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Abstract

Global health disparities continue to widen as professional standards for effectiveness of mental health services provision become more precise and difficult to achieve across varied economic and social contexts. Within the US, health disparities are evident in Latinx populations. Globally, the health disparities are also evident in Latin America as compared to the US and other economically affluent nations. The diversification of psychology in content and persons has led to a unique opportunity to build bridges that can help reduce disparities in-and outside of the US mainland. Collaborations can be of great use in addressing health disparities internationally but also are of critical importance in testing the ecological validity of existing interventions. It is imperative that researchers approach these exchanges as truly collaborative and power even, as researchers in all locations stand to learn and grow from the partnership, otherwise US-based researchers can unwittingly engage intellectual colonization and advance cultural imperialism. US-based researchers must be particularly thoughtful about disparities in both resources and consequences for success and failures in research contexts. We discuss specific failures, recoveries, and successes that may be useful to other researchers engaged, or seeking to engage in, international collaborations.
© 2018, American Psychological Association. This paper is not the copy of
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article will be available, upon publication, via its DOI: 10.1037/lat0000121
Scaling Out Evidence-Based Interventions Outside
the US Mainland: Social Justice or Trojan Horse?
Melanie M. Domenech Rodríguez
Ana Baumann
Alejandro L. Vázquez
Nancy G. Amador-Buenabad
Natalie Franceschi Rivera
Nydia Ortiz-Pons
J. Rubén Parra-Cardona
Author Note:
Melanie M. Domenech Rodríguez, Department of Psychology, Utah State University;
Ana Baumann, Brown School, Washington University in St. Louis; Alejandro L. Vázquez,
Department of Psychology, Utah State University; Nancy G. Amador-Buenabad, Investigaciones
Sociales, Instituto Nacional de Psiquiatría Ramón de la Fuente Muñíz; Natalie Franceschi
Rivera, Private Practice, Ponce, Puerto Rico; Nydia Ortiz-Pons, School of Behavioral and Brain
Sciences, Ponce Health Sciences University; J. Rubén Parra-Cardona, Steve Hicks School of
Social Work, University of Texas, Austin.
Correspondence concerning this article may be addressed to Melanie M. Domenech
Rodríguez, Department of Psychology, Utah State University, 2810 Old Main Hill, Logan, UT
84322-2810. Email: melanie.domenech@usu.edu
Please cite as:
Domenech Rodríguez, M. M., Baumann, A., Vázquez, A. L., Amador Buenabad, N. G.,
Franceschi Rivera, N., Ortiz Nolasco, N., & Parra-Cardona, J. R. (2018, Online First).
Scaling out evidence-based interventions outside the US mainland: Social justice or
Trojan horse? Journal of Latina/o Psychology. doi: 10.1037/lat0000121
Abstract
TROJAN HORSE? 2
Global health disparities continue to widen as professional standards for effectiveness of mental
health services provision become more precise and difficult to achieve across varied economic
and social contexts. Within the US, health disparities are evident in Latinx populations. Globally,
the health disparities are also evident in Latin America as compared to the US and other
economically affluent nations. The diversification of psychology in content and persons has led
to a unique opportunity to build bridges that can help reduce disparities in- and outside of the US
mainland. Collaborations can be of great use in addressing health disparities internationally but
also are of critical importance in testing the ecological validity of existing interventions. It is
imperative that researchers approach these exchanges as truly collaborative and power even, as
researchers in all locations stand to learn and grow from the partnership, otherwise US-based
researchers can unwittingly engage intellectual colonization and advance cultural imperialism.
US-based researchers must be particularly thoughtful about disparities in both resources and
consequences for success and failures in research contexts. We discuss specific failures,
recoveries, and successes that may be useful to other researchers engaged, or seeking to engage
in, international collaborations.
Key words: health disparities, intervention research, research methods
Public significance: The authors caution researchers to examine their methods carefully when
transporting evidence-based interventions across international boundaries. There is a great need
to address mental health treatments globally, yet US-based interventions may not be appropriate
and their implementation could possibly do more harm than good.
Resumen
TROJAN HORSE? 3
Las disparidades de salud globales continúan incrementado a medida que los estándares
proesionales para determinar la efectivdads de los servicios de salud mental se tornan más
precisos y difíciles de lograr en contextos económicos y sociales variados. Dentro de los Estados
Unidos, las disparidades de salud son evidentes en las poblaciones de Latinx. A nivel mundial,
las disparidades de salud también son evidentes en América Latina en comparación con los
Estados Unidos y otras naciones económicamente ricas. La diversificación de la psicología en
contenido y personas ha llevado a una oportunidad única para construir puentes que pueden
ayudar a reducir las disparidades dentro y fuera de los Estados Unidos continentales. Las
colaboraciones pueden ser de gran utilidad para abordar las disparidades de salud a nivel
internacional, pero también son de importancia crítica para evaluar la validez ecológica de las
intervenciones existentes. Es esencial que los investigadores aborden estos intercambios como
verdaderamente colaborativos y con igualdad de poder, ya que los investigadores en todas las
ubicaciones pueden aprender y crecer de la asociación, de lo contrario, los investigadores con
sede en EE. UU. pueden involuntariamente caer en la colonización intelectual y avanzar en el
imperialismo cultural. Los investigadores con base en los Estados Unidos deben ser
particularmente cuidadosos con las disparidades en los recursos y las consecuencias para el éxito
y los fracasos en los contextos de investigación. Discutimos fallas, recuperaciones y éxitos
específicos que pueden ser útiles para otros investigadores comprometidos o que buscan
participar en colaboraciones internacionales.
Palabras claves: disparidades de salud, investigación de intervención, métodos de
investigación
Valor público: Los autores piden cautela por parte de investigadores en el uso de métodos para
trasladar los tratamientos basados en evidencia a diversos contextos internacionales. Hay una
TROJAN HORSE? 4
gran necseidad a nivel global de attender problemas de salud mental, sin embargo intervenciones
desarrolladas en los EEUU puede que no sea apropaidas a otros contextos y su implementación
pudiera causar más daño que beneficio.
Scaling Out Evidence-Based Interventions Outside
the US Mainland: Social Justice or Trojan Horse?
There is an inherent excitement in connecting with an international research partner
especially when one partner has a tool (e.g., a treatment package) and the other has an unmet
need (e.g., increasing rates of substance use). However, establishing these partnerships goes
beyond the simplicity of matching a tool with a need. There are many assumptions and
expectations that must be examined in the service of improving the quality of mental health care
for Latinxs in the US and abroad. Collaborations can result in powerful vehicles to address health
disparities or can, conversely, result in harm when assumptions are not uncovered or discovered
and the efforts result in negative or no change.
Global health disparities continue to widen (WHO, 2011) as professional standards for
effectiveness of mental health services provision become more precise and difficult to achieve
across varied economic and social contexts (Suarez-Balcazar, Mirza, & Garcia-Ramirez, 2018;
Subrahmanian & Swami, 2018). As for available treatments, many evidence-based interventions
have been developed in the United States and tested mostly in the United States. Regardless of
the wealth of resources for treatment within the US, health disparities continue to be evident in
Latinx populations (Alcaraz et al., 2017; SAMHSA, 2015; Vega, Rodríguez, & Gruskin, 2009).
In Latin America, health disparities are pronounced compared to the US and other economically
affluent nations (WHO, 2011). The growth of the profession of psychology around the globe
brings a unique opportunity to build bridges that can help reduce health disparities (a) within the
TROJAN HORSE? 5
US across ethnic groups and (b) internationally across countries with differing levels of
resources.
The purpose of this manuscript is to share opportunities and challenges and potentially
provide guidance to scientists conducting collaborative research across nations that may build the
knowledge-base regarding the effectiveness of evidence-based interventions (EBIs). We
recommend that researchers attend to (a) the selection of theory, constructs, and measures, as
well as the acceptability and relevance of the intervention, (b) the suitability of research
procedures, and (c) the accuracy of data analysis and interpretation. Collaborations in which
power is uneven and one partner dominates can unwittingly result in intellectual colonization and
the advancement of cultural imperialism. We discuss specific failures, recoveries, and successes
that may be useful to other researchers engaged, or seeking to engage in, international
collaborations.
Cultural Imperialism, Intellectual Colonization, and Cultural Appropriation
Cultural imperialism, intellectual colonization, and cultural appropriation all point to
relationship dynamics wherein the will of one entity is imposed on another through forthright or
subtle use of power. For the purposes of our paper, these dynamics occur between researchers in
distinct geographical areas. Although a careful sociohistorical analysis is beyond the scope of
this manuscript, we believe it is critical to consider these concepts in the process of scaling up
interventions. The scale up studies are built with good intentions: to spread an evidence-based
intervention for different settings or populations (i.e., scale out; Aarons et al., 2017). The
argument is that an intervention that has been proven to improve the quality of life for one
population could potentially have benefits for others who also need to improve certain outcomes
(Aarons et al., 2017; Klinger, Boardman, & McMaster, 2013). But scaling up can also serve to
TROJAN HORSE? 6
transport values, beliefs, and practices considered to be superior by persons in one cultural
context to another cultural context in which the values, beliefs, and practices are not the same.
Aarons et al. (2017) argue for the separation of the concepts of scale out and scale up.
