Fuerte is a novel prevention program targeting newcomer immigrant youths (12 – 20 years) from Latin American countries in local area school districts. The program uses the trauma-informed, evidence-based practices of the Attachment, Self-Regulation, and Competency (ARC; Blaustein & Kinniburgh, 2010) framework, combined with cognitive-behavioral therapy skills, to target newcomer youth at risk for behavioral health concerns. The program’s content was derived from input from community members, including newcomer immigrant youth, to be relevant to our population. Acculturation stress (Schwartz, Unger, Zamboanga, & Szapocznik, 2010) immigration-related stress (Perreira, 2013), and client-centered approaches (Falicov, 2013) were theoretical frameworks and approaches to frame, target, and make our program relevant to populations of Latin American newcomer immigrant youths. Finally, Fuerte also uses a trauma-informed approach (National Child Traumatic Stress Network, 2022) to its development, implementation, and dissemination, setting up the groundwork to model that approach to the greater system of care serving these youths. Fuerte has been translated into Spanish, employing local community partners with extensive experience with this population in the translation. Fuerte was also designed from the ground up using a community-based participatory approach that involved input on its design and implementation from multiple stakeholders, including school officials, public health personnel, academic researchers, parents of newcomers, and the newcomers themselves.

English, Spanish

Latino/Latina/Latinx

The Fuerte program targets newcomer immigrant youth ages 12-20 from Latin American, Spanish-speaking countries. We define “newcomer” using the definition typically used by local school districts which is any student who has arrived in the United States in the last five years or less. The ideal Fuerte candidate are youths experiencing acculturation and/or immigration-related stressors, as well as those youths who may have experienced more traumatic events as part of their immigration narratives. The intervention was designed originally to be delivered in school settings, but it has also been delivered in outpatient mental health clinics, primary care centers, and community-based organizations, such as recreation centers.

Acculturation, Adjustment Disorders

To our knowledge, no other prevention program neither locally nor in the evidence-base that specifically targeted Latin American newcomers at-risk for behavioral health concerns due to exposure to immigration-related stress and trauma. Additionally, the program had to also be relatively brief, and flexible so that it could be easily implemented at school sites in the local district. As the program was being implemented in a high cost of living area of the country, most of the newcomer immigrant youths work afterschool and on weekends to help contribute to paying for their own and their families’ basic needs. Therefore, the program needed to be able to be modular and adaptable to a particular school and cohorts needs, to be as flexible as possible.

N/A

The program uses the trauma-informed, evidence-based practices of the Attachment, Self-Regulation, and Competency (ARC; Blaustein & Kinniburgh, 2010) framework, combined with cognitive-behavioral therapy skills, to target newcomer youth at risk for behavioral health concerns. The program’s content was derived from input from community members, including newcomer immigrant youth, to be relevant to our population. Acculturation stress (Schwartz, Unger, Zamboanga, & Szapocznik, 2010) immigration-related stress (Perreira, 2013), and client-centered approaches (Falicov, 2013) were theoretical frameworks and approaches to frame, target, and make our program relevant to populations of Latin American newcomer immigrant youths. Finally, Fuerte also uses a trauma-informed approach (National Child Traumatic Stress Network, 2022) to its development, implementation, and dissemination, setting up the groundwork to model that approach to the greater system of care serving these youths.

Groups

Inclusion criteria are Spanish-speaking youths 12 – 20 years old from Latin American countries that have arrived in the United States within the last five years. All group materials are in Spanish, and thus, for our evaluation we wanted to specifically focus on this group. However, many of our newcomers in the area also speak indigenous languages and it is quite possible in the future to adapt our materials so that they are easier to use with those languages (e.g., Mam). Exclusion criteria include excluding youths for which a group format may not be appropriate, such as youths with significant impairments to language, or with significant disruptive behaviors that might impede group dynamics.

