Making Deep-Structure Adaptations: A Community-Engaged Qualitative Study for Culturally Adapting Suicide Prevention Interventions for Black Youth

Abstract

Objectives:

This study responds to the suicide crisis among Black youth populations by tailoring suicide interventions to meet their specific cultural needs. We obtained insight from community stakeholders about culturally adapting suicide prevention interventions for Black youth, using the Linking Individuals Needing Care intervention as an example.

Methods:

Using a Culturally Adaptive Qualitative Design Process, we conducted a series of community-engaged focus groups over six months with four distinct participant groups of diverse genders, including Black youth ages 13-19, caregivers, community members, and providers. Our participants (N = 58) provided feedback on intervention adaptations in a reiterative process aligned with the Ecological Validity Model.

Results:

We found recommendations for deep-structure-level cultural adaptations versus surface-structure-level adaptations. Themes included (1) Using wellness and collective focused language, (2) Prioritizing mutual trust, (3) Disrupting and reframing cultural myths, (4) Integrating Black-focused content to validate identities, (5) Affirming Black youth and family protective factors and stressors, (6) Developing relevant and attainable youth and family goals, (7) Infusing culture into crisis planning, and (8) Creating a Black-centered community of care. Findings illuminate the need for a focus on racial socialization and validating the strengths of Black youth versus their struggles, which is meaningful for suicide prevention efforts.

Conclusions:

For suicide prevention intervention design with Black youth, community feedback needs to be prioritized, deep-structure level adaptations included, and racial socialization content embedded.

The increasing rates of suicide among Black youth in the U.S. have been amplified as a national public health crisis (The Congressional Black Caucus Emergency Taskforce on Black Youth Suicide and Mental Health, 2020). Additionally, Black youth experience higher rates of suicide attempts but also experience lower engagement in treatment and support services (Robinson et al., 2016). Culturally inclusive suicide prevention interventions for Black youth and their caregivers are needed to help combat the alarming increases in suicide among Black youth (Richardson et al., 2024; Sheftall & Boyd, 2022; Vance et al, 2022).

Existing suicide interventions provide a generalized approach to reducing suicide risk and have not been adapted to address the unique cultural, linguistic, and developmental needs and strengths of Black youth and their caregivers (Abrutyn & Mueller, 2021; Mushunje & Graves, 2023; Robinson et al., 2016). There is also a lack of research on how existing prevention and intervention approaches are impacted by psychosocial stressors, oppression, racial identity, and environmental barriers experienced by Black youth and caregivers (Lee et al., 2020; Richardson et al., 2024; Street et al., 2012). Further, African-centered psychology principles, values, and traditions that could inform protective factors, cultural strengths, and assets are often not integrated (Grills, 2004). Consequently, current interventions are not sufficiently positioned to reduce suicide risk among Black youth (Gordon, 2020).

Therefore, interventions aimed at decreasing suicide risk should focus on identifying and treating mental health symptoms, improving problem-solving skills and family functioning, and increasing access to mental healthcare (Donovan, 2020). There is also a need to recognize how risk and protective factors specific to Black youth and families serve as barriers and facilitators to care (Baiden et al., 2023; Vance et al., 2022; Richardson et al., 2022; Richardson et al., 2024; Sheftall et al., 2022; The Congressional Black Caucus Emergency Taskforce on Black Youth Suicide and Mental Health, 2020). For example, it is important to acknowledge that Black youth and families are less likely to engage in mental health services that do not incorporate their sociocultural experiences (Lu et al., 2021). Understanding suicide risk factors such as systemic racism, racial discrimination, community violence, and socioeconomic disparities should be considered in the development of interventions (Cheeks et al., 2020; Lee et al., 2020; Kogan et al., 2024; Reed & Adams, 2020; Robinson et al., 2022). Conversely, protective factors and strengths, such as positive views on racial and ethnic identity, racial socialization, strong family and community support, and religious and spiritual involvement, should be central to intervention development (Acevedo & Solorzano, 2021; CDC, 2020; Kandel et al., 1991; Lennon & Yard, 2024; Stevenson & Arrington, 2009; Reed & Adams, 2020; Reed et al., 2021). Further, Davidson et al. (2011) also identifies hope as a significant protective factor to reduce suicidal thoughts. When expected outcomes are not achieved for a specific population and variability exists in risk and protective factors, cultural adaptations of interventions are necessary (Barrera & Castro, 2006; Scott et al., 2019). Such adaptations have been found to preserve the efficacy of targeted interventions and enhance outcomes (Kelly et al., 2000).

