Abstract
Increasing suicide rates among Latino/x men in the United States, particularly in Massachusetts, underscore the critical need for culturally responsive suicide prevention interventions. This study applies Barrera and colleagues’ best practices for culturally adapting behavioral health interventions to modify the MassMen website, a mental health resource for men. We conducted a community-engaged study using survey data and eight bilingual (English/Spanish) focus groups with Latino/x men (N = 31, ages 19–59). We applied the principles of grounded theory to analyze transcripts. Fifteen focus group participants completed post-year surveys evaluating cultural modifications. Participants revealed significant website limitations, including inadequate representation, poor Spanish translation, and cultural irrelevance. Key modifications included professionally translating the website, repositioning important information, and developing bilingual “Everyday Stories” videos featuring Latino/x men sharing mental health experiences. A follow-up survey demonstrated that 33.3% of participants revisited the website, and 46.7% referred others to it. Participants appreciated the new videos, reporting feeling “seen” and “not alone.” We engaged in three of five cultural adaptation processes to culturally modify MassMen for Latino/x men: information gathering, preliminary design, and preliminary testing. Despite limitations such as convenience sampling, a small sample size, and a 54% survey response rate, the study successfully illustrated the importance of community involvement in modifying a behavioral health intervention. Future directions include conducting focus groups with veterans and high-risk workers, applying intersectionality analysis, and expanding bilingual marketing strategies. These results emphasize the need to build relationships with Latino/x communities to promote suicide prevention resources.
Keywords
Background
The Hispanic/Latina/o/x population (from now, Latino/x, to be inclusive of participants who identified as Latino and gay, bisexual, and queer participants who identified as Latinx) is a multiracial, multilingual, and multinational racialized ethnic group in the United States (Martínez & Rhodes, 2020). There are about 60.6 million Latinx persons in the United States (Krogstad, 2020), and they have been the largest U.S. racial and ethnic minority group since 2003 (History.com, 2003). There has been an increase in suicidal ideation, suicide attempts, and deaths by suicide among Latino/x adults in the United States. For example, between 2010 and 2020, there was a 35.7% increase in completed suicides among Latino/x working-aged men aged 20 to 64 (Khubchandani & Price, 2022). Specifically, between 2016 and 2017, Latino/x men in the state of Massachusetts, experienced a 76% increase in deaths by suicide and continue to be above the state average (10.5 deaths per 100,000 vs. 8.9 deaths per 100,000 in 2022) (Massachusetts Department of Public [MDPH], 2020). Despite Massachusetts experiencing a 5% decline in suicides between 2019 and 2020, there continued to be a 4% increase among Latino/x men (MDPH, 2020). Explanations for this increase include cultural stressors, economic instability, mental health stigma, social isolation, and less access to behavioral healthcare services (Kwon & Han, 2019; Stack, 2021). As this racial-ethnic population continues to grow, it becomes increasingly important to modify behavioral interventions to prevent suicidal behavior in adults and adapt them to meet the sociocultural, linguistic, and economic needs of Latino/x men.
We discuss how we applied Barrera et al. (2013) best practices for culturally adapting behavioral health interventions using Latino/x men’s recommendations to culturally modify MassMen, a Massachusetts state website that provides a mental health screener and diverse supports and resources for men and their loved ones with the goal of reducing suicide. Barrera and colleagues seek to make evidence-based interventions more effective for subcultural groups by considering cultural factors (Barrera et al., 2013). The systematic process for adapting behavioral health interventions consists of five stages: (a) Information Gathering: This stage involves collecting data about the target culture with the goal of understanding the cultural norms, values, and barriers relevant to the intervention. (b) Preliminary Design: Based on the information gathered, initial modifications are made to the intervention. These adaptations can involve changes in language, format, or content to align the intervention with the cultural values of the target population. (c) Preliminary Testing: The adapted intervention is tested with a small group from the target culture to assess its effectiveness and acceptability. Feedback from this stage informs further modifications. (d) Refinement: After testing, the intervention undergoes further revisions based on the feedback and outcomes from the preliminary testing phase to improve its cultural relevance and effectiveness. (e) Final Trial: The fully adapted intervention is tested in a larger trial to evaluate its overall effectiveness compared to the original intervention.
