Two people in chef's coats cutting vegetables Two participants in the Bienvenido Program, a father and daughter from Mexico who own a restaurant, prepare food in their kitchen. (Photo by Sergio Ortiz) 

Over the last 30 years, researchers have called for increased community involvement in developing interventions to broadly improve community health and well-being. Community involvement in the implementation of mental health interventions often focuses on applying strategies to identify a population’s behavioral health needs, on engaging hard-to-reach communities in the use of interventions developed and tested in clinical settings, and, in some cases, on soliciting input to modify existing interventions and make them more relevant to members of these communities. Yet, these strategies are researcher-initiated and rely on community members as informants rather than experts in their own right. The current movement toward equitable implementation requires centering community perspectives in implementation research and practice.

Bringing Equity to Implementation

Implementation science—the study of the uptake, scale, and sustainability of social programs—has failed to advance strategies to address equity. This collection of articles reviews case studies and articulates lessons for incorporating the knowledge and leadership of marginalized communities into the policies and practices intended to serve them. Sponsored by the Anne E. Casey Foundation

In what follows, we present community-defined evidence as a potential framework for equitable implementation. This approach features the local experiences and knowledge of marginalized communities, and includes a keen understanding of the root causes of the health challenges they face. Community-defined evidence depends on active collaboration of local residents in the development and use of culturally responsive, community-focused interventions that address their social and behavioral conditions, as these residents define them. The Bienvenido Program, a mental health promotion program created at the Northeastern Center (NEC), a well-established community mental health center in Ligonier, Indiana, demonstrates the successful application of the community-defined evidence model for program implementation.

Defining a Need

While Latinx families have resided in parts of the rural Midwest for more than a century, recreational vehicle manufacturing jobs attracted significant numbers of Latinx residents to northeast Indiana in the 1990s. Ligonier, a small rural community, saw its Latinx population grow by 522 percent between 1990 and 2003.

To better serve the mental health needs of this community, NEC staff established a collaborative needs assessment process as a first step in program development. To initiate this process, NEC staff and members of the Latinx community worked together to formulate questions to assess local mental health concerns and met several times to train. NEC staff reached out to community leaders at their workplaces and in churches, schools, and businesses, which created opportunities to build rapport and trust. This process incorporated pastors, business owners, teachers, and recreational league managers as cocreators. Responses by Ligonier’s Latinx residents to the assessment directly shaped the Bienvenido Program. It revealed that only 6 percent had ever visited a mental health center and that depression, anxiety, and substance abuse were prevalent.

Shortly after its inception in 2003, the Bienvenido Program expanded to five additional Ligonier communities, and outpatient services increased by 124 percent. It effectively became a prime destination for Latinx residents from Northeastern Indiana communities seeking mental health services, drawn to the high number of bilingual therapists that were available to serve them. More recently, the NEC has collaborated with universities and other organizations to expand the program in 13 other states. Its success underscores the need to support equitable implementation efforts that incorporate deliberate engagement and collaboration with community members, grounded in the local experiences and context of participants.

Culturally Relevant Elements

In 2009, coauthor Linda Callejas and University of South Florida researchers included Bienvenido in a nationwide study to examine behavioral health interventions specifically designed for Latinx communities that incorporated intensive engagement and collaboration. Bienvenido developers interviewed for the study, including NEC staff and Ligonier residents, emphasized the importance of three culturally relevant elements to the program: collectivism, cultivation of social support networks, and community integration. By establishing the elements as foundational, Bienvenido incorporates a healing framework that encourages participants to:

  • Acknowledge possible trauma and distress resulting from immigration and stigmatized social status;
  • Identify positive coping strategies;
  • Learn about mental health and navigating available services when needed; and
  • Build social support networks and increase participation in local social and political life.

