An Exploratory Evaluation Case Study on Latinx-Maternal Acceptance Promotion of LGBTQ+ Youth Using Participatory Culture-Specific Intervention Modeling (PCSIM) Methods

Abstract

Family acceptance is one of the strongest predictors of mental health in youth with diverse sexual orientations and genders (LGBTQ+) In Latinx communities, where the values of familismo, machismo, and religion may present as both strengths and barriers to facilitating family acceptance, culture-responsive programming can encourage LGBTQ+ youth acceptance. This study uses an exploratory evaluation case study design to learn how using participatory culture-specific intervention modeling (PCSIM) methods can facilitate Latinx maternal acceptance of LGBTQ+ youth and to identify the successes and challenges researchers encountered throughout the process to inform future intervention implementation efforts. A total of n = 16 Latinx community members participated in the brief psychoeducational programming. The participants were Latinx women—predominately mothers—and ranged in age from 14 to 55 years old. All the participants spoke Spanish and n = 4 also spoke English. The study presents the PCISM process and mothers’ evaluation of their experience and perceptions using mixed methods. The maternal reports indicated favorable qualitative acceptability and efficacy findings but demonstrated minimal statistical significance. This study conveys how researchers implemented the PCSIM approach to yield brief, culture-responsive programming with Latinx mothers to facilitate their openness towards accepting LGBTQ+ children in their homes and communities. The researchers reviewed how the practices from this current study can be used or amended in future culture-responsive programming that partners with Latinx mothers and community centers collaborating with this community to facilitate acceptance of LGBTQ+ youth to yield more generalizable and sustainable program development.

1. Introduction

Youth with diverse sexual orientations and genders (LGBTQ+) navigate culture-specific stressors that contribute to their exacerbated mental health and wellness outcomes at greater rates compared to their heterosexual, cisgender peers [1]. The culture-specific stressor of parental rejection, particularly from mothers, has been documented as one of the leading stressors in LGBTQ+ youths’ lives and has demonstrated relationships with outcomes of displacement and increased internalizing symptomology [2,3,4]. Conversely, in the presence of maternal acceptance, where child–parent relationships exhibit open, mutual, and low-conflict communication [5], LGBTQ+ youth are significantly more likely to present as resilient and exhibit improved wellness [3]. Given the protective impact of maternal acceptance for LGBTQ+ youth, it is an important construct to facilitate and promote.

The facilitation of maternal acceptance is additionally important to investigate when working with communities who hold intersecting identities [6]. This is important, as their worldviews are influenced by cultural values and lived experiences that may differ from the worldviews that the existing programming was intended to serve (e.g., a white, English-Speaking, upper-middle class audience), resulting in existing programs failing to resonate with culture-specific communities. Thus, program messaging that promotes maternal acceptance must be culturally relevant, especially when working with mothers who hold intersecting identities [7]. Latinx communities are exemplars of finding strength and pride in their family units and can also be strongly guided by religious values that can conflict with tenets of affirming their LGBTQ+ family members [8]. Nevertheless, minimal programming or guidance exists to facilitate maternal acceptance among Latinx mothers, indicating that most available programming may lack cultural relevance and consideration of their unique lived experiences. For example, existing programming does not acknowledge the strength and resilience that Latinx families in America have exhibited considering the language barriers for some and their ongoing exposure to discrimination [9]. Existing programming also lacks culture-specific messaging that recognizes Latinx families’ unique strength in valuing their families or their resilience in continuing to seek care despite community members’ experiences of medical mistrust [10]. Nevertheless, LGBTQ+ Latinx youth deserve to experience maternal acceptance and could benefit from the development of culture-responsive programming aimed at fostering these experiences.

This study recognizes the need to develop a culture-specific programming that facilitates maternal acceptance of LGBTQ+ youth among Latinx mothers. To meet this goal, researchers collaborated with a community organization partner using Participatory Culture-Specific Intervention Modeling (PCSIM, [7]) methods to develop a brief psychoeducation session for Latinx mothers who had interest in learning how to support their LGBTQ+ children and community members. This psychoeducation session was collaboratively developed so the session would exhibit cultural relevance and buy-in. In this paper, we illustrate our use of PCSIM to develop this culture-responsive psychoeducation session, present the efficacy and acceptability findings from the session, and offer guidance to practitioners and researchers from our exploratory evaluation case study that can facilitate future programming with Latinx mothers seeking to accept their LGBTQ+ youth and community members.