Elements of a successful adaptation include linguistic modifications, the inclusion of culturally relevant examples, and addressing both nurturing and barrier elements of the culture. We are currently at the Refinement Stage and will discuss below how information gathering informed preliminary designs of MassMen to the MDPH for Latino/x men and how we engaged in preliminary testing of the cultural modification. This is a larger ongoing project, and we will continue to collect data until May 2025 and culturally modify the MassMen website to address suicide disparities that emerge from future epidemiological data and Latino/x men’s lived experiences.
Methods
The Behavioral Science Team for the MA Comprehensive Suicide Prevention project is tasked with: (a) identifying facilitators and barriers to suicide prevention care among vulnerable populations, including Latino/x men, (b) to convene a community advisory board, and (c) modify existing suicide prevention interventions for these vulnerable populations. Data used for the cultural modification of the MassMen website are from a community-engaged, multi-method design, including Latino/x men’s focus groups, a follow-up survey with the participants, and reviews with our community partners. Our community partners were community stakeholder interviewees of an initial environmental scan of suicide prevention resources for Latino/x men in Massachusetts. Many stakeholder interviewees expressed interest in joining our community advisory board, which meets bimonthly. The interviews enabled us to link providers to suicide prevention training provided by MDPH through this CDC grant and facilitated the recruitment of focus group participants. Our community partners were involved in the preparation of data collection materials such as the bilingual focus group protocol and demographic survey. Community partners also informed us how much to pay participants and how we broach these topics and suggested that we have a therapist present at each focus group in case a participant became emotionally triggered. Three of our community partners who were behavioral health providers provided emotional support during the focus groups. Community partners continue to provide technical assistance in the creation and execution of suicide prevention interventions, including the transcreation of the MassMen website. One of our community partners and coauthors (GP) provided emotional support in our Spanish focus groups and was active in the transcreation of the MassMen website. He produced the English and Spanish introductory MassMen videos, which explained how to use the website. He also identified three Latino/x volunteers to share their mental health journey on a MassMen feature called “Everyday Stories.”
Focus group participants (n = 31) were self-identifying Hispanic, Latino/x, or Latin American men (ages 18–64) from Spanish-speaking Latin American countries who lived in Massachusetts. We recruited men by posting flyers on social media, sharing flyers with community stakeholders, attending community outreach events, and posting flyers in public spaces like barber shops, gyms, libraries, restaurants, and temporary staffing agencies in Middlesex, Hampden, and Hampshire Counties. Focus groups were conducted in the participant’s preferred language (English/Spanish) and took place via Zoom or in person. Focus group participants provided written consent prior to participation and completed a sociodemographic survey before the focus group. Participants received a $75 gift card at the end of the focus group. The focus groups were conducted between September 2022 and May 2023.
We applied methodological tools from grounded theory (GT), such as coding, memoing, and constant comparative methods, to analyze focus group transcripts from September 2022 to May 2023 (Strauss & Corbin, 1998). We used GT over other qualitative approaches because this method seeks to capture human action and processes (Strauss & Corbin, 1998). We wanted to identify conditions that lead to emotional distress and suicidal ideation, describe men’s coping and help-seeking behaviors, and highlight their recommendations for immediate modification of the MassMen website. Focus groups had a specific section that inquired about participants’user experience, first impressions, issues with and recommendations to modify the MassMen website. The analysis team consisted of five gender and racially diverse academic researchers (ADM; SK; DH; PD; PF). Transcripts were transcribed verbatim. Field notes and transcripts were analyzed as they became available. Spanish transcripts were coded in Spanish by ADM, DH, and PF. Results from the transcript analyses were presented verbally and visually to our community partners and the third-party marketing agency working for MDPH to modify MassMen. The marketing agency was only in charge of modifying the website, but our team and community partners conducted the research and synthesized the data that informed the cultural modification of the MassMen website.
