Keywords

4.1 Purpose and Approach

This chapter describes the construct of cultural factors. Cultural factors are constructs that capture significant life experiences of people and families from major racial/ethnic minority groups, i. e., from ethnocultural groups (Bernal & Adames, 2017). In the United States, these major ethnocultural groups are Hispanics/Latinxs, Blacks/African Americans, Asian Americans and Pacific Islanders, and American Indians/Native Americans. We also recognize that beyond these ethnocultural groups, other important identity groups exist that are defined by gender are LGBTQ people.

We examine select studies that conducted research involving cultural factors, some of which are culturally common across ethnocultural groups, meaning that they occur and have recognized meaning across two or more groups, for example, discrimination stress. By contrast, some cultural factors are culturally specific, meaning that they are primarily recognized and understood within a single ethnocultural group, such as efforts to avoid loss of face as discussed by Asians. Accordingly, a more complete understanding of ethnocultural individuals, families, and communities within the context of their own culture is facilitated by understanding the roles and meanings conveyed by various cultural factors.

4.2 Concepts of Culture

Culture has been a core element of human societies since the beginning of human civilization. Culture is a complex construct that has many dimensions. “Culture consists of ideals, values, and assumptions of about life,” such as beliefs and expectations, “that guide specific behaviors” (Brislin, 1993)(p. 23). From a psychological perspective, the construct of subjective culture (Triandis et al., 1973) focuses on culture as a human schema, an organized “world view” or “explanatory model,” that consists of symbols, attitudes, behaviors, values, and norms transmitted from one generation to the next. This “cultural world view” is constructed by members of an ethnocultural group to interpret their world. These human schemas capture the ethnocultural group’s collective wisdom for living and include familial and community norms, practices, and traditions, which facilitate the group’s survival and well-being (Lehman et al., 2004; Shiraev & Lewy, 2010).

Worldwide, large variations exist in expressions of culture, as manifested by the diversity of languages, religious systems of belief, sociocultural attitudes, family values, and sociocultural norms. Across societies worldwide, a dynamic tension exists between community efforts toward modernization , making changes to improve social structures, and efforts toward traditionalism , a resistance to change that favors preserving ancestral traditions (Ramirez, 1999; Shiraev & Lewy, 2010). Factors that promote modernization, such as international globalization, emphasize growth and standardization in monetary currencies and in consumer products, thus creating a homogenization of cultural practices. By contrast, factors that promote traditionalism (Ramirez, 1999) consist of distinct “local subcultures” that create diverse communities that have their own distinct culture, identity, traditions, and lifeways. Migrating individuals who relocate to a new cultural environment, whether between nations or within a nation, often face the challenges of acculturation , the process of adapting to a new community environment, and assimilation , the process of fully integrating into that new community, which often includes adopting the human schema of the new cultural group or society (Berry, 1980, 2005).

4.3 Cultural Factors: Operationalizing “Culture” for Prevention Research

4.3.1 Origins of Cultural Factors

Cultural factors originate as cultural constructs, abstract ideas drawn from everyday observations about social and family processes (Cuellar et al., 1995; Triandis et al., 1973). Established hierarchical structures based on racial and ethnic background, religious orientation, and socioeconomic status establish expectations and sociocultural norms that constitute rules of acceptable behaviors in a given situation (McGoldrick et al., 2005). Within a cultural group, widely accepted and frequently practiced norms can also become longstanding cultural traditions. For example, within traditional Latinx cultures, parents expect their children to respect elders, i.e., the Latinx cultural value of respeto (respect) (Castro & Hernandez Alarcon, 2002). In traditional families and community settings, the concept of respeto has become a sociocultural norm or rule that children are expected to follow. Thus, within traditional Latinx families, the norm of respeto prescribes familial and social expectations that a youth should show proper respect to an elder. Some Latinx families no longer adhere to this traditional sociocultural norm.

4.3.2 What Are Cultural Factors?

In summary, culture is a broad and rich construct that captures “real-life” aspects of an ethnocultural group’s history, beliefs, practices, and traditions. A cultural factor operates as a specific experiential element or component of that complex culture (Castro & Nieri, 2010). Thus, cultural factors have been described as “personal, interpersonal, or environmental factors that are particularly influential or meaningful for members of a certain cultural group or population” (Castro et al., 2013)(p. 766). Another Latinx cultural factor, cultural pride, consists of a person’s strong identification and bonding with their native ethnocultural group as expressed by asserting “I am very proud” to be a Latino or a Latina. As with other cultural factors, cultural pride captures an ethnocultural person’s positive feelings toward their culture, ethnicity, and ancestry.

Among African American/Black groups, a major cultural factor is Africentric values . Africentric values emerged in popularity in the 1970s by emphasizing the longstanding sense of “peoplehood” and cultural pride that existed for years within this ethnocultural group. In the past, that pride has been expressed by the affirmation that “Black is beautiful,” when endorsing an African-centered world view (Parham et al., 2011). Various cultural factors, such as folk beliefs, involve cultural factors about health and well-being that can influence health-related behaviors. Some cultural factors can also operate as risk or protective factors that can impede or facilitate health and wellness (Castro et al., 1984; Whaley, 2003).

As noted, some cultural factors exist within several racial/ethnic groups in the United States, such as the individualism-collectivism dichotomy, traditionalism, and acculturation (see Table 4.1). The cultural factor of acculturation is broadly applicable to Latinx and Asian ethnocultural groups, since these populations contain large sectors of immigrants or children of immigrants, who have experienced the challenges of adapting to a new and different cultural society. Conversely, and as noted, other cultural factors tend to be culturally specific, capturing a salient and perhaps unique feature of an ethnocultural group’s ethnic beliefs and life experiences. For example, among traditional Asian Americans, loss of face refers to a concern over embarrassing oneself and family, followed by shame from engaging in some improper conduct. The consciousness and moral values directed at avoiding this embarrassment has been referred to as loss of face (Lau et al., 2009; Zane & Yeh, 2002)

Table 4.1 Major cultural factors in racial/ethnic communities
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4.3.3 Cultural Factors and Cultural Variables for Testing Theory and Models

Given that a cultural factor consists of a specific cultural concept, it can operate as a component of a theory or conceptual framework. That cultural factor can be converted into a measurable cultural variable generated from a reliable and valid scale and used as a variable in statistical model analyses (Triandis et al., 1973; Zane & Yeh, 2002). For example, a multiple regression model or a structural equation model can incorporate the measured cultural variable of ethnic pride as a predictor or moderator variable. This model can then test the influence of ethnic pride in preventing the use of alcohol and tobacco among Latinx adolescents (Castro et al., 2009).

