Throughout these 5 cohorts, our research team conducted in-depth process evaluation approaches to identify strengths and weaknesses of the program from the community’s perspective. With this feedback, we engaged in self-reflection as a team and opened our ears to participant’s voices and implemented their suggested changes. In line with the NBLIC’s CBPR principles, our research team along with previous participants and community partners identified four lessons that guided the development and adaptation made to the LEADS intervention over time. Specifically, we learned the importance of (1) developing a culturally sensitive curriculum; (2) recruiting diverse research team members with shared lived experiences and engaging in self-reflection; (3) recognizing heterogeneity among families from minority racial-ethnic backgrounds; and (4) utilizing a strength-based research approach. The comprehensive process in which we learned these lessons and adapted the LEADS program is described in detail below.
Lesson 1: developing a culturally sensitive curriculum
Initially, the LEADS intervention curriculum focused on health promotion and partially integrated cultural resilience and stress management content (See Table
1 for detailed Timeline). Weekly sessions included key content, interactive activities, group discussions, stress management techniques, group exercise videos, and family bonding take-home activities. Key content targeted a range of topics regarding health promotion, stress management, and positive parenting strategies (See Table S2 Supplemental Materials for curriculum details). As shown in Table
1 (Timeline), only a few of the 10 sessions included cultural-focused content, including discussions on how racial stress impacts health, parenting strategies for safety concerns, and considering family traditions of stress-coping and cultural activities. To assess the feasibility and acceptability of our intervention curriculum, including the minimal cultural resilience components, we collected qualitative and quantitative data from family participants. Qualitative data included interview questions focused on family’s perception of the utility and understanding of various intervention topics. Sample questions included “What would you have changed about the program,” “How understandable and “user friendly” was the program,” and “How enjoyable was talking about stress management and coping skills.” Quantitative data was collected through surveys completed by parents and teens that similarly targeted acceptability and comprehension of curriculum. The surveys also provided open-ended feedback for families to express additional feedback that they may not have been comfortable vocalizing directly to the facilitator.
Table 1
LEADS Development Timeline
Summer 2021 | Cohort 1 begins (Partially Integrated Cultural Intervention vs. Health Education) |
| Curriculum had very minimal focus on racial discrimination, cultural traditions Assessment of individual midpoint feedback (qualitative and quantitative) with each intervention family around Week 5 Midpoint qual and quant items focused on SMART goals, Fitbit concerns, Stress management exercises, General feedback (comprehension, enjoyment, difficulties), Text messages, Group/family communication Week 10 Group Testimonial (qualitative and quantitative) Qual & quant items focused on SMART goals, Fitbit concerns, PA and diet topics, Text messages, General feedback (comprehension, enjoyment, difficulties), Stress Management exercises, Racial discrimination and health, Family and Cultural traditions for coping |
Fall 2021 | Cohort 2 begins (Partially Integrated Cultural Intervention vs. Health Education) |
| No changes to curriculum Assessment of individual feedback Week 3 and Week 7 with each intervention family Personalized individual family meetings for goal setting & Fitbit check-in Individual midpoint feedback (qualitative and quantitative) with each intervention family around Week 5 Midpoint qual and quant items focused on SMART goals, Fitbit concerns, Stress management exercises, General feedback (comprehension, enjoyment, difficulties), Text messages, Group/family communication Week 10 Group Testimonial (qualitative and quantitative) Qual & quant items focused on SMART goals, Fitbit concerns, PA and diet topics, Text messages, General feedback (comprehension, enjoyment, difficulties), Stress Management exercises, Racial discrimination and health, Family and Cultural traditions for coping |
Spring 2022 | Cohort 3 begins (Partially Integrated Cultural Intervention vs. Health Education) |
| Individual feedback Week 3 and Week 7 with each intervention family Goal setting & Fitbit check-in Individual midpoint feedback (qualitative and quantitative) with each intervention family around Week 5 Midpoint qual and quant items focused on SMART goals, Fitbit concerns, Stress management exercises, General feedback (comprehension, enjoyment, difficulties), Text messages, Group/family communication Week 10 Group Testimonial (qualitative and quantitative) Qual & quant items focused on SMART goals, Fitbit concerns, PA and diet topics, Text messages, General feedback (comprehension, enjoyment, difficulties), Stress Management exercises, Racial discrimination and health, Family and Cultural traditions for coping |
Fall 2022 | Cohort 4 begins (Partially Integrated Cultural Intervention vs. Fully Integrated Cultural Intervention) |