A year after the first modifications to the website, we sent a follow-up survey to focus group participants to inquire about their return, use, and referrals to MassMen 1 year (June 2024–August 2024) after learning about the website. The survey included demographic questions, including veteran, employment, and housing status, the information sought on MassMen if they referred anyone to MassMen, and their evaluation of the Introductory and “EveryDay Stories” videos. They also made further recommendations for improvement. We used Stata 18 to produce descriptive statistics of these data. Each participant received a $25 gift card after completing the survey. This study was approved by the University Institutional Review Board.
Results
Table 1 reports the sociodemographic characteristics of the focus group participants. Three of the focus groups were facilitated in Spanish, while the remaining five were facilitated in English. A total of 31 individuals participated in the focus groups before the modification of the MassMen website between October 2022 and June 2023. Three participants declined further contact for additional surveys, so 28 participants received follow-up surveys about their use of MassMen since their focus group. These follow-up surveys were conducted from June to August 2024. Of the 28 participants, 15 responded, yielding a 54% response rate. Table 2 reports the sociodemographic characteristics of those who completed the follow-up survey. Below, we provide a brief description of the qualitative findings, changes to MassMen, and results of the follow-up survey.
Demographics of Latino/x Male Focus Group Participants Prior to the Adaptation of the MassMen Website (n = 31).
Participants in this category either selected Mestizo (n = 8), or a combination of White/European, Black/African American/Afro-descendant, Latin American Indigenous, and/or American Indian and Alaskan Native/Indigenous ancestries (n = 7).
Participants who selected “Other” wrote in Hispanic/Latino (n = 5) or Puerto Rican or Dominican nationality (n = 2).
Demographics of Latino/x Male Focus Group Participants in Follow-Up Survey, Post-Adaptation of MassMen (n = 15).
Participants in this category either selected Mestizo (n = 5), or a combination of White/European, Black/African American/Afro-descendant, Latin American Indigenous, and/or American Indian and Alaskan Native/Indigenous ancestries (n = 2).
Participants who selected “Other” wrote in Hispanic/Latino (n = 2) or did not provide additional information (n = 1).
First Impressions of the MassMen Website
None of our focus group participants, including those who were physicians, first responders, and social service providers, knew about MassMen prior to participation. During focus groups, most men interacted with the website for the first time from their mobile phones. They indicated that the mobile phone view needed to be structured in a way that presented the website’s purpose immediately. Although both English- and Spanish-speaking participants appreciated the website’s existence, as they said that men’s mental health is rarely, openly discussed. Participants shared concerns about the website’s inadequate representation. They noted the website lacked images of non-white men or LGBTQ community members, as well as healthcare resources (e.g., Ryan White Program). They also shared that there was little to no information to combat mental health stigma and recommended increasing interactive features for user engagement.
Issues with MassMen
In both English and Spanish focus groups, men perceived the website to be “outdated” because it had too much text and lacked color, images, and video. The text was also too technical. For example, the participants indicated that if men have not been socialized to discuss their emotional and mental health, why would they click on a section on anxiety? They immediately noticed that there were few to no images of men of color representing different ages, occupations, and identities (e.g., therapists, urban/rural, military, and parents).
I don’t think that there’s a lot of Latino guys there, but I think that in terms of uh, just guys talking about their feelings and their mental health. We just don’t really get that a lot in general, even with like white guys. Um, it’d be… it’d be nice to see some different faces in some different cultures. –20-year old Puerto Rican man, English Focus Group
One of the distinct differences between the English and Spanish-speaking focus groups was that 10 of our 13 Spanish-speaking participants were recent immigrants (<5 years). They often expressed social isolation in the absence of family and friends back home. As new immigrants navigating a new mental healthcare system, they wanted the website to include resources on locating a bilingual mental health provider.
