Culturally Tailored Depression/Suicide Prevention in Latino Youth: Community Perspectives

Culturally Tailored Depression/SuicidePrevention in Latino Youth: CommunityPerspectives

Rebecca E. Ford-Paz, PhDChristine Reinhard, PhDAndrea Kuebbeler, LCSWRichard Contreras, PhDBernadette Sánchez, PhD

Abstract

Latino adolescents are at elevated risk for depression and suicide compared to otherethnic groups. Project goals were to gain insight from community leaders about depressionrisk factors particular to Latino adolescents and generate innovative suggestions to improvecultural relevance of prevention interventions. This project utilized a CBPR approach toenhance cultural relevance, acceptability, and utility of the findings and subsequentprogram development. Two focus groups of youth and youth-involved Latino communityleaders (n = 18) yielded three overarching themes crucial to a culturally tailored depressionprevention intervention: (1) utilize a multipronged and sustainable intervention approach, (2)raise awareness about depression in culturally meaningful ways, and (3) promote Latinoyouth’s social connection and cultural enrichment activities. Findings suggest that bothadaptation of existing prevention programs and development of hybrid approaches may benecessary to reduce depression/suicide disparities for Latino youth. One such hybrid programinformed by community stakeholders is described.

Address correspondence to Rebecca E. Ford-Paz, PhD, Ann & Robert H. Lurie Children’s Hospital of Chicago,Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave, Box 10B, Chicago, IL 60611, USA. Phone:+1-312-2276039. Fax: +1-312-2279461. E-mail: [email protected].

Christine Reinhard, PhD, Children’s Hospital of Philadelphia, Philadelphia, PA, USA.Andrea Kuebbeler, LCSW, Alternatives, Inc., Chicago, IL, USA.Richard Contreras, PhD, Healthcare Alternative Systems, Chicago, IL, USA.Bernadette Sánchez, PhD, DePaul University, Chicago, IL, USA.The project described was supported by the National Center for Research Resources, grant 5UL1RR025741, and is now at

the National Center for Advancing Translational Sciences, grant 8UL1TR000150. The content is solely the responsibility ofthe authors and does not necessarily represent the official views of the NIH.

Journal of Behavioral Health Services & Research, 2013. 1–15. c) 2013 National Council for Behavioral Health. DOI10.1007/s11414-013-9368-5

Depression/Suicide Prevention for Latino Youth FORD-PAZ et al.

Introduction

Latino adolescents are at increased risk for depression and suicide compared to other ethnic groups, lessthan half as likely as European-Americans to have received a diagnosis of depression or evidence-basedtreatment, and more likely to drop out of depression treatment prematurely.1–4 Salient obstacles to helpseeking for Latino adolescents include lack of access to health insurance, language barriers, Latinoparents not recognizing symptoms of depression as a serious healthcare issue, stigma of seekingpsychiatric care, and lack of knowledge on treatment options and benefits of treatment.5–8 As a result ofdelayed help seeking, the point of entry into the mental healthcare system for Latino youth is oftenthrough emergency departments and/or inpatient psychiatric hospitalization following a suicide attempt.9

Although evidence-based treatment for adolescent depression exists, treatment is underutilizedby depressed Latino youth and alone cannot reduce the number of new cases of depression; thusprevention efforts are warranted.10,11 Since depression is conceived as one of the most salient riskfactors for adolescent suicide, depression prevention and ensuring access to treatment are oftenconceptualized as key components of suicide prevention.12–14 Current approaches to depressionprevention have not successfully reduced depression or suicide prevalence disparities in Latinoyouth. Potential explanations for the apparent limited impact of these interventions on theadolescent Latino population in the USA include reliance on tertiary prevention (targeting youthwho are already depressed or suicidal), focus on individual-level intervention as opposed tocommunity-level intervention for youth at risk for depression, high refusal rates of depressionprevention services by Latino adolescents and families, reliance on delivery by highly trainedmental health professionals, implementation in one setting only for a limited time, and lack ofcontent related to contextual factors that increase Latino adolescents' vulnerability to depres-sion.15–19 Common cultural beliefs and values among many Latino ethnic groups could constitutethe building blocks of culturally relevant and effective depression prevention programming.20

Experts have recommended that to enhance the cultural relevance of prevention interventions,researchers must work with the community of interest to conduct qualitative research to informintervention.20,21

Accordingly, an exploratory qualitative study that emerged from a community academicpartnership was conducted. The aims of this study were to (1) obtain insight into perceivedlimitations of prevention efforts for Latino adolescents, (2) identify sociocultural factors particularto the development of depression in Latino adolescents to be targeted by prevention efforts, and (3)generate innovative ideas for culturally tailoring depression/suicide prevention interventions forLatino adolescents.