| Curriculum changes based on participant feedback from prior cohorts. Developed fully integrated cultural intervention to integrate cultural resilience into each session. Utilized more lay terms with self-affirmation and cognitive reframing. Created mission statement and positionality statements. Transparency of leadership and co-partnership with community Individual feedback Week 3, Week 5, and Week 7 with fully integrated group & partially integrated group Fully integrated cultural curriculum items focused on SMART goals, Fitbit concerns, Stress management exercises, Text messages, Group/family communication, AND Racial Stress activities, Culture and Traditions · Sought feedback on cultural resilience intervention components early into the program (Week 3) Example items: How have addressing racial stressors in our program been helpful? How has this been helpful? What about the conversations & activities have you enjoyed the most? Do you enjoy talking about racism and other barriers to health? What might you not enjoy about it? Are there any topics related to racial stress you think that we should cover in the future? What have you thought about the discussions and activities about culture and traditions? What have you thought about the discussions and activities about race and how you talk about race as a family? Partially Integrated Cultural Curriculum items focused on SMART goals, Fitbit concerns, Stress management exercises, Text messages, Group/family communication Week 10 Group Testimonial (qualitative and quantitative) Qual & quant items focused on SMART goals, Fitbit concerns, PA and diet topics, Text messages, General feedback (comprehension, enjoyment, difficulties), Stress Management exercises, Racial discrimination and health, Family and Cultural traditions for coping, Racial Identity, Racial Socialization, Cultural Assets (Items focused on specific activities, e.g., family tree, healthy substitutes for cultural food) |
Sept-Dec 2022 | Qualitative interviews conducted with prior LEADS families |
Spring 2023 | Cohort 5 begins (Partially Integrated Cultural Intervention vs. Fully Integrated Cultural Intervention) |
| Curriculum changes based on participant feedback from prior cohorts, specifically to separate sessions covering health behavior goal setting/tracking and racial stress Individual midpoint feedback with fully integrated group & partially integrated group. Adjusted check-ins to be only at midpoint given participant feedback on burden of multiple feedback meetings Fully Integrated Cultural Curriculum items focused on SMART goals, Fitbit concerns, Stress management exercises, Text messages, Group/family communication, AND Racial Stress activities, Culture and Traditions Example items: How have addressing racial stressors in our program been helpful? How has this been helpful? What about the conversations & activities have you enjoyed the most? Do you enjoy talking about racism and other barriers to health? What might you not enjoy about it? Are there any topics related to racial stress you think that we should cover in the future? What have you thought about the discussions and activities about culture and traditions? What have you thought about the discussions and activities about race and how you talk about race as a family? Partially Integrated Cultural Curriculum items focused on SMART goals, Fitbit concerns, Stress management exercises, Text messages, Group/family communication Week 10 Group Testimonial (qualitative and quantitative) Qual & quant items focused on SMART goals, Fitbit concerns, PA and diet topics, Text messages, General feedback (comprehension, enjoyment, difficulties), Stress Management exercises, Racial discrimination and health, Family and Cultural traditions for coping, Racial Identity, Racial Socialization, Cultural Assets (Items focused on specific activities, e.g., family tree, healthy substitutes for cultural food) |
While the majority of the qualitative and quantitative measures targeted health promotion and stress management curriculum, a few items targeted feedback on the few cultural-focused topics included in the session such as engaging in family cultural traditions and coping with racial discrimination. In reviewing the qualitative feedback, participants from Cohorts 1 through 3 endorsed acceptability of conversations about racism, discrimination and racial pride. One participant commented, “I think when we have our little breakout sessions and we get the chance to talk candidly about, especially when we were talking about discrimination and race and everything, and how do that look from different perspectives. And, because sometimes the issue is no one is talking and no one is listening, you know, and that becomes a big problem because I have my own perspective but maybe if you hear how it make me feel, I might can change your perspective. Or, if you, if I’m able to express to you in words and not anger and not getting upset and not getting so emotional, but actually convey my sentiments of how I feel about what is happening in the world and to not even just me or my family but just people like me and my family and how that makes me feel. Similarly, our quantitative feedback demonstrated high acceptability from families in our initial cohorts regarding topics of family cultural traditions and exploring coping techniques specific to racial stress (see Table S3 for data).
