Illustration of five people talking together (Illustration by Maggie Chiang) 

Despite the accelerated growth of the field of implementation science,1 critical lessons have yet to be learned about the best implementation approaches to reduce the persistent disparities in mental and physical health that impact diverse populations across the United States.2 For example, although Latinxs have been essential to the growth of the United States as a nation, low-income Latinx immigrants remain largely excluded from primary systems of care.3

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

Most recently, the COVID-19 pandemic has clearly demonstrated the profound economic inequities and health disparities that Latinxs experience. Specifically, low-income Latinxs are among the ethnic groups most disproportionately affected by COVID-19 infection rates.4 Throughout the pandemic, Latinx immigrants have remained an active labor force, despite the high risk for infection associated with their traditional lines of work. Our reflections on these challenges suggest that the implementation science field has fallen short of acknowledging the critical importance that faith-based organizations have in the lives of underserved Latinx immigrants and other populations of color, as well as the role that they can play in the implementation of physical and mental health care initiatives.5

Why do faith-based organizations play such a central role? For one, diverse populations facing complex challenges and difficulty accessing basic services frequently identify churches as organizations they trust. For example, immigration clinics and other key support services for undocumented immigrants, such as food banks, are often housed in faith-based organizations, which convey a sense of safe harbor to these populations. Churches also have ministries that focus on different areas of service. This facilitates access to various social networks for the implementation of intervention and prevention initiatives.

Furthermore, lay church members trained as mental health providers can convey a unique sense of trust that is critical for implementing initiatives within populations exposed to historical adversity. Lay church members also tend to remain in their congregations for many years and constitute a steady presence, which helps sustain interventions that become part of church ministries.6

Finally, during times of crisis, such as the xenophobic and persecutional policies promoted by the Trump administration that caused fear, anxiety, and family separation, many churches were perceived as safe havens by vulnerable Latinx immigrant parents. By contrast, the field of implementation science mostly maintained a passive role during this humanitarian crisis. The field must do better.

Facing Adversity

Low-income Latinx immigrants have been essential in positioning the United States as the dominant world economic power. But the adversity they experience continues to go largely unacknowledged, let alone addressed. Specifically, poor Latinx immigrants are likely to have jobs characterized by low wages, few benefits or protections (such as paid sick days), and strenuous working conditions. They are also commonly exposed to social isolation, language barriers, discrimination, and multiple barriers to access formal health and mental health care services.7

Further, research shows that the health of Latinx immigrants suffers from the various forms of discrimination they experience.8 Latinx children’s perceptions of discrimination experienced by their parents are also associated with increased risk for depression and anxiety among Latinx youths.9 Under the Trump administration, undocumented Latinx immigrants were the target of forced and permanent family separations with extremely harmful, lasting impacts for children and youth.10

Flawed Frameworks and Strategies

Most implementation science frameworks and strategies have been developed according to flawed assumptions of inclusion that do not apply to the most vulnerable immigrant populations in the United States. For example, poor foreign-born Latinx immigrant parents who lack documented status are ineligible for basic systems of care, despite their critical contributions to the US economy. 

Furthermore, these frameworks and strategies did not originate with core constructs examining dynamics of oppression, such as racial discrimination. As a result, the implementation science field continues to privilege the voices of academics and researchers over those of the individuals most affected by historical oppression.

In our view, the only way to move the field forward and address these issues is by elevating the voices of leaders in underserved communities of color. As these individuals remain in the trenches with diverse populations and are themselves continuously exposed to adversity, they are uniquely positioned to communicate how implementation science can become a science truly informed by social justice.

 

Learning, Adapting, and Tailoring

To explore what this means in practice, we present a case study that describes an alternative approach to promoting the well-being of Latinx immigrant populations through the implementation of culturally adapted parenting interventions. There are two types of adaptations that we consider critical for success: the cultural adaptation of evidence-based parenting interventions, and the cultural adaptation of implementation strategies.

Although the adversity experienced by low-income Latinx immigrant parents can negatively affect their parenting practices,11 evidence-based parenting interventions are scarce in US Latinx immigrant communities.12 In addition, few evidence-based parenting interventions overtly address the impact of racism and other forms of discrimination experienced by low-income Latinx immigrants. For this reason, our research team, composed of university researchers and community leaders, has sought to culturally adapt parenting interventions for implementation in low-income Latinx immigrant communities.

The core of our proposed model establishes a working alliance among intervention developers, cultural adaptation researchers, and church leaders. The model also includes advocacy support for families. We consider advocacy services to be essential in supporting families as they cope with various intense stressors by the environment in which they live. Finally, we identify the business community as having a crucial role in ensuring the long-term sustainment of interventions.