Methods

A community-based participatory research (CBPR) approach is useful in doing formative work,such as intervention development, to address mental health disparities with ethnic minority andimmigrant populations. By involving community partners and stakeholders in early stages ofintervention development, the cultural relevance, acceptability, and utility of the research to thecommunity of interest is enhanced.22 Through multiple meetings to build trust and define aresearch agenda, academic and community partners from the city of Chicago (Table 1)collaboratively selected depression/suicide prevention as a topic of mutual interest and conductedfocus groups with adult and adolescent leaders in the Latino community to inform an innovativeand culturally tailored approach to depression/suicide prevention in Latino youth. From July 2010to June 2011, partners met bimonthly to build trust and capacity to conduct research and tocontribute equitably to the study design, data collection, analysis, and interpretation. Thecommunity partners, predominantly bilingual/bicultural (Spanish and English), enriched theacademic members' knowledge and understanding of the Chicago Latino communities with their

The Journal of Behavioral Health Services & Research 2013

hands-on experience living and working in these communities and played an equal role in decisionmaking throughout.

Participants

Purposive sampling achieved a heterogeneous sample of adult and adolescent focus groupparticipants consisting of bilingual leaders endogenous to the Chicago Latino community whowere diverse in ethnic/national backgrounds, socioeconomic status, language preference,profession, neighborhood, and sex. Relying heavily on community partners' expertise, contact,and familiarity with members of the community, partners nominated, discussed, and came to aconsensus on leaders to target for recruitment due to their potential to provide rich, relevant, anddiverse perspectives. Adults were youth program organizers, pediatricians, clergy, schoolpersonnel, community health workers, and parents. Adolescents were youth council members,health leaders at local agencies, volunteers with the police, members of the school health club, peereducators, tutors, and community activists. All adolescents and over three quarters of the adultsknew someone personally who had depression.

Procedure

Informed consent was obtained from 10 adult and 11 adolescent participants consistent with theprocedures of Children's Memorial Hospital's Institutional Review Board, but 3 later withdrewciting schedule conflicts. Study participation involved attending three meetings (informationalsession, focus group, and member checking discussion), each of which lasted approximately120 min. Participants received transportation to the meetings (held at a community partner agency),breakfast, on-site childcare, and a US$20 gift certificate at each session. Prior to the focus groups,nine adult and nine adolescent participants attended an informational meeting to (1) gain a basicunderstanding of the topic of depression, mental health disparities in Latinos, and currentprevention efforts; and (2) encourage innovation in suggestions to improve depression/suicideprevention interventions' utility and relevance to Latino adolescents.

Table 1Community and academic partners

Partner Description

Ann & Robert H. Lurie Children's Hospital ofChicago (formerly Children's MemorialHospital), Northwestern University FeinbergSchool of Medicine

Academic partner

Healthcare Alternative Systems Behavioral/social service provider forpredominantly Latino population

Alivio Medical Center Healthcare provider serving low-incomeLatino community

Alternatives, Inc. Youth development/behavioral health agencyserving predominantly ethnic minorityyouth


Focus groups

Focus groups are an excellent way to explore group ideas about an issue and elicit communityperspectives.23 Focus groups took place a week after the informational session. The 18 adult andadolescent participants split into simultaneous focus groups co-facilitated bilingually by oneacademic and one community partner (see Table 2 for the demographics of focus groupparticipants). All co-facilitators were fluent in English and Spanish and had extensive histories ofworking with Latino populations. The focus group guide contained open-ended questions on eighttopics: risk factors, limitations of existing prevention programs, cultural factors important toprevention programming, detection of early warning signs, improving referral rates, image ofmental health care, technology and outreach, and the “ideal” program. Group facilitators askedquestions in Spanish and English and projected the written questions on the wall in both languages.All focus group participants used pseudonyms to preserve their confidentiality and responded intheir language of preference. Focus groups were audiotaped and transcribed. At the conclusion ofthe focus groups, participants completed a short demographic questionnaire that included thefollowing question: “Do you know anyone who has experienced depression?”