An Existing Model of Care for Suicidal Youth

Linking Individuals Needing Care (LINC) is an existing youth and family-centered suicide prevention intervention that focuses on assessing and monitoring suicide risk, safety planning, psychosocial education, promoting healthy coping skills, and providing community referrals and linkages (Gryglewicz et al., 2021). The intervention is delivered in person or remotely (online or by phone) by a trained team of care coordinators over 90 days. The intervention aims to reduce suicide risk, address needs and barriers to seeking care, build resilience and community support, and enhance protective factors for youth and families (see Gryglewicz et al., 2021 for more information). An evaluation of the LINC intervention revealed a decrease in depressive symptoms and suicide risk for youth who participated in the program. Findings also supported increased service use engagement for both mental health and non-mental health services.

Vance et al. (2022) examined differences in service use engagement for Black youth enrolled in the LINC intervention. Service use disparities were found with Black youth who had lower mental health management and medication service utilization rates. Black youth who reported poor relationships with providers and who experienced other systemic barriers (e.g., waiting lists for treatment) had increased odds of engaging in non-mental health services (e.g., after-school programs, spiritual/religious care) than mental health services. Further, having access to a mentor decreased the likelihood of receiving therapy and medication management services, and this additional support appeared to decrease the odds of receiving other mental health services. Researchers in this study highlighted the importance of focusing on the assets within the community and the need to culturally adapt the LINC model of care through a community-engaged approach (Vance et al., 2022). This resulted in the development of the Culturally Adapted Linking Individuals Needing Care (CA-LINC) intervention, which is undergoing testing through an open trial followed by a randomized clinical trial.

A Cultural Adaptation Framework: The Ecological Validity Model

When making cultural adaptations to a given intervention, there is a need to focus on population segmentation, in this case, Black youth (Resnicow et al., 2000; Trimble, 1995). Cultural adaptations can include content modifications, which seek to modify various domains of an intervention. The Ecological Validity Model (EVM) developed by Bernal et al. (1995) is a cultural adaptation framework focusing on eight domains which include language (word and syntax), people (cultural/ethnic matching), metaphors (concepts, symbols, sayings, images, and artifacts), content (knowledge about customs, traditions, and values), concepts (congruence between constructs with culture and intervention), goals (between provider and youth), methods (procedures for accomplishing goals), and context (daily stressors, developmental stages, and sociopolitical context). The EVM was utilized by Robinson et al. (2016) to culturally adapt a Cognitive Behavioral Therapy suicide-prevention model for Black youth and was found to significantly reduce suicide risk among adolescents.

Content modifications can occur either on a deep-structure or surface-structure level, and both methods are found to reinforce cultural sensitivity (Nierkens et al., 2013; Resnicow et al., 1999). More commonly used are surface-structure adaptations, which include observable and basic characteristic changes such as ensuring the intervention has images of the cultural identities of the target population (Nierkens et al., 2013). Conversely, deep-structure changes embed core values and include cultural, social, ethnic, historical, or environmental factors in the adaptation process (Nierkens et al., 2013). For instance, in Black culture this involves reevaluating the underlying assumptions, values, and power dynamics within an intervention. Then, incorporating diverse perspectives, centering voices and experiences of Black individuals, addressing systemic inequities, and promoting cultural humility and sensitivity through the process.

The Present Study

This study aimed to gather qualitative feedback on recommended cultural adaptations for suicide prevention interventions targeting Black youth, using LINC as an example to gain insights. We focused on soliciting feedback from four groups of participants: youth, caregivers, providers, and community members. The goal was to integrate the EVM framework to address the practical, systemic, linguistic, cultural, and developmental needs of Black youth and caregivers. To our knowledge, this is the first study to gather community feedback on adaptations of a suicide prevention care coordination intervention specifically designed for Black youth. This research will contribute to the scientific knowledge in tailoring approaches for suicide interventions.

We explored the following research question: Using the EVM framework, what types of cultural adaptations are recommended to ensure that suicide prevention interventions address the needs and preferences of Black youth and caregivers?

Method

The research team utilized a qualitative study design incorporating focus groups. Focus group sessions were selected as they have been found to be effective in gaining insight into cultural adaptations for suicide interventions (McLean et al., 2020). This research design was also guided by community-based participatory principles, specifically engaging community members in the research process (Pinto et al., 2011). The first step in this process was establishing a Community Collaborative Board (CCB) and integrating community voices (i.e., focus group participants). The community chairperson of the CCB is a Black African-centered community-engaged therapist and coauthor of this paper. The CCB collaborated with the research team to review study goals and focus group questions, suggest culturally responsive recruitment strategies and materials, and provide feedback on adaptations. Table 1 outlines the details of our research design process.

Table 1.