What are the best ways to culturally adapt interventions? Scholars agree that a variety of methods are necessary. In our 15 years of experience adapting parenting interventions for Latinx immigrant families, we have learned that three strategies are essential: learning about the most relevant life and cultural experiences of focus populations prior to conducting adaptations; adapting and tailoring interventions according to the most relevant contextual and cultural experiences of diverse families; and continuously tailoring adapted interventions to ensure high contextual and cultural relevance.

In addition, planning for sustainable interventions is important and should be implemented at the outset of community-based initiatives.13 In our current work, we are identifying business leaders who are committed to social innovation—there is an emerging expectation in the business world that entrepreneurs become agents of social change in underserved communities.14 We consider this strategy essential, particularly because we must find and provide innovative models capable of sustaining community-based prevention initiatives beyond temporary funding cycles.

The Value of Cultural Adaptation

Our cultural-adaptation work over the past decade has focused on the evidence-based parenting intervention known as Parent Management Training Oregon (GenerationPMTO). The positive impacts of GenerationPMTO have been demonstrated in several studies over the past 40 years.15 The first cultural adaptation of GenerationPMTO for Latinx immigrant populations, Criando con Amor, Promoviendo Armonía y Superación (Raising Children with Love, Promoting Harmony and Self-Improvement),16 or CAPAS, followed a rigorous model of cultural adaptation.

In a prevention study of CAPAS with Latinx immigrant families in Michigan with children ages 4 to 12, we demonstrated the importance of overtly addressing immigration-related challenges and biculturalism. Specifically, we compared a version of the CAPAS intervention exclusively focused on parent-training components, with a CAPAS-enhanced intervention in which parenting components were complemented by sessions focused on immigration-related challenges, discrimination, and biculturalism. According to study results, the CAPAS-enhanced intervention was associated with the highest improvements in child mental health outcomes such as reduced anxiety and fewer behavioral problems.17 Parents expressed satisfaction with the CAPAS-enhanced intervention, as they had become aware of the ways in which immigration-related stressors such as discrimination negatively affected their parenting practices.18 Most recently, we completed a study with a version of CAPAS for immigrant families with adolescent children that demonstrated similar intervention impacts.19

We recently established a collaboration with San José Catholic Church, a major faith-based organization in Texas. As a foundational step, we conferred with church leaders to confirm that the proposed adapted parenting intervention was relevant to the needs expressed by community members. Next, we implemented a qualitative study with 30 parents to learn about their experiences as immigrants and their parenting needs. We then tailored the parenting intervention to their life experiences.

As expected, Latinx parents who participated in the qualitative study expressed a strong interest in attending parenting programs at churches. The sense of urgency to receive support was repeatedly highlighted by parents. “We all feel pressured about parenting,” one father told us. “There are many parents with adolescents in this community and they do not know where to go for help. ... We just need a lot of help.”

Caregivers also wanted parenting programs to be informed by a clear understanding of the discrimination that affects their lives and parenting practices. One mother described just one among the many examples of racial discrimination she encountered:

We attended a rally on immigration and a man walked toward us and told me, “You do not know what you are doing. President Trump is right about immigration. It is about cleaning the whole country, the whole United States.” My daughter told him, “I am a US citizen and I am also Mexican!” And he said back to us, “Yes, and that is why we need to clean the whole United States!”

Parents provided several painful testimonies about work exploitation, such as this one:

Our boss would take advantage of us because she knew we had a lot of needs and if the other workers did not like the job, they would just leave. But we were always there and they would never give us protection. One day, I cut my forehead very badly with a glass they left exposed, but she did not do anything for me. I had to go to the emergency room on my own and I had to pay for all my medical expenses.

In addition to quantitative indicators of intervention impact, parents confirmed their personal satisfaction with culturally adapted parenting programs. For example, caregivers consistently reported that the parenting practices learned in group led to stronger involvement with their children to implementing discipline in nonpunitive ways. “The discipline we learned here works really well,” one mother said. “Discipline by being firm but without fighting with them, offending them, disrespecting them. Now they are learning rules but also respect.”

Similarly, parents consistently emphasized the importance of learning new ways of interacting with their children. As one father said, “I always asked my children stuff by yelling at them. ... Practicing how to give good directions helped me a lot. ... I was the problem because I was always angry. We are basically learning how to be good parents.”

Co-Leadership Grounded in Community

In addition to adapting interventions, it is essential to implement culturally relevant strategies aimed at building trust, co-leadership, and active participation of community members. In our current collaboration, San José Catholic Church is the community leader of this initiative.