Data analysis

A general inductive approach informed by grounded theory was utilized which allows researchfindings to emerge from the frequent, dominant, or significant themes inherent in raw data.24 The firstauthor trained a community partner, postdoctoral fellow, and graduate student on qualitative coding andanalysis and joined them in repeated readings of the transcripts to collaboratively identify major codesand subcodes and develop a codebook. When there were disagreements in codes, the team discussedand arrived at a mutually acceptable code or created a new code together, continuing to revise the

Table 2Demographics of participants

Youth (n=9) Adults (n=9)

Average age, years (range) 16 (14–18) 46.22 (27–61)Gender, n (%)

Male 6 (67) 4 (44)Female 3 (33) 5 (56)

Ethnicity, n (%)Mexican/Mexican-American 6 (67) 3 (33.33)Puerto Rican 1 (11) 1 (11.11)Ecuadorian 1 (11)Salvadoran-Honduran 1 (11)Colombian 1 (11.11)Honduran 1 (11.11)Argentinian 1 (11.11)Puerto Rican-Guatemalan 1 (11.11)Non-Latino white 1 (11.11)

Country of origin, n (%)USA 5 (56) 5 (56)Foreign born/born in Puerto Rico 4 (44) 4 (44)

Range of years of education 8, grade school–some college 6, grade school–medical school


categories of codes in the codebook. The team coded transcripts independently and met weekly to cometo a consensus on the final codebook until no new codes were being generated. After the codebook wasfinalized, the data analysis team coded the transcripts independently a final time and met to resolvediscrepancies in final codes attached to the text.

Member checking is a technique used in qualitative research to increase the credibility andtrustworthiness of the findings.25 At a third meeting, 3 months after the focus groups, partnersreconvened study participants (six youth and three adults), presented preliminary results andprogram ideas, and asked participants to comment on the findings and whether the researchers'interpretations reflected their input accurately.

Results

The data produced three overarching themes essential to the success of a culturally tailoredintervention for depression and suicide in Latino youth: (1) utilize a multipronged and sustainableapproach, (2) raise awareness about depression in culturally meaningful ways, and (3) promotesocial connection and cultural enrichment activities. Table 3 provides an outline of the majorthemes, subthemes, and exemplary quotes.

Theme 1: utilize a multipronged and sustainable approach

One salient finding was that a singular strategy (i.e., restricted to one venue/modality) or a time-limited intervention was perceived as insufficient to undo pervasive and deep-seated stigmatizedattitudes, lack of knowledge, and reluctance to seek help in the Latino community. Both groups werestartled by the scope of disparities in depression/suicide prevalence and mental health service use andadvocated for combining multiple strategies (e.g., public awareness campaigns, educational outreach,youth development activities, skill-building activities) to reach different subpopulations and ensurelong-term sustainability. Discussion included the prevention of symptom onset and progression ofsubclinical symptoms to clinical depression and suicidal behavior.

Theme 2: raise awareness about depression in culturally meaningful ways

A pervasive theme was the importance of a culturally tailored depression/suicide awareness andeducational campaign that, instead of targeting solely Latino youth, would infiltrate the entireLatino community. This educational campaign would increase knowledge about depression andevidence-based treatment, combat stigma, and encourage early mental health service utilization asopposed to crisis intervention for suicidal behavior. Two subthemes, described below, emerged asessential components of a “culturally tailored” campaign.

Information that highlights risk factors specific to Latino youth

Focus group discussions of risk factors were broad, but special attention was given to issues thatput Latino adolescents at particular risk for depression and suicide. One common theme was howstigma presents a barrier to help-seeking behaviors and significant pressure to manage problemswithin the family. Many participants discussed how Latino culture frowns upon expressingemotions and seeking professional help for distress, labeling those who do as “crazy.”