The Bienvenido Program is implemented in weekly one-hour sessions over a nine-week period. Local residents, trained as facilitators, allow discussion to flow freely and encourage participants to share their experiences. NEC staff interviewed Bienvenido developers, trainers, and participants to identify the struggles that participants encountered in their daily lives, including discrimination, isolation, and economic precarity. Participants said that by listening to and sharing their stories about mental health concerns, they learned effective strategies for coping with stressors and learned to access mental health services. Participants also said the program increased their confidence about participating in community meetings, interacting with local elected officials, and speaking to health professionals about their health and potential treatments.

Based on this positive response, the lead program developer worked with local teachers, parents, and immigrant Latinx high school students to adapt the program for adolescents. They added topics on family-school engagement and acculturative stress often experienced by Latinx youth in immigrant families. The Bienvenido Program for Adolescents, established in 2009, incorporated discussions between youth and their parents to encourage bonding between participants and caregivers over mutual interests, shared experience, heritage, and family strengths.

Scaling Success

As NEC outpatient services to local Latinx residents increased, so did NEC’s number of employees. By 2007, the agency had grown its bilingual outpatient staff from one Latinx therapist and one Latinx psychiatrist to a team of seven: four bilingual therapists, a bilingual case manager, a bilingual nurse, and two bilingual administrative assistants.

The positive response from Bienvenido participants led to requests from local community organizations throughout Indiana for a formal Bienvenido facilitator training program to replicate the approach within their own communities. These efforts were further supported by a partnership with the Indiana Minority Health Coalition to train staff as Bienvenido facilitators in nine partner coalitions across Indiana. The state’s Division of Mental Health and Addiction approved funding to train seven mental health centers across Indiana in the Bienvenido curriculum, and Mennonite Church USA asked for help training church leaders across the country.

In 2008, Bienvenido was nominated to an evaluation consultation program sponsored by the Substance Abuse and Mental Health Services Administration, the federal agency that leads public health efforts to advance behavioral health at the national level. The program received support to strengthen its theory of change, clarify program components, and identify measurable outcomes. The following year, the NEC established a partnership with the National Network to Eliminate Disparities in Behavioral Health to train mental health professionals and leaders in 20 community-based organizations around the country.

Equitable Implementation in Action

The Bienvenido Program used a collaborative community process in program development, responding to mental health concerns identified in the needs assessment with considerable input from local residents. Program development was grounded in the perspective that local residents, community leaders, and facilitators possessed cultural knowledge critical to program development, including ideas on where to best launch the program. This input led the NEC to inaugurate its first Bienvenido group at a local literacy center where many Latinx individuals received language and other community services—a trusted space for Bienvenido sessions. Program expansion and sustainability efforts made use of this strategy, which was incorporated into trainings with state and national partners.

The cultivation of Bienvenido facilitators from among the Latinx community was an important strategy that seeded further progress. Their training helped build a local workforce comfortable with cross-cultural perspectives about mental health. Various Bienvenido facilitators have since pursued careers in the field, securing employment at mental health agencies and local health coalitions as patient advocates, life skills trainers, case managers, and interpreters. Their career trajectory effectively established a support network for facilitators entering new professional spaces and advocating for local community needs from within their respective workplaces.

Continued implementation of Bienvenido also established a loose advocacy network of active former participants working together to engage state and local elected officials, asking them to acknowledge the contributions of Latinx community members and support additional programming and services for the community. Facilitators and participants worked together with local Latinx leaders and allies to advocate for immigration reform and against anti-immigrant policies gaining currency statewide at the time. This real-world community of practice broadened the perspective of former participants and encouraged them to focus more broadly on service systems, local policies, and state mental health laws. In this way, the program expanded the potential for widespread community change and improved Latinx access to mental health across the state and beyond.

The expansion of Bienvenido in Indiana and 13 other states and the interest from national organizations demonstrates that the program fills an important need. Its formal evaluation findings are limited, and more reporting is necessary. But Bienvenido’s implementation shows the critical importance of community-defined evidence to the development, use, and evaluation of programs that seek to improve the health and well-being of underserved communities of color.

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Read more stories by Linda M. Callejas, Gilberto Perez, Jr. & Francisco J. Limon.