4.3.4 Modeling the Effects of Cultural Factors

Informed by minority stress theory (Carter, 2007), in a sample of Mexican heritage college students, Cheng and colleagues tested the potential moderator effect of the cultural factor, familismo, on the effects of another cultural factor, acculturation stress, as an antecedent (predictor) of the development of depressive symptoms (Cheng et al., 2016). These investigators reasoned that students of Mexican ancestry, who have high levels of familismo, relative to those having lower levels, would benefit from family-related support that can buffer exposures to acculturation stress, thus attenuating the development of depressive symptoms.

Figure 4.1 presents a simple model of this dynamic process. In this model, acculturative stress (Factor 1) is hypothesized as a cultural factor that can produce depressive symptoms (Factor 3). The cultural factor of familismo (familism, strong family bonds) is also hypothesized as a moderator (an effect modifier) that can buffer (attenuate) the effects of acculturative stress on the occurrence of depressive symptoms. Among other effects that Chen and collaborators tested in their hierarchical multiple regression analyses, they showed that greater acculturative stress was associated with higher levels of depressive symptoms (β = 0.21, p < 0.01). Then they reported the acculturative stress-familismo interaction, which was also significant (β = 0.22, p < 0.01), indicating that the interaction of acculturative stress and familismo also exerted a significant effect on depressive symptoms, ideally in the manner hypothesized. Finally, when examining the effect of low versus high levels of familismo, as indicated by two simple slopes, the slope for high level of familismo was greater (β = 0.24, p < 0.001) when compared with the slope at the low level of familismo (β = 0.11, p < 0.05). This analysis revealed that relative to low levels of familismo, high levels exerted a stronger moderating (attenuating or buffering) effect, which reduced the effects of acculturative stress on depressive symptoms (Cheng et al., 2016). This result suggests that for these young adults of Mexican heritage, the cultural factor of familismo can operate as a protective factor against acculturative stress in reducing the development of depressive symptoms.

Fig. 4.1
figure 1

A simple moderation model with two cultural factors

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4.4 Cultural Factors Toward Reducing Health Disparities

4.4.1 Pervasiveness of Health Disparities Among Communities of Color

Ethnocultural populations and their communities are affected by many types of social inequities and related health disparities. This includes limited access to healthcare services, which can also produce low rates of health service utilization, which can also perpetuate existing health disparities and inequities. A health disparity consists of a significant difference in the rates of a health problem, e.g., rates of HIV/AIDS, within a socially disadvantaged population as compared with a socially advantaged population (Braveman, 2006).

As examined across a series of health-related problems, e.g., rates of obesity, heart disease, and cancers, the profile of health disparities often reveals a greater extent of impaired health within the disadvantaged group. Unfortunately, this health disparity profile constitutes a recurring pattern among the major ethnocultural groups in the United States (Braveman et al., 2010). Within many of these ethnocultural communities, health status is influenced by the presence of several comorbidities. For example, co-existing depression can aggravate an existing somatic health problem, such as type 2 diabetes (T2D).

4.4.2 Cultural Factors to Inform Preventive Intervention Development

Beginning in the early 1970s, community and cultural psychologists observed that culture also is expressed by “human environments” created by communities. Accordingly, in addition to cultural norms, environmental structural components could also operate as cultural factors and as “cultural variables,” which operate as determinants of human behavior (Triandis et al., 1973; Zane & Yeh, 2002). Unfortunately, many major sociocultural theories, such as the influential social cognitive theory (Bandura, 1986), did not explicitly incorporate the effects of culture and cultural factors as determinants of behaviors among ethnocultural groups in the United States.

In 1999, the National Institute on Drug Abuse (NIDA) published a research-based guide that identified 13 principles of effective drug abuse treatment (NIDA, 1999). These principles included the principles that (a) effective treatment attends to the client’s multiple needs and not just to drug abuse and (b) remaining in treatment is crucial to treatment effectiveness. Ironically among these principles, a striking omission was that none of these principles referred to cultural factors and their possible roles as risk or protective factors in recovery from drug abuse. This omission highlighted the importance of recognizing cultural factors among ethnocultural people as additional factors that can affect recovery from drug abuse. This limitation had been mentioned a few years earlier as important for a more efficacious drug abuse treatment provided to African Americans/Blacks, Hispanics/Latinos, and Native Americans (Terrell, 1993).

Shortly after the year 2000, cultural factors gained greater recognition as important culture-related influences on drug use treatment outcomes among ethnocultural groups (Zane & Yeh, 2002). Other research studies began incorporating cultural factors into regression model analyses to model their effects as etiological, moderator, mediator, or outcome variables to better understand the determinants of drug abuse etiology and treatment (Castro & Hernandez Alarcon, 2002; Castro et al., 2007).

4.4.3 Developing and Implementing Preventive Interventions in Various Settings

4.4.3.1 Urban Contexts

A study of factors in the process of building capacity to address health disparities in urban African American neighborhoods identified five capacity building factors. These factors are (a) leadership, (b) institutional commitment, (c) trust, (d) credibility, and (e) interorganizational networks (Gilbert et al., 2010). This approach endorsed the development of community partnerships to generate resources under an ecological systems approach for reducing health disparities. These investigators conducted a case study in creating partnerships to build community capacity. They interviewed 18 participants from nonprofit, government, academic, and civic organizations. As coordinated by a Center for Minority Health, this study identified emerging themes for building these partnerships in an urban environment. These themes also highlighted the importance of (a) sustained funding to address health disparities, (b) creating changes in existing organizational cultures, and (c) leadership for modifying a participating organization’s mission and vision statements.

Further, trust and credibility emerged as important factors for establishing and sustaining interorganizational partnerships and in creating interorganizational networks for addressing health disparities within urban environments. This effort coordinated the participating organizations’ role in providing instrumental, financial, and functional support to other participating organizations.

In total, this effort included (a) building each individual organization’s readiness to respond to important community needs, (b) establishing organizational leadership structures to galvanize institutional commitments for engaging in transformative change, (c) reestablishing trusting relationships with local African American communities and organizations, (d) convening a diverse network of stakeholders, (e) understanding local community infrastructures to design culturally relevant interventions, (f) promoting the adoption of a culturally relevant model that includes one or more cultural factors that influence health promotion and disease prevention, and (g) organizing and conducting data collection, analysis, monitoring, and evaluation activities (Gilbert et al., 2010). In summary, this study provides a basic framework of approaches for developing and organizing an interorganizational system of resources and support that can be mobilized to address targeted health disparities within a local urban context.