Another prominent risk factor was the Latino youth's perceived lack of support and pronouncedsocial alienation. Participants explained that Latino parents are not available or open to discussionof adolescents' feelings, resulting in bottling up of emotions. Furthermore, youth, particularlyLatinas (due to traditional gender role value systems), were thought to feel higher levels of stressand lower levels of parental support due to complicating factors resulting from low socioeconomic


Table 3Overarching themes, subthemes, and exemplary quotes

Overarching themes Subthemes and exemplary quotes

1. Utilize a multipronged and sustainableapproach

•Aurora* (adult): “I think it can't just be one outlet,you have to have multiple outlets… not justschool, not just community. It has to be a holistickind of thing.”

•Pablo (adult): “I just think that it's very importantthat whatever… methods are established, that ithas to be consistent, it has to be persistent, it hasto be something that is not just a 10 week thing.They have to be a long-term plan … It cannot be aone year thing.”

2. Raise awareness about depression inculturally meaningful ways

•Aurora (adult): “Starting some of those healthtrainings at a younger age with the parents so thatthey're equipped with some type of knowledge toreally just understand adolescents. … this is what anormal teenager acts like… these are signs ofdepression.”2.1. Risk factors particular to Latino youth

2.1.1. Stigma•Pablo (adult): “…What goes on within the

Latino family stays within that family. So youngpeople are not encouraged to speak outside of thefamily - what they're feeling, their issues. So ifthere's something going on in the family it has tostay ‘hush hush.’”

2.1.2. Social alienation, lack of social support•Vinnie (teen): “Hispanic families are not really

open with their kids… it really doesn't give the kidan option to speak out what they're feeling - toexpress themselves in a way that it wouldn't beholded and bottled in, and it progresses and it goesmore than it has to be.”

•Carlos (adult): “Our youth … many timesare alone. The father, the mother are working andthey (the youth) have to take care of the youngerones…the parents are not around when they (theyouth) have a need…”

2.1.3. Immigration and acculturation issues•Rafa (adult): “Latino youth who are illegal in

the United States, and as such have a lot of barriers. Iknow kids that get to college, they can't get jobs, theyare blocked from this or that…they know it is unjustbut they are the ones being punished for the systemwe have. Not just in Arizona, but Chicago too.”

•Andrea (adult): “Our children come from adifferent culture, and we live in the United States


Table 3(continued)


where they're faced with different ways oflifestyles. And I think that they expect somethingat home from them, the schools and thecommunity expects something else…”

2.1.4. Discrimination•Sergio (teen): “The way the news talks about

the Latino community, like ‘oh, we're gonnatighten the border,’ or, ‘we need to send moreborder patrols.’ So all of that is directed towardLatinos, how does that make the Latinocommunity feel? It makes the Latino communityfeel unwanted and makes them feel like weshouldn’t be here as opposed to every other race.”

2.2. Cultural relevance to Latino youth2.2.1. Education delivered by people with

whom Latinos can identify•Aurora (adult): “Teenagers really look to

people who kind of they can see themselves in, orthey've seen have been through some type ofexperience… They really look to someone thatthey can say, ‘You went through it’ or ‘You lookjust like me and you understand my culture. Youknow what it's like.’”

2.2.2. Importance of family•Marcela (adult): “I think that family is

incredibly important.”•Nando (teen): “In the program we should

also include some… a bridge program for family.”2.2.3. Use of technology

•Pablo (adult): “Social network is massiveright now … If we can somehow structure acampaign utilizing what young people are alreadyusing,… you can get the word out. Text messagingcampaigns, Facebook campaigns, all thesedifferent methods that we can use. I think it'sincredibly valuable resource…”

3. Promote social connection and culturalenrichment activities for Latino youth

•Marcela (adult): “…Being productive is reallyimportant as a prevention to depression. I thinkthat one of the best ways to get depressed is to beidle.”