The authors define scale out as “the deliberate use of strategies to implement, test, improve, and
sustain EBIs as they are delivered in novel circumstances distinct from, but closely related to,
previous implementations” (p. 2, emphasis added), a concept that is different than scale up,
defined as an EBI designed for one setting expanded to reach a greater number of people in the
same target audience. If psychologists are to scale out, then it would be critical to stating the
assumptions of theories and treatments and test whether the (a) core elements of the interventions
are the same across the different populations, (b) underlying mechanisms of actions are the same,
and (c) organizational or system support where the intervention is supportive of the intervention
being delivered (Aarons et al., 2017). As such, and if we consider that a number of EBIs being
implemented for Latinx populations have been originally developed for other populations, we
propose that these EBIs are being scaled out and need thoughtful and deliberate tests of their
assumptions, mechanisms of actions, and supporting systems. In that process, we argue that three
constructs are particularly important to our discussion: cultural imperialism, intellectual
colonization, and cultural appropriation.
Cultural imperialism is not easily defined for the inherent difficulty in defining both
culture and imperialism (Tomlinson, 2002). The definition is further complicated by the
consideration that the term shifts meanings depending on context. For the purposes of this
manuscript, we center the definition in the context of scaling out EBIs. We use a broad definition
of “culture as the context within which people give meanings to their actions and experiences,
and make sense of their lives.” (Tomlinson, 2002, p. 7), and of cultural imperialism as “a form of
TROJAN HORSE? 7
domination [that] exists in the modern world, not just in the political and economic spheres but
also cover those practices by which collectivities make sense of their lives” (Tomlinson, 2002).
Cultural imperialism can occur when theories, methods of research, interventions and
intervention strategies, data analyses and interpretations, and dissemination efforts are used from
a dominant culture and applied in other contexts. There has been vocal criticism from two
prominent authors in mental health. In Crazy like us: The globalization of the American psyche,
Ethan Watters (2010) writes “Our golden arches do not represent our most troubling impact on
other cultures: rather, it is how we are flattening the landscape of the human psyche itself. We are
engaged in the gran project of Americanizing the world’s understanding of the human mind”.
Watters documents how culturally specific mental illnesses are disappearing and are replaced by
increasing rates, globally, of American-born illnesses such as post-traumatic stress disorder and
restrictive eating disorders. Similarly, Burton (2015), a British psychiatrist, notes that rates of
mental illness have skyrocketed in the United Kingdom. Burton acknowledges the reality of the
human suffering and asks “But are they really all suffering from a mental disorder, that is, a
medical illness, a biological disorder of the brain? And if not, are doctors, diagnoses, and drugs
necessarily the best response to their problem?”
Watters (2010) claims that “indigenous forms of mental illness and healing are being
bulldozed by disease categories and treatments made in the USA.” Clear evidence exists through
the ubiquitous use of the Diagnostic and Statistical Manual of Mental Disorders, a publication of
the American Psychiatric Association and the rapid dissemination of evidence-based practice, a
concept very much rooted in US-based clinical psychology. In this paper we argue that, while
scaling up or scaling out evidence-based interventions from one country to another could be
TROJAN HORSE? 8
based on the assumption that it could benefit others, scaling out without a thoughtful process in
place can also have negative consequences to others (Aarons et al., 2017).
Intellectual colonization or intellectual imperialism is the “domination by one people by
another in their world of thinking” (Alatas, 2000, p. 24). Domination is an enactment of power
and colonization points to a group-level dynamic rather than an individual-level one (Horvath,
1972). In intervention research, the massive economic inequities seen globally play out in a
scholarly arena. By virtue of economic and social advantages, the US has the corner market on
research production, providing a dominant body of scholarship that has the potential to shape
world views about the proper conduct of research, from theory, to methods, to data analysis and
interpretation.
Cultural appropriation is a concept that has come into popular media recently as people
debate the merits of using symbols from one cultural group (e.g., a Native headdress) for the
purposes of entertainment by another (e.g., trick-or-treaters looking for a costume). In
scholarship, cultural appropriation is “defined broadly as the use of a culture’s symbols, artifacts,
genres, rituals, or technologies by members of another culture” (Rogers, 2006, p. 474). In
intervention research cultural appropriation may occur when practices of one cultural group are
packaged into a treatment protocol for the benefit of another. Recent mindfulness practices have
been criticized on this front. In our work, cultural appropriation is a lesser concern relative to
intellectual colonization and cultural imperialism because of the much higher likelihood of using
interventions developed in the US abroad, compared to the probability of importing interventions
developed outside the US for implementation here. However, we would be remiss not to mention
this important concept. Rogers (2006) called the avoidance of cultural appropriation “inescapable
when cultures come into contact, including virtual or representational contact.” (p. 474).
TROJAN HORSE? 9
We believe it is important for researchers to be aware of these concepts because we
estimate that actions that advance cultural imperialism or intellectual colonization are likely the
result of good intentions gone awry. In our collective experience we have yet to meet highly
educated and committed professionals who wish to advance their agendas by force. We have,
however, met (and perhaps embodied) many enthusiastic life-long learners who see the
international arena as providing opportunities for meaningful exchange and mutual learning.
However, the lack of awareness about potential perils can seriously detract from this ultimate
goal. Roysircar (2004) provides an important perspective on awareness in the context of clinical
work that providers “do not distance themselves from their clients but rather perceive their
perspectives to be changed by encounters with those who are different from them.” (p. 660). We
might add that researchers are changed by encounters from persons and contexts that are
different from them and understanding the broader social forces that may be at play will increase
the probability of an exchange that is more likely to be power-even.
The Silent Assumptions of a Research Enterprise
The research process begins well before any particular hypothesis is posed when theories
are developed to understand human behavior. Testing EBIs within and across national borders
involves a careful examination of the intervention selected as well as the research methods
utilized. Any intervention selected should have a theory, constructs believed to be the causal
agents of change, and procedures or methods for delivery (Ford & Urban, 1998). Theories
provide guidance on specific constructs and relationships between constructs. For interventions
specifically, theories specify the mechanisms of change associated with improved outcomes. It is
assumed that theories (and therefore interventions) are proven when they are applicable across
groups and situations, thus generalizable or universal. Indeed, within the field of psychology the
TROJAN HORSE? 10
predominant approach to research has been towards generalizability (Hall, Yip, & Zárate, 2016),
wherein human behavior is universal and research seeks to uncover universal truths. The
generalizability approach tends to yield research in which group differences are largely ignored
or treated as nuisance information (Hall et al., 2016).
A major pitfall of the generalizability approach is that it beckons researchers to test the
universality of theories. For example, social interaction learning theory (Patterson, 2016) posits
that five core parenting practices are responsible for externalizing child behavior outcomes.
Within the theory, context exerts its influence on child behavior primarily through parents
(mediation model). Practitioners intervening using approaches developed from social interaction
learning theory will specifically target parents or direct caregivers and specifically aim to change
parental positive involvement, skills building, problem solving, monitoring, and effective
discipline. Researchers will measure each of those constructs following specific operational
definitions for each of the parenting practices as well as the child outcomes. From the outset,
researchers must ask themselves: Do the constructs apply to the population under study? If so,
are operational definitions relevant to the cultural context? And are the relationships between
constructs relevant to the context?
Interventions also come with unstated underlying assumptions that could be made visible
and examined. For example, the training of interventionists (including mode, frequency and
dose), the delivery mode (e.g., face to face or online), and fidelity monitoring and support for
interventionists and of participants are rarely empirically tested (Baer et al., 2007). Interventions
require a physical space. Testing these interventions requires the selection and application of
measures, data entry and management, and data analysis and interpretation. Once tested, the
findings are presented; the context for the presentation (e.g., oral, written; scholarly, popular) and
TROJAN HORSE? 11
the responsibility for disseminating findings must be clarified. Because of all the aforementioned
assumptions, the selection – and implementation - of evidence-based interventions must be
approached with the utmost care.
The invisible can be made visible by shifting processes. Two ways in which research has
shifted are (a) engaging in cultural adaptations of EBIs and (b) using community-based
participatory research methods in all aspects of the research enterprise.
Within the US there has been significant advancement in the literature on the cultural
adaptation of evidence-based interventions. Cultural adaptations are the “the systematic
modification of an evidence-based treatment (EBT) or intervention protocol to consider
language, culture, and context in such a way that it is compatible with the client’s cultural
patterns, meanings, and values. (Bernal, Jimenez-Chafey, & Domenech Rodríguez, 2009, p.
362). Advances are both theoretical (e.g., Domenech Rodríguez & Bernal, 2012) and applied
(e.g., Hall, Ibaraki, Huang, Marti, & Stice, 2016; Smith & Trimble, 2016). There are also many
advances in the cultural adaptation and application of EBIs internationally (Hodge & Turner,
2016; Saraceno et al., 2007; Singla et al., 2017). These treatments hold promise for reducing
health disparities but must be deployed carefully in collaboration with local professionals with
expertise in mental health needs, research methods, and interventions. Indeed, after much focus
on the brain and much research, attention has solidly turned to social determinants of health and
major funding agencies in the US are calling for the consistent use of community based-
participatory research in reducing health disparities (CBPR; Harris et al., 2018; Institute of
Medicine, 2012; Lucero et al., 2018). CBPR requires collaborations between scientists and
community stakeholders and/or agencies as equal partners. Formal methods have emerged for
examining engagement across stakeholders (Goodman & Thompson, 2017; Goodman et al.,
TROJAN HORSE? 12
2017). Our collective experience has taught us that it is feasible to conduct a careful examination
of the fit of an existing EBI with a local context, make needed adaptations to the intervention as
well as the research procedures and conduct a careful examination of effectiveness (e.g., Amador
Buenabad et al., under review).
Below, we describe the cultural and national contexts of our work and how we have
approached the adaptation and assessment of fit of an evidence-based parent intervention to these
Latinx settings. Within each we highlight challenges and opportunities within the setting.