Culturally-Adapted Research Design Process

Step 1	Developed Community Collaborative Board(CCB) Engaged prospective members (e.g., health and mental health providers, parents, youth) through email and phone contacts. Held introductory CCB meeting to review.
Step 2	Consulted with CCB and Research Team Reviewed and provided feedback to focus group questions. Aligned focus group questions with the Ecological Validity Model (EVM) to ensure each domain was included. Adapted content/images for designing culturally appropriate recruitment flyers. Assisted with recruitment of participants for focus groups.
Step 3	Conducted the Round I Focus Group Inquired about perceptions and needs as it relates to Black youth mental health, service engagement and use, suicide risk detection, safety planning, existing interventions. Analyzed feedback from Round I sessions to make any adaptations to Round II focus group questions.
Step 4	Conducted the Round II Focus Group Aligned Round 2 questions with EVM to ensure feedback on modifications correspond to each domain. Presented LINC care coordination intervention, components of model, and care flow processes. Analyzed feedback from sessions to make cultural adaptations to LINC intervention to present in Round III. Made modifications to Round III focus group questions.
Step 5	Conducted the Round III Focus Group Presented the culturally adapted suicide prevention care coordination intervention based on feedback from Round II focus groups. Inquired about the extent to which recommendations were adequately addressed, identified the need for additional changes, and provided alternative strategies to improve service delivery and prevent barriers to implementation. Analyzed feedback from focus group sessions. Utilized findings to develop culturally adapted intervention with additional feedback from the CCB.

Next, a series of focus group sessions were conducted from October 2023 to April 2024 with each of the following independent groups: (a) Black youth (aged 13-19, (b) caregivers of Black youth, (c) behavioral health and healthcare providers, and (d) community stakeholders (e.g., faith-based and local leaders). Caregivers participating in the study were not obligated to have their youth enrolled, nor were youth required to have their caregivers participate. Focus group sessions were moderated by trained research study team members who used a semi-structured interview guide to facilitate discussions. Participants in each category were invited to attend three focus group sessions for their respective groups (i.e., Round 1 - Youth, Round 2 - Youth, Round 3 - Youth). A total of 58 participants attended focus group sessions for their respective category, with 42 groups facilitated over six months. To accommodate groups, seven sessions were facilitated for youth, eight sessions for caregivers, 13 sessions for community members, and 14 sessions for providers. Providers and community members required additional focus groups due to scheduling conflicts. The average focus group size consisted of three participants. Based on feedback from our CCB, focus groups were conducted virtually via Zoom to ensure accessibility; each session was approximately 90 minutes. Ethical approval was received from the university’s Institutional Review Board.

Researcher Description

Acknowledging the positionality of researchers and how our identities shape the research process is important for qualitative studies (Kincheloe & McLaren, 2011). The research team comprised scholars with experience in intervention development, cultural adaptations, community-engaged research, and service delivery with Black communities. Among the multidisciplinary team consisting of psychologists and social workers, four researchers identified as Black and one Biracial, while the remaining identified as White. To increase trustworthiness among the participants, we ensured racially/ethnically diverse team members were engaged with the consenting process, focus group facilitation, and CCB.

Interview Protocol

Focus group questions for all three rounds were mapped to the EVM (Bernal et al., 1995). For Round I sessions, youth were asked about services used in the past, the effectiveness of these services, support needed, and preferred engagement methods with care providers. Caregivers, providers, and community members were asked about mental health supportive services available for Black youth, challenges and barriers faced when accessing mental health services, engagement strategies needed for youth and caregivers, and resources needed to support youth and families.

For Round II focus group sessions, participants were asked to provide feedback about the LINC intervention model, specific strategies used in the LINC model, ways to adapt existing strategies to meet the needs of Black youth and caregivers, and types of educational resources needed for families. Youth were asked to share positive aspects of the intervention, identify needed services, suggest topics of focus, and provide recommendations for the frequency of contacts.

Round III focus group questions centered on the degree of fit between changes made to the LINC intervention (developed as CA-LINC) and feedback provided by Round II participants. Participants were asked to reflect upon the extent to which recommendations were adequately addressed, identify the need for additional changes, and provide alternative strategies to improve service delivery and prevent barriers to implementation.

Participants

Participants in the focus group sessions (N = 58) were racially and ethnically diverse (93% Black/African American and 7% Afro-Latine) and included youth ages 13-19 (n = 21) and adults ages 18 and over (n = 37). There were more participants in the mixed age and gender focus groups for Black youth (n = 21) compared to community leaders (n = 19), mental health and healthcare providers (n = 10), and caregivers (n = 8). Of the total participants, 59% (n = 34) identified as female and 41% (n = 24) as male. There was attrition with the series of focus group sessions, and several participants (n = 25) were unavailable to complete the final round (session three) due primarily to timing and availability. Due to the sensitive nature of the study on suicide, we did not inquire about socioeconomic or gender minority status to support participation in the study and build trust. All participants had access to technology, including a phone and/or computer, to complete the virtual sessions via Zoom.