•Nando (teen): “…Games, trivia, poetry, art, musicand things like that that we all like, that makes usfeel better. That if we are doing something that welike, we're gonna eliminate those signs ofdepression…”


status, such as having to assume adult responsibilities early on (e.g., childcare, housework). Likewisedue to financial pressure and many parents' limited educational backgrounds, Latino youth feelunsupported by their families in pursuing their educational goals and pressured to contribute to familyincome. Increased responsibilities often preclude Latino adolescents from participating in extracurric-ular activities that might serve to raise self-esteem and/or combat social isolation.

Frequently linked to discussions of financial pressure were issues related to immigration statusand acculturation. For undocumented Latino youth and families, limitations on economic mobility,educational aspirations, and employment opportunities are significant contributors to a sense ofhopelessness. Often played out in family dynamics, the process of acculturation or adapting tobiculturalism involves English language acquisition and navigating clashes between mainstreamUS culture and their culture of origin. Participants discussed the stress involved in trying to meetcontradictory expectations of parents and the American society (e.g., peers, school). As youth tendto learn English more quickly than their parents and parent–child communication is hindered,participants explained that the linguistic acculturation process often compounds adolescents'feelings of alienation, and, subsequently, the role of the parent as a life guide is undermined.Feelings of social alienation also were thought to come from the youth's progressive lack ofconnection with and knowledge about their culture of origin.

Finally, discrimination was recognized as a contributor to elevated rates of depression in Latinoyouth. Youth discussed getting teased for speaking Spanish and pressured to assimilate linguistically asearly as kindergarten. Participants also discussed how Latinos are often targeted and put down by otherethnic minority groups due to their immigrant backgrounds.

Table 3(continued)


3.1. Interactive/promoting social connectedness•Vinnie (teen): “I think having a program thatwould, you would interact with more peoplewould be better … go to the park and stuff, havea family picnic with the program or something.Even if they don't bring your family, they couldjust have the people there that are with them causethey might become like family to them, they mightstart becoming closer and closer like playingsports, softball, baseball, having a good time…”

3.2. Cultural enrichment activities•Paco (teen): “Also I think the background, historybackground should be included. Because… asLatinos we don't know a lot about our backgroundculture because what we learn in school is a lotabout American history, not as in our culture. …And it's a lot of wonderful things and a lot ofbeautiful art that a lot of us as Latinos don't knowabout.”

Themes and subthemes are italicized*Pseudonyms have been used to protect the participants' identity


Making education culturally relevant to Latino youth

Participants focused on the absence of culturally relevant content included in existentdepression/suicide prevention campaigns. They described several key elements to ensure culturalrelevance of awareness and education campaigns benefiting Latino adolescents. Emphasis wasplaced on educators being the people with whom Latino youth and families can identify. Attributesof such educators included ethnic and generational similarity to the audience and culturalcompetence. Additionally, the use of testimonials was accentuated as an effective way topersonalize and destigmatize the information presented. Both groups discussed the importance offamily in Latino culture. Many mentioned the need to educate parents about risk factors fordepression and early warning signs, while others emphasized the need to improve parent–childcommunication and connection through family interventions. Lastly, in tune with normativebehavior for adolescents in modern times, both groups emphasized the central role that technology(e.g., Facebook, texting) should play in disseminating information and publicizing educationalevents.

Theme 3: promote social connection and cultural enrichment activities for Latino youth

In response to the risk factors of social isolation and acculturation stressors, another majortheme discussed was the involvement of Latino youth in positive activities that would affordopportunities for emotional expression, social connection, and cultural enrichment. While bothadults and adolescent groups focused on increasing physical activity and after-school didacticprogramming, youth participants discussed the importance of engaging youth in the communitythrough social, interactive, and experiential activities, instead of relying on individual-levelinterventions that utilize didactic techniques or emphasize self-help. Many mentioned the desire toincrease the sense of connection with family or other community members to decrease socialisolation. Likewise, youth, but not adults, discussed at length the need for interventions to includecultural enrichment activities that would build self-esteem and a sense of connection with cultureand community. Thus, increasing Latino youth's participation in creative activities, sports, clubs,and cultural enrichment activities was a strategy that all participants thought would serve aprotective function.