The current intervention is being evaluated as part of a delayed waitlist, randomized control trial funded through the California Mental Health Services Oversight and Accountability Commission. We are wrapping up year three of our five-year study, but due to the pandemic and the subsequent problems it has caused for doing school-based work, our project has less than 50 subjects enrolled (we should have had closer to 200 at this point in the study). Further information on the research design can be found at clinicaltrials.gov (Identifier: NCT04156373).

However, there is other data available as to its feasibility. Early pilot feasibility data (Martinez et al., 2020) showed that not only were schools and community partners interested in collaborating on the delivery of Fuerte, but youths and their families were also very excited about having this type of program. Parents and other immigrants often reported to us in focus groups and community planning meetings how they wished this program existed when they had first arrived in the United States.

Additionally, qualitative data of the implementation of the program also yielded promising information on the feasibility of implementing Fuerte via a telehealth model (Martinez et al., 2022). Interestingly, several students reported how the groups, even though they were delivered remotely, still helped them feel less socially isolated, even within the context of all their learning being remote. Repeatedly participants in the early pilot groups reported the biggest benefit of Fuerte is how it helped them establish community and meet other youths going through the similar challenges of being an immigrant in a new land. The theme came up so often, we added it as an outcome for our current intervention so we can better evaluate if Fuerte indeed is improving the perceptions of social isolation of these youths.

Research evidence for Fuerte

Martinez, W., Patel, S. G., Contreras, S., Baquero‐Devis, T., Bouche, V., & Birman, D. (2022). “We could see our real selves:” The COVID‐19 syndemic and the transition to telehealth for a school‐based prevention program for newcomer Latinx immigrant youth. Journal of Community Psychology. Early view online. https://doi.org/10.1002/jcop.22825

Martinez, W., Cooch, P., Vo, H., Oo, H., Chhabra, D., San Miguel, R., Farahmand, F., Rocha, M., Quintanilla, A, Romano, A., Romero, M., & Matlow, R. (2020). Patient and community engagement for mental health disparities in Latinx youth immigrant populations: The Fuerte program. In A. Breland-Noble (Ed.), Community Mental Health Engagement with Racially Diverse Populations. Cambridge, MA: Elsevier.

The chapter cited above goes into this in much more detail but part of our funding is also to evaluate the collaborative partnerships necessary to deliver this program to a population with immense social determinants of health needs without any specific system of care to target the unique needs of this population. Thus, we are also using implementation science and organizational psychology frameworks to better understand what partnerships and structures need to be in play for successful implementation of the project as we disseminate to school districts around the state of California and beyond.

N/A

The program is designed to be delivered in group format to foster community among the youth participants. Social isolation is common among newcomer immigrant youths and we wanted the modality of the group to be, in and of itself, an “intervention” to improve social isolation. The Fuerte program serves as both primary and secondary prevention. For some population of students, the skills and coping strategies they learn through Fuerte will be enough to prevent the onset of mental health concerns related to their immigration journeys. Additionally, Fuerte screens all participants for risk for behavioral health concerns, and those who are at-risk are referred to specialty mental health services for further evaluation. Thus, for another population of students, Fuerte serves as early screening and linkage to help stem behavioral health issues from becoming more acute.

Fuerte was originally designed to be delivered in a school-based, group format. However, during the shift to remote learning during the COVID-19 pandemic, we were able to successfully implement a telehealth adaptation of the program with some success (Martinez et al., 2022).

We have had a lot of community feedback through our focus groups and community planning meetings on whether to make the groups also “gender responsive.” However, when examining this issue further, the “gender responsiveness” of groups appeared to not be focused on the content, but rather, with pre-empting potential barriers to engagement, i.e., female-identified students would be more comfortable participating without the presence of male-identified students. Therefore, until we have more evidence, we do not make recommendations on whether the groups should be gender diverse or segregated by identified gender. We leave that flexibility to each school site and local culture. However, we do see it as problematic that in practice this typically follows Western binary notions of gender, and the students are now having to fit their chosen gender based on these prescribed categories.

Licensed clinician

Yes

To learn more about this intervention and/or receive training, please contact Dr. William Martinez @ fuerte@ucsf.edu