4.4.3.2 Rural Contexts

A study of rural community conditions examined the cultural beliefs, practices, and lifestyle choices of rural community residents to identify the factors that impede the utilization of healthcare services toward reducing the occurrence of chronic diseases (Murimi & Harpel, 2010). Targeting a reduction of obesity and related chronic diseases among low-income residents living within a rural setting, a group of local community members created a multidisciplinary project charged with developing a consortium of local organizations, schools, and churches. The related study investigated personal, cultural, and external barriers among community residents from participating in community-based preventive outreach program for reducing obesity, diabetes, heart disease, and hypertension. Investigators conducted six focus groups to identify specific barriers to healthcare utilization by comparing community resident who did not utilize healthcare services with those who did.

These focus groups identified four themes associated with barriers to participation in preventive care services: (a) time involving daily routines, such as family and work responsibilities, that prevented participation in health outreach program activities; (b) low priority given to seeking preventive care; (c) fear of the unknown, exemplified by fears that a screening test may reveal a disease, such as having cancer; and (d) lack of companionship support for accompanying individuals in seeking healthcare services.

These investigators concluded that low-income status and low education were associated with a low motivation for seeking preventive healthcare services. To improve healthcare services seeking among these vulnerable sectors of their local rural communities, these investigators endorsed proactive disease prevention efforts and self-care education that could be provided by a coalition of policy-makers, funding agents, healthcare providers, community leaders, and community residents (Murimi & Harpel, 2010).

4.4.3.3 Structural Interventions for Macrolevel Effects

Structural interventions target changing existing inequities that originate in social, physical, economic, or political environments (Brown et al., 2019). For a more comprehensive approach to health promotion and disease prevention, an ecodevelopmental systems framework is important for informing a multi-domain (macro-, meso-, and microlevel) analysis and design for creating multilevel structural interventions (Richard et al., 2011). From this multi-domain approach, inequities operate as drivers of health disparities, in part by shaping and constraining health behaviors and outcomes. Clearly, these inequities are detrimental to ethnocultural persons, families, and communities. To address these oppressive contexts, preventive interventions are needed, which focus on interventions delivered at one or more ecodevelopmental domains, e.g., families, organizations, and communities, as focal points for reducing and eliminating these drivers of inequity. This approach consists of increasing protective factors and reducing or eliminating risk factors to support healthful behaviors and environmental changes to reduce or eliminate these inequities (Brown et al., 2019).

A systematic review of ecodevelopmental factors was used to identify protective factors to reduce the existing “school-to-prison pipeline.” This is a structural condition that leads many Latinx youth into contact with the juvenile justice system (Hoskins et al., 2020). Investigators argue that strength-based interventions that address cultural, familial, and community factors are needed to counter the effects of longstanding structural inequities and the factors that produce and perpetuate this pipeline. Investigators emphasized incorporating the Latinx familial cultural factors of collectivism and familism (familismo) for engaging Latinx youth to initiate and remain in treatment (Hoskins et al., 2020). These investigators endorse the design of preventive interventions that incorporate the cultural factors of collectivism and familismo as core components for greater intervention efficacy and acceptability with Latinx youth and families.

4.4.3.4 Structural Factors in Healthcare Settings

Integrating Psychological Services Into Integrated Healthcare (IHC)

As noted, health disparities are pervasive adversities imposed on vulnerable ethnocultural communities by structural inequities in healthcare availability. One systemic action for increasing health equity is to improve the availability of integrated healthcare to provide preventive and treatment interventions in a culturally relevant manner. This can be directed toward reducing major chronic degenerative diseases, including cardiovascular disease, cancer, type 2 diabetes, HIV, and AIDS (Thobaben, 2004).

Integrated healthcare systems offer services provided by physicians, psychologists, and other culturally competent healthcare providers. For more effective health services to patients from ethnocultural groups, these providers can also develop cultural competence that consists of knowledge of the cultures of local ethnocultural groups. Culturally competent health professionals have an in-depth understanding of core aspects of healthcare delivery as relevant to the needs and preferences of ethnocultural individuals and families from local disadvantaged communities (Petersen et al., 2011).

In summary, given that physical illness is often accompanied and exacerbated by emotional, social, and cultural factors, implementing medical treatment without addressing illness-related psychological, social, and culture factors often compromises the effectiveness of the medical treatment that is provided. Accordingly, integrating psychological and sociocultural services into healthcare settings, especially those treating vulnerable ethnocultural populations, can increase the efficacy of the medical care provided (Petersen et al., 2011).

Integrated Care Outcome Studies with Ethnic Minority Participants

Based on a chronic disease conceptual model, integrated care programs have been defined as those having one or more of the following components: (a) a healthcare system as a venue for the delivery of integrative services, (b) community resources that support the delivery of integrative services, (c) support for client self-management, (d) delivery systems design to deliver effective care, (e) decision-support that includes empirically based guidelines and technical support from experts, and (f) a clinical information system for information sharing and sending client reminders (Lemmens et al., 2015). The need for integrated care services is especially acute for patient populations affected by somatic disease and co-occurring psychological disorders, such as depression. Such comorbidities are associated with a poorer quality of life, greater disability, poor disease outcomes, and higher mortality (Lemmens et al., 2015).

The IMPACT (Improving Mood—Promoting Access to Collaborative Treatment) is an intervention that focused on reducing depression among patients from 18 primary care clinics in 5 states (Gilmer et al., 2008). Ethnocultural patients constituted 23% of the total sample of N = 1087 patients. Depression care managers and consulting psychiatrists were added to a clinic’s staff to provide “collaborative stepped care,” which included depression treatment that combined antidepressant medication and problem-solving psychotherapy. Compared to usual care, this integrated care intervention produced a greater reduction in depression at a 12-month assessment.

Another study focusing on depression treatment among patients in medical care (Miranda et al., 2003) utilized co-located integrated care that was provided to outpatients at San Francisco General Hospital and affiliated clinics. Participants were 199 primary care patients, including 77 Spanish-speaking Latinos, 46 African Americans, and 18 Asians and American Indians, who were randomly assigned to receive (a) a cognitive-behavioral therapy (CBT), (b) a group therapy intervention, or (c) the CBT intervention combined with clinical case management designed to increase engagement and reduce dropout. These investigators adapted the CBT intervention for low-income/low-education patients and for Latino patients as guided by Spanish and English-language manuals written at appropriate reading levels. Cultural factors incorporated into this study to provide cultural relevance for Latinx patients included the cultural values of respeto, personalismo, and simpatia (see Table 4.1).

Patients receiving the group CBT plus case management attended more CBT sessions and were less likely to drop out of therapy, when compared with those receiving the group CBT alone. The effects of treatment condition on depression outcomes were moderated by patients’ language use. That is, Spanish-speaking participants, who received this group CBT plus case management, reported less depression at the 6-month follow-up, when compared with patients receiving group CBT alone. For English-speaking participants, there were no differences between treatment conditions on depression at the 6-month follow-up.