Synthesizing the themes for program development

Feasibility considerations

While the cultural importance of family was highlighted during focus groups, parentalinaccessibility was emphasized in both groups as a significant barrier to the feasibility of manystrategies. A possible solution to accessing Latino parents was equipping trusted and respectedleaders/helpers already embedded in different community settings to disseminate educationalinformation in their routine contacts with Latino families. Natural youth-involved communityleaders (e.g., teachers, pediatricians, clergy, community health workers, school counselors, youthpeer leaders) were mentioned as alternative sources of social support for at-risk youth, informationfor youth and families, and linkage to services for Latino adolescents and their parents whendepressive symptoms have already emerged.

Marcela (adult): “Pediatricians … we're very much trusted providers and if we say to parents, ‘you know this issomething you can do to prevent or encourage your child to succeed,’… those are messages that are really taken atnot just at face value but with an extra, extra strength.”Jesse (adult): “I was never so aware as I have been this past week of how strong the problem is… I think that doingmore programs with civic leaders is very, very important. Teachers, priests, ministers, we work with young people tobe really much more conscious and aware because honestly it wasn't something we even thought about before.”


Initial program ideas receiving participant support

From the synthesis of overarching themes and participant feedback during member checkingemerged the idea of a multifaceted, community-based, culturally tailored depression education andoutreach program benefitting both Latino youth at risk for and those exhibiting early signs ofdepression (see Table 4 for an outline of how this program idea incorporated major themes). Toincrease the potential of reaching the most marginalized members of the Latino community,naturally embedded, trusted, and respected community leaders/helpers in a variety of communitysettings would be the target participants of the program. Preliminary program structure includes atraining, bilingual community resource toolbox, tour of outpatient psychiatric facilities todestigmatize help seeking, and a follow-up phase to support outreach/educational and screening/referral activities. Training of community leaders/helpers will increase their knowledge aboutdepression/suicide, treatment options, risk factors in Latinos, and outreach strategies. Additionally,they will be trained in engaging youth at risk for depression in evidence-based strategies to increaseactivity level and social connectedness, as well as new interventions centered on increasing ethnicpride through youth group activities that raise awareness about cultural heritage and customs.Finally, leaders/helpers will learn strategies to improve the depressed youth's and their families'motivation to seek help, support engagement in services, and monitor compliance with treatmentand skill practice on an ongoing basis.

Discussion

This study is unique in its utilization of a CBPR approach that included adolescent stakeholdersto elicit community perspectives on sociocultural factors that impact depression and help seekingand generate innovative ideas for culturally tailored depression and suicide preventioninterventions for Latino youth. Focus group participants predicted that Latino youth would notdemonstrate adequate response to traditional depression prevention initiatives using individual-level and time-limited approaches. Results of this study suggest that the impact of existingdepression/suicide prevention interventions may be strengthened by including culturally relevantinformation and adopting a multifaceted (combination of strategies), ecological/community-levelapproach. To achieve this goal, both the adaptation of existing depression/suicide preventionprograms and the development of hybrid approaches are likely to be relevant.

Although study participants used different (lay) terminology to describe suggested interventions,their recommendations for depression/suicide prevention for Latino youth encompassed aspects ofseveral strategies described in the literature, including mental health literacy/first aid campaigns,positive youth development programs, and training of gatekeepers and community health workers.Findings paralleled Pérez and Muñoz's support of multitiered prevention interventions that equipcommunity members to intervene on two levels: the prevention of the onset of depressivesymptoms in the at-risk Latino adolescent population (selected or secondary prevention) and theexacerbation of mild symptoms (indicated or tertiary prevention).20 Echoing depression preventionexperts,18,20 community stakeholders also suggested that utilization of a combination of strategiestargeting culturally relevant risk factors and delivery by non-mental health professionals wouldimprove the effectiveness of depression interventions for Latino adolescents. Although thesuperiority of multifaceted and long-lasting interventions is widely recognized,14,18–20,26

depression prevention programs for the youth in general continue to focus on intervention in onevenue (e.g., school) for a limited number of sessions.15 Community stakeholders in this studystressed that a culturally tailored intervention for Latino youth must be comprised of ongoingmultimodal intervention to address the deeply entrenched stigmatized beliefs and attitudes aboutmental health help seeking, not only in the youth themselves but also in their caregivers and socialnetworks. As CBPR has been identified as an ideal way to design depression-specific anti-stigma