We also recognized families valued these culturally salient topics, as they consistently discussed concerns regarding community violence, racial stress, identity discussions, and complexities of African American parent–child dynamics during group sessions. However, our curriculum had very little emphasis on these topics that were prominent sources of stress to our African American families. Cultural needs are a crucial consideration in CBPR, and we realized that we needed to assess a greater degree of contextual stressors to better serve our families (Quattlebaum et al.,
2021; Kipp et al.,
2024). We were eager to adjust the curriculum to address the specific needs and concerns of African American families more effectively.
To fully understand how best to adapt our curriculum to be more culturally relevant and salient, we sought out additional feedback from our LEADS families that had already completed the program. Specifically, our research team conducted qualitative interviews with LEADS families to gather their recommendations on how to integrate activities and discussions related to racial stress and cultural and family resilience resources into the LEADS curriculum. In total, 16 adolescents and parents from LEADS participated in the interviews. Interview questions focused on exploring families’ personal experiences coping with racial stress and family discussions about racial stress, racial identity, and racial pride, as well as seeking out suggestions on specific activities on these topics to integrate into LEADS. Findings from these interviews showed that adolescents and parents endorsed a variety of cultural and family resilience resources for managing racial stress, including racial pride (parent and adolescent: 62.5%), egalitarian messages (e.g., equal treatment for all) (adolescent: 62.5%, parent: 50%), and preparing for racial bias (adolescent: 37.5%, parents: 50%). Adolescents and parents also endorsed several shared cultural and family activities, traditions, and routines to manage stress that could be integrated into the LEADS project, including using spirituality as a coping tool (parent: 25%), traditions around food (adolescent: 25%, parent: 12.5%), and structured family bonding time or activities (adolescent: 37.5%, parent: 50%). Some participants also suggested integrating preparation for bias messages and role playing how to handle a racial stressor into the LEADS project. These qualitative themes were critical in guiding our next steps in adapting our curriculum to integrate more culturally salient intervention curriculum activities.
In addition to leaning on qualitative feedback from LEADS families, our team also employed a range of strategies highlighted by Kreuter et al. (
2003) to culturally adapt the LEADS curriculum. Specifically, we utilized evidential strategies (showing evidence relevant to African American populations) and sociocultural strategies (having discussions in context of cultural and social values) while adapting the curriculum. We responded to families’ engagement with social and cultural issues by facilitating more discussions about current events that specifically impacted African American communities, including community violence, racial stressors/discrimination and parenting, as well as addressing resources (Kreuter et al.,
2003).
Additionally, we used culturally salient theoretical frameworks to guide our intervention changes. This included expanding our conceptual model (Figure
S1 in supplemental materials) to incorporate Murry’s Integrated Stress Model for Black American Families and Utsey’s Africultural Coping theory, which highlights cultural differences, contextual risks related to racial stressors, and core protective cultural resilience resources unique to African American families (Murry et al.,
2007,
2018). Drawing on the insights gained from our qualitative and quantitative findings, as well as leaning on these culturally salient theoretical frameworks, our Principal Investigators (Wilson, Martin) and intervention facilitators met weekly to thoroughly examine each facilitator guide to integrate culturally relevant content.
At this time we also developed a Mission Statement (see Table
2) and positionality statements (see Table S4 in Supplemental Materials). During the recruitment process for our initial cohorts, families expressed curiosity regarding why the target population exclusively focused on African American families. This highlighted the need for our research team to clearly communicate our values and intentions to the community. To address this, our research team developed a mission statement in co-partnership with our participating families that explicitly highlighted our team’s commitment to working with African American families (see Table
2). This helped align program values with the community's expectations and ensure that our team’s intentions were transparent and understood, fostering trust and engagement.
