted by research study staff, use the same motivational
interview approach, be 5 min or less in duration, and be
solely designed to encourage completion of the interven-
tion and behavior change (i.e., not to be psychotherapy). If
an adolescent reveals that depression is worsening or
endorses suicidal thoughts during the coaching call, a cli-
nician assessment will be made immediately by phone
using a suicide protocol. If the adolescent is judged to have
significant risk of self-harm or injury, an immediate dis-
patch of appropriate professionals will occur to perform a
face-to-face assessment.
Adolescent Internet Component
The Internet component consists of 14 Internet-based
modules based on BAC (Jacobson et al. 2001), CBT
(Clarke 1995), Interpersonal Psychotherapy (IPT) (Mufson
et al. 2004; Stuart and Robertson 2003), and resiliency
building (Bell 2001; see Table 1). The first module is an
Internet introduction to the program. To emphasize the
core goals of BAC, the Internet component includes three
modules that focus on engaging the adolescent in mean-
ingful activities, stopping avoidant behaviors that reinforce
depressed mood, and incorporating a healthy rhythm of
activities in one’s life. These include the concepts of
teaching resiliency to adolescents as described by Bell
(2001) as well as the BAC approach described above
(Jacobson et al. 2001). The CBT modules include four
modules that teach participants to identify and counter
pessimistic and irrational thoughts. Also, participants learn
how to conduct basic problem-solving skills and how to
anticipate and plan responses to difficult situations. The
IPT skills modules include four modules that teach par-
ticipants how to cope with transitions in roles or location
and how to identify and resolve relationship problems. In
the final two modules, participants learn how to recognize
the symptoms of depression, current treatment options, and
how to overcome stigma.
The basic design and structure of each module from
CATCH-IT was not changed in the development of the
CURB program. The Internet website was constructed
with three goals: (a) careful attention to instructional
design to ensure delivery of the core behavior change
curriculum (Gagne et al. 1992), (b) minimize participant
burden, and (c) maximize motivation for change. These
goals are important since well-designed interventions
have the goals to: (1) gain the attention of the learner, (2)
inform the learner of objectives, (3) stimulate the recall of
essential knowledge, (4) provide required stimulus mate-
rial, (5) promote learning guidance, (6) measure perfor-
mance, (7) provide feedback on performance correctness,
(8) assess performance, and (9) enhance transfer and
retention (Gagne et al. 1992). Each module includes the
following sections: (1) what you will learn (goals and
introductory video); (2) review/warm-up; (3) lesson
(explanation of coping strategies); (4) stories (five stories
of adolescents’ lives that develop across time and dem-
onstrate the coping strategies); (5) skill builders (on-line
Fig. 3 CURB intervention. BAC behavioral activation, CBT cogni-
tive behavioral psychotherapy, IPT interpersonal psychotherapy
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practice exercises); (6) feedback (opportunities to rate
experience); (7) wrap-up (summary); (8) doing goals
(things you can do to practice coping skills in the coming
week); and (8) reward (brief Internet-based reward-like
coupons).
Parent Component
The parent component of the intervention is based on an
adaptation of Beardslee and Gladstone’s clinician-facilitated
and lecture intervention approaches from the Preventive
Table 1 Intervention phases
and components
PCP MI primary care physician
motivational interview, PIP
parent intervention program,
BAC behavioral activation, CBT
cognitive behavioral
psychotherapy, IPT
interpersonal psychotherapy
Component Content and exercises (theoretical model) Behavioral target
Adolescent program
Motivational
component
PCP MI at baseline and 3 months (CURB arm) or 3 and
6 months (wait-list control)
Under-attainment of
milestones
Phone calls at 1, 2, 3, and 7 weeks after intervention Low motivation for
prevention
Modules 2–4 Event scheduling Loss of response,
contingent
reinforcement
Practicing active behaviors (BAC)
Modules 5–8 Identifying and countering pessimistic automatic thoughts,
general beliefs and hopelessness
Cognitive distortions
Problem solving (CBT) Pessimistic cognitive
style/content
Poor coping skills
Modules 9–12 Improving communication skills, coping transitions,
conflict resolution
Lack of social support
Engaging new networks (IPT) Social skills deficits
Lack of peer support
Module 13–14 Flexibility/humor/persistence Inflexible responses
Community involvement Low levels of pro-social
activities
Barriers to treatment (resiliency concept)
Parent program
Modules 1–2 Activism Cultivating strengths
PIP Connectedness Encourage discussion,
behavioral activation
Affect recognition Resiliency behaviors and
expression of emotion
Table 2 Sites and gender, race/ethnicity, and insurance status
Site Gender
(% female)
Race/ethnicity Insurance status
Federally Qualified Health Center (FQHC)
Primary Care sites (4 sites total)
65 % 83% AA* (N=4,565 visits)
9 % Latino (N =495 visits) or
1,200 unique patients (N =996
AA, N =108 Latino) [400 at risk
for depression
75 % Medicaid
16 % Uninsured
9 % Private insurance
School–Based Clinic (affiliated with
FQHC above)
65 % 8 % Caucasian/other
Public Hospital Clinic 60 % 55% AA, 45% Latino 45 % Medicaid
50 % Uninsured
AA African American
J Child Fam Stud (2013) 22:150–160 157
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Intervention Project. This intervention builds resiliency in
adolescents and families (Beardslee and Gladstone 2001;
Beardslee et al. 2003). In terms of resiliency, this interven-
tion helps parents develop the awareness and skills needed to
support their children in the development of supportive peer
relationships and age-related developmental tasks (e.g.,
parental participation in and leadership of adolescent orga-
nizations, adolescent sports and other adolescent activities).