Table 4Incorporation of themes into hybrid program development

Overarching themes Depression literacy and outreach program

1. Utilize a multipronged and ustainableapproach

•Multipronged because1. Participants in depression literacy training wouldcome from multiple settings (e.g., schools,religious institutions, social service agencies,primary care) and thus have the potential toreach out to youth and families who accessservices in one setting, but not others

2. Intervention would combine preventionstrategies and strength-based approaches

3. Intervention would be multitiered—preventingonset and exacerbation of depression

•Sustainable in time and cost because the leaders trainedalready have a commitment to and role in thecommunity that will long outlast the research project

2. Raise awareness about depression inculturally meaningful ways2.1. Risk factors particular to Latino youth •Educational focus on early warning signs and risk

factors particular to Latino youth2.2. Cultural relevance to Latino youth •Delivered by people with whom the community can

identify to increase acceptability of the educationalcampaign-Participants who are trusted and respected communityleaders, including both bilingual (and when possiblebicultural) adult and adolescent leaders

-Testimonials can personalize the information andincrease identification with the material

•Involvement of family-Training will emphasize the importance ofdisseminating information (e.g., including riskfactors such as social alienation and acculturationdifficulties) to parents in trainees' routine contactswith them

-Training will include information on the disruptionof parent–child communication due toimmigration, acculturation, and economic stressors

-Community resource toolbox will includeinformation on parent–child communication

•Technology-Training will emphasize the importance of utilizingtechnology such as texting, Facebook, web pages,etc. to disseminate information and publicize events

-PowerPoint training curriculum and electronicmaterials with visuals and film clips of Latinoindividuals will be made available in Spanish andEnglish


campaigns relevant to populations who might experience multiple prejudices,27,28 this researchmakes an important contribution to the literature to address mental health disparities in Latinoyouth.

Consistent with Jorm's definition of mental health literacy, the partnership defines depressionliteracy as the knowledge on how to prevent depression, early signs of depression, treatmentoptions, effective self-help strategies for mild problems, and first aid skills to support others incrisis.8 Focus group data suggested moving beyond individuals' depression literacy by trainingcommunity members on outreach approaches to influence community depression literacy.Consistent with Pérez and Muñoz's recommendations20 to enhance cultural competence ofprevention interventions for Latinos, it was further suggested that interventions for Latinoadolescents should emphasize culturally relevant risk factors and incorporate the core cultural valueof the importance of family. By increasing awareness on how Latino youth are differentiallyaffected by risk factors, community members and parents may be impelled to engage in activitiesthat would mitigate these risk factors, vigilant for early symptoms of depression, and motivated toseek treatment earlier to avoid suicidal crises.

Depression/suicide prevention programs have been dominated by models utilizing evidence-based treatment (e.g., cognitive behavioral therapy) techniques that target intrapersonal deficits(e.g., cognitive, interpersonal, and emotional) on an individual level with those already showingsigns of mild depression.19,29 Due to the ongoing disparities in rates of depression amongLatino youth, alternative and complementary strategies must be considered. Strength-basedinterventions that focus on fortifying social support networks and enhancing competencies incommunities of at-risk individuals have been suggested as an alternative approach to adolescentdepression/suicide prevention.19,29,30 The National Research Council and Institute of Medicine'slandmark report on prevention of mental illness strongly recommended the need forenvironmental interventions that address social and community factors (e.g., nurturing personalenvironments).31 Positive youth development programs are one such intervention, the goals ofwhich include promoting social connection, fostering resilience, instilling hope, and developinga positive identity.32 Positive youth development programs, although not intended to preventdepression, have many attitudinal (e.g., self-concept, self-efficacy) and behavioral (e.g., problemsolving) competency targets that are implicated in the etiology and maintenance ofdepression.19 Results from this study suggest that involving youth in community-based positiveyouth development programs focused on cultural enrichment and resiliency (e.g., exposure to

Table 4(continued)