Mental Health Disparities Research
Mexico
Previous research has found that Latinxs living in marginalized urban areas in Mexico are
exposed to high rates of poverty, accessibility of substances, mental and physical health
disorders, malnutrition, and limited medical and psychological services, which negatively impact
their quality of life and global functioning (Reyes-Morales et al., 2009). Moreover, Latinxs in
Mexico may experience discrimination due to their mental health status. It is estimated that over
one third of Mexicans (39.2%) with a mental illness reported experiencing significant
marginalization related to their mental health (WHO, 2011). These rates are higher than those of
any chronic physical condition. This is further exacerbated by the limited availability of mental
health providers in Mexico. Heinze, Chapa, and Carmona-Huerta (2016), reported that the
number of psychiatrists is well below the WHO recommended levels necessary to address
national mental health problems. Moreover, 61.3% of psychiatrists are located in three areas:
Mexico City, Jalisco, and Nuevo León, creating structural barriers to access services for many of
Mexico's citizens. This is of concern because many Latinx youth in Mexico may develop mental
TROJAN HORSE? 13
health difficulties due to coming in contact with adversity and may lack available services, which
could negatively impact academic persistence and entry into the workforce (Benjet et al., 2012).
In Mexico, service utilization rates are low. In a national survey of mental illness and
services utilization, the prevalence of mental illness following ICD-10 guidelines was 28.6% for
lifetime, 13.9% for past year, and 5.8% for past month (Medina-Mora et al., 2003). Men reported
a higher lifetime prevalence (30.4%) compared to women (27.1%), but women reported higher
prevalence in the last year (14.8%) than men (12.9%). In that same survey, only 1 in 10 persons
who reported at least one mental illness sought any services. There was little access to
specialized services provided by a psychiatrist, psychologist, mental health nurse, or social
worker. Among respondents, specialized services were most commonly sought for panic disorder
(17.1%), mania (12.7%), and major depression (11.9%). Similar to the United States, Latinxs in
Mexico have low accessibility to substance use treatment. Borges and Colleagues (2009),
findings indicate high rates of unmet need for substance use intervention services in several of
Mexico’s major urban centers, with only 11% of individuals identified as having a substance use
disorder receiving intervention services. Substance use is an emerging problem in Mexico as
rates among children have risen (Villatoro Velázquez et al., 2016), which may contribute to
higher rates of substance use disorders in the future (King & Chassin, 2007). Mexican boys and
indigenous youth appear to be especially vulnerable to substance initiation during childhood (i.e.,
5th, 6th grade), suggesting an urgent need for early substance use prevention programs (Vazquez et
al., under review). Despite the existence of effective substance use intervention services, policy
in Mexico needs to address treatment disparities that are negatively impacting the health and
future of their citizens.
TROJAN HORSE? 14
What the literature may not reflect is information on how Mexico’s context offers
different opportunities and creates different challenges in conducting intervention research.
Issues of measures and intervention materials presented a challenge initially for the need to
translate and culturally adapt. However, there was ample expertise in the research team and there
were amazing opportunities with talented colleagues in Mexico whose work to culturally adapt
the manual itself resulted in what could only be fairly described as a work of art. Whereas in the
US, professors are fairly constrained in the definitions of productivity for the purposes of
advancement, in Mexico there was more flexibility. A professor in graphic design became part of
our research team and his contributions were in the form a beautiful manual and ancillary
materials; he received institutional accolades for his work, which were helpful for his later
promotion. Unexpectedly, public schools in Mexico were much more open to collaboration in
intervention research than we have experienced in the US. Intervention groups were held in local
schools and parents flocked to groups. In addition, our team of collaborators have traditionally
experienced the human subjects protections review in Mexico as collegial and unobtrusive.
Finally, the work was built on a strong empirical foundation. Mexico has excellent national level
data for youth outcomes, including substance use and intentions to use and demographic,
academic, familial, and social characteristics.
There are notable challenges. In international work, it is common for community sites to
not have ethics boards that can review our work and this can present challenges with human
subjects approval in the US. Additionally, we have painfully observed over the years that the
work context of our colleagues is invariably different. Within our teams, US-based researchers
are located at research institutions and are quite privileged with access to computers with
statistical software needed to run analyses and programs to gather online data. US-based
TROJAN HORSE? 15
researchers have access to library materials that are within reach, at no personal cost. Many US-
based researchers enjoy permanency in tenured positions. Some US-based researchers are
fortunate to have grants and course releases associated with those grants. Mexico-based
researchers often do not experience these privileges. The ownership of data and authorship
decisions can be more complex. As an example, merit evaluations in Mexico are tied to
publication productivity, as is the case in the US for many, but these productivity evaluations
may also have implications for basic needs, such as housing assignments and continuation of
work contracts.
Furthermore, the access to resources can change rapidly with political elections.
Sometimes the need for programs to reflect political initiatives can present opportunities for
rapid funding. On the other hand, change in leadership can result in the immediate loss of funds
for projects either proposed or underway (Baumann, Domenech Rodríguez, Amador, Forgatch, &
Parra-Cardona, 2014). In addition to funding, these time elements can present structural barriers
to carrying out research in a manner keeping with ideal standards (e.g., having a great measure to
capture constructs before intervening). Here too we have faced ethical challenges: move forward
even though the stage is not ideally set and risk engaging in intellectual colonization or cultural
imperialism? Or miss an opportunity to examine the impact of an intervention that the team feels
fairly confident would result in benefits to the local community? Is caution in the research
enterprise just another privilege of US-based researchers? (Baumann, Domenech Rodríguez, &
Parra-Cardona, 2011).
A notable strength in the Mexican context is the pool of very talented researchers and
scholars. It is our observation that the expectations for the completion of a doctoral degree in
Mexico are quite stringent and research projects are larger and more complex than might be
TROJAN HORSE? 16
typical in the US. We also note that there is greater creativity in problem solving especially
around issues having to do with resources. Finally, our experience is that in Mexico, scholars are
more connected to a broad international community and, as such, attend to a much broader base
of knowledge and methods that enriches research. In a recent exchange, a subset of the authors
was frustrated with dissemination roadblocks, and our Mexico colleague (fourth author) quickly
identified sources of funding tied to movements propelled by global organizations like WHO and
the Pan American Health Organization.
Puerto Rico
The Puerto Rico Mental Health and Anti-Addiction Services Administration
([MHAASA], 2016) reported that prevalence of mental health disorders (i.e., DSM-IV criteria)
among Puerto Ricans (i.e., 18-64 years of age) was 18.7% of the population, with anxiety (e.g.,
generalized anxiety disorder, social phobia) and mood (e.g., major depressive disorder, bipolar
disorders) being the most commonly diagnosed. Of those Puerto Ricans, 7.3% met criteria for a
serious mental illness that required treatment. Yet, 36.1% of individuals identified as being
seriously mentally ill did not receiving mental health services. Puerto Rican men were especially
at risk for mental health service disparities, with 73.6 % not receiving services relative 62.5% for
women. Even more alarming, the percent of suicides reported in 2017 were overwhelmingly
completed by men (85.5%; Roig Fuertes, 2018). This may be related to culturally prescribed
gender roles that may lead men to feel “weak” for seeking mental health services. Providers may
need to be particularly aware of these gender disparities and address treatment acceptability,
engagement, and adherence especially among Puerto Rican men.
Puerto Ricans with serious mental illness cited several perceptual and practical barriers to
mental health care such as believing problems would improve on their own (63.0%), wanting to
TROJAN HORSE? 17
handle problems on their own (61.2%), time commitment or inconvenience (55.7%), treatment
would not be effective (42.2%), and concerns regarding the cost (40.5%). These barriers provide
a context for the social and cultural factors that may impact mental health services on the island.
Among these are cultural beliefs that problems are best handled “at home” and the current
economic crisis that has deeply affected Puerto Ricans living on the island. Increasingly,
professionals are opting to migrate to the mainland US in search of better opportunities, salaries,
and quality of life. On the other hand, in Puerto Rico, health insurance plans have increased their
costs and reduced their benefits, further limiting access to quality mental health services for the
population. Of the general population, 11.5% percent of Puerto Ricans were diagnosed with a
substance use disorder, with 15.5% having a co-occurring mental health disorder. Mirroring the
United States and Mexico, Puerto Rico experiences significant disparities among its citizens with
substance use disorder, with 69.8% alcohol dependence and 56.4% drug dependence going
untreated.
According the World Health Organization (2012), Puerto Rico invests a significantly
greater proportion of its health services budget on medical services (i.e., 90%) relative to mental
health (i.e., 10%). Given limited investment in mental health services, many Puerto Ricans may
have to seek services for mental health problems from general physicians that may lack the
training necessary to effectively address psychopathology (Alegría et al.,1991). Evidence-based
interventions may be a particularly powerful resource in the context of low resources. And,
further investment in mental health services may be needed to address significant rates of unmet
need by increasing access to professionals trained to address mental health difficulties among
Puerto Ricans.
TROJAN HORSE? 18
The nature of the relationship between Puerto Rico and the US creates unique challenges
and opportunities in a research context and in life in general. The media coverage following
Hurricane María provided clear examples. On September 20, 2017, Hurricane María hit Puerto
Rico leading to a level of destruction that had not been experienced on the island for generations.
News coverage revealed significantly delayed aid to the island on the part of the US government,
a minimization of damages compared with similar disasters (e.g., Hurricane Katrina), and a very
slow period of recovery marked by increases in the occurrence of suicides (Figueroa Cancel,
2018; Roig Fuertes, 2018). On August 14, 2018, nearly one year after the hurricane’s
devastation, the local newspaper, Primera Hora, reported that “AEE dice que ya todos en Puerto
Rico tienen luz” [AEE says that now everyone in Puerto Rico has electricity; Agencia EFE,
2018]. Puerto Ricans on the island did not receive the same disaster aid that bona fide states have
received in the past during natural disasters. Indeed, the invalidation was as basic as
acknowledging the death toll (Kishore et al., 2018). The result of this response was indignation
and uncertainty among Puerto Ricans and is understood to be responsible for a massive exodus
of Puerto Ricans that decreased the island population by 6% (Criollo Oquero, 2018). Regardless
of these challenges, communities mobilized and began rebuilding with or without help. An
example of community mobilization was reported by the periodical El Nuevo Día. The
community in San Sebastián was mobilized by the city mayor to restore electrical power. By
December 28, 2017, the “Pepino Power Authority,” a homegrown brigade named after the town’s
nickname, had restored power to more than 2,000 households (Ayala Gordián, 2017).