1.1. Family and Maternal Acceptance of LGBTQ+ Youth

Family acceptance of LGBTQ+ youth refers to families’ demonstrated resilience and support in coming to terms with their child’s LGBTQ+ identity, as exhibited by open, mutual, and low-conflict communication [5]. When this construct is discussed specifically in relation to the experience of mothers, we call it maternal acceptance. When LGBTQ+ youth perceive increased maternal acceptance, research has demonstrated a significant decrease in their alcohol use [11], cigarette smoking [12], suicidal attempts [13], and a reduced exposure to HIV risk [14]. Transgender and gender-diverse youth appear to significantly benefit from parental acceptance, which is exhibited by their documented higher life satisfaction, lower perceived burden of being transgender, and having reduced depressive symptomology in its presence [4].

The converse construct, parental rejection of LGBTQ+ youth, often refers to parental disapproval of LGBTQ+ identity and is a leading predictor of deleterious outcomes. Familial disapproval of LGBTQ+ youth can manifest as youths’ reduced access to tangible support from parents [15], parent-sought reparative/conversion therapy for thier LGBTQ+ children [16], youths’ displacement and homelessness [17], and an their overrepresentation in the foster system [18]. Youth are additionally impacted by parental rejection in their exacerbated mental health outcomes, with significantly greater symptoms of depression [2], post-traumatic stress disorder [19], increased substance use [2], engagement in risky sexual behaviors [3], and suicide attempts [13] compared to those exposed to parent rejection at lower rates. Given the beneficial impact of family acceptance on LGBTQ+ youth, the converse impact of parent rejection, and the role of mothers in Latinx households as the primary caregiver- as dictated by familismo and machismo cultural values- it is imperative that family acceptance, particularly by mothers of LGBTQ+ youth, be championed.

Family Acceptance Programs

While minimal programming exclusively targets maternal acceptance, a common mechanism for promoting family acceptance is therapeutic programming [20]. Newcomb and colleagues (2019) wrote a call to action identifying the programming factors that would contribute to effective familial acceptance outcomes for LGBTQ+ youth. They recommended that families develop their skills in parenting practices (e.g., negotiation and modeling healthy coping strategies) and become aware of the implications that their parenting can have on their children’s health behaviors and wellness outcomes (e.g., self-esteem and substance use). They additionally recognized that promoting effective parenting practices among parents of LGBTQ+ youth require balancing the complex additional skills of affirming children while also engaging in more general practices of monitoring children’s safety and setting boundaries when safety may be compromised. They also recognized the importance of developing family awareness of the impact negative or rejection-informed responses can have (e.g., encouraging gender conformity or conversion therapy) when their child comes out. Learning strategies were posed to help these parents resist rejecting their child when they do come out [3,21,22]. To facilitate acceptance of LGBTQ+ youth, families must- at a minimum- be aware of and commit to tolerating their child’s LGBTQ+ identity and gender expression and must support their children in obtaining accurate culture-specific information to promote their health [5].

Existing therapeutic programs promote LGBTQ+ family acceptance. Attachment-based family therapy (ABFT) has been implemented with transgender youth, aimed at correcting familial interactions to yield a more affirming and secure base of attachment, which, in turn, has remediated LGBTQ+ children’s internalizing symptomology [23,24]. Bowenian family therapy has remediated LGBTQ+ youths’ internalizing concerns and conflictual family dynamics in highly religious families [25]. Additional programs, such as Lead with Love [26], use educational videos that provide evidence-based psychoeducation to parents on ways to improve their relationship with their LGBTQ+ child. Programming has also been developed for children in foster care to repair and strengthen their relationships with their foster or birth parents [27]. Lastly, the Family Acceptance Project (FAP) provides evidence-based psychoeducational resources on acceptance to the parents and practitioners of LGBTQ+ youth. Although qualitative findings have indicated that these programs may exhibit efficacy in promoting parental acceptance of LGBTQ+ youth, none have used randomized control trials or pre/post methods to determine their statistical efficacy. Thus, researchers must strive to develop an empirical and evidence-informed foundation for the therapeutic programming available to support the parental acceptance of LGBTQ+ youth.