In summary, within the emerging context of integrated care, the need exists for policy-makers, treatment providers, and other professionals to ensure high quality in service delivery to maximize the attainment of successful treatment outcomes (Rutkowski et al., 2012). In the past, the delivery of behavioral health services has been bifurcated into treatment settings that offered substance use treatment, separate from those that offered mental health treatment. A more effective approach in integrated care is to provide both substance use and mental health treatment services as complements to medical care, with all three components provided within a single location, and as delivered by a collaborative team of health professionals. In this effort, a systems approach is necessary for a more complete and effective conceptualization of these complex processes for better service planning and delivery within a primary care setting, as this coordination can significantly improve the health and well-being of ethnocultural clients and patients, especially among those affected by co-occurring health problems (Collins, 2018).

4.4.4 Cultural Factors Among Major US Ethnocultural Groups

4.4.4.1 Overview

The US Census Bureau for the year 2010 reports that the total population of the United States consisted of over 308 million (U.S. Census Bureau, 2012). By contrast, in July of 2019, that total US population consisted of over 267 million persons classified as persons who are “not of Hispanic origin,” along with over 60 million persons classified as being “of Hispanic origin.” In total, these two sub-populations (Hispanics and non-Hispanics) comprised a total US population of over 328 million (U.S. Census Bureau, 2021). Among these, the major ethnocultural populations in the United States, when ranked in order of population size, are Hispanics or Latinxs, Blacks or African Americans, Asian Americans and Pacific Islanders, and American Indians or Native Americans. Each of these populations is also composed of several within-population populations or community sectors defined by nationality of origin, tribal subgroup, and other characteristics.

4.4.4.2 Cultural Factors in Hispanic/Latinx Communities

The US Census Bureau in 2010 reported that the population identified as being of Hispanic or Latinx heritage and who also reported being of “one or more races in combination” numbered over 50 million. This population grew to over 60 million in 2019, constituting 18.45% of the total US population of over 328 million (U.S. Census Bureau, 2021). Latinx, the largest ethnocultural population in the United States, is composed of several Hispanic/Latinx subgroups that have a family heritage from Mexico, Puerto Rico, Cuba, and other Latin American countries. Many Hispanics/Latinxs express pride in their national heritage, such as being from Mexico, although variations exist in the extent to which individuals identify with the generic term of Hispanic or Latino/a (Latinx) or in how much they identify with their national heritage, such as being Mexican, Cuban, Costa Rican, etc.

Hispanics/Latinxs have a history greatly influenced by the Spanish conquest that occurred during the 1500s. That conquest in time created racial admixtures of Europeans and indigenous heritages. From the conquest, Hispanic/Latinos inherited the Spanish language and Catholicism, although today several variation exist in the religious affiliations and linguistic practices of Latinos and Latinas, that is, there exist three acculturation-related population sectors: (a) whether they are bilingual/bicultural, (b) primarily Spanish-speaking and of low acculturation into the American society, or (c) primarily English-speaking and of high acculturation. Immigration issues constitute an important feature in the life experiences of many Latinos (Falicov, 2005).

The process of acculturation (cultural change) has created variations in the extent to which Latinxs identify and adopt the lifeways of the mainstream American culture and society. For some Latinxs, this process of acculturation creates acculturation stress. Acculturation stress often involves sociocultural and identify conflicts, an addition to other stressors that do not involve cultural issues. Becoming bilingual and bicultural constitutes a core identity for many Latinos and Latinas, although some are very traditional and prefer to retain completely their native cultural identity and to adhere to their native cultural traditions. Others prefer to integrate almost entirely into the American culture and society, integrating completely, thus assimilating into American society. The value of collectivism, which involves strong family bonds (familismo), respect for authority, and the observance of religious and secular traditional practices, constitutes a core cultural family value that exists among many of the more traditional Latinx families (Falicov, 2005).

The Latinx/Hispanic and Asian American and Pacific Islander ethnocultural groups contain large population sectors that have a significant immigration history. Accordingly, these immigration experiences prompt the occurrence of acculturation and assimilation, thus inducing the creation of the cultural factors of acculturation and assimilation. For Asian and Latinx immigrant individuals and their families, these two cultural factors have strong meaning and significance (Lopez-Class et al., 2011; Schwartz et al., 2010). Acculturation refers to a “sociocultural process in which members of one cultural group adopt the beliefs and behaviors of another group,” (Lopez-Class et al., 2011)(p. 1556). Assimilation refers to an individual’s or a group’s complete integration into a new host society (Portes & Zhou, 1993). The process of developing a bicultural identity constitutes another cultural factor that develops as a consequence of the process acculturation change as manifested among many Latinos and Latinas.

Cultural Factors and Health-Related Outcomes

Beginning about the year 2000, studies of racial/ethnic group differences in military veterans exposed to major stressors reported on ethnocultural differences in which Hispanic/Latinx veterans exhibited a higher probability of developing post-traumatic stress disorder (PTSD), although without higher levels of dysfunction (Ortega & Rosenstock, 2002). In a study of trauma survivors, relative to non-Hispanic white Americans and the African Americans, Hispanics reported greater overall PTSD symptom severity (Marshall et al., 2009). These investigators identified discrimination, economic hardships, and the loss of strong familial, religious, and social networks as factors in the development of PTSD among these Hispanics.

Based on the theory of gender and power, Wingood and colleagues identified certain Latinx cultural norms and traditional practices as influences on male-female power differentials that may operate as risk factors for increasing HIV risk behaviors (Wingood & DiClemente, 2000). Two prominent cultural factors within Latinx population are the traditional cultural factors involving gender role norms and expectations. These cultural factors are machismo (male dominance) and marianismo (female modesty and submissiveness to males). Daniel-Ulloa and collaborators conducted an analysis of studies examining the influence of Latinx cultural factors on gender-related beliefs and behaviors related to HIV/AIDS risks (Daniel-Ulloa et al., 2016). These investigators advocated for further research to develop culturally relevant theoretical models that explicitly include and test the influences of various cultural factors to better understand their effects on HIV-related risk behaviors among Latinx women and men.

In a study directed primarily at Spanish-speaking Latino patients, the IMPACT depression intervention was combined with a culturally relevant diabetes intervention (Project Dulce) to treat depression in Latinx persons receiving diabetes care in three southern California community clinics (Gilmer et al., 2008). By combining these two interventions, the overall project was described as a “co-located, co-managed” form of integrated care. Project Dulce consisted of a peer-led diabetes self-management intervention. IMPACT was delivered by bilingual staff and was culturally adapted by making it “more flexible for responding to cultural norms and beliefs, low literacy, socioeconomic barriers, and social stigma” (Gilmer et al., 2008) (p. 1324). In that study, a pre-post intervention evaluation revealed that depressed diabetes patients were able to significantly lower depression scores at the 6-month assessment by an average of 7.5 points as measured by the PHQ-9 while also significantly improving their nutrition.