In Puerto Rico, all federal (US) regulations apply, thus human subjects review is
simplified by the parallel nature of the process. However, language issues in both measurement
and intervention materials are present as they have been in the US Latinx and Mexico contexts.
TROJAN HORSE? 19
The work in one context does facilitate the work in another. For example, our research team
worked to translate parenting measures that have been used in our work across the three Latinx
contexts with minor language modifications. Research procedures have also been translated and
adapted for use across contexts (e.g., Family Interaction Tasks). Some of our findings have
revealed some issues with the measurement of concepts (e.g., parenting; Domenech Rodríguez,
Donovick, & Crowley, 2009) and constructs (e.g., discipline; Domenech Rodríguez et al., 2013)
that need to be further explored. There is a particularly noticeable dearth of research in Puerto
Rico on Puerto Rican families and parenting providing both little foundation for ongoing
research but also ample opportunity for discovery. The experience of colleagues sits somewhere
between the US and the Mexico models where there are some resources but not quite as plentiful
as in the US, there are structures of support but they can be fleeting. At present, Puerto Rico is
facing a tremendous fiscal deficit that resulted in US intervention and that has had a major
impact on the University of Puerto Rico, a leading academic institution on the island. The current
fiscal plan includes the reduction or elimination of academic programs, merger of campuses,
administrative restructuring, and budget cuts in excess of $160 million (University of Puerto
Rico, 2018). This increases the challenges to researchers, faculty, and students in engaging local
research.
Much like in Mexico, the dearth of resources in Puerto Rico leads to inventive and
collaborative approaches to challenges. When a small subset of our larger team was studying
parenting practices in Puerto Rican families, we hit a recruitment slowdown. Research team
members quickly reached out through their networks and connected with colleagues across
institutions that led to the successful conclusion of our work. The level of collaboration for
completion of projects was unusual for the US-based researcher who observed Puerto Rico-based
TROJAN HORSE? 20
researchers helping each other collect and code on a volunteer basis. This reciprocity led to
strong productivity in a context of low resources. Finally, there is a habit of critical examination
among Puerto Rico-based scholars in our research team and the broader academic circles that is
based partly on the colonial relationship that the US and Puerto Rico have. This is a strength in
the process of scaling out as there is already a habit for unmasking unstated assumptions and
examining them carefully before proceeding.
United States
Many Latinx families living in the US experience disproportionately higher rates of
poverty as compared to Whites American families (Center for Disease Control ([CDC], 2014).
Thus, they are more likely to come in contact with factors known to negatively impact mental
health such as community violence (Fowler et al., 2009), residential instability (Buu et al., 2009),
and high availability of substances (Crum, Lillie-Blanton, & Anthony, 1996). Moreover, Latinxs
living in the United States may be exposed to other factors detrimental to mental health such as
discrimination (D'Anna, Ponce, & Siegel, 2010) and acculturation stress (Zeiders, Umaña-Taylor,
Updegraff, Jahromi, & White, 2016). It is possible that exposure to poverty, discrimination, and
acculturation stress within the United States contributes to the greater prevalence of
psychopathology observed among American Latinxs relative to their immigrant counterparts
(Alegría et al., 2007; Ault-Brutus & Alegría, 2016). Given the increased exposure to factors
associated with mental health difficulties, Latinxs living in the United States may be especially in
need of accessible and effective mental health services.
Despite greater vulnerability among Latinxs in the United States, the Substance Abuse
and Mental Health Services Administration ([SAMHSA]; 2015) reports that Latinx adults with a
mental illness have lower rates of mental health service utilization (27.3%) as compared to
TROJAN HORSE? 21
Blacks (29.8%) and Whites (46.3%). Latinxs with unmet mental health need reported that they
did not seek services due to cost and lack of insurance (52.6%), fear of prejudice and
discrimination (33.1%), structural barriers (33.2%), low perceived need (21.3%), and not
thinking service would be helpful (6.6%). Furthermore, Latinxs living below the poverty line
report lower rates of mental health service use as compared to Whites and Blacks with similar
economic resources. Similar trends have been found in Latinxs’ access to care for substance use,
as financial barriers (i.e., unemployment, housing instability) limit their ability to engage in
intervention programs to address substance abuse (Saloner & Cook, 2013).
Latinxs in the US also have the lowest likelihood of having insurance of any ethnic group
in the US (USDHHS, 2017). This is further compounded by perceived stigma (Young & Rabiner,
2015), limited transportation (Aguilar-Gaxiola et al., 2002), lack of knowledge on how to access
services (Scheppers et al., 2006), distrust of the mental health system, and fear of discrimination
due to ethnicity/language (D'Anna et al., 2010), which could deter Latinxs from seeking mental
health services. Thus, despite the focus on the development and implementation of effective
evidence-based mental health services in the United States (ConnorSmith & Weisz, 2003),
including the development of the field of implementation science (e.g., Brownson, Colditz, &
Proctor, 2017) and a journal for the field (i.e., Implementation Science Journal), vulnerable
Latinx populations may have greater difficulties accessing these services as compared to other
racial/ethnic groups.
Some specific issues that have arisen in our work with US Latinxs are tied to structural
limitations. For example, conducting research in school settings, where Latinx families may be
most comfortable, can be challenging for the complexities inherent in gaining support from
overworked teachers and administrators in schools. We have had more success partnering with
TROJAN HORSE? 22
community agencies. Sometimes these partnerships are strong and sometimes they can quickly
and unexpectedly shift when staff, administrators, or policies change. These complexities are
amplified when doing research, for example, such as when researchers have to apply for separate
Institutional Review Board approvals at their universities and also within the school district. In
addition, Latinxs in the US are a heterogeneous group and this creates complexities for
researchers doing intervention research. For example, decisions have to be made about inclusion
and exclusion criteria based on language and national origin. When working with Spanish-
speakers, we have faced the same issues of limited validated measures and intervention resources
as when we do work internationally and we are in good company (Spilka & Dobson, 2015). The
applicability of theories, constructs, and interventions is also relevant for intervention researchers
working with US Latinxs. By way of example, the first author led a trial of a parenting
intervention in a rural Western community. After extensive cultural adaptation work and careful
consideration of measures (Domenech Rodríguez, Baumann, & Schwartz, 2011), the team
retained time out as a discipline strategy. During one of the intervention groups, when covering
discipline strategies, a father angrily announced “Time Out is an American thing and I didn’t
come here to learn how to be an American parent. I am a proud Mexican!” It was an excellent
point and led to a rich discussion within the research team. Important to note in this discussion is
that we have addressed the importance of addressing culture and context and of being attuned to
families’ feelings about how researchers are respecting and honoring their culture (Mejia,
Leijten, Lachman, & Parra-Cardona, 2017; Parra-Cardona et al., 2018).
International and Local Standards
The concerns about international collaborations transcend individual researchers’ own
constructions of what constitutes research and how to best carry it out. In conducting human
TROJAN HORSE? 23
subjects research in any setting, researchers must be aware of the ethical guidelines that provide
guidance for carrying out the work in a manner that protects participants. A complexity of
intervention research in an international context is that there are a multiplicity of ethical
guidelines as well as laws that govern the activities of both clinicians and researchers. For
clinicians, there are important differences that could present challenges or opportunities in
dissemination. For example, in the US and Puerto Rico, psychologists must be doctoral level
clinicians. This is not the case in most of Latin America. Doctoral degrees in psychology outside
of the US typically reflect expertise in research not clinical intervention skills.
The Office of Human Subjects Protections has compiled laws, regulations, and guidelines
available for researchers conducting sociobehavioral research (USDHHS, 2017). Additionally,
the Council for International Organizations of Medical Sciences (CIOMS, 2016) has published
international guidelines for research that are thorough in the considerations provided. Finally,
each setting has ethical guidelines specific for psychologists (American Psychological
Association, 2017; Asociación Psicológica de Puerto Rico, 2007; Sociedad Mexicana de
Psicología, 2007) as well as laws regulating their behavior. It is critically important that members
of the team have access to those codes and seek proactively to abide by them. We have not
experienced any ethical or legal standards in opposition or in conflict in our years conducting
research across national borders.
The human protections review process is an opportunity to learn actively about the local
context (Domenech Rodríguez, Corralejo, Vouvalis, & Mirly, 2017). Adherence to standards of
human protections across countries can be time consuming but critically important. A recent case
borrowed form medicine demonstrates the potential abuses of power in carrying out research in
international settings. A Southern Illinois University professor, William Hartford, collaborated
TROJAN HORSE? 24
with a private company, Relational Vaccines (also in Illinois) to develop a Herpes vaccine
(Young, 2017). The two recruited 20 US-based participants on Facebook and transported them to
St. Kitts to receive the trial vaccine there. By all accounts, the trial did not undergo IRB review
in the US nor was reviewed in St. Kitts. Indeed, the Ministry of Health in St. Kitts reported they
had no knowledge of the study. In this case, there were no local collaborators and the two so-
called researchers were exploiting a possible loophole that made it possible to eschew both IRB
and FDA review. Their actions have probably made international collaborations for US-based
researchers all the more difficult.