Participant Recruitment and Selection

Participants were recruited via the CCB, social media, and networking with local organizations. Interested participants were consented and screened to ensure they met study criteria. Adult participants needed to be over the age of 18, identify as Black or working with Black populations, be able to fluently speak and read English, reside in the targeted community of interest, and remain in the area for one year. Youth participants needed to self-identify as Black, have prior risk of suicide and/or history of mental health problems and/or engage in help-seeking behaviors, and be between the ages of 13-19. To minimize risk, researchers involved in screening and/or interviewing participants were trained to follow crisis protocols in the event of detecting suicide risk during any of the research processes (Brown et al, 2018).

Procedures

Consented participants were assigned to one of the four focus groups based on their participant category (i.e., youth, caregiver, behavioral health and healthcare providers, community stakeholder). A $20 gift card incentive was offered to participants for each focus group attended (maximum $60).

Data Analytic Strategies and Methodological Integrity

Focus group data was recorded and transcribed electronically. To verify accuracy and completeness, 14 trained research staff members verified transcripts and audio recordings word by word. Next, the data was assigned to a team of coders, with either two or three people coding. The research team ensured racial diversity representation among coders, with at least one Black researcher helping with coding and translation.

First, independent coders read through verified transcripts for the focus groups. Using constant comparative methodology (Charmaz, 2000; Glaser & Strauss, 1999; Robinson et al., 2016), coders independently dissected each narrative to identify initial codes relevant to Bernal and colleagues’ (1995) EVM. Once this process was conducted, coders met to discuss findings, noting and discussing any discrepancies. The team continued to code or recode the data until a consensus was reached. A master codebook was created to delineate codes. If new codes emerged, they were added to the codebook, and prior transcripts were re-coded accordingly. Coders compared codes and discussed discrepancies until they reached intercoder reliability.

We then analyzed the data for each group separately and combined the findings to provide collective final coding, allowing the research team to seek saturation with the data and develop broad cultural themes (Charmaz, 2000; Glaser & Strauss, 1999). Qualitative results were further analyzed and used to inform cultural adaptations. Data was organized, analyzed, and coded using NVivo 18 software. Utilizing results from the focus group data and CCB feedback, the research team made additional adaptations.

Results

Based on the collective analysis, thematic findings were conceptualized using the eight dimensions of Rosselló and Bernal's (1996) EVM for cultural adaptations. The findings provide generalizable recommendations for cultural adaptations, rather than focusing on specific changes to the LINC intervention. These themes and recommendations for making adaptations are described below and highlighted in Table 2.

Table 2.

Recommendations for Deep-Structure Adaptations for Suicide Prevention Interventions

Dimension	Theme	Recommendations for Deep-Structure Adaptations
Language	Using wellness focused and collective language	Reduce stigmatized language (i.e., mental health, suicide) Prioritize cultural connectivity by connecting the youth to someone relatable (i.e., speaks their language, looks like them) Provide opportunities for the family to learn and connect Pay attention to verbal and nonverbal language
Persons	Prioritizing mutual trust	Provide cultural and ethnic matching with providers Develop and foster trusted relationships Create safe spaces for youth to be authentic
Metaphors	Disrupting and reframing cultural myths	Demystify cultural myths regarding suicide and mental health with multi-generational psychoeducation with the family Focus on the strengths of the youth and family versus the struggles
Content	Integrating Black-focused content to validate identities	Integrate content about Black history and Black success Amplify and normalize lived experiences of Black youth and families Include ethnic-racial identity and racial socialization
Concepts	Affirming black youth and family protective factors and stressors	Focus on protective factors and strengths while acknowledging stressors Assess whether the caregiver, school, and/or environments are protective or stress related for the youth Minimize disclosure to adults without youth approval
Goals	Developing relevant and attainable youth and family goals	Ensure goals are relevant to the cultural needs Set more short-term and attainable goals Track goals with youth and family and acknowledge small successes
Methods	Infusing culture into crisis planning	Develop youth/family coping for handling crisis-related events Connect family to practical and inclusive resources Include transition planning as part of the crisis plan
Context	Creating a Black-centered community of care	Develop a community of care of local supports to wrap around Black youth and families Develop and improve youth/family connectedness in the community

Using Wellness and Collective Language

According to Rosselló and Bernal (1996), language is vital to the delivery of an intervention as it demonstrates an integration of culture, which in turn may improve the effectiveness of a given intervention. For instance, this may include delivering an intervention by clinicians who speak the same native language or changing words or phrases to reflect a specific culture.

Each stakeholder group reported how the topic of mental health and suicide in Black culture can be stigmatizing. According to a community participant,

There’s a stigma in our community when it comes to mental health. It’s difficult for us to even accept the fact that someone in our family is in that position, that they’re thinking about suicide. So a lot of time, they hold these issues in, they internalize it…but you know [it would be helpful to] create an environment where the youth can sit down and feel comfortable talking about their issue.