4.4.4.3 Cultural Factors in Black/African American Communities

For the year 2010, the US Census Bureau reported that the Black or African American population in the United States numbered over 40 million (U.S. Census Bureau, 2012). And, the US Census Bureau reported that the Black or African American population in the United States for the year 2019 grew to over 44 million, which consisted of 13.53% of the total US population of over 328 million (U.S. Census Bureau, 2021). One of the landmark historical events among African Americans in the United States is the history and legacy of slavery and its influences on African American familial and social relations (Black & Jackson, 2005). Another prominent historical feature, a cultural resource, has been Black churches that provide spirituality and intergenerational connections, which serve as sources of strength, coping, and resilience in the face of chronic social stressors (Moore Hines & Boyd-Franklyn, 2005). A related historical context is segregation and the disproportionate distribution of African Americans into lower socioeconomic communities and poverty.

Institutionalized racism and discriminatory structural conditions have become significant social determinants of health, contributing to longstanding inequities and health disparities . These historical and sociocultural conditions have created social barriers and a potent “ripple effect” that produced waves of social oppression, which are still prominent among sectors of the African American population of the United States (Black & Jackson, 2005). By contrast, the emergence of Africentric values and traditions (Parham et al., 2011) among African Americans has rekindled a “sense of peoplehood” and collective struggle, instrumental for coping with racism and discrimination with collective strength in the face of many adversities (Moore Hines & Boyd-Franklyn, 2005).

HIV/AIDS Prevention

In the area of HIV and AIDS, beyond evidence-based efforts to change individual behaviors, an ecosystemic approach has been encouraged, which gives attention to contextual factors in prevention and treatment. This approach is a more comprehensive and a likely efficacious approach for reducing health disparities among African American youth and adults (Lightfoot & Milburn, 2009). Toward preventing early sexual behaviors and HIV risks among African America youth, relevant contextual factors include low socioeconomic status, neighborhood structures and dynamics, and disproportionate sources of adversity, which adversely affect African American communities. For African Americans, these factors have produced high rates of incarceration and involvement in the criminal justice system.

Lightfoot and Milburn argue that HIV prevention should attend to African American cultural factors that are associated with the disproportionately high representation of African American youth as HIV/AIDS cases. Countering these adverse influences involves the incorporation of protective cultural factors into the design of HIV preventive interventions for African American youth. These cultural factors include supportive family relationships, Africentric values, and racial socialization that includes enhancing racial/ethnic pride. These preventive interventions should also be designed to modify some of the surrounding contextual factors, such as local community economic and geographic conditions. Within this approach, two guiding questions are “How can culture be incorporated into HIV interventions to reduce HIV-related risk behaviors among African American youth” and “What makes an HIV intervention for African American youth culturally sensitive and culturally appropriate?” (Lightfoot & Milburn, 2009).

A qualitative study of storytelling as shared by HIV-positive African American women has been used to provide advice to at-risk African American women (Robillard et al., 2017). This storytelling narrative approach was used to capture the richness of cultural factors for teaching about cognitive and emotional intervention contents and activities that facilitate healthful behavior change. These narratives identified five emergent themes that linked social determinants of health to HIV/AIDS prevention. These themes were (a) providing advice for prevention, (b) mobilizing support systems to aid in prevention, (c) the need for education, (d) developing empowerment and self-care capabilities, and (e) identifying barriers to prevention. Emerging issues included barriers imposed by the stigma of having HIV. These issues revealed the need to provide participants with (a) strategies for coping with an HIV-positive diagnosis, (b) understanding the challenges of interacting with sexual partners, (c) understanding gender-related power politics, (d) understanding the challenges of access to healthcare, and (d) obtaining social support. Also emphasized was the beneficial role of having HIV-positive African American women as lay-health workers serving as agents of change, when incorporated into community-focused HIV preventive interventions designed for young African American women.

Preventing Cigarette Use

In a study of protective cultural factors that may “buffer” the effects of stress on cigarette smoking initiation among African American adolescents, Belgrave and collaborators examined the potential buffering effects of two cultural factors: religious support and intergenerational connections, as moderators of the effects of stressors on cigarette smoking behaviors (Belgrave et al., 2010) (see Fig. 4.1). In prior research with African American families, religious beliefs, religious practices, and traditional family practices emerged as potential moderators of youth substance use. Also, spiritual ways of coping have been found beneficial for reducing the stressors experienced from a difficult life event. Similarly, intergenerational connections were important in providing youth with social supports received from parents and other supportive adults from the local neighborhood. It appeared that positive family influences and youth engagement in school activities could also operate as protective factors against cigarette smoking.

Using hierarchical multiple regression model analyses, Belgrave and collaborators found that the cultural factor of intergenerational connections moderated the effect of stressors on the past 30-day tobacco use. Similarly, religious support moderated the effect of stressors on 30-day tobacco use. These results suggest that religious beliefs and social support from caring adults from the local community operated as intervention cultural factors, core components, and “active ingredients,” which can be incorporated into a preventive intervention designed to prevent early cigarette use among Black/African American adolescents.

Obesity Prevention

Important obesity-related issues emerge from ethnocultural group comparisons of age-adjusted obesity prevalence values based on data from the National Health and Nutrition Examination Surveys (NHANES). In those studies, obesity was assessed with body mass index (BMI) values of 30 kg/m2 and greater. Data for men from the years 2017–2018 that compared non-Hispanic white, non-Hispanic black, and Hispanic groups revealed prevalence values of 44.7, 41.1, and 45.7 for these ethnocultural groups, respectively (Fryar et al., 2020). In these comparisons, Hispanic men exhibited the highest prevalence of obesity. In similar comparisons for this same time period of 2017–2018, among women, these prevalence values were 39.8, 56.9, and 43.7, respectively, for non-Hispanic white, non-Hispanic black, and Hispanic women (Fryar et al., 2020). These data for women reveal a remarkably higher prevalence of obesity among non-Hispanic black women. In summary, recent data from the NHANES indicates comparatively higher prevalence values of obesity among Hispanic men and among Black women.