Forging Forward
The focus of this special issue is on methods and it may be puzzling to understand how
this manuscript fits with a methods theme. For our research team, methodological considerations
begin at the level of establishing a collaboration between partners: What is the purpose of the
research? Who benefits and how? What are the best ways to engage each other so that all parties
can have substantive contributions and meaningful opportunities for learning? The answers to
these questions have methodological consequences on the outcomes chosen, the measures
selected and the designs of the studies (Baumann et al., in print).
Although we framed the discussion of cultural imperialism and intellectual colonization
as part of an important awareness for researchers to have as they work with international
partners, similar concerns are true within the US when working with vulnerable populations.
Much care needs to be taken to increase awareness of our positions of power from academic
centers when working with communities that may not have the resources that are assumed
necessary or fundamental in the implementation of EBIs.
TROJAN HORSE? 25
Internationally, researchers have developed novel ways to be flexible. For example,
Spilka and Dobson (2015) recently recommended using benchmarking to evaluate treatments
used across international boundaries. Their approach was thoughtful and creative and flexiblized
the stringent criteria that have created problems with transporting treatments. In benchmarking,
outcomes data from clinical practice can be measured against that of research settings to arrive at
an estimation of impact. They recommend to first define problem, population, and treatment
model (Step 1), then identify a gold standard comparison outcome study (Step 2), then deliver
the treatment in novel settings using effectiveness guidelines (Step 3), and finally compare
outcomes to determine effectiveness in the population/context (Step 4). This approach is
commendable, yet may still impose Western psychological views on conceptualization and
intervention on international partners. In a thoughtful critique, Cardemil (2015) recommend
instead to generally increase the capacity of communities to: (a) identify context-specific
experiences and expressions of distress, (b) develop and evaluate culturally relevant and
efficacious treatments, and (c) utilize cost-effective and sustainable methods to disseminate and
implement those treatments. We might add that engaging in the activities recommended by
Cardemil (2015) can result in important knowledge and changes in US-based research.
International research is critical to science. Indeed, a “true psychology of the human
experience requires increased inclusion of world populations in research of the ways in which (a)
historically grounded sociocultural contexts enable distinct meaning systems that people
construct, and (b) these systems simultaneously guide human formation of environments”
(Dvorakova, 2016). Scaling out to places and spaces outside of the US mainland provides an
opportunity to ensure the ecological validity of our psychological theories and interventions.
However, we need to proceed deliberately and thoughtfully as to not “Americanize” efforts to
TROJAN HORSE? 26
implement and disseminate EBI abroad. One possible solution is to approach collaboration with
international researchers on equal plains to reduce power differentials which contribute to
cultural imperialism, intellectual colonization, and cultural appropriation.
US-based researchers must also be particularly thoughtful about disparities in both
resources and consequences for success and failures in research contexts. International
implementation efforts may have limited resources relative to the US, with structures of support
that can be fleeting. Although engaging in international efforts to disseminate and implement
EBIs may be a unique opportunity to build bridges that can help reduce health disparities,
disengaged collaboration may contribute to deviations that result in the poor application of both
intervention and research methods to the detriment of participants, researchers, and
psychological science. Thus, adherence to standards of human protections across countries could
be critically important in promoting beneficence in our attempts to address international
treatment disparities through research and practice. Despite these challenges, there exist a wealth
of talent and commitment among professionals internationally that can be harnessed through
collaboration to reach our goal.
References
Aarons, G. A., Sklar, M., Mustanski, B., Benbow, N., & Brown, C. H. (2017). “Scaling-out”
evidence-based interventions to new populations or new health care delivery systems.
Implementation Science, 12(1). https://doi.org/10.1186/s13012-017-0640-6
Agencia EFE (2018, August 14). AEE dice que ya todos en Puerto Rico tienen luz. Primera
Hora. Retrieved from: http://www.primerahora.com/noticias/puerto-
rico/nota/aeedicequeyatodosenpuertoricotienenluz-1297450/
TROJAN HORSE? 27
Aguilar-Gaxiola, S. A., Zelezny, L., Garcia, B., Edmondson, C., Alejo-Garcia, C., & Vega, W. A.
(2002). Mental health care for Latinos: Translating research into action: Reducing
disparities in mental health care for Mexican Americans. Psychiatric Services, 53(12),
1563-1568. https://doi.org/10.1176/appi.ps.53.12.1563
Alatas, S. H. (2000). Intellectual imperialism: Definition, traits, and problems. Southeast Asian
Journal of Social Science, 28, 23-45. https://doi.org/10.1163/030382400x00154
Alcaraz, K. I., Sly, J., Ashing, K., Fleisher, L., Gil-Rivas, V., Ford, S., … Gwede, C. K. (2017).
The ConNECT Framework: a model for advancing behavioral medicine science and
practice to foster health equity. Journal of Behavioral Medicine, 40, 23–38.
https://doi.org/10.1007/s10865-016-9780-4
Alegría, M., Robles, R., Freeman, D. H., Vera, M., Jiménez, A. L., Ríos, C., Ríos, R. (1991).
Patterns of mental health utilization among Puerto Rican poor. American Journal of
Public Health, 81, 875-879. https://doi.org/10.2105/ajph.81.7.875
Alegría, M., Mulvaney-Day, N., Torres, M., Polo, A., Cao, Z., & Canino, G. (2007). Prevalence
of psychiatric disorders across Latino subgroups in the United States. American Journal
of Public Health, 97, 68-75. https://doi.org/10.2105/ajph.2006.087205
Amador Buenabad, N. G., Sánchez Ramos, R., Díaz Juárez, A. D., Guitierrez López, M. L., Ortiz
Gallegos, A. B., González Ortega, T. G. … Villatoro Velázquez, J. A. (2017). Efectividad
del modelo Huellitas-CAPAS-Mx para la prevención de conductas de riesgo a partir del
desarrollo de habilidades sociales y de prácticas de parentalidad positiva en niños y sus
cuidadores. Manuscript under review.
American Psychological Association. (2016). Ethical principles of psychologists and code of
conduct. Retrieved from: http://www.apa.org/ethics/code/
TROJAN HORSE? 28
Asociación Psicológica de Puerto Rico. (2007). Código de ética de APPR. Retrieved from:
http://www.asppr.net/reglamento
Ault-Brutus, A., & Alegria, M. (2018). Racial/ethnic differences in perceived need for mental
health care and disparities in use of care among those with perceived need in 1990–1992
and 2001–2003. Ethnicity & Health, 23, 142–157.
https://doi.org/10.1080/13557858.2016.1252834
Baer, J. S., Ball, S. A., Campbell, B. K., Miele, G. M., Schoener, E. P., & Tracy, K. (2007).
Training and fidelity monitoring of behavioral interventions in multi-site addictions
research. Drug and Alcohol Dependence, 87, 107-118.
https://doi.org/10.1016/j.drugalcdep.2006.08.028
Baumann, A. A., Domenech Rodríguez, M. M., Amador, N. G., Forgatch, M. S., & Parra-
Cardona, J. R. (2014). Parent Management Training-Oregon Model (PMTOTM) in Mexico
City: Integrating cultural adaptation activities in an implementation model. Clinical
Psychology: Science and Practice, 21, 32–47. https://doi.org/10.1111/cpsp.12059
Baumann, A., Domenech Rodríguez, M., & Parra-Cardona, J. R. (2011). Community-based
applied research with Latino immigrant families: Informing practice and research
according to ethical and social justice principles. Family Process, 50, 132–148.
https://doi.org/10.1111/j.1545-5300.2011.01351.x
Baumann, A., Mejía, A., Lachman, J. L., Parra-Cardona, J. R., Lopez-Zeron, G., Amador
Buenabad, N. G., . . . Domenech Rodríguez, M. M. (in press). Parenting programs for
underserved populations: Issues of scientific integrity and social justice. Global Social
Welfare.
TROJAN HORSE? 29
Benjet, C., Hernández-Montoya, D., Borges, G., Méndez, E., Medina-Mora, M. E., & Aguilar-
Gaxiola, S. (2012). Youth who neither study nor work: Mental health, education and
employment. Salud Pública de México 54, 410-417. https://doi.org/10.1590/s0036-
36342012000400011
Bernal, G., Jiménez-Chafey, M. I., & Domenech Rodríguez, M. M. (2009). Cultural adaptation
of treatments: A resource for considering culture in evidence-based practice. Professional
Psychology: Research and Practice, 40, 361-368. https://doi.org/10.1037/a0016401
Borges, G., Medina-Mora, M. E., Orozco, R., Fleiz, C., Villatoro, J., Rojas, E., & Zemore, S.
(2009). Unmet needs for treatment of alcohol and drug use in four cities in Mexico.
Salud Mental, 32(4), 327-333.
Brownson, R. C., Colditz, G. A., & Proctor, E. K. (Eds.). Dissemination and implementation
research in health: Translating science to practice. Oxford University Press, 2017.
Burton, N. (2015). The meaning of madness (2nd ed.). United Kingdom: Acheron Press.
Buu, A., DiPiazza, C., Wang, J., Puttler, L. I., Fitzgerald, H. E., & Zucker, R. A. (2009). Parent,
family, and neighborhood effects on the development of child substance use and other
psychopathology from preschool to the start of adulthood. Journal of Studies on Alcohol
and Drugs, 70, 489-498. https://doi.org/10.15288/jsad.2009.70.489
Center for Disease Control ([CDC], 2014). Persons below poverty level, by selected
characteristics, race, and Hispanic origin: United States, selected years 1973–2014.
