The development of a culturally relevant preventive intervention

Researchers often publish the numerical findings of their intervention studies while overlooking the experiential findings that could help promote more appropriate and effective interventions in the future. The present paper describes the process by which we developed a culturally relevant preventive intervention for Korean American adolescents aged 11 to 14 years and their parents. We discuss the main findings of a series of pilot studies and demonstrated how lessons learned from each study guided the development process and informed the research that followed. Program development is an iterative process that incorporates feedback from study participants. Cultural relevance is ensured when participants’ voices are reflected in the program development, implementation, and evaluation process. The final outcome of the development process was the preventive intervention improving parent-child relationships, increasing parental knowledge, enhancing parental selfefficacy, and decreasing parental stress among Korean American parents, and ultimately promoting Korean American adolescents’ mental health. The specific aims of this two-group, repeated-measures, controlled randomized study were to test the feasibility of the PRIDE (Promoting Intergenerational Dialogue about Emotional Problems) intervention and to compare its efficacy with an attention control (AC) group regarding parental knowledge, parental and filial self-efficacy, parent-child (P-C) communication, P-C conflicts, and P-C satisfaction.


INTRODUCTION 1.Korean American Adolescents' Mental
Health and Parent-Child Relationships Among Korean immigrants to the US, children assimi-late to American culture and acquire English more quickly than their parents, who tend to adhere to Korean culture [1].In Kim and Wolpin's study (2008), 95% of Korean American adolescents (KAAs), children of Korean immigrants, reported that they could speak fluent English, whereas only 21% of their mothers and 40% of fathers reported that they could speak English "fairly well" or "well."As a result of cultural and language barriers, Korean American (KA) parents often feel powerless, guilty, and incompetent as parents.Their children often experience emotional burdens and disconnection from their parents [2][3][4].About half of the KAAs reported that their parents show high levels of control and low levels of care which indicates an affectionless control parenting style [5].Consequently, KAAs are unlikely to discuss with their parents critical developmental issues, concerns, and their school life and often do not receive enough parental guidance, which may lead to parentchild (P-C) conflict [2,4,[6][7][8][9]].An inadequate P-C relationship was found to be associated with depression, somatic complaints, hostility, withdrawal, anxiety, aggression, substance use, and suicidal behaviors among KAAs [5,6,[10][11][12][13][14].

Gaps between the Needs of and Services Available to KA Families
Numerous preventive interventions focusing on strengthening P-C relationships and promoting adolescents' mental health have been found to be successful in the US [15].However, the content and format of these programs do not sufficiently reflect issues that ethnic minorities or immigrant families encounter in their daily lives [16,17].To minimize chances for mismatches between existing preventive interventions and the needs of ethnic minority or immigrant families, to increase recruitment/retention rates, and to maximize treatment efficacy, researchers have adapted existing interventions to ethnic minority and ethnic minority needs [18].While culturally adapted interventions significantly increased recruitment and retention rates in one study, the interven-

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tions reduced treatment efficacy [16].In addition, a lengthened intervention resulted in a decreased retention rate among Asian/Pacific Islanders [16].KA parents who are culturally and linguistically isolated have not benefited from either the existing or the adapted preventive interventions [19][20][21].No preventive intervention has yet been developed or tested for KAAs and their parents.
In response to this wide gap between the needs and services available to KA families, we developed a culturally relevant preventive intervention for them, "Promoting Intergenerational Dialogue about Emotional Problems (PRIDE)".We expected the optimistic acronym, PRIDE, would attract KA participants, who are generally reluctant to attend programs with negative connotations, such as conflict resolution or mental health treatment.The program title capitalizes on cultural concepts that are important in KA communities: that parents being proud of themselves and instilling pride in their children are essential to harmony and mental health.To develop PRIDE in a culturally relevant way, we obtained feedback on program development, implementation, and evaluation from KA parents, KAAs, and professionals working with KA families, consistent with the recommendations of previous studies [22,23].
While researchers frequently publish the numerical findings of their intervention studies, those that do not also report the experiential findings overlook a way that could help researchers implement more appropriate and effective interventions in the future.The present paper describes the process by which we developed a culturally relevant preventive intervention for KAAs aged 11 to 14 years and their parents.This paper describes the detailed steps of the intervention development by summarizing the procedures and findings of three pilot studies.In study 1, we identified the main topics and structure of PRIDE based on findings from individual interviews with KAAs and their parents.Based on findings from study 1, we developed the first draft of PRIDE.During study 2, PRIDE was critiqued by KAAs, parents, and key personnel in the KA community and a final version of PRIDE was developed.Lastly, PRIDE was implemented and evaluated in study 3.