Overarching themes Depression literacy and outreach program

3. Promote social connection and culturalenrichment activities for Latino youth

•Training will emphasize outreach and connectionwith Latino youth

3.1. Interactive/promoting socialconnectedness

•Training in basic behavioral activation as a self-helpstrategy to facilitate youth goal setting and increaseactivity level (with special emphasis on social andcultural enrichment activities)

3.2. Cultural enrichment activities •Training on youth development activities alreadyavailable in the community

•Training on how to influence parental willingness toencourage Latino youth to participate in activitiesoutside the home that would increase self-esteem


positive role models from the same ethnic background, group activities that educate the youthabout their cultural heritage and history, and openly discussing and problem solvingacculturation/immigration stressors) could buffer the toxic effects of social isolation,discrimination, and immigration and acculturation stress.

Interventions that train community gatekeepers and lay community health workers have beeneffective in raising community awareness, skill building, case finding, and linkage toprofessional services in culturally relevant ways for various health conditions.12,14,33,34

Consistent with the mental health literacy literature, study findings suggest that a key to youthseeking help is equipping their supporters (e.g., family, teachers, friends) with knowledge aboutdepression, treatment options, the benefit of treatment, how to access services, and earlyintervention and crisis management skills.5,21 While education of family members wasemphasized as highly desirable in this study, programs targeting Latino parents directly havebeen hampered by very low participation, suggesting a lack of feasibility.35 By trainingcommunity helpers with routine contacts with hard-to-reach Latino parents, depression educationmay be disseminated to Latino families more effectively. Also, non-mental health professionalcommunity helpers have been successful in learning and implementing evidence-basedtherapeutic strategies to reduce depression in other countries.36 In order to increase access toevidence-based strategies to prevent depression in underserved populations, Latino communityhelpers could be trained in simple evidence-based therapeutic strategies (e.g., behavioralactivation) and educated about the importance of cultural enrichment activities in particular tointervene on several different levels (e.g., with individuals, families, communities). Althoughmany of these strategies have been discussed in the literature,12,20,37 they have seldom beenutilized concurrently and have not been applied in the context of depression/suicide preventionfor Latino adolescents.

Limitations

Although qualitative data collection is considered complete when “thematic saturation” isachieved, Krueger and Casey suggest that a minimum of three to four focus groups beconducted.38 Since two focus groups were conducted, the findings may be idiosyncratic or notgeneralizable. This concern, however, is somewhat alleviated by careful attention placed onrecruiting a heterogeneous sample with diverse ethnic, socioeconomic, linguistic, professional,and national backgrounds. Additionally, data analysis included member checking to enhancecredibility and trustworthiness of the data. No new themes were revealed during memberchecking, providing some evidence that thematic saturation was achieved. However, given theexploratory nature of this study and the small sample, the results should be considered asinitial suggestions for intervention adaptation and development and should be explored furtherin future research.

Implications for Behavioral Health

This exploratory CBPR study generated insights from community stakeholders, including Latinoadolescents, valuable in informing culturally tailored, community-based depression/suicideprevention interventions benefitting Latino youth. Findings indicate that combining multipleprevention and strength-based strategies and enhancing the cultural competency of the interventioncontent hold promise in decreasing disparities in depression and suicide in Latino youth. In contrastto traditional prevention interventions, the proposed approach would benefit Latino youth who areat risk for or showing early signs of depression, be delivered by non-mental health professionals,continue long term, and emphasize community education on culturally relevant risk factors fordepression/suicide. More research is needed to develop and test the effectiveness of such hybrid


interventions in reducing risk factors and enhancing protective factors in Latino youth, improvingaccess to evidence-based treatment for depressed Latino youth, and increasing depression literacyand professional help seeking in the Latino community.

Acknowledgments

This project would not have been possible without the cooperation and time of the staff andadministrators from Alivio Medical Center, Alternatives, Inc., and Healthcare Alternative Systems.The authors gratefully acknowledge the editorial assistance of Darius Tandon, PhD.Conflict of interest The authors do not have financial or any other conflicts of interest regarding thecontents of this manuscript.

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Culturally Tailored Depression/Suicide Prevention in Latino Youth: Community Perspectives