San José Catholic Church is the largest faith-based organization serving the Latinx immigrant population in Travis County, Texas. The church is composed of several ministries serving the needs of Latinx immigrant families. In this project, we work closely with the San José Social Justice Ministry, which is led by lay leaders engaged in initiatives focused on promoting the rights of Latinx immigrants. For example, Ofelia Zapata, the president of the ministry, serves on the board of trustees of the local school district where most low-income Latinx families reside.

The social justice ministry implements initiatives that are highly relevant to the local immigrant community. For example, the ministry is actively collaborating with key government agencies, such as law enforcement, to produce personal church IDs for undocumented immigrants. The objective is for immigrants to carry IDs that can be presented to law enforcement officials and demonstrate their affiliation with a highly recognized faith-based organization, in an effort to prevent biased police arrests and harassment.

The ministry also sponsors immigration legal aid programs that offer free-of-charge legal counsel to prepare mixed-immigrant-status families for the possibility of forced family separation by immigration authorities. Prior to the COVID-19 pandemic, the ministry gathered families to talk to immigration attorneys and discuss action plans if parents were deported by immigration authorities (e.g., transferring parental rights to relatives who are US citizens). These meetings would be followed by participation in our focus groups, in which parents discussed their parenting experiences and needs. To this day, our research team talks about the extraordinary resilience of these families in the face of intense adversity.

Why is San José’s leadership essential to this parenting support initiative? San José’s social justice ministry and its head priest, Father Jairo Sandoval-Pliego, have always demonstrated committed support toward this initiative, including obtaining all necessary authorizations that were required from San José’s Pastoral Council. In addition, the social justice ministry has been essential in helping us recruit ministry leaders who are already actively involved in implementing the parenting program. Furthermore, as we disseminate the intervention, the ministry will support these efforts by relying on their extensive network of collaborations with churches committed to serving Latinx immigrant populations in central Texas.

Takeaways

Our work has taught us a great deal about implementation, and we have found the following strategies especially helpful.

Parents as Interventionists | In the initiatives we have implemented, 83 percent of participating families have completed the parenting programs. We attribute this success partly to parenting groups being cofacilitated by both a clinician with a master’s degree and a parent from the community. The composition of the intervention-delivery team is important: Trained clinicians can identify and manage delicate clinical situations that often arise in parenting groups, while parent educators provide for a sense of empathy, safety, and trust that only community members can provide.

Beyond Interventions: Advocacy as a Human Right | Another implementation strategy crucial to our program’s success is supporting immigrant families beyond the prevention interventions. We believe this is a matter of social justice, particularly because there is a tendency for researchers and academics to fixate on “research outcomes.” We pair each participating family with an advocate whose role is to help families find resources to cope with a variety of contextual stressors, such as finding low-cost immigration legal services, food-assistance programs, and access to health care. In our current project, this work is led by the Migrant Clinicians Network (MCN), whose organizational mission is to reduce health disparities for people who need care but are unable to access it because of contextual challenges. Based on their mission and expertise in assisting families exposed to intense diversity, the MCN constitutes an ideal co-leader in this project.

Establishing Sustainment from the Beginning | Planning for sustainable interventions is a critical strategy that should be implemented at the outset of community-based initiatives. For this reason, we consider the involvement of business leaders who are committed to social innovation to be essential for these types of programs, particularly because it is important to provide innovative models capable of sustaining community-based prevention initiatives beyond temporary funding cycles.

It is unacceptable for the basic needs and human rights of poor Latinx immigrants in the United States to continue to go largely unaddressed, despite their role in undergirding the strongest economy in the world. We see this phenomenon as grounded in historical xenophobia, racism, and dehumanized capitalism. Thus, it is essential to promote conversations in implementation science aimed at finding alternatives to support the lives of underserved immigrant populations.

As the field moves forward, it must recognize and embrace the extraordinary leadership of faith-based organizations committed to serving vulnerable immigrant communities. We hope this article highlights the need to amplify the voices of faith-based community leaders as a counterbalance to those of researchers and academics whose voices have historically dominated the field. These leaders, their organizations, and the families they serve should always be recognized as the primary agents of change in ending legacies of adversity and oppression.

Support SSIR’s coverage of cross-sector solutions to global challenges. 
Help us further the reach of innovative ideas. Donate today.

Read more stories by Rubén Parra-Cardona, Ofelia Zapata, Maria Emerson, Deliana Garcia & Rev. Jairo Sandoval-Pliego.