Study 1: Identification of PRIDE Content
The purpose of this qualitative description study was to explore KAAs' and their parents' perceptions of the main topics that a culturally relevant preventive intervention for them needs to address.We used this study design because we had very limited knowledge about KAAs' and their parents' mental health needs [24].Previously, no one has explored KAs' perceptions of a preventive intervention designed especially for KAAs and their parents.

Study Procedures
The purposive sample for this study consisted of 20 KAAs aged 11 to 14 years (10 boys and 10 girls) and their 21 parents (18 mothers and 3 fathers) who resided in the Chicago metropolitan area.Prospective participants were recruited from four KA churches that served as the religious as well as sociocultural institutions for KAs.To be eligible to participate in the study, KAAs needed to: 1) self-identify as KA; 2) be between 11 and 14 years old; 3) be born in Korea or the United States; 4) currently live in the United States with at least one of their parents; and 5) be willing to participate.KA parents needed to: 1) self-identify as KA; 2) be born in Korea and currently live in the United States; 3) have more than one child aged 11 -14; and 4) be willing to participate.The data were collected through in-depth, face-to-face, individual interviews, and the participants were interviewed either in English or Korean, according to their preferences.All parents and six KAAs chose to be interviewed in Korean.The interviews were conducted in the participants' homes, public libraries, or coffee shops and all interviews were audio recorded.Parents and KAAs were asked to identify main topics that the interventions need to address and possible barriers to the success of the interventions.They were also asked to list convenient times and locations that would facilitate participation in the program.The audio recordings were transcribed, and those in Korean were translated into English.Accuracy of the transcription and translation procedure was monitored by two independent researchers.Conventional content analysis was used to analyze the data and the quality of the data analysis procedure was assured through discussion among the researchers who coded the data independently.Data were then organized based on core interview questions (e.g., main content, format, barriers, and strategies).

Summary of Findings
KAAs and their parents identified the main topics for preventive intervention: adolescent development, stressors experienced by KAAs, communication skills, parenting skills, common mental health problems experienced by KAAs, ethnic identity, and knowledge about the US education system.Both KAAs and their parents agreed that the intervention should help them "understand each other," "teach them how to manage P-C conflicts effectively," and thus "make them bond naturally." The participants reported a need to increase productive and open communication between parents and their adolescents, especially around issues related to ethnic identity and pride that are necessary for KAAs to endure dis-crimination and acculturative stress.In addition, parents expressed concerns about their children's mental health and the need for knowledge about prevalent mental health problems experienced by KAAs.They wanted programs that increase parental knowledge about the U.S. education system and American culture to enhance their confidence as parents.The majority of the parents agreed that the father's participation in the intervention would be important.
Both the parents and KAAs reported that possible barriers to the success of the intervention would be limited time, a busy schedule, reluctance to share family problems in public, and lack of trust in the helpfulness of the intervention.Fathers mentioned that they would feel embarrassed and uncomfortable if there were more mothers than fathers and they were one of few fathers in the parent group.Regarding an appropriate time for the intervention, the parents preferred to have the intervention on weekends or weekday evenings.The parents and KAAs listed KA churches, community centers, libraries, and schools as the proper places for the intervention, but the majority of the participants agreed that KA churches and community centers would be the ideal places to conduct the intervention.

Development of PRIDE
The findings from study 1 guided the development of the first draft of PRIDE for KAAs between 11 and 14 years and their parents.The goal of PRIDE was to improve the P-C relationship by increasing parental knowledge of adolescence, school life, and adolescent mental health, by enhancing parental and filial self-efficacy, and by decreasing parental stress among KAAs and their parents.The main contents included adolescent development and stressors, communication, assertiveness, the US education system, cultural and generational gaps, and adolescent mental health.
PRIDE was designed as a six-session 90-minute faceto-face group intervention to be conducted weekly for six weeks.The main delivery methods were didactic presentation, structured group discussion, and role play.PRIDE was designed to offer five separate sessions for parents and KAAs and one joint session for both parents and adolescents.Separate sessions were designed to allow parents and KAAs to master knowledge and skills that matched their needs in their preferred language, English for KAAs and Koreans for parents.In addition, we expected the separate sessions would provide opportunities to address the main topics in more developmentally appropriate ways.During the interviews, KAAs reported that including fun and interactive learning activities was essential for adolescents, while parents chose didactic learning as the preferred teaching method.One joint P-C session (session 4) was designed to offer KAAs and their parents the opportunity to share their diverse perspectives on generational and cultural gaps in P-C relationships together.A KA church was chosen for the main setting for the intervention.

Study 2: Finalization of PRIDE
The second study was designed to finalize the development of PRIDE by having the tentative PRIDE program critiqued by the target population of the program, KA parents, KAAs, and key personnel in the KA community.