1.2. Intersectionality: Family Acceptance of LGBTQ+ Youth among Latinx Families

In learning how to promote family acceptance of LGBTQ+ youth, additional specificity should be considered when facilitating this acceptance with families whose youth hold intersectional identities. Intersectionality is when people hold multiple systems of inequality (e.g., race, gender, and social class, etc.) as part of their individual identity, and these systems intersect to create a unique dynamic, often marked by experiences of discrimination [6]. People with intersecting identities often have distinct lived experiences that can make programming designed without an intent to align with specific intersectional identities seem culturally irrelevant and out of touch. For instance, programming may fail to recognize the unique stressors that communities experience given their exposure to discrimination across multiple marginalized identities, which can be invalidating and even harmful. Thus, it is important to consider culture responsiveness when facilitating parental acceptance among families with intersectional identities, ensuring that their values and worldviews are accounted for [7].

Researchers and practitioners could benefit from an intersectional understanding of how to yield culture-responsive therapeutic practices for Latinx families seeking to accept their LGBTQ+ youth, given the community’s central value of family [28]. Additionally, Latinx LGBTQ+ youth disproportionately experience adverse mental health outcomes (i.e., depression) compared to their non-racially/ethnically diverse LGBTQ+ peers, which has been attributed to the minority stressors of perceived stigma and parental rejection of their LGBTQ+ identity [3,29,30]. Pastrana [31] challenged these findings and found that Latinx youths’ outness was not related to their families’ conservative religious values, but also identified that familial support for LGBTQ+ Latinx youth was the strongest predictor of their outness to their families. Pastrana also identified that significant predictors of LGBTQ+ Latinx youths’ outness were the belief that one’s sexual orientation is an important part of their identity and the value of having a connection to the LGBTQ+ community. The absence of a relationship among LGBTQ+ Latinx youths’ outness and having a religious family was contradictory to hypotheses consistent with family rejection expectations, where youth would be less out in religious families as being LGBTQ+ in many religions has been conveyed as sinful [32]. Thus, these findings indicate that family acceptance may function differently for LGBTQ+ Latinx youth and their families, where family dynamics can present as both a source of resilience and stress [33].

1.3. Latinx Values That Contextualize Parent-LGBTQ+ Child Relationships and Engagement with Medical/Therapeutic Care

When collaborating with Latinx families of LGBTQ+ youth, it is important to consider their culture-specific values; many Latinx community members tend to adhere to more traditional family values (e.g., familismo) and gender norms (e.g., machismo and marianismo) in comparison to non-Latinx white families [28,29]. These machismo values encompass strict gender roles and guidelines for masculine behavior, which are often associated with hypermasculinity and a connection to family [34]. While machismo is often considered to be a protective factor within the Latinx community, Gerena [35] conducted a systematic review and identified conflicting values between being gay and valuing machismo. The dissonance between machismo and identity has been linked to LGBTQ+ youth endorsing a greater risk of rejection, poor mental health outcomes, substance use, suicidal ideation, and internalized homonegativity [36,37]. A qualitative study by Abreu et al. [38] reflected on fathers’ support of their sexual minority children, finding that fathers who endorsed being involved in the lives of their sexual minority children conveyed their interest in prioritizing their child’s membership in their family above their disapproval of their sexual orientation. Simultaneously, fathers acknowledged their struggle in accepting their child’s identity.

In contrast, the cultural value of familismo encourages individuals’ strong identification with and obligation to their family, a reliance on their family for support, and the prioritization of their family’s needs over their individual needs. Familismo also values parental aspirations for the upward growth of their children through encouraging education, hard work, and ongoing success. In considering how familismo functions for LGBTQ+ Latinx community members, Figueroa and Tasker [39] illustrated narratives by lesbian mothers from Chile, who conveyed they could count on support from their mothers after coming out to them, while simultaneously experiencing intense disapproval from many of their remaining family members. Altogether, familismo depicts that, while Latinx families may struggle accepting the LGBTQ+ part of their children’s identities, guidance from the familismo value may present as a family wanting to support their children regardless and overlooking this part of their lives. Within the Latinx LGBTQ+ community, religion has also been documented as serving as both a source of stress and resilience (e.g., [40,41]). Fortunately, some religious denomination dogmas on LGBTQ+ topics have evolved in more recent years, with some recognizing and even condoning same-sex relationships [42].