The second distinct difference with the Spanish-language participants was their disapproval of MassMen’s Spanish translation. MassMen was only available in Spanish if participants clicked on a Google Translate button, which was not visible on mobile device screens. Once participants applied Google Translate, the translation was poor. For example, one of our participants found that the translation of “vets” (veterans in English) was translated by Google to “veterinarians” in Spanish. Another participant noticed that the diminutive of Massachusetts, “Mass,” was translated into “misa” or the Spanish word for the Catholic service. More importantly, the lack of proper translation made the participants feel unimportant and neglected by the state as a participant indicated below: And those kinds of things make people feel like they [MDPH] don’t give a darn* about how the text is written, that is, they put nothing in [but] the machine to do it. And there’s no love, there’s not really a matter of pay[ing] attention to what one is reading. -27-year old Colombian immigrant man; [translated to English from a Spanish Focus Group]
Spanish-speaking and bilingual men strongly recommended that MDPH review the translations with native Spanish speakers prior to publishing the webpage.
The earlier version of the MassMen website included a section with short videos at the bottom of the homepage called “Everyday Stories.” The videos presented white men discussing their mental health challenges and how they sought help. Participants enjoyed the videos but said that more diverse men needed to tell their stories and that the men featured in the videos lacked diversity in age, which limited their ability to resonate with younger male audiences. They wondered why important phone numbers, such as the suicide crisis hotline, 9-8-8, or the behavioral health hotline, were not at the top of the website. They suggested that if someone is in an emergency, they should not have to search throughout the website to find that critical information, as it may lead them to lose interest and not seek help. Below we discuss modifications that MDPH has made based on our focus group results.
Cultural Modifications to MassMen Website
Between January and May 2023, one of our partners, a mental health clinician (GP), the MDPH communications team, and the Behavioral Science Team worked with a local marketing company to initiate the transcreation of the MassMen website for Latino/x men. The focus group participants’ recommendations led to MDPH implementing immediate modifications to MassMen, including creating a Spanish landing page (MDPH, n.d.a), which was professionally translated. The second immediate change was to provide a short description of the website at the top of the page as “Life Tools for Men.” Also, MDPH positioned the 9-8-8 suicide crisis hotline closer to the top of the page and reorganized tabs so that they were easier to navigate. These modifications have been appreciated by participants in later focus groups (June–December 2023).
The largest change to the MassMen website was to produce a series of videos with Latino/x men. The participants recommended having examples of Latino/x men who expressed their vulnerability, emotional and mental distress, and how they overcame those challenges. MDPH contracted a local Latinx-owned production company to create nine videos for MassMen’s landing page. Two videos were produced to introduce and describe the MassMen website. The subsequent videos capture the stories of three Latino/x men who discuss their struggles with mental health, addiction, and problem gambling, as well as how they sought help and behavioral health services to prevent suicide. All the men’s stories were produced in English and Spanish to capture our bilingual population and acknowledge that many Latinx men may not speak Spanish. Videos can be found here (MDPH, n.d.b).
The videos have resonated with subsequent focus group participants, conference attendees with whom we share the videos, and our 50-member community advisory board. Table 3 reports quantitative results from the follow-up survey conducted with 15 Latino/x males, post-adaptation of MassMen. Of the participants, 33.3% revisited the MassMen website after the focus group, with most participants drawn to sections such as “Issues Faced by Men” and “Resources for Help.” In addition, 46.7% reported referring someone to the website following the focus group.
Follow-Up Survey Results with Latino/x Participants Post-Adaptation of MassMen (n = 15).
Everyday Stories
Survey respondents who watched “Everyday Stories” on the MassMen website (n = 14) reported feeling “seen” and “not alone,” as well as other emotions such as relief and happiness, highlighting the personal impact of the stories. Many found the videos informative, helping them understand MassMen’s purpose and how to use the site. All respondents said they would recommend sharing the videos to others.