Study Procedures
To ensure that PRIDE was culturally relevant and consisted of appropriate content, we had the preliminary version of PRIDE critiqued by KA parents, KAAs, and key personnel in the KA community.We obtained critiques from KAAs aged 11 to 14 years, their parents, and key personnel who have a minimum of 2 years of experience working with KAAs and their parents in the following areas: acceptance, cultural relevance, strengths and weaknesses, clarity, and areas for improvement in content and structure of the program.Using a purposive sampling strategy, we recruited participants from KA community centers and KA churches.To obtain diverse opinions, we recruited participants from different churches from the ones used for Study 1.We used focus groups for KAAs and their parents and individual faceto-face interviews for key personnel.A focus group is useful for gathering perspectives from key stakeholders or consumers with common characteristics or interests.This method is commonly used when developing or improving programs through direct interaction among participants as well as between the researcher and participants [25].
After consent and parental permission and assent from the KAAs were obtained, parents and KAAs were given the PRIDE manual to review at home.The manual contained detailed information about each of the six sessions and step-by-step scripts.After a week of reviewing the manual, the focus groups were conducted: two focus groups for parents and two groups for KAAs.The focus groups were held at two different Korean churches and one educational institution located in the KA community.The focus group discussion began with an introduction that explained the purpose, ground rules, and duration.The moderator of the group made clear that all contributions would be valued.During focus groups and interviews, participants critiqued the content and structure of the program for cultural and developmental relevance.Sample questions used for the focus groups and individual interviews are listed in Table 1.
A total of 10 mothers and 9 KAAs (3 boys and 6 girls) participated in one of the fou focus groups.Both parent r focus groups and one of the two KAAs' groups were conducted in Korean.The group sessions were audiotaped, and confidentiality was assured.A focus group meeting lasted between 60 and 100 minutes.The same procedure as in study 1 was used to monitor the quality of the data management and analysis.
A purposive sample of 8 key personnel (2 youth pastors, 1 senior pastor, 3 teachers, and 2 social workers) constituted the sample of key personnel.We conducted individual interviews for key personnel due to their busy schedule.After the key personnel agreed to participate in the study, they were given the PRIDE manual to review for a week.Interviews were performed by a bilingual and bicultural interviewer.Four of the professionals chose to be interviewed in English and the rest of the key personnel chose to be interviewed in Korean.Interviews were conducted at their offices, churches, or other agreedupon convenient places and were audio-taped.Individual interviews lasted between 50 and 70 minutes.The interviews were audiotaped, transcribed, translated from Korean to English, and analyzed.

Summary of Findings
Overall, the participants agreed that the contents of the PRIDE curriculum were culturally and developmentally appropriate for KAAs and their parents.The participants also agreed that the contents of the program fit together and flowed smoothly.The majority of the KA professionals and KAAs reported that information about adolescent development would be very helpful for parents but not for KAAs, who are already exposed to similar information through physical education and other special classes at school.A junior high school English teacher also said that KAAs would feel uncomfortable and embarrassed to discuss puberty and physical development issues with their parents in a group setting.
The participants suggested that the contents be simple and interesting and use everyday words.They said that it was very important to present culturally-specific topics that KAAs and their parents could easily relate to, such as issues that KA families frequently argue about (e.g., culturally appropriate dress and manner, parental pressure for academic achievement, and peer relationships).Participants also mentioned that it would be most helpful to present information about mental health issues relevant to KAAs such as current statistics and culture-specific risk factors for mental health problems prevalent among KAAs, not general information on mental health.
The participants pointed out that the face-to-face group method, particularly the P-C joint session, may not be the most culturally relevant delivery method for KA families for the following reasons: 1) KAs are reluctant to discuss family problems in public, especially in the presence of friends and other parents; 2) KAAs and their parents have different educational needs; 3) language barriers exist between parents and children and between newcomers and US-born KAAs, and 4) KAAs and their parents have busy schedules, including extracurricular activities for KAAs and work schedules for parents.
Besides the didactic approach, the participants recommended using a variety of teaching strategies to maintain parents' and KAAs' attention.Effective teaching methods recommended were the use of video clips, vignettes, and role-modeling, particularly when teaching communication skills.All delivery methods should reflect situations and issues pertinent to KAAs and their parents.Parents and KAAs suggested situations and issues based on their experiences to be used in video clips (e.g., conflicts between an authoritarian father and Americanized son, conflicts between a mother feeling shameful about her inability to help with her son's school work and her son who is insensitive to his mother's feelings).
Concerning the lengths of the program, the majority of participants agreed that the program should not be long.A program that lasted more than 5 weeks would not be feasible for KAs, particularly for KAAs and their fathers who are consumed by extracurricular activities and work, respectively.The majority of the participants agreed that Korean churches would be the most appropriate setting.However, the participants strongly suggested that we use more than one church to avoid appearing to be associated with a particular KA church.A pastor said that if PRIDE is conducted only at one church, "other people will think it's a form of evangelism to recruit people to the church.It's sad but that barrier is there.I think that having different churches shows that you are trying to help people, not help the specific church."