Ickes and collaborators conducted a literature review of childhood obesity preventive interventions among African American youth for the years 2005–2010 (Ickes & Sharma, 2011). These investigators targeted empirical studies having samples of African American youths of 35% or higher. This review revealed that most studies screened did not contain a meaningful number of African American participants, suggesting that many studies consisted of samples of African American youths that essentially constituted unplanned samples of convenience. This review revealed that most of these studies were not designed to focus on African American youths, also suggesting that these studies lacked a focus on the cultural factors that are important to African American families and communities. Further, most studies also focused on individual behavior change, rather than examining broader systemic changes that can reduce obesity. The few studies that focused on changing social and environmental factors, such as access to resources and policy-related changes, focused on interventions deliverable in community-based, home-based, or school-based settings. This review also revealed that most of the interventions for obesity reduction focused on promoting nutrition and physical activity, including weight reduction as assessed by decreases in body mass index. Intervention activities included skill building, goal setting, and increasing self-efficacy while also making the intervention enjoyable to children and adolescents.

Regarding cultural factors in the design of interventions for African American youth, the culturally relevant components, such as role modeling and mentorship, can be provided by caring African American adults. One distinct weakness needing attention in future study designs was that among the identified 18 interventions, only 3 included parents in these obesity reduction interventions. Clearly, parental inclusion emerged as an important factor for maintaining healthful behavior changes in obesity reduction among these African American children and adolescents.

4.4.4.4 Cultural Factors in Asian American Communities

For the year 2010, the US Census Bureau reported that the population of Asians in the United States numbered over 16 million (U.S. Census Bureau, 2012). Further, the US Census Bureau also reported that there are over 1 million persons who identify as Native Hawaiian and Other Pacific Islanders, for a combined total of over 17 million Asians in the year 2010 (U.S. Census Bureau, 2012). Then for the year 2019, this combined population of Asians and Native Hawaiian and Pacific Islanders grew to almost 23 million, constituting 7% of the total US population of over 328 million (U.S. Census Bureau, 2021). Individuals sharing common characteristics as Asians consist of over 30 ethnocultural subgroups, with Pacific Islanders consisting of another 21 subgroups (Lee & Mock, 2005a). Among Asian Americans, the largest ethnocultural groups by population size are Chinese, Filipino, Asian Indian, Japanese, and Korean.

Among Asians, immigration and the process of acculturation and assimilation constitute core cultural themes that reflect many of their life experiences. Regarding within-group cultural variations that exist among Asians, these variations include their use of a non-English language, as well as diversity in their social, religious, and other backgrounds. Despite this extensive diversity, Asian Americans share many common cultural threads. Among these are the centrality of the family unit and the value of collectivism (versus American individualism), the pervasiveness of immigration issues in their lives, and the presence of effective cultural coping strategies despite exposures to trauma, racism, and discrimination (Lee & Mock, 2005a).

Centuries-old Confucian teachings have been a source of common Asian American characteristics. These teachings emphasize the importance of harmonious interpersonal relationships, interdependence, hierarchical family roles, and obligations and duties to the family (Lee & Mock, 2005b). With strong adherence to these longstanding traditional Chinese values, many Asian Americans exhibit strong family bonds, value educational achievement, practice self-discipline and hard work, and exhibit social modesty, which are often expressed as an unassuming and non-confrontational interpersonal style. These cultural features have led to the Asian American stereotype of being a “model minority.” Also, many traditional Asian Americans refrain from seeking mental health services to avoid the shame of exposing personal and family difficulties to outsiders. In summary, traditional Asian Americans exhibit a strong adherence to their cultural values and traditions, as this includes family loyalty, reverence for elders, maintaining their native language, and observing familial traditions, rituals, and customs (Lee & Mock, 2005b).

A study by Anyon and collaborators examined assets and barriers to help seeking among Asian American high school students in 15 public high schools. This study was conducted as part of a school-based mental health (SBMH) prevention program conducted in an urban community having a significant Asian population (Anyon et al., 2014). Study investigators recognized the influence of several systemic and cultural factors, such as Asian students’ internalization of distress, their focus on somatic rather than psychological symptoms, their conformity to group norms, and the stigma and shame felt over publicly disclosing embarrassing topics, each of which could discourage their use of mental health services (Sue & Sue, 1999).

Investigators conducted multilevel regression model analyses to examine risk and protective factors in four domains: structural conditions, organizational settings, cultural factors, and social relationships, as predictors of mental health service utilization. After controlling for several covariates, including the school-based contextual variable of school racial composition, investigators found that the Asian students, when compared with Black, Latino, and multiracial students, exhibited significantly lower odds of using these school-based mental health services. Among the Asian students, self-reports of various risk factors (alcohol, tobacco, and drug use, externalizing behaviors, and truancy), based on teacher or self-referrals, increased the odds of using this program’s mental health services. Nonetheless, among Asian students, self-reports of depressive symptoms were not associated with the use of these mental health services, suggesting still that cultural factors of stigma and shame (loss of face) associated with disclosing feelings of depression and suicidal ideation still operate as barriers to the use of mental health services among many Asian students.

4.4.4.5 Cultural Factors in Native American Communities

For the year 2010, the US Census Bureau reported that persons identifying as American Indians and Alaska Natives numbered over 4 million (U.S. Census Bureau, 2012). Further, for the year 2019, that population grew as a population of American Indians and Alaska Natives, numbering over 4 million, which constitutes 1.34% of the US population of over 328 million  (U.S. Census Bureau, 2021).

Native Americans/American Indians are people represented by over 500 native tribes in the United States. Despite that diversity, a central feature of their cultures is the importance of kinship and family bonds. This includes respect and reverence for elders and their family ancestry. Another core feature of Native American lifeways is the importance of spirituality in their relationship with nature and kin (Sutton & Broken Nose, 2005). This reverence for nature and connections with kin constitute expressions of collectivism, whereby one’s identity is based not on the individualized self but instead on the family and extended family as the unit of lifeways.

Based on a history of oppression and being relocated from their original ancestral lands into desolate frontier settings, many Native American tribes were relegated to lives of poverty and discrimination. Yet many Native American communities preserved their traditional tribal values, language, and folkways as sources of collective strengths. Despite efforts to survive, the risk of suicide has emerged as a significant problem affecting Native American youth. Suicidal ideation and intents have been associated with early alcohol use that in short time transcends to heavy alcohol use. This progression appears associated with youth conflicts in reconciling indigenous and Westernized lifeways. By contrast, preventive interventions in support of healthful beliefs and actions among Native American youth have emphasized the importance of establishing indigenous connections that promote spirituality and cultural traditions (Kulis et al., 2017). These connections seek to help Native American youth survive within Westernized environments, aided by various skills for “surviving in these two worlds.”

As noted, early alcohol use among Alaska native youth constitutes a risk factor for subsequent alcohol abuse and suicidal ideation. Using indigenous theory applicable to prevention, Allen and collaborators examined two cultural factors meaningful to Native American communities (Allen et al., 2018). In a multilevel cultural intervention focusing on individual, familial, and community levels of analysis, two youth skill development outcomes were reasons for life and reflective processes. Reasons for life refers to beliefs and expectancies that make life enjoyable and worthwhile. Illustrative items assessed by this study’s measurement scales are “My elders teach me that life is valuable” and “People see that I live my life in a native way.” Similarly, reflective processes refers to thinking about the negative consequences of drinking alcohol. Illustrative items are “I would feel embarrassed to have drinking in my family” and “I do not want to lose control over myself.”