Table 2
LEADS Mission Statement
Our mission is to listen to the voice of Black parents and adolescents in understanding their daily lived experiences pertaining to stress, coping, and health. We have a strong focus on a holistic approach to faster family strengths and connectedness to improve overall health and wellbeing. The goal of our program is to use participatory approaches to co-create (equal partnership, equally valued participation) a family-based intervention to address cultural issues and stressors which have been linked to important health behaviours such as physical activity and diet. | |
We integrated concepts from Murry and Utsey’s models (Murry et al.,
2007,
2018; Utsey et al.,
2007) as we revised the facilitator guides. These models purport core sources of cultural resilience that serve as a protective buffer of racial stress, including racial socialization, racial identity, and cultural assets. Racial socialization involves the explicit and implicit transmission of knowledge, values, and beliefs related to race, racism, and discrimination within a family unit (Neblett,
2023). It can include various practices such as cultural teachings, discussions about racial discrimination, promotion of cultural pride, preparation for bias encounters, and fostering cross-cultural relationships (Anderson & Stevenson,
2019). Racial socialization has the potential to promote positive racial attitudes, resilience, and a sense of cultural belonging in youth, while also equipping youth with the tools to navigate and challenge racial inequalities in society (Neblett,
2023). We integrated racial socialization into the LEADS program, including family discussions around what they are teaching their teens about what it means to be Black, creating a family tree to build understanding of traditions, and discussions regarding how parents prepare their teens for experiences of racism. By integrating racial socialization, our program addressed promoting positive racial attitudes, cultural belongingness, and a more comprehensive understanding of a community's strengths and resources.
Racial identity was another prominent cultural resilience resource that we integrated in LEADS. Racial identity refers to an individual's self-perception and understanding of their own racial background, the significance they attribute to it, and how they navigate and experience the world based on their racial identity (Neblett,
2023). Racial identity is a complex construct influenced by a variety of factors, including family, cultural, historical, and societal influences. It can evolve over time and may be influenced by individual experiences, social interactions, and broader socio-political contexts. Developing a positive and healthy racial identity is important for individuals as it can enhance self-esteem, resilience, and a sense of belonging, while also contributing to a more inclusive and equitable society (Neblett,
2023). This core cultural component was integrated into the LEADS program through activities such as practicing building a positive affirmation around one’s identity and identifying Black role models through family discussions.
Additionally, we integrated core cultural assets specific to African American families within our LEADS curriculum. Cultural assets refer to the positive attributes, values, and practices that are unique to a particular cultural or ethnic group (Neblett,
2023; Murry et al.,
2007,
2018). These strengths can be manifest in various aspects of life, including family dynamics, social relationships, education, and overall well-being. Cultural strengths are often rooted in traditions, shared experiences, and historical resilience contexts. They can include characteristics such as strong community bonds, respect for elders, intergenerational support, collectivism, spirituality, adaptability, and a keen sense of identity and pride (Neblett,
2023). Recognizing and understanding cultural strengths is crucial for promoting cultural diversity, fostering inclusivity, and addressing disparities in various domains of society. With this framework, we integrated activities highlighting cultural strengths, including African dance, spirituality as a coping tool, and leaning on extended kinship and communalism for support.
Upon adapting our intervention curriculum to be more culturally salient, we were eager to hear from families on their response to the fully integrated cultural curriculum. Thus, we collected additional qualitative and quantitative data from LEADS families exposed to the adapted curriculum. We prioritized meeting with families at Week 3 of the program to gather feedback early into the intervention so that the material was fresh in their memory and to allow time to adjust any material later on in the intervention if needed. During the individual meetings with families, LEADS facilitators conducted brief semi-structured interviews asking for families’ perspectives on the intervention curriculum, with a particular emphasis on the culturally salient content. The quantitative feedback provided by families was collected through surveys that measured acceptability and usefulness of specific session activities, including culturally relevant content.
The qualitative and quantitative findings showed mixed results. During individual feedback interviews, several families reported that the delivery of our culturally tailored content came across unclear and somewhat difficult to relate to at times. With one participant reporting:
“I didn’t understand how it [conversations about racial stress] was related to this type of health. It seemed to come out of thin air. It was odd.” We also heard from families about the need to integrate language that highlighted African American families’ strengths as opposed to highlighting inequity and elevated risks, with a participant noting "It feels weird when those questions are just thrown in there. It was weird to just be asked about what it’s like to be in a Black family. Like were you saying that Black families aren’t healthy? Or not able to be healthy?”.