The intervention also seeks to reduce known risk factors for
adolescent depression (i.e., parental and family discord and
hostile or overly critical parenting styles). To accomplish
this, the intervention helps parents to remove misunder-
standings about depression that increase guilt or blaming and
teaches them communication skills. Parents are also taught
to recognize the symptoms of depression in themselves and
their children. The parent program includes three modules
and five brief videos demonstrating the resiliency building
strategies that parents can practice in dialogue with their
adolescent. The parent program has been translated into
Spanish.
Evaluation
Overview
The evaluation will consist of a randomized clinical trial
comparing CURB (GROUP A) to a wait-list condition
(3 month wait, GROUP B). Group B becomes GROUP C
after receiving CURB and will be followed for 3 more
months (see Fig. 4). Similarly, Group C will be compared
to wait-list control experience (Group B, same individuals,
different time points). To date, performance sites include
four primary care clinics of a federally qualified health
center, with plans to include a school-based clinic and a
public hospital clinic (Table 2). Adolescents will be
recruited from all performance sites by screening for risk of
future depressive disorder in primary care/school based
clinic sites. Adolescents with depressed mood ([2 weeks
duration) will be eligible unless they already exceed the
diagnostic threshold for major depressive disorder. The
CURB intervention will include two motivational inter-
views (conducted by primary care providers at the clinics)
and the CURB Internet intervention.
Dissemination
We developed training materials for CATCH-IT (including
videos, primary care scripts, flyers, posters, screening
instruments, etc.) for practices which will be modified for
CURB during the first 6 months of the budget period. We
developed a tool box method for ‘‘starting up’’ the inter-
vention similar to the successful Enhancing Developmen-
tally Oriented Primary Care (EDOPC) method (used to
change pediatric practice in Illinois; Allen et al. 2010). We
see ourselves leveraging the ease of distribution of the
intervention itself with video conferencing to train pro-
viders over lunch hours or short increments of time. Given
that our performance sites are community health centers,
one limitation of our study is that we will not likely be able
to recruit African-American and Latino adolescents from
middle and high socio-economic status (SES) for com-
parison of the intervention’s effectiveness in adolescents
across socio-economic strata. One future direction of our
study may be implementation of CURB in academic and
Fig. 4 CURB evaluation study
158 J Child Fam Stud (2013) 22:150–160
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private practice settings where adolescents of middle and
high SES may be more easily accessible. However, we
believe that the CURB intervention would represent value
to both health systems and patients. CURB is low cost,
easily accessible, and easily disseminated using the online
training materials and interventions describe above. CURB
targets known risk factors as well as barriers to resolution
of disparities (person, practice, community, and system) to
reduce likelihood of depressive illness. If proven benefi-
cial, CURB would meaningfully impact racial/ethnic dis-
parities in depressive outcomes via early preventive
intervention in adolescence.
Conclusions
CURB is a culturally adapted, low-cost, primary care/
Internet-based depression prevention intervention for
African American and Latino adolescents. CURB targets
common barriers in accessing mental health services (cost,
difficulty in distribution and low acceptability of some
face-to-face interventions). CURB also utilizes Internet
technologies to address the limited supply of mental health
resources. Key innovations of CURB include the follow-
ing: (1) it targets both adolescent and parent vulnerability
and protective factors in separate interventions, using an
ecological model; (2) it is personalized to reflect race/
ethnicity and culture; and (3) it uses media-based learning
strategies including stories and photographs within the
Internet modules to convey learning. A unique strength of
CURB is its ability to be easily implemented in a primary
care setting, enabling a clinician to intervene quickly for
adolescents at risk for depressive disorder.