Along these same lines, a caregiver echoed this sentiment when speaking about cultural connections and the use of language. This caregiver remarked that youth often drop out of programs because they do not “feel connected enough to continue.” Further emphasizing the significance of cultural connectivity in an intervention, this caregiver noted the importance of not only “connecting with someone who looks like you, but also who speaks your language, or you know, is relatable.” They felt this helps to prevent youth from ‘falling through the cracks.’ This was also reinforced by a provider who stressed the need for culturally responsive training, particularly to teach other providers how to connect with youth and families by using culturally relevant language.

Another community participant expressed how communication should embrace a collective approach. Specifically, participants noted the value of “identifying the strengths in each family…providing options for caregivers to get connected at whatever level they want to be connected …[and providing opportunities for families to] learn, connect, and engage” with diverse support in the community.

Importantly, stakeholder groups also spoke about the need to use language that is common for Black youth. This extends language beyond Black vernacular to account for developmental age. For example, one provider noted:

We have to have another language for the kids…. [it could be] code language that the young people might say, that will give you more choices than just them coming out and say they're suicidal or they have ideation thoughts, or I want to hurt myself or hurt somebody.

Further, when asked about assessing for suicide risk among Black youth, providers and youth only highlighted the importance of recognizing verbal and nonverbal clues, as Black “youth have learned how to really hide themselves well.” Providers expounded on this, saying that youth have “some type of reverse coded language where they don't really realize, maybe, that they're giving you their truth with it…so then, so that they're not able to hide.” Body language was deemed to be an important “clue” by a youth participant. Moreover, having trusted support persons to recognize subtle or overt changes in behaviors is vital, as expressed by a provider, “sometimes, it takes another figure…to kind of pull them out of the shell that they're in, [their] state of depression.”

Prioritizing Mutual Trust

The persons category refers to cultural matching or racial and ethnic similarities between the youth and provider in a given intervention (Rosselló & Bernal, 1996). Findings from this study highlight the importance of balancing power dynamics between the provider and youth to build trust. In general, findings around these topics were consistently voiced among various stakeholder groups.

To build trust, stakeholder groups reinforced the need for cultural matching. In addition to this, youth also emphasized the importance of fostering meaningful relationships, with one youth specifically noting that connection with others was “more of a thing of…trust.” Creating a space in which the youth could feel safe enough to talk about suicide was also important for building trust. Similarly, the need for privacy was found to be essential for youth to feel comfortable expressing themselves freely. As one youth noted, “kids don't want anybody to know what they're going through.” That same youth provided further insight into how a safe and trusting environment can be built: “We want to know what you are doing with this information I'm giving you and if I can trust you with it?”

Participant groups also highlighted ways to help youth feel valued and empowered to participate in decisions about their own well-being. One youth shared, “I feel like they [e.g., care provider] should be able to spend some time together, whether it is digitally or in person, because their connection will go a lot better, and they feel like, again, more trust.” Several providers emphasized transparent communication and shared decision-making as meaningful strategies for an intervention like CA-LINC: “I think those things to consider, especially early on, is just being transparent…And building that relationship…listening to what they're saying that they need and that they desire…[and] meeting them where they are.” Similarly, a caregiver reiterated how “trust has to be built within a program” and how shared experiences can be used to build trust.

Disrupting and Reframing Cultural Myths

Metaphors are defined as concepts, symbols, images, and artifacts that are commonly used within cultural groups (Rosselló & Bernal, 1996). In this study, metaphors were presented differently and reflected a need to change concepts or symbolism associated with mental health. Due to historically-rooted stigma and mistrust associated with mental health and providers, stakeholder groups shared reasons and perceptions for not engaging in mental health treatment. For the most part, this centered on the reluctance to even talk about mental health and the “negative connotations around it.” Community members acknowledged that an intervention like CA-LINC may be beneficial; however, they also voiced concerns about the acceptance and participation of Black families, as noted by one participant, “They're gonna be hesitant…they're still gonna have that block of, you know, in this community, we don't do, you know, this mental illness kind of a thing…so I think that that'll probably be the big challenge to overcome.”

To help promote comfortability with this intervention, there was also an acknowledgment of the need to demystify cultural perceptions across participant groups. Part of addressing possible barriers to mental health treatment or participating in suicide prevention programs requires education. As noted by a community participant, “we need to do a better job of educating the community about how real it is [suicide] and how it is impacting our youth.” Ideally, education should extend to caregivers, as it appeared that generational gaps, which have been informed by historical and often traumatic experiences, may impact attitudes toward treatment. This was also acknowledged by a youth participant who stated,

Our generation knows more about things…[we] know more about mental health than some parents, so if you could, like, advocate it [interventions] to parents more because I know this, like a lot of parents are just like there's no such thing as like mental health like, or that it exists.

On the other hand, one caregiver noted that there is often a focus on struggles rather than strengths: “when those good things happen, we don't advertise it in that way, but they are going to talk about that crisis.” This caregiver also spoke to the importance of reframing to focus and share positive outcomes to help rewrite negative stories about mental health care in the Black community.