Retrieved from: https://www.cdc.gov/nchs/hus/contents2015.htm#002
ConnorSmith, J. K., & Weisz, J. R. (2003). Applying treatment outcome research in clinical
practice: Techniques for adapting interventions to the real world. Child and Adolescent
Mental Health, 8(1), 3-10. https://doi.org/10.1111/1475-3588.00038
TROJAN HORSE? 30
Council for International Organizations of Medical Sciences. (2016). International ethical
guidelines for health-related research involving humans. Retrieved online:
https://cioms.ch/shop/product/international-ethical-guidelines-for-health-related-research-
involving-humans/
Criollo Oquero, A. (2018, March 9). Puerto Rico perdió 6% de su población tras huracán
María. CB en Español. Retrieved from: http://cb.pr/puerto-rico-perdio-6-de-su-
poblacion-tras-huracan-maria/
Crum, R. M., Lillie-Blanton, M., & Anthony, J. C. (1996). Neighborhood environment and
opportunity to use cocaine and other drugs in late childhood and early adolescence. Drug
and Alcohol Dependence, 43, 155-161. https://doi.org/10.1016/s0376-8716(96)01298-7
D'Anna, L. H., Ponce, N. A., & Siegel, J. M. (2010). Racial and ethnic health disparities:
evidence of discrimination’s effects across the SEP spectrum. Ethnicity & Health, 15,
121-143. https://doi.org/10.1080/13557850903490298
Departamento de Salud, Estado Libre Asociado de Puerto Rico. (2016). Salud mental de Puerto
Rico: Análisis de situación de la salud en Puerto Rico. Retrieved from:
https://salud.gov.pr
Dvorakova, A. (2016). The cultural psychology endeavor to make culture central to psychology:
Comment on Hall et al. (2016). American Psychologist, 71, 888-889.
https://doi.org/10.1037/amp0000053
Domenech Rodríguez, M. M., Baumann, A, & Schwartz, A. (2011). Cultural adaptation of an
empirically supported intervention: From theory to practice in a Latino/a community
context. American Journal of Community Psychology, 47, 170-186. doi: 10.1007/s10464-
010-9371-4
TROJAN HORSE? 31
Domenech Rodríguez, M. M., & Bernal, G. (2012). Conceptual frameworks of cultural
adaptation. In G. Bernal & M. M. Domenech Rodríguez (Eds.), Cultural Adaptations:
Tools for Evidence-Based Practice with Diverse Populations (pp. 23-45). Washington,
DC: APA Press. doi:10.1037/13752-000
Domenech Rodríguez, M. M., Donovick, M. R., & Crowley, S. L. (2009). Parenting styles in a
cultural context: Observations of “protective parenting” in first-generation Latinos.
Family Process, 48, 195-210. doi: 10.1111/j.1545-5300.2009.01277.x
Domenech Rodríguez, M. M., Franceschi Rivera, N., Sella Nieves, Z., & Félix Fermín, J. (2013).
Parenting in Puerto Rican families: Mothers and father’s self-reported practices.
Interamerican Journal of Psychology, 47, 299-312.
Ford, D. H., & Urban, H. B. (1998). Contemporary models of psychotherapy: A comparative
analysis (2nd ed.). Hoboken, NJ: Wiley.
Fowler, P. J., Tompsett, C. J., Braciszewski, J. M., Jacques-Tiura, A. J., & Baltes, B. B. (2009).
Community violence: A meta-analysis on the effect of exposure and mental health
outcomes of children and adolescents. Development and Psychopathology, 21, 227-
259. https://doi.org/10.1017/s0954579409000145
Goodman, M. S., Thompson, S., & L, V. (2017). The science of stakeholder engagement in
research: Classification, implementation, and evaluation. Translational Behavioral
Medicine, 7, 486–491. https://doi.org/10.1007/s13142-017-0495-z
Goodman, M. S., Thompson, V. L. S., Johnson, C. A., Gennarelli, R., Drake, B. F., Bajwa, P., …
Bowen, D. (2017). Evaluating community engagement in research: Quantitative measure
development. Journal of Community Psychology, 45, 17–32.
https://doi.org/10.1002/jcop.21828
TROJAN HORSE? 32
Hall, G. C. N., Ibaraki, A. Y., Huang, E. R., Marti, C. N., & Stice, E. (2016). A meta-analysis of
cultural adaptations of psychological interventions. Behavior Therapy, 47(6), 993–1014.
https://doi.org/10.1016/j.beth.2016.09.005
Hall, G. C. N., Yip, T., & Zárate, M. A. (2016). On becoming multicultural in a monocultural
research world: A conceptual approach to studying ethnocultural diversity. American
Psychologist, 71(1), 40–51. https://doi.org/10.1037/a0039734
Harris, J., Cook, T., Gibbs, L., Oetzel, J., Salsberg, J., Shinn, C., … Wright, M. (2018). Searching
for the impact of participation in health and health research: Challenges and methods.
BioMed Research International, 9427452. https://doi.org/10.1155/2018/9427452
Heinze, G., Chapa, G. C., Carmona-Huerta, J. (2016). Los especialistas en psiquiatría en México:
Año 2016. Salud Mental, 39, 69-76. doi: 10.17711/SM.0185-3325.2016.003
Hodge, L. M., & Turner, K. M. (2016). Sustained implementation of evidencebased programs in
disadvantaged communities: A conceptual framework of supporting factors. American
Journal of Community Psychology, 58, 192-210. https://doi.org/10.1002/ajcp.12082
Horvath, R. J. (1972). A definition of colonialism. Current Anthropology, 13, 45-57.
https://doi.org/10.1086/201248
Institute of Medicine (2012). How far we have come in reducing health disparities? Progress
since 2000. Washington, D.C.: The National Academies Press.
Kataoka, S. H., Zhang, L., & Wells, K. B. (2002). Unmet need for mental health care among U.S.
children: Variation by ethnicity and insurance status. The American Journal of
Psychiatry, 159, 1548-1555. https://doi.org/10.1176/appi.ajp.159.9.1548
TROJAN HORSE? 33
King, K. M., & Chassin, L. (2007). A prospective study of the effects of age of initiation of
alcohol and drug use on young adult substance dependence. Journal of Studies on
Alcohol and Drugs, 68, 256-265. https://doi.org/10.15288/jsad.2007.68.256
Klingner J. K., Boardman, A. G., & McMaster K. L. (2013). What does it take to scale-up and
sustain evidence-based practices? Exceptional Children, 79, 195–211.
https://doi.org/10.1177/001440291307900205
Lucero, J., Wallerstein, N., Duran, B., Alegria, M., Greene-Moton, E., Israel, B., … White Hat,
E. R. (2018). Development of a mixed methods investigation of process and outcomes of
Community-Based Participatory Research. Journal of Mixed Methods Research, 12, 55–
74. https://doi.org/10.1177/1558689816633309
Medina-Mora, M. E., Borges, G., Lara Muñoz, C., Benjet, C., Blanco Jaimes, J., Fleiz Bautista,
C., … Aguilar-Gaxiola, S. (2003). Prevalencia de trastornos mentales y uso de servicios:
Resultados de la Encuesta Nacional de Epidemiología Psiquiátrica en México. Salud
Mental, 26(4), 1-16.
Mejia, A., Leijten, P., Lachman, J. M., & Parra-Cardona, J. R. (2017). Different strokes for
different folks? Contrasting approaches to cultural adaptation of parenting interventions.
Prevention Science, 18, 630–639. https://doi.org/10.1007/s11121-016-0671-2
McHugh, R. K., & Barlow, D. H. (2010). The dissemination and implementation of evidence-
based psychological treatments: A review of current efforts. American Psychologist,
65(2), 73–84. https://doi.org/10.1037/a0018121
Parra-Cardona, J. R., Aguilar, E., Wieling, E., Domenech Rodríguez, M., & Fitzgerald, H.
(2015). Closing the gap between two countries: Feasibility of dissemination of an
TROJAN HORSE? 34
evidence-based parenting intervention in México. Journal of Marital and Family
Therapy, 41, 465-480. doi: 10.1111/jmft.12098
Parra-Cardona, R., Leijten, P., Lachman, J. M., Mejía, A., Baumann, A. A., Amador Buenabad,
N. G., … Domenech Rodríguez, M. M. (2018). Strengthening a culture of prevention in
low- and middle-income countries: Balancing scientific expectations and contextual
realities. Prevention Science. https://doi.org/10.1007/s11121-018-0935-0
Patterson, G. R. (2016). Coercion theory: The study of change. In T.J. Dishion & J. Snyder
(Eds.), Handbook of coercive relationship dynamics. New York: Oxford University Press.
Puerto Rico Mental Health and Anti-Addiction Services Administration (MHAASA; 2016) Need
Assessment Study of Mental Health and Substance Use Disorders and Service Utilization
among Adult Population of Puerto Rico. Retrieved from:
http://www.assmca.pr.gov/BibliotecaVirtual/Estudios/Need%20Assessment%20Study
%20of%20Mental%20Health%20and%20Substance%20of%20Puerto%20Rico
%202016.pdf
Rogers, R. A. (2006). From cultural exchange to transculturation: A review and
reconceptualization of cultural appropriation. Communication Theory, 16, 474–503.
https://doi.org/10.1111/j.1468-2885.2006.00277.x
Roig Fuertes, S. (2018, July 17). Conversatorio multisectorial: Suicidio en Puerto Rico.