These measures reflect indigenous cultural factors regarded as protective against youth alcohol use and suicide. In the Alaskan Yup’ik community, Philip and collaborators examined the protective effects of social network components (Philip et al., 2016). Social network characteristics examined included network size, network density, connections to adults, and connections to elders, each as a protective factor operating at community, familial, and individual levels. Using the identified cultural factors of reasons for life and reflective processes, this Qungasvik multilevel intervention examined social network characteristics to assess the effects of these cultural factors as protective against alcohol use disorders and suicide.

4.4.5 Mixed Methods for Designing Culturally Focused Preventive Interventions

4.4.5.1 Emergence of Mixed Methods Research

Within the past two decades, the mixed methods field has emerged as a “third paradigm” beyond the conventional qualitative and the quantitative research paradigms (Johnson et al., 2007; Tashakkori & Teddle, 2010). The mixed methods field offers novel methodologies for conducting deep-structure analyses that contribute rich and contextual information (Resnicow et al., 2000). Accordingly, mixed methods research designs can generate a greater “yield” when compared with the sole use of a qualitative or quantitative research methodology, thus providing “the best of both” (QUAL and QUAN) methodologies. A hallmark of mixed methods research is the aim of integrating qualitative and quantitative evidence to attain this grater yield (Curry & Nunez-Smith, 2015). This dual methods approach is well suited for the analysis of cultural factors as potential core components of culturally relevant preventive intervention.

4.4.5.2 Mixed Methods Research Designs

Mixed methods research designs have been used extensively in implementation research to identify factors and conditions to inform the processes of dissemination, adoption, implementation, and sustainability of evidence-based preventive interventions (EBPIs), as well as to apply this knowledge for informing for empirically validated treatments (EBTs) (Nastasi & Hitchckci, 2016). In principle, this information will aid in eliminating implementation barriers to improve the implementation of preventive and treatment interventions delivered within integrated care settings (Palinkas et al., 2011).

In their analysis of mixed methods studies, Palinkas et al. (2011) identified three major elements of mixed methods research when designing implementation studies. These major elements are (a) structure, the study’s mixed methods research design which consists either of a concurrent/convergent or sequential approach and the relative importance of the study’s qualitative and quantitative components (e.g., “QUAL ➔ quan” or “QUAL + QUAN”); (b) function, the utilization of one of four major approaches (purposes) for conducting a mixed methods study (i.e., convergence, complementarity, expansion, development); and (c) process, the manner in which the qualitative and quantitative data are integrated (i.e., merged, connected, embedded).

Methods guiding the conduct of mixed methods research are now available in several texts (Creamer, 2018; Curry & Nunez-Smith, 2015; Nastasi & Hitchckci, 2016), some in their second edition or beyond (Creswell & Creswell, 2018; Tashakkori & Teddle, 2010). This includes books that focus on qualitative techniques, research methods, and data analysis (Bernard et al., 2017). Both rigor and cultural sensitivity in intervention assessment as conducted within a healthcare setting can be attained by using well-specified research designs, coupled with a well-planned implementation of a mixed methods research (Castro et al., 2014).

4.4.5.3 Mixed Methods for “Unpacking” and In-Depth Analysis of Cultural Factors

“Unpacking” and In-Depth Analysis of a Cultural Factor

Mixed methods analyses can generate explanatory “thick description” narratives that constitute the essence of a deep-structure analysis. This approach can be used to explore the analysis of an intervention’s core components and their effects on targeted intervention outcomes. This approach is useful for understanding complex cultural issues that affect the health and well-being of diverse ethnocultural groups.

The identification of core themes and their structure can be linked to existing theoretical models (Ryan & Bernard, 2003). This approach aids in exploring an intervention’s likely mechanisms of change. Textual data for conducting a thematic analysis can be gathered from participants using in-depth interviews. These interviews can generate culturally rich and informative emergent themes for “unpacking” meanings and nuances and the structure of complex cultural factors, such as acculturation, ethnic identity, and traditionalism (Castro & Coe, 2007; Castro et al., 2010).

In their mixed methods study, Castro and Coe conducted deep-structure focus question interviews with Latinas from two rural communities in Arizona. One study aim was to “unpack” the meaning of the complex cultural factor of family traditionalism as conceptualized by adult rural Latinx women (Castro & Coe, 2007). The quantitative (QUAN) assessment of the construct of traditionalism involved administering three cultural variable scales: family traditionalism, rural lifestyles, and folk beliefs (folk remedies). Furthermore, the open-ended focus questions were administered via one-to-one interviews conducted by promotoras (lay-health workers) to identify emerging themes that reflect traditional Latinx family beliefs and practices. For eliciting these deep-structure themes, some of these focus questions were as follows: “How ‘should’ husbands, wives, and children act?; What is the right way to act? What are certain family members supposed to do?”

A thematic analysis of qualitative textual responses for each of these focus question responses generated six themes: (a) male (macho) privilege, (b) family trust and respect, (c) family unity (familismo), (d) valuing traditions, (e) adherence to customs, and (f) resistance to change. A representative response about the theme of family trust and respect (respeto) was “[The family] always shares everything equally and there should be respect among everyone; between couples and children.” An illustrative response about the theme of resistance to change was “[A traditional woman] does not believe in changing her ways. Everything that her parents believe, so does she.” In summary, these thematic analyses “unpacked” the construct of family traditionalism by identifying emergent themes. This analysis yielded nuanced, deep-structure text narrative responses that described core features of Latinx family traditionalism, as manifested within rural Latinx communities (Castro & Coe, 2007).

4.4.5.4 Mixed Methods Analyses for Cultural Enhancement of EBIs for Integrated Care

Studies can be conducted within integrated care settings by utilizing mixed methods research designs that utilize purposeful sampling of strategically selected groups of participants to analyze the effects of a preventive or treatment intervention (Castro et al., 2014; Creswell & Creswell, 2018). For example, a mixed methods research study that interviews therapists and clients who participated in a treatment intervention can elicit responses that answer specific and well-developed focus questions about the participant’s reactions to treatment. For example, (a) “What intervention activities appeared to operate as “active ingredients” for attaining the targeted outcomes?” (b) “In what ways did the intervention contribute toward attaining its targeted outcomes?” and (c) “What were some weaknesses or limitations of this intervention, and what modifications of this intervention are needed to improve it?” In a “systematic mapping review” of empirical studies that utilized a qualitative component incorporated into controlled clinical trials, O’Cathain and colleagues describe how qualitative data provided contextual information regarding the manner in which the intervention study was implemented and how that intervention may have produced the targeted outcomes (O’Cathain et al., 2013).