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... The PEN-3 model is a theoretical framework used to foreground culture in the development, implementation and evaluation of health interventions [47]. For instance, in a depression prevention intervention for urban African American and Latino adolescents, the PEN-3 model guided the identification of individual, interpersonal and community level barriers and promoters of depression and this information was applied to improve the visual and linguistic appeal of the program publications [48]. With regards to our study's findings, the PEN-3 model could be applied to develop interventions that address cultural and social conceptions of ideal body sizes, to deconstruct myths surrounding the link between weight loss and HIV, as well as promote an environment where all community members are accepted irrespective of HIV and weight status. ...
... Peer bullying interventions that tackle body shaming and weight-related victimization in adolescents are also warranted. As extant interventions show a small to medium effect on weight-biased attitudes and beliefs, novel interventions informed by the findings of this review are needed [48]. ...
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Full-text available
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... Application of cultural sensitivity frameworks has been successful in maintaining treatment fidelity to the treatment protocol, in participant retention and engagement, and in positive outcomes among Latina/ os and African Americans suffering from chronic health (e.g., type-2 diabetes) and behavioral health conditions (e.g., depression, somatization) [31][32][33][34][35]. Moreover, research has provided preliminary evidence in support of adapted behavioral activation interventions for treating depression among Latina/os and African Americans [36,37]. ...
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The mental health benefits of physical activity and exercise are well‐documented and asylum seekers who may have poor mental health could benefit from undertaking recommended levels of physical activity or exercise. Digital mobile applications are increasingly seen as feasible to precipitate behaviour change and could be a means to encourage asylum seekers to increase their levels of physical activity and exercise. This paper reports on a study that aimed to assess the feasibility of asylum seekers using the digital animation as a tool to change behaviour and increase their physical activity and exercise levels. A feasibility study underpinned by the principles of the COM‐B behaviour change model was undertaken in West Yorkshire, UK, in 2019. Thirty participants were purposively recruited and interviewed. Peer interpreters were used as necessary. Deductive thematic analysis was undertaken to analyse the data. Overall, participants were positive about the feasibility of asylum seekers using the application as a behaviour change intervention. All expressed the view that it was easy to follow and would motivate them to increase their physical activity levels. Participants identified facilitators to this as the simplicity of the key messages, the cultural neutrality of the graphics and the availability of the mobile application in different languages. Identified barriers related to the dialect and accents in the translations and the over‐simplicity of the application. This study has identified that a targeted digital animation intervention could help asylum seekers change their behaviour and hence improve their health and well‐being. In designing such interventions, however, researchers must strongly consider co‐design from an early stage as this is an important way to ensure that the development of an intervention is fit for purpose for different groups.
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Providing accessible and effective healthcare solutions for people living in low- and middle-income countries, migrants, and indigenous people is central to reduce the global mental health treatment gap. Internet- and mobile-based interventions (IMI) are considered scalable psychological interventions to reduce the burden of mental disorders and are culturally adapted for implementation in these target groups. In October 2020, the databases PsycInfo, MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Web of Science were systematically searched for studies that culturally adapted IMI for mental disorders. Among 9438 screened records, we identified 55 eligible articles. We extracted 17 content, methodological, and procedural components of culturally adapting IMI, aiming to consider specific situations and perspectives of the target populations. Adherence and effectiveness of the adapted IMI seemed similar to the original IMI; yet, no included study conducted a direct comparison. The presented taxonomy of cultural adaptation of IMI for mental disorders provides a basis for future studies investigating the relevance and necessity of their cultural adaptation. PROSPERO registration number: CRD42019142320.
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Discussed interpersonal psychotherapy (ITP) for depressed adolescents. Interpersonal psychotherapy for depressed adolescents is a short-term, manualized, individual treatment for adolescent depression. The focus of the treatment is on alleviating depressive symptoms and improving interpersonal functioning. Details of ITP and how it works are outlined. The efficacy of ITP has been demonstrated in 2 randomized controlled clinical trials. Current empirical investigations of ITP aims to provide treatment in community-based practice settings and/or with adaptations to make treatment delivery more cost-effective and accessible to more teens. (PsycINFO Database Record (c) 2012 APA, all rights reserved)