Although families reported the previously noted concerns, families also had positive feedback regarding the culturally salient curriculum. Specifically, one participant commented, “I think it’s important because it teaches you in certain situations you can handle it one way or the other. And how do you let that drive you, and so I just using it as a driving force and say, you know what, I belong here. And so, you know, I don’t have to prove myself to them but in those situations you have to, because at work when you get promoted in order for you to be heard you have to be exceptional and that’s the only standard you have. And so I just think that is important in this program because that is a huge stressor.” Furthermore, our quantitative feedback also demonstrated relatively high acceptability of these various topics (Table S3 see supplemental materials). Prominent activities and discussions endorsed were family communication about how to manage racial stress, managing community stressors (violence) and promoting community safety, spirituality as a way to cope with stress.
With this feedback, we re-examined each of our facilitator guides to address these concerns. Key content that utilized more deficits-based language was adjusted to emphasize the historical systemic inequalities that have contributed to exacerbated risks among African American populations. Additionally, we drew on a strengths-based lens to consider how African Americans lean on cultural traditions and values that are protective factors. Based on feedback that topics of health behavior goal setting and racial stress together were unclear, we presented this content in separate sessions rather than together. We also integrated activities recommended from prior LEADS families on how they recommended we integrate discussions related to racism and health and cultural strengths as part of our program.
After making these additional adjustments to our culturally relevant curriculum, we sought feedback from LEADS families exposed to this new curriculum. Both qualitative and quantitative findings showed improved acceptability of our culturally salient curriculum. Specifically, qualitative findings showed that cultural activities and discussions emphasized family traditions and values. One participant reported
“I love those activities because it makes me think back to different stuff like today it made me think about things my grandparents used to do when I was younger.” Quantitative findings from cohorts 4 and 5 also demonstrated high acceptability of these adapted cultural resilience topics among both adolescents and parents (see Table
3).
Table 3
Cultural Resilience Intervention Acceptability Feedback – Cohorts 4 and 5
Utility of Cultural Resilience Tools |
It was useful to identify cultural foods and cultural traditions around food | 3.50 | 1.51 | 4.64 | 0.67 |
It was useful to build a positive self-statement about being Black | 3.60 | 1.35 | 4.73 | 0.65 |
It was useful to discuss family communication about how to manage racial stress | 4.00 | 1.05 | 4.45 | 0.82 |
It was useful to discuss family communication about cultural pride | 3.70 | 1.57 | 4.45 | 0.69 |
It was useful to discuss spirituality as a way to cope with stress | 4.20 | 0.79 | 4.73 | 0.47 |
It was useful to learn about the physical and mental health consequences of racism | 3.90 | 1.29 | 4.64 | 0.67 |
Overall Program Acceptability |
The LEADS program has been useful for me | 3.90 | 0.99 | 4.82 | 0.40 |
I enjoy the LEADS group sessions | 4.00 | 0.67 | 4.82 | 0.40 |
I learned new things in the LEADS group sessions | 4.10 | 0.88 | 4.73 | 0.65 |
We also utilized our Essential Elements to guide the adaptations to our curriculum to ensure they aligned with our theoretical frameworks (Table S5 Supplemental Materials). Developing an essential elements and curriculum matrix that is sensitive to issues around racial stressors is crucial for creating effective programs that address the unique needs of African American populations. Racial stressors, such as discrimination, microaggressions, and systemic inequalities, can profoundly impact the mental and physical health of individuals within these communities (Neblett,
2023; Murry et al.,
2007,
2018). By incorporating this understanding into the curriculum, program developers can provide targeted interventions and strategies that empower individuals to navigate and cope with these stressors effectively.
We also were intentional about considering the heaviness of discussions regarding racial stress and health inequities and the importance of presenting this information in a sensitive manner. Specifically, to account for this sensitive material (e.g., bullying, racial trauma and family stressors), at least one of the facilitators was a doctoral student in a Clinical Psychology program with thorough training in delivering culturally appropriate evidence-based mental health care. If any elevated mental health concerns were reported or noticed throughout group sessions, this facilitator followed up individually with the family to provide further support and families were referred to a local counseling clinic. All LEADS families were provided resources on local counseling clinics in the area, so they had tools to pursue more intensive support to manage stressors, including racial stress beyond the scope of the LEADS group intervention. Further, following discussions of race or racial stress, the LEADS team provided intervention families with an American Psychological Association (APA) pamphlet on racial stress and self-care. Throughout all sessions, the LEADS facilitators encouraged families to only share based on their comfort level to ensure no undue pressure was placed on families to discuss these challenging topics.