Integrating Black-Focused Content to Validate Identities

Rosselló and Bernal (1996) defined content as knowledge about cultural customs, traditions, and values. Stakeholder groups echoed the need for positive experiences, including exposure to the history and current success stories of Black individuals. All stakeholder groups suggested including subject matter that amplified Black history and success stories within suicide prevention to validate youth identities. One community member expressed this sentiment by stating, “I would definitely say teach [the youth] about their history…we really just hear the negative and the things…that we had to go through.” As such, rather than focus on the harm that the Black community has experienced throughout history, participants emphasized the need to talk about the excellence that the Black community has demonstrated. One caregiver recommended the need to include different types of education in the intervention, commenting that Black youth need to be taught “self-love and their history.” This same caregiver further lamented of the negative effects of not doing this: “if we don't start teaching our kids that, we're gonna continue this struggle, what we're dealing with…it's about teaching them about who we are, and then they'll have a better respect for one another.”

Although participants believed that integrating Black history into the intervention was important, youth and caregivers also stressed the need for it to support racial socialization for Black youth. One youth suggested we do this by amplifying the Black experience, such as “includ[ing] more Black people's success…[as] there's still a huge lack of representation.” This youth further commented that this “goes along with mental health is that showing that we as a community can be great and we are great [emphasis added].” Another caregiver offered insight on what was “valuable” for her son:

He was involved in many Black-based experiences and that helped him, you know he believed he was everything because we built him up that way, so then he could be in other places and spaces and not feel less than.

Interestingly, providers were the only participant group to address the need to include diverse Black identities, including the experiences of African immigrants and Black Trans people. This included language to suggest that immigrants and trans people are “the Black community” and their caregivers are “infusing their behavior and cultural normal on them.”

Affirming Black Youth and Family Protective Factors and Stressors

Rosselló and Bernal (1996) identified the dimension of concept as focused on the congruence between constructs within a culture and the intervention. Our findings indicate a need to acknowledge youth and family stressors while also leaning into protective factors for intervention planning and delivery. For youth and caregivers, they disclosed more personal experiences. When asked about stressors, one youth shared:

School is like a big stress…you have to worry about like what your parents say about you, what your teacher says about you… So, it's just like that stress as a lot to you…[and] you kind of always trying to work and do these things to like, manage yourself, which is really stressful.

Other youth affirmed other types of stressors, including “stress…that parents have on their kids, like with expectations, and that can be a result of school,” as well as unsupportive school environments where “teachers and the school don't do their jobs.” Stressors within the home and school environment leave youth feeling unsupported.

Not being able to trust adults was also perceived as a source of stress for youth. Several youth participants noted that when other adults involve their parents during a crisis without their approval, this could lead to feelings of betrayal and worsen their engagement in care. One youth participant stated that adults talking to their parents “seems like a betrayal, like you went behind my back.” This youth along with other youth reported feeling like they did not have a place to turn due to this lack of trust.

Alternatively, providers and community members shared the need to validate caregiver and youth stressors for families served. “Parents are highly affected,” one community member expressed. They also commented that “when something like that happens [child in crisis] they need support…[and] guidance, too, because when you're actually going through it, you don't know what to do.”

Promoting youth and family protective factors was emphasized by community members and youth. For these participants, having a “safe space” to go to and caring supports to turn to were important. As one community member stressed, services should offer support so that “kids feel someone is listening to them.” Having someone who is dedicated to checking in and continuously assessing for suicide risk and the need for support was deemed as a “groundbreaking” approach by another community stakeholder.

Developing Relevant and Attainable Youth and Family Goals

The goals dimension highlights the need for agreed-upon goals between the provider and the youth. Rosselló and Bernal (1996) assert that it takes up to four sessions to develop goals, including parental goals. Our findings support the need to develop goals that are “achievable” and do not add “additional stress,” as echoed by youth participants. Youth stressed the importance of focusing on small goals such as “waking up in the morning,” “getting to class,” and “passing a test” as opposed to developing future goals. Although long-term goals were acknowledged as important, they can be harder to achieve at the onset of an intervention and can potentially set individuals up for failure. Youth also liked the idea of including a way to track goals and acknowledge small successes.

Similarly, caregivers, providers, and community members echoed the need for “short-term, relevant, and attainable goals.” Among caregivers, communication and openness in sharing thoughts about suicide were deemed to be important goals. One caregiver stressed this point by stating, “the goal is to get [the youth] to open up and share freely, without feeling judged, without feeling like [they are] going to be taken away.” Relatedly, another caregiver expressed how caregivers need help building a connection with their youth and promoting a greater understanding of what their youth is experiencing:

I was overloading my child, literally like my goal was to make her happy. Keep her happy, and we'll be happy and suicide off the list. But that's not how it works…It's not something I can buy, or it's not something that I can offer to give her. She has to feel that inside on her own. So, I had to learn.