Administración de Servicios de Salud Mental y Contra las Addicción. Retrieved from:
https://drive.google.com/file/d/1eJTodKqVPMT_HMY90saEbriwlPSoIK9j/view
Saraceno, B., van Ommeren, M., Batniji, R., Cohen, A., Gureje, O., Mahoney, J., . . . &
Underhill, C. (2007). Barriers to improvement of mental health services in low-income
TROJAN HORSE? 35
and middle-income countries. The Lancet, 370, 1164-1174.
https://doi.org/10.1016/s0140-6736(07)61263-x
Saloner, B., & Cook, B. L. (2013). Blacks and Hispanics are less likely than whites to complete
addiction treatment, largely due to socioeconomic factors. Health Affairs, 32, 135-145.
https://doi.org/10.1377/hlthaff.2011.0983
Scheppers, E., van Dongen, E., Dekker, J., Geertzen, J., & Dekker, J. (2006). Potential barriers to
the use of health services among ethnic minorities: A review. Family Practice, 23, 325-
348. https://doi.org/10.1093/fampra/cmi113
Singla, D. R., Kohrt, B. A., Murray, L. K., Anand, A., Chorpita, B. F., & Patel, V. (2017).
Psychological treatments for the world: Lessons from low-and middle-income countries.
Annual Review of Clinical Psychology, 13, 149-181. https://doi.org/10.1146/annurev-
clinpsy-032816-045217
Smith, T. B., & Trimble, J. E. (2016). Foundations of multicultural psychology: Research to
inform effective practice. Washington, DC: American Psychological Association.
Sociedad Mexicana de Psicología. (2007). Código ético del psicólogo. México: Editorial Trillas.
Suarez-Balcazar, Y., Mirza, M. P., & Garcia-Ramirez, M. (2018). Health disparities:
Understanding and promoting healthy communities. Journal of Prevention &
Intervention in the Community, 46, 1-6. doi: 10.1080/10852352.2018.1386761.
Subrahmanian, K., & Swamy, P. (2018). Global health disparities in high-resource settings. In:
K. Subrahmanian, & P, Swamy (Eds.), Global child health: A toolkit to address health
disparities (pp. 17-37). Springer, Cham: SpringerBriefs in Public Health.
Substance Abuse and Mental Health Services Administration. (2015), Racial/ ethnic differences
in mental health service use among adults. HHS Publication No. SMA-15-4906.
TROJAN HORSE? 36
Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved
from: http://www.samhsa.gov
Tomlinson, J. (2002). Cultural imperialism: A critical introduction. Continuum: London, UK.
U. S. Department of Health and Human Services, Office of Minority Health. (2017). Profile:
Hispanic/Latino Americans. Retrieved from:
https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=64
U. S. Department of Health and Human Services, Office for Human Research Protections,
(2017). Socio-behavioral research standards across the globe. Retrieved from:
https://www.hhs.gov/ohrp/international/compilation-human-research-
standards/index.html
University of Puerto Rico. (2018, March 21). Revised fiscal plan. Retrieved from:
http://www.upr.edu/wp-content/uploads/2018/03/UPR-Fiscal-Plan-21marzo2018.pdf
Vazquez, A. L., Domenech Rodríguez, M. M., Schwartz, S. E., Bustos, M., Gutierrez, M.,
Amador Buenabad, N., & Villatoro Velazquez J. A. (under review) Early adolescent
substance use in a national sample of Mexican youths: Demographics characteristics that
predict use of alcohol, tobacco, and other drugs.
Vega, W. A., Rodriguez, M. A., & Gruskin, E. (2009). Health disparities in the Latino population.
Epidemiologic Reviews, 31, 99–112. https://doi.org/10.1093/epirev/mxp008
Villatoro Velázquez, J. A., Medina-Mora Icaza, M. E., Del Campo Sánchez, R. M., Fregoso Ito,
D.A., Bustos Gamiño, M. N., Resendiz Escobar, E. . . . Cañas Martínez, V. (2016). El
consumo de drogas en estudiantes de México: tendencias y magnitud del problema. Salud
Mental, 39, 193-203. https://doi.org/10.17711/sm.0185-3325.2016.023
TROJAN HORSE? 37
Watters, E. (2010). Crazy like us: The globalization of the American psyche. Free Press: New
York, NY.
Wells, K., Klap, R., Koike, A., & Sherbourne, C. (2001). Ethnic disparities in unmet need for
alcoholism, drug abuse, and mental health care. American Journal of Psychiatry, 158,
2027-2032. https://doi.org/10.1176/appi.ajp.158.12.2027
World Health Organization. (2011). Fact file on health inequities. Retrieved from:
http://www.who.int/sdhconference/background/news/facts/en/
World Health Organization. (2012). Report on health systems in Puerto Rico. Retrieved from:
http://www.who.int/mental_health/evidence/puerto_rico_whoaims_report.pdf?ua=1
Young, M. (2017). Bypassing an IRB review, researchers held herpes vaccine trial on an island.
IRB Advisor, 17, 121-123. Retrieved from: https://www.ahcmedia.com/newsletters/21-irb-
advisor
Young, A. S., & Rabiner, D. (2015). Racial/ethnic differences in parent-reported barriers to
accessing children’s health services. Psychological Services, 12, 267-273. http://doi.org/
10.1037/a0038701
Zeiders, K. H., Umaña-Taylor, A. J., Updegraff, K. A., Jahromi, L. B., & White, R. M. B. (2016).
Discrimination and acculturation stress: A longitudinal study of children’s well-being
from prenatal development to 5 years of age. Journalof Developmental and Behavioral
Pediatrics, 37, 557-564. doi: 10.1097/DBP.0000000000000321
... However, Puerto Ricans face several barriers when seeking help for mental health. According to Domenech et al. (2018), Mental Health in Puerto Rico is practically a taboo and some of the barriers that can be found among Puerto Ricans are created by themselves. Puerto Ricans tend to think that mental health problems could be resolved by itself, and also think that seeking help for mental health is a waste of time (Domenech et al., 2018). ...
... According to Domenech et al. (2018), Mental Health in Puerto Rico is practically a taboo and some of the barriers that can be found among Puerto Ricans are created by themselves. Puerto Ricans tend to think that mental health problems could be resolved by itself, and also think that seeking help for mental health is a waste of time (Domenech et al., 2018). Further, over time, insurers have increased the costs of medical plans and reduced services, particularly limiting access to mental health services (Domenech et al., 2018). ...
... Puerto Ricans tend to think that mental health problems could be resolved by itself, and also think that seeking help for mental health is a waste of time (Domenech et al., 2018). Further, over time, insurers have increased the costs of medical plans and reduced services, particularly limiting access to mental health services (Domenech et al., 2018). The World Organization (2012) reports that just 10% of the funds that are assigned for health in Puerto Rico goes to mental health services. ...
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... In the U.S., GenerationPMTO has received significant empirical support as a method of reducing youth antisocial behavior despite difference in treatment intensity (Forehand et al. 2014) and has been adapted with good results to Mexico's cultural context . The cost of implementing and disseminating evidence-based packages can be a barrier to scaling out in low-and middle-income countries such as Mexico (Rodríguez et al. 2018). Identifying important parenting factors associated with early substance use may provide new insight into common areas of intervention associated with parent training, potentially increasing the ability to implement the most needed components of interventions thus improving the odds of developing evidence-based treatments by narrowing interventions to high value parenting practices. ...
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Determine whether parent characteristics and practices differentiate between substance using and non-using children in Mexico. Data consisted of 52,171 children (i.e., 5 th and 6 th grade) who participated in the National Survey of Drug Use Among Students. The relative importance of student reported parenting factors in classifying lifetime substance use were assessed across outcomes with a logistic regression algorithm. Machine learning algorithms utilizing parent characteristics and practices classified tobacco, marijuana, inhalants, and other substance use. Parenting factors were poor classifiers of lifetime alcohol use. The algorithm generally selected important classifiers broadly associated with parental illicit substance use and monitoring practices across child substance use outcomes. Findings suggest that leveraging parental influences during childhood may be a high value point of intervention for preventing non-alcoholic substance use. Important classifiers identified by the current study represent potential targets for childhood substance use prevention efforts.
... Representation alone (i.e., diversity) is not sufficient to create a truly international organization. Power-uneven approaches to international collaborations can result in intellectual colonization, cultural imperialism, or cultural appropriation (e.g., in research, see Domenech Rodríguez et al., 2018). Practicing principles of inclusion wards off against engaging internationalization in the fashion of explorers/colonizers of the past. ...
... Scholars within the Genera-tionPMTO team have focused on addressing health disparities nationally and internationally, and have become experts in adaptations of EBPs as well as experts in Gen-erationPMTO. Because of our collective experience with scale up of the intervention [36][37][38][39], we explored an innovative platform to improve the capacity to serve ethnic/racial minority patients. We believed that the BL strategy could serve as a model for training across EBPs in general, and for those programs seeking to train practitioners to address health disparities in particular. ...
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... The final paper in this special issue highlights strengths and challenges for international collaborations and extending research on evidencebased interventions to Latin American countries Domenech- Rodriguez et al. (2018). The authors eloquently address assumptions and problems of cultural imperialism, intellectual colonization, and cultural appropriations that can occur in attempts to scale up international research. ...
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There have been significant advances in Latinx psychology research in the past two decades, and the field is now in a position to focus on how new methodologies can advance research in this area. The promising new methods can further our understanding of key factors that research has found to be important in Latinx psychology. In this vein, this special issue highlights how methodological advances can advance research on parenting, relationships, community contexts, intersectional identities, intersectional oppressions, and international contexts. In this issue, we provide examples, insights, and recommendations into qualitative, quantitative, and mixed method approaches. Three empirical examples demonstrate methodology with Latinx populations of children and parents, romantic partners, and adults in community contexts. Three conceptual papers provide guidelines on effective implementation of qualitative methods with Latinx populations, an overview of intersectional approaches to quantitative analyses, and insight into how international collaborations can advance global Latinx psychology. Effective use and application of innovative methods will improve the quality of our research studies and, in turn, enhance the scientific advances we make in Latinx psychology.