Future MassMen Recommendations
In the survey, the men were given the opportunity to share any positive or negative feedback about the MassMen website post-modification. There was largely positive feedback along with some suggestions. A common suggestion was to include more videos. The first was to include a video about the role intersectionality plays in the life of a Latino/x man who also identifies as GBTQ. Another participant reinforced that sentiment by suggesting adding more content for elderly, gay Latino/x men.
Two participants mentioned that they sought help for their emotional and mental distress. One suggested a video that included a man who improved through therapy. Another participant mentioned the importance of seeking help. This could give men an idea of the process to seek help and destigmatize therapy. Overall, the comments were helpful in showing us specific groups of men who want to see themselves reflected on the website.
Conclusions
Our goal was to discuss how we applied Barrera and colleagues’ (Barrera et al., 2013) best practices for culturally adapting behavioral health interventions to modify MassMen for Latino/x men in Massachusetts. We employed information gathering by hosting bilingual focus groups with self-identified Latino/x working-aged men in Massachusetts and soliciting our community partners’ input on our qualitative analyses. We engaged in preliminary design by culturally modifying MassMen for English- and Spanish-speaking Latino/x men that addressed the participants’ challenges navigating the website, the types of information they sought, and how the information was presented to resonate with their personal struggles, through the bilingual videos, “Everyday Stories.” We did preliminary testing through the follow-up survey with our initial focus group participants.
Throughout the cultural modification of MassMen, we learned that involving the community is key to ensuring that interventions are culturally relevant and supported. Working with community stakeholders, such as Latinx-owned businesses and social service agencies, helped us tap into existing networks to recruit underserved populations. We received valuable feedback that helped us adjust our approach to better connect with the target audience. Customizing interventions to meet the specific needs of diverse racial-ethnic groups, such as Latino/x men, is crucial for making mental health resources more accessible and reducing suicidal behavior. We also found that addressing the wider social and economic needs of Latinx men, such as health and employment, alongside suicide prevention efforts, is essential for creating lasting change and reducing social isolation.
Limitations of this study include that we used a convenience sample, we had a small sample and a 54% response rate for the follow-up survey. Recruiting certain high-risk groups such as Latino/x active military and veterans, re-entry populations, and those in high-risk occupations is challenging because they are often reluctant to seek help or discuss mental health issues due to stigma or structural barriers, further complicating the effectiveness of outreach efforts. Despite our sampling strategy and small sample, we had a diverse group of men who represented eight different Latin American countries, distinct development stages (i.e., young, middle-aged, and older adults), with diverse life experiences (immigrants, re-entry, single-parents, and veterans) and identities (Afro-Latino/x, Indigenous, gay/bisexual/queer). Moreover, we have a diverse analysis team and constant feedback about our findings with our community advisory board.
Future Directions
We are currently in the fourth stage of the cultural modification of MassMen, Refinement, in which we are conducting additional focus groups with veterans, active military service members, and men in high-risk occupations. We will apply an intersectionality analysis to make recommendations for the state to continue to capture the needs of multiply marginalized Latino/x men on MassMen. We have also formed a technical assistance subgroup among our community stakeholders on how to extend evidence-based suicide prevention interventions to Latino/x men. In addition to marketing MassMen on social media, we would like to use Latino/x men’s recommendations to expand bilingual marketing of MassMen to include signage in places where Latino/x men work, meet, and seek services. Following Barrera and colleagues’ framework, our results emphasize (a) cultural adaptation of content through linguistic and conceptual translation; (b) engagement of community stakeholders in design and content development; and (c) careful consideration of cultural nuances in suicide prevention messaging. The reduction of Latinx suicidal behavior requires building relationships with Latinx communities to modify existing suicide prevention resources to resonate with Latinx men to reduce social isolation, increase help-seeking, and find resources to meet their economic and health needs.