In this context, developing goals for both youth and caregivers can help foster a more holistic approach to wellness. Additionally, helping caregivers better understand their child can lead to sustained change and greater support for the whole family system.

Infusing Culture into Crisis Planning

The methods dimension identifies procedures for accomplishing the goals of a given intervention (Rosselló & Bernal, 1996). Our findings suggest the need to validate barriers that might impact how families respond to their youth being in crisis. Connecting families to practical resources can help bolster their ability to prepare for a crisis: when families can provide for their physical needs, they have an increased capacity to react to emotional needs. A provider further stressed the importance of “education and helping people develop some type of plan of action and a system of support” and preparing families with the skills needed “before the crisis.”

Stakeholder groups also noted that for crisis planning, we need to consider the culture around the use of phones for this age group and how they access information. One provider reinforced the importance of youth having an accessible version of their crisis plan: “kids are kind of quick to go on social media or something, so it's like if they could just have it…stored on a phone like it, even if it's saved like as a picture on their phone or something.” One of the youth participants emphasized how cell phones could be a useful tool for providing resources efficiently, stating, “send it out, you know, text and stuff like that like follow up.” As technology continues to progress, interventions must adapt to connect with youth in a way that is accessible and familiar.

Another cultural consideration expressed by participants included recognizing the value placed on the relationship between the provider and the family, particularly during the termination process. One community participant noted this could be viewed negatively by youth, as “they [youth] see people in and out of their lives all the time.” Another community participant reinforced the importance of having a clear termination process that has “a time limit so that people know we're gonna do this, for so many times, this is how it’s going to happen, so clear instructions about what's going to happen and when this is going to end.” Several participants also emphasized the need for transition strategies within crisis planning for families to maintain support after termination so that progress can be sustained.

Creating a Black-Centered Community of Care

Context is considered when designing an intervention within the realm of daily stressors, developmental stages, and the sociopolitical context for diverse cultural groups (Rosselló & Bernal, 1996). Due to the pervasiveness of these stressors, our findings support the need to facilitate the development of a community of care to wrap around Black youth and families. This community of care is needed to address systemic barriers, offer culturally relevant resources and services, and provide holistic mental health and well-being support. Participants emphasized having a “support system” of “people you can trust” as a critical component for an intervention. As one caregiver expressed, “it would be nice to have someone who knows about the community.” This caregiver further expounded on this tension: “it's hard for someone to come into my community and tell me what I should do, where I should go, and who I should see when they don't know.” A provider emphasized “wrap-around support” being “essential” and noted the importance of youth being “able to relate to the individuals that are supporting them.”

Community support was emphasized as a means to supplement professional support, especially when it may not be available. One community participant expressed:

They can help you when you guys need help, because at 3 o'clock in the morning, unless you call an EMS, you are on your own, you go ahead and wait for the daylight. And so what do you do through the night? If this child is saying they're gonna, you know harm themselves. Do you have a plan of what you're gonna do? Is there somebody else who can come and sit at your house and watch the child?

One area of support in helping youth navigate stressors is ensuring that they feel a sense of connectedness to the people in their community. This acts as a strong protective factor that can contribute to the overall wellness of the youth and family. Additionally, creating a strong community breaks down stigma and builds existing resources and relationships.

Discussion

We gathered feedback from Black youth, caregivers, health and behavioral healthcare providers, and community members about their perceptions and needs as it relates to Black youth mental health service engagement, use, and risk detection using an existing suicide care coordination intervention. Additionally, we utilized community feedback with the EVM (Bernal et al., 1995) to explore ways to culturally adapt an intervention within the context of the eight dimensions of the framework. Through focus groups with diverse community member groups (i.e., youth, caregiver, behavioral health and healthcare providers, community stakeholder), we garnered additional insight into recommended cultural adaptations.

The overarching goal of cultural adaptations is to improve the effectiveness of an intervention for the specific population for which it was adapted, as some researchers have suggested that non-culturally adapted interventions are potentially subpar for diverse populations (Hall et al., 2016; Soto et al., 2018; van Mourik et al., 2016). Based on our study, the EVM helped to inform our cultural adaptations for a Black youth suicide care coordination intervention using the eight dimensions of the framework. However, our findings stress the importance of adding more depth to suicide prevention intervention modifications through deep structured cultural adaptations.

While a hallmark of EVM is retaining the core components of the intervention to support its effectiveness (Bernal & Saez-Santiago, 2006), deep structure adaptations along the eight dimensions of the framework need to address social, psychological, and cultural factors (Resnicow et al., 2000) Our varied participant groups each converged on the need for deep adaptations, resisting the more common surface level adaptations (e.g., ADD some examples of what this means) that are generally provided for Black mental health and suicide interventions (Robinson et al., 2016). As such, deep structure adaptations centered on addressing risk factors and promoting protective factors unique to Black youth (Clark et al., 2021).