We were also intentional in reflecting the sensitive nature of the cultural resilience intervention components through our consent, assent, and protocol materials through the Institutional Review Board. Specifically, we highlighted our curriculum topics in detail within our study protocol. Additionally, within the risks and benefits section of our consent and assent, we clearly indicated that discussion of stress, race, and racial stress can be uncomfortable and may cause discomfort or distress. Thus, as part of the orientation and enrollment process of the LEADS project, families were well-informed on the range of topics covered and their rights as research participants to withdraw or no longer participate in the program.
Lesson 4: utilizing strengths-based research approaches
Strength-based research in CBPR emphasizes the exploration and recognition of existing strengths and assets within a community (Merves et al.,
2015). This approach shifts the focus from solely identifying problems and deficits to understanding and leveraging the positive aspects and resources within the community (Neblett,
2023; Murry et al.,
2018). With this approach, researchers collaborate with community members to identify and build upon the inherent strengths, skills, knowledge, and capacities that exist within the community (Wilson & Sweeney,
2024). This approach recognizes that communities possess valuable resources and expertise that can contribute to their own growth and development. By emphasizing strengths, CBPR promotes empowerment, resilience, and self-determination among community members, fostering a sense of ownership and pride in their community's abilities and potential (Israel et al.,
1998). This approach not only leads to more effective and sustainable interventions (Cyril et al.,
2015; Wallerstein & Duran,
2010) but also fosters a positive and asset-based narrative that challenges stigmatization and promotes a more holistic understanding of communities and their capacities.
Throughout our 2-years of the LEADS Project, the program underwent significant changes, and one of the most impactful was transitioning to a strength-based approach in our curriculum. This transition involved incorporating African American representation and feedback from African American facilitators and integrating in discussions on cultural strengths, racial identity, and family racial socialization practices in our sessions. This task proved to be complex because we realized how much we needed to grow in our strength-based approaches. These changes were guided by listening to our families’ qualitative feedback and soliciting feedback from our African American intervention facilitators on what could be improved to make our curriculum more strength-based in focus (Neblett,
2023). Specifically, one of the primary concerns vocalized by families during individual feedback interviews with our facilitators was how they felt their lived experiences were not captured by how the health information we presented with statistics of African Americans health risks and deficits being emphasized over strengths.
To address this concern, we reviewed every week of our curriculum to adjust the language regarding health data that was negatively worded or did not show the full experience of African American families. Specifically, this included adjusting any deficit-based health information that showed negative health outcomes to integrate the social or political context. This was important to ensure that participants felt a sense of empowerment moving forward with their health promotion goals rather than defeat or stigma. Additionally, changes included having more discussions in sessions about cultural strengths and how those can be reflected in our health. Changes also included in-depth discussion about racial identity and families’ racial-ethnic socialization practices, which are recognized as strengths-based protective factors (Neblett,
2023). Further, we incorporated depictions of African American figures as models for strength-based efforts in Black families. We focused on challenging deficit-based narratives and promoting a more accurate understanding of the strengths and resilience within Black and African American families (McAdoo,
2007). McAdoo (
2007) specifically highlighted the significance of family support networks and coping strategies that Black and African American families employ to navigate and overcome adversity. McAdoo (
2007) stressed the importance of extended family, kinship networks, and community connections in providing emotional, social, and material support to individuals and families. Recognizing and leveraging these support networks can be crucial for strengthening Black and African American families and promoting positive outcomes. McAdoo (
2007) also argued that Black and African American families have a long history of resilience, often drawing from cultural values, spirituality, and community resources to thrive in the face of challenges. Recognizing and fostering these resilience factors can help Black and African American families build upon their existing strengths and navigate systemic barriers effectively.
Overall, by adopting a strength-based perspective, researchers and practitioners can develop interventions that empower and support Black and African American families in achieving their full potential. Utilizing a strength-based focused we refocused our framework to reflect positive outcomes in African American communities, integrating cultural strengths into our curriculum, and facilitating discussions that included cultural strengths (e.g., religiosity, family traditions, cultural history). This pushed us to sustain a curriculum that was strength-based, presenting information that made families feel a sense of pride and competence.