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Background Few existing evidence-based parent interventions (EBPIs) for prevention and treatment of child and youth mental health disorders are implemented in low-middle-income countries. This study aimed to translate and confirm the factor structure of the Evidence-Based Practice Attitude Scale (EBPAS-15) survey in Brazilian Portuguese with the goal of examining providers’ perspective about EBPIs. Methods We translated and back translated the EBPAS-15 from English to Brazilian Portuguese. Participants were recruited via snowball sampling and data were collected using an online survey from August of 2019 through January of 2020. A confirmatory factor analysis was conducted to determine if the scale retained its original structure. Open-ended questions about providers’ perspectives of their own clinical practice were coded using the Theoretical Domains Framework (TDF). Analysis included data from 362 clinicians (318 women, 41 men) from 20 of the 27 states of Brazil. Participants averaged 26.7 years old, held specialist degrees in the field of psychology, actively worked as therapist, and practiced in private clinics. Results The translation of the EBPAS to Brazilian Portuguese retained the same four-factor structure as the English version except for dropping one item from the Divergence domain. When asked about the challenges in their practices, providers generally referred to parents as clients with little skills to discipline their children and lacking knowledge about child development. Discussion The Brazilian version of the EBPAS-15 is promising, but future research should consider using quantitative data alongside qualitative information to better understand providers’ attitudes about evidence-based interventions to inform implementation efforts. Trial registration. N/A
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Research suggests that parenting programs are effective for preventing behavioral and emotional difficulties in children, but a lot more attention needs to be paid to issues of context and culture during the development, testing, and implementation of these interventions. The views and needs of underserved and disenfranchised communities in the USA and the Global South are often not taken into account for the development and testing of interventions. The successful implementation of evidence-based interventions for vulnerable children and families in underserved and marginalized communities requires careful consideration of how existing paradigms of prevention, evaluation, and implementation science impact issues of social justice and equity. This paper will describe how a team of parenting program researchers has been collaborating with their partners globally in generating local knowledge by balancing the need for rigorous scientific methods with issues of power. Authors from the USA, Latin America, Africa, and Southeast Asia draw on their experiences regarding challenges and successes with issues regarding study design and measurement, the transferability and adaptation of interventions, and the dissemination and implementation of different parenting interventions while placing communities at the center of their efforts through participatory methods. We describe innovative approaches that span the continuum of intervention development, adaptation, optimization, evaluation, implementation, and scale-up of different parenting programs for vulnerable children and families across the world. We conclude by offering specific and pragmatic recommendations to increase access of culturally relevant and effective parenting programs in these communities.
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BACKGROUND Quantifying the effect of natural disasters on society is critical for recovery of public health services and infrastructure. The death toll can be difficult to assess in the aftermath of a major disaster. In September 2017, Hurricane Maria caused massive infrastructural damage to Puerto Rico, but its effect on mortality remains contentious. The official death count is 64. METHODS Using a representative, stratified sample, we surveyed 3299 randomly chosen households across Puerto Rico to produce an independent estimate of all-cause mortality after the hurricane. Respondents were asked about displacement, infrastructure loss, and causes of death. We calculated excess deaths by comparing our estimated post-hurricane mortality rate with official rates for the same period in 2016. RESULTS From the survey data, we estimated a mortality rate of 14.3 deaths (95% confidence interval [CI], 9.8 to 18.9) per 1000 persons from September 20 through December 31, 2017. This rate yielded a total of 4645 excess deaths during this period (95% CI, 793 to 8498), equivalent to a 62% increase in the mortality rate as compared with the same period in 2016. However, this number is likely to be an underestimate because of survivor bias. The mortality rate remained high through the end of December 2017, and one third of the deaths were attributed to delayed or interrupted health care. Hurricane-related migration was substantial. CONCLUSIONS This household-based survey suggests that the number of excess deaths related to Hurricane Maria in Puerto Rico is more than 70 times the official estimate. (Funded by the Harvard T.H. Chan School of Public Health and others.)
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Internationally, the interest in involving patients and the public in designing and delivering health interventions and researching their effectiveness is increasing. Several systematic reviews of participation in health research have recently been completed, which note a number of challenges in documenting the impact of participation. Challenges include working across stakeholders with different understandings of participation and levels of experience in reviewing; comparing heterogeneous populations and contexts; configuring findings from often thin descriptions of participation in academic papers; and dealing with different definitions of impact. This paper aims to advance methods for systematically reviewing the impact of participation in health research, drawing on recent systematic review guidance. Practical examples for dealing with issues at each stage of a review are provided based on recent experience. Recommendations for improving primary research on participation in health are offered and key points to consider during the review are summarised.
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Background Implementing treatments and interventions with demonstrated effectiveness is critical for improving patient health outcomes at a reduced cost. When an evidence-based intervention (EBI) is implemented with fidelity in a setting that is very similar to the setting wherein it was previously found to be effective, it is reasonable to anticipate similar benefits of that EBI. However, one goal of implementation science is to expand the use of EBIs as broadly as is feasible and appropriate in order to foster the greatest public health impact. When implementing an EBI in a novel setting, or targeting novel populations, one must consider whether there is sufficient justification that the EBI would have similar benefits to those found in earlier trials. Discussion In this paper, we introduce a new concept for implementation called “scaling-out” when EBIs are adapted either to new populations or new delivery systems, or both. Using existing external validity theories and multilevel mediation modeling, we provide a logical framework for determining what new empirical evidence is required for an intervention to retain its evidence-based standard in this new context. The motivating questions are whether scale-out can reasonably be expected to produce population-level effectiveness as found in previous studies, and what additional empirical evaluations would be necessary to test for this short of an entirely new effectiveness trial. We present evaluation options for assessing whether scaling-out results in the ultimate health outcome of interest. Conclusion In scaling to health or service delivery systems or population/community contexts that are different from the setting where the EBI was originally tested, there are situations where a shorter timeframe of translation is possible. We argue that implementation of an EBI in a moderately different setting or with a different population can sometimes “borrow strength” from evidence of impact in a prior effectiveness trial. The collection of additional empirical data is deemed necessary by the nature and degree of adaptations to the EBI and the context. Our argument in this paper is conceptual, and we propose formal empirical tests of mediational equivalence in a follow-up paper.
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Relevant initiatives are being implemented in low- and middle-income countries (LMICs) aimed at strengthening a culture of prevention. However, cumulative contextual factors constitute significant barriers for implementing rigorous prevention science in these contexts, as defined by guidelines from high-income countries (HICs). Specifically, disseminating a culture of prevention in LMICs can be impacted by political instability, limited health coverage, insecurity, limited rule of law, and scarcity of specialized professionals. This manuscript offers a contribution focused on strengthening a culture of prevention in LMICs. Specifically, four case studies are presented illustrating the gradual development of contrasting prevention initiatives in northern and central Mexico, Panamá, and Sub-Saharan Africa. The initiatives share the common goal of strengthening a culture of prevention in LMICs through the dissemination of efficacious parenting programs, aimed at reducing child maltreatment and improving parental and child mental health. Together, these initiatives illustrate the following: (a) the relevance of adopting a definition of culture of prevention characterized by national commitments with expected shared contributions by governments and civil society, (b) the need to carefully consider the impact of context when promoting prevention initiatives in LMICs, (c) the iterative, non-linear, and multi-faceted nature of promoting a culture of prevention in LMICs, and (d) the importance of committing to cultural competence and shared leadership with local communities for the advancement of prevention science in LMICs. Implications for expanding a culture of prevention in LMICs are discussed.
Book
Fifteen to twenty years is how long it takes for the billions of dollars of health-related research to translate into evidence-based policies and programs suitable for public use. Over the past 15 years, an exciting science has emerged that seeks to narrow the gap between the discovery of new knowledge and its application in public health, mental health, and health care settings. Dissemination and implementation (D & I) research seeks to understand how to best apply scientific advances in the real world, by focusing on pushing the evidence-based knowledge base out into routine use. To help propel this crucial field forward, leading D & I scholars and researchers have collaborated to put together this volume to address a number of key issues, including: how to evaluate the evidence base on effective interventions; which strategies will produce the greatest impact; how to design an appropriate study; and how to track a set of essential outcomes. D & I studies must also take into account the barriers to uptake of evidence-based interventions in the communities where people live their lives and the social service agencies, hospitals, and clinics where they receive care. The challenges of moving research to practice and policy are universal, and future progress calls for collaborative partnerships and cross-country research. The fundamental tenet of D & I research–taking what we know about improving health and putting it into practice–must be the highest priority. This book is nothing less than a roadmap that will have broad appeal to researchers and practitioners across many disciplines.
Chapter
Living in a high resource country or continent does not render one immune to pathology. There is no doubt that the burden of poor health falls on low and middle income countries. According to the WHO the average life expectancy in low income countries is 62 years while in high income countries it is 81 years (World Health Organization 2016). A child from Sierra Leone has a life expectancy of 50 years, while a baby born in Japan on average, will live to 84 years of age (World Health Organization 2016).
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This themed issue focuses on understanding and addressing several public health issues affecting communities today nationally and internationally. Health disparities, and global health in general, cover a large breadth of health concerns impossible to address in one issue. Here we provide a scope of some health disparities while focusing on health promotion and well-being of diverse populations, specifically within urban undeserved populations, rural communities in Peru, Roma minorities in Spain, and refugee communities. We focus on understanding contextual issue that affect health disparities as well as on examining the effectiveness of community-based interventions and community coalitions designed to address disparities.
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Support for meditation is found across academic communities and popular culture. Although the application of meditative practices has yielded positive treatment outcomes, larger purposes of the practice are perhaps lost in the empirically driven West, thus driving a risk of appropriation. In response, the authors outline 4 implications for best practice for counselors who aspire to engage in the culturally responsible use of meditative practices. © 2018 by the American Counseling Association. All rights reserved.