4.4.6 Developing EBPIs for Implementation in Community Settings

4.4.6.1 Challenges of Taking an Evidence-Based Intervention to Scale

In 2008, Green observed that the outcomes of most behavioral research are not implemented in practice (Green, 2008), noting that only about 17% of these findings are incorporated into practice. Further, for these findings, it takes approximately 17 years for that to occur (Balas & Boren, 2000). There are many reasons for this. The most commonly cited reason is that many clinicians do not regard these research findings to be relevant; they do not apply to their patient populations or their settings (Correa et al., 2020). We are challenged by the following mainstream conundrum: there is a massive literature considered to be elegantly designed and that supports the efficacy of psychological and behavioral interventions for the treatment of medical and psychological problems typically seen in primary care (Maragakis & O’Donohue, 2018) Nonetheless, this body of research is made irrelevant by the inherent limitations of these research designs (Holtrop et al., in press). Conventional research relies on designs that maximize internal validity to attribute research results with high certainty to the intervention. These pristine research designs maximize the homogeneity of participant samples by minimizing variations in patients’ presenting problems. These designs also minimize variations in organizational functioning and implementation fidelity, whereby the intervention is often delivered by highly experienced research staff.

By contrast, issues of external validity have been greatly minimized or neglected, thus limiting the generalizability and capacity for “real-world” implementation of these research results within diverse community settings. This limited external validity has lacked attention toward external environmental contexts, including cultural variations in the participants from a local community who could be the beneficiaries of that intervention. This inattention also involves a lack of implementation planning to “real-world” variations in the types of organization or settings in which the intervention would be implemented, such as medical centers, clinics, community-based agencies, as well as attention to broader community environments and contexts (urban, suburban, rural, frontier). Given this design inattention to external validity, is it any surprise that most research-based interventions have not been taken to scale?

To make research meaningful and implementable, Kessler and Glasgow proposed that from the beginning, research should (a) be practical and have feasible interventions, (b) address key contextual factors, (c) have transparent reporting, and (d) use a design that fits the question of interest (Kessler & Glasgow, 2011). They further suggest that all these be applied to core research elements: the design selection, intervention characteristics, choice of evaluation measures, and data analyses (Kessler & Glasgow, 2011).

4.4.6.2 Strategies for Facilitating EBPI Dissemination and Implementation

Over the last 15 years, these issues involving the gap between formal research studies and their transferability to community-based services have coalesced into new frameworks and theories identified as dissemination and implementation (D&I) research. This field focuses on efforts to effectively transfer evidence-based preventive interventions (EBPIs) and empirically validated treatments (EVTs) into local community and healthcare settings. For reducing one or more health disparities among one or more ethnocultural groups, the goal is to design from the beginning an evidence-based preventive or treatment intervention that is “scale-up ready” (Fagan et al., 2019) and transferable with high adaptability (fit and function) (Alvidrez et al., 2019) into one of several community settings and implemented expeditiously to confer targeted benefits to clients from one or more ethnocultural groups. The following sections provide four select strategies, among many, that are important in this process of developing an intervention that is designed as readily “scale-up ready” and transferrable from the efficacy testing phase, for implementation within one of several community settings for the benefit of improving health and wellness in diverse ethnocultural groups.

4.4.6.2.1 Coordinating with Agency Administration and Staff

Once adopted, organization administrators need to exercise leadership in setting certain priorities for the implementation and sustainability of the intervention, as supported by their own organization. This may include administration-approved guidelines and expectations for intervention staffing, roles and responsibilities, and plans for implementation sustainability. It is important to ensure that the individuals mandating the change have the authority to do so, given that the implementers often lack such authority.

4.4.6.2.2 Assess Intervention “Scale-Up Readiness” and Identify Implementation Facilitators and Barriers

This assessment is typically guided by a conceptual framework or model that identifies factors that may impede implementation within various community settings. For example, an intervention’s “scale-up” readiness (Fagan et al., 2019) will be impeded if the new setting lacks leadership support. Thus, effectively implementing the innovation would require a focus on leadership engagement and education to promote effective intervention delivery. That assessment may also determine whether staff from that site have prior experience in using that intervention, thus inviting them to serve as an implementation champion.

4.4.6.2.3 Adapting the Intervention for the Local Contexts

Identify ways that the intervention can be adapted to meet local needs (Barrera et al., 2017). It is useful to identify components of successful implementation. When adapting an intervention, it is critical to identify and ensure that the intervention’s presumed core components are delivered with fidelity to the theory or the intervention’s logic model, which serves as the scientific foundation believed to produce intervention’s treatment outcomes (to produce intervention efficacy), i.e. ,the mechanisms by which the intervention “works.” This includes identifying needed adaptations for the intervention’s fit and function within the local clinical setting and meeting the needs of local community residents. In this regard, these adaptations may consist of tailoring discrete implementation strategies (intervention contents and activities) to eliminate barriers and leverage facilitators for an efficacious implementation process and capacity to attain targeted outcomes.

4.4.6.2.4 Engaging Consumers Under a Social Participatory Approach

Community clients are also key individuals in this implementation process – under a partnership that includes their views as consumers of this intervention. It is also important to orient these consumers to the intervention’s guiding theory or logic model, in ways that consumers can understand. This orientation will allow consumers to ask questions, also clarifying their role as active participants for enhancing their own health and wellness. This includes their role as active participants in intervention-related decision-making and monitoring their own progress in attaining intervention-related goals.

4.4.7 Final Comments About Cultural Factors

This chapter provided an overview of cultural factors as important constructs and measurable cultural variables that can be used to conduct more probing deep-structure analyses about the cultural experiences of persons from the major ethnocultural groups in the United States. Cultural factors can operate as core elements of culture and can reveal rich nuances from those cultural experiences. When converted into quantitative cultural variables, these elements can be incorporated into multivariate data analyses to expand existing models or develop new models and aid in a rigorous analysis of complex relationships and associations among variables in a given model. The use of mixed methods analyses that include cultural factors introduces the combined analytic power and yield from the integration of qualitative and quantitative data, thus adding further depth of analysis that can yield more complete conclusions from this mixed methods approach. Finally, cultural factors can add depth of analysis in the design, dissemination, and implementation of evidence-based preventive and treatment interventions, at the intersection of prevention science and implementation science. This approach can improve the transfer of tested and effective interventions into community settings to promote the health and well-being of multiple constituencies, including vulnerable members of ethnocultural groups, and contribute to reducing inequities and health disparities for a more comprehensive approach for improving the nation’s health.