Final Version of PRIDE
As a result of the focus groups and individual interviews, the original contents, structure, and delivery method of PRIDE were revised.First, PRIDE was redesigned as a parent-centered intervention.Through this parent-centered preventive intervention, parents are expected to implement their newly learned knowledge and skills with their children at home.This parent-centered approach will empower KA parents by placing them in positions of leadership in P-C interactions and assisting them in mastering knowledge and communication skills, thus restoring the P-C relationship and family roles.After the parent-centered preventive intervention is successfully implemented, a modified intervention for KAAs will be implemented.Second, PRIDE was changed to a 3-week, individually administered, computer-based preventive intervention.An individually-administered computer in-tervention is an effective delivery method for accommodating KA families' busy schedules and especially for recruiting and retaining working parents.This delivery method was also chosen to respect KA families' reluctance to share sensitive family issues in public.This 3-week program consists of three sessions with three media files containing lectures, case studies, video clips, and testimonies.(See Table 2 for detailed contents of PRIDE.)These resources were designed to provide an enhanced interactive learning experience.The case studies and video clips were developed based on situations shared and issues identified by the participants.

Study 3: Implementation and Evaluation of PRIDE
As the final step, using a two-group, controlled randomized design, we tested the feasibility and efficacy of PRIDE with 30 KA families recruited from a KA community.Participants were randomly assigned to either the PRIDE intervention group (n = 16 families) or the attention control groups (n = 14 families).Parents received a 3-week, individually administered, computer-based preventive intervention.Intervention feasibility was assessed by examining recruitment, retention, completion rates, and participants' satisfaction and acceptance of PRIDE.The efficacy of the program was determined by comparing the intervention and attention control groups on changes in outcome variables immediately at the end KAAs received no intervention, but completed an on-line survey at three points in time: before their parents watched the first media file, after their parents completed the 3-week intervention, and at 1 month post-intervention.We successfully retained all 30 families (28 fathers, 30 mothers, and 30 KAAs).At the completion of the program, we also conducted individual interviews with a subsample of the participants in the PRIDE group (4 fathers, 3 mothers, and 3 KAAs) to obtain their feedback on the strengths, weakness, and areas for improvement of the program.
In short, PRIDE was found to be feasible for KA families and was favored by both parents and adolescents.The results of the initial efficacy study were also promising at 1 month post-intervention.Particularly, fathers' parental knowledge (d = 0.82), mothers' parental knowledge (d = 1.95), fathers' report on P-C communication (d = 0.61), and KAAs report on conflicts with the father (d = 0.44) showed medium to large effect sizes of PRIDE compared to an attention control (AC) condition.Details of the initial efficacy study will be discussed elsewhere.

CONCLUSIONS
Many community-based programs have been implemented to promote adolescents' mental health.It is not uncommon for researchers to develop programs based on their own knowledge and suppositions about "what's best for the clients" [26].Furthermore, the efforts to offer culturally relevant programs have often been limited to an ethnic or linguistic match between the program providers and the clients.However, an ethnic or linguistic match does not necessarily guarantee the cultural relevance and the effectiveness of the program.To ensure the cultural relevance and the success of the program, it is important to listen to "active voice" of the prospective participants throughout the program development process [23].
This paper described the process by which we developed and strengthened a culturally relevant preventive intervention for KAAs and their parents, particularly how feedback from study participants and community members can inform future research.We believe that the lessons we learned from the process have made the PRIDE intervention more culturally relevant and a more effective program for KAAs and their parents.Even if the PRIDE was developed particularly for KA families, the development process and the main contents of the PRIDE can be easily applied to other groups of immigrant families, particularly Asian Americans.We also believe that researchers or clinicians developing or modifying preventive interventions would find the experiential findings discussed in this paper very useful.

Table 1 .
Sample questions for individual interviews and focus groups.

Table 2 .
Schedule and main contents of PRIDE.How adolescents' developmental characteristics can affect P-C communication and relationship  Effective ways to respond to those developmental changes without raising P-C conflict. Effective P-C communication skills  Understanding the significance of nonverbal communication and how to utilize nonverbal communication effectively  How to minimize misinterpretation  Understanding cultural differences in communication patterns and norms between Korean and U.S. culture  Understanding the importance of active listening and emotional support Overview of the US education system  Being familiar with different roles of school personnel (e.g., teachers, counselors, nurses, psychologists, social workers)  Parents' roles, rights, and expectations  What to ask and what to discuss with a child regarding his or her school life of the last session and at 1 month post-intervention.Outcome variables include parental knowledge, parental and filial self-efficacy, parent-child (P-C) communication, P-C conflicts, and P-C satisfaction.