Based on concordant feedback from the varied participant groups, addressing racial socialization was a key factor to address and was embedded through each of our eight themes aligned within the EVM domains. From themes of disrupting and reframing cultural myths under the metaphor dimension to integrating Black-focused content under the content dimension to validate identities, each dimension was ungirded with strategies for affirming racial identities. As racial socialization helps to enhance positive racial identity and mediates perceived racism (Crocker & Major, 1989; Stevenson et al., 2009), our research amplified the community’s desire for the integration of racial socialization within each of the EVM’s eight domains, particularly for Black youth suicide prevention. Future studies exploring Black youth suicide prevention interventions may wish to consider infusing racial socialization within their adaptation processes.

Overall, our findings extended existing knowledge regarding cultural adaptations (Nierkens et al., 2013; Resnicow et al., 1999) as the community primarily articulated deep-structure adaptations that focused on building trust, valuing youth input and decision-making, fostering transparent communication, honoring the strengths of others, and wrapping the youth around a trusting village of supports. Researchers have described deep-structure versus surface-structure adaptations as a means to reinforce cultural sensitivity (Nierkens et al., 2013; Resnicow et al., 1999). Indeed, deep-structure recommendations included adding racial socialization content, which is a protective factor for Black youth well-being and suicide prevention (Cheeks et al., 2020; Richardson et al., 2015; Robinson et al., 2022). Interestingly, under the content domain, participants recommended including information about Black history and positive messaging on the Black experience. The ability for Black youth and families to learn and embrace their culture while receiving a suicide intervention was amplified. This knowledge teaches them how to respond to racism as Black youth, which is found to be meaningful for suicide prevention efforts (Jackson-Lowman et al., 2023; Kogan et al., 2024). This content has often been excluded from evidence-based interventions. Another deep structure recommendation example came from the language domain as the community focused more on reducing stigmatizing language and increasing the use of positive language. These recommendations are aligned with historical, cultural, and social contexts resisting deficit-focused language. Further, the recommendation for connecting youth to someone who looks like them and uses their language extends ethnic matching to a focus on language matching. Previous studies of cultural adaptations indicate that in the language domain, surface-structure changes were made, such as changes in the names in the vignettes (Clarke & Lewinsohn, 1995; Robinson et al., 2016). However, in our study, the language category took on a different meaning and focused on using language to build trust, thus moving from surface-structure to deep-structure adaptations. Further, while surface-structure changes have been found to reduce suicide risk for diverse populations (Robinson et al., 2016), we expect similar or better results with deep-structure changes.

Consistent with other research (McLean et al., 2020), making cultural adaptations to an intervention requires input from individuals with relevant lived experiences to ensure that future modifications are meaningful and culturally inclusive for targeted populations. We engaged in an iterative process to culturally adapt a suicide care coordination intervention through three rounds of focus groups with community stakeholders. After incorporating feedback from the first two rounds of focus groups, we sought a final round of input on the adapted intervention design. This final feedback was crucial for accurately capturing and including cultural preferences in the adaptation. The participants found the proposed cultural adaptations acceptable, and this feedback process helped us finalize the adapted intervention (Barrera et al., 2013). It is recommended that researchers engaging the community in intervention design include additional opportunities for feedback on different iterations of the model, and determine if the participants find the model acceptable, particularly prior to testing in a clinical trial.

Limitations and Constraints on Generality

This sample is situated in one urban community, which limits generality. Results in this study, particularly the cultural adaptations, were informed by these participants. Additionally, we were unable to capture information on participants' LGBTQ+ status, which is also important in informing suicide prevention and intervention efforts (Richardson et al., 2022). Lastly, attrition with our focus group sessions resulted in some participants not completing all three sessions.

Conclusion

This study offered insight into cultural adaptations for mental health and suicide intervention design for Black youth. Community feedback needs to be prioritized when designing cultural adaptations to provide necessary modifications, particularly with deep-structure adaptations and the addition of racial socialization content. This community-engaged approach to cultural adaptation is responsive to the recommendation for a ground-level approach to suicide intervention planning for Black youth (Sheftall & Miller, 2021). Lastly, this approach honors communal and collective values, which uphold and support Black youth during stressful experiences and validate their racialized identities. Further, it promotes epistemic justice by recognizing and affirming the community's role as knowers.

Public Significance Statement:

This study extends existing knowledge regarding cultural adaptations for suicide prevention interventions among Black youth, suggesting the need for deep-structure adaptations that focus on building trust, fostering transparent communication, and surrounding the youth with a supportive community that values their input and decision-making. Additionally, deep-structure recommendations include embedding racial socialization content in the intervention, as it serves as a protective factor for Black youth’s well-being and suicide prevention among Black youth.