Additionally, collaborators should consider Latinx community members’ resilience considering their experiences of medical mistrust. Medical mistrust refers to a minoritized individual’s mistrust in and disengagement from medical services, which occur because of their mistreatment and misdiagnoses from medical providers, which can, in turn, exacerbate health outcomes and mortality rates [10]. Historically, Latinx community members report greater ethnicity-based discrimination than non-Hispanic white individuals when navigating their healthcare [43]. Experiences of medical mistrust have not significantly altered the frequency of Latinx community members’ care visits, however, their overall satisfaction with this care has been significantly impacted [44]. Medical mistrust has been contextualized within the Latinx young adult values of familismo and machismo. Findings have indicated that holding machismo beliefs is associated with increased perceptions of medical mistrust among women, while holding values of familismo is associated with decreased perceptions of medical mistrust among community members [8].

1.4. Culturally Responsive Programming: Family Acceptance among Latinx Families of LGBTQ+ Youth

Given the rich culture of the Latinx community, their documented medical mistrust, and the unique intersection of being Latinx and LGBTQ+, the Latinx community deserves culturally relevant programming to promote the familial acceptance of their LGBTQ+ youth. Fortunately, therapeutic programming aimed at facilitating family acceptance, such as Familias con Orgullo [45], has been specifically developed using participatory methods for this community. Familias con Orgullo is described as a family- and parent-only program taking place over seven sessions, which conveys parents as change agents for their LGBTQ+ youth, psychoeducates parents on LGBTQ+ youth stressors and lived experiences, and contextualizes how the culture-specific constructs of familismo and machismo can serve as strengths and barriers to accepting LGBTQ+ youth (see [45] for additional detail).

While Familias con Orgullo was developed to prevent adverse health outcomes in Latinx LGBTQ+ youth by working with families to promote their acceptance, parents receive this intervention once their child is out as an LGBTQ+ community member and the efficacy of this program, assessed via randomized control methods or pre/post designs, is unknown. Additionally, limited programming is available that promotes parental acceptance for Latinx families of LGBTQ+ youth when their youth may not be out, or that promotes this acceptance prior to having a poor encounter with their child when they come out. Additionally, developing programming to facilitate maternal acceptance among Latinx mothers of LGBTQ+ youth could be beneficial given the shared familismo and machismo values of mothers, who tend to be the primary caregiver. Familias con Orgullo ultimately presents as a critical resource in promoting culturally relevant therapeutic resources within the Latinx community, and additional programming should be developed to meet a range of parental and maternal acceptance needs.

1.5. Guiding Frameworks: Cultural Humility, Participatory Culture-Specific Intervention Modeling, and Mixed Methods

In this article, we implement an exploratory evaluation case study using Participatory Culture-Specific Intervention Modeling methods (PCSIM, [7]) with community collaborators to develop therapeutic programming aimed at facilitating Latinx maternal acceptance of LGBTQ+ youth. We identify what contributed to the evaluations’ successes and limitations. PCSIM is an empirically supported, transformative, action-based research model aimed at yielding culture-relevant programming. PCSIM achieves culturally relevant programming due to it being jointly informed by the expertise of researchers/practitioners in their empirical- and evidence-based practices and the expertise of community collaborators, such as Latinx families and cultural brokers, in their own community and culture [7]. Cultural brokers are individuals who are part of the culture-specific community who facilitate building relationships among researchers/practices and the collaborating community [7]. PCSIM’s effective application in producing culturally relevant programing has been well documented [46]. The four overarching phases of PCSIM and what each phase entails are shown in

Table 1. Four phases of PCSIM and a summary of what they Entail.

Phase	Name & Description
Phase 1	System Entry
Phase 2	Developing trusting relationships with community members and learning culture-specific knowledge of the partnering community, while maintaining awareness of personal worldviews. Culture-Specific Model Development
Phase 3	Working collaboratively to understand how SEB screening will facilitate identification, intervention, and knowledge about culture-specific student mental health and wellness. Phase two ultimately leads to an overall understanding—or a working model—of what values should be addressed in the programming. Culture-Specific Program Development
Phase 4	Developing programming in an ongoing partnership with community members and cultural brokers to yield culture-responsive results. Program Continuation or Extension
	Building a sustained programming capacity so efforts can continue to be implemented and transcend the research partnership.

. The recursive nature of PCSIM is critical to its effective implementation, where changes to programming continue occur when feedback indicates that the programming is problematic or culturally irrelevant [7].

We additionally value exhibiting cultural humility to guide our collaborative partnership with Latinx community members and development of PCSIM-informed programming. Cultural humility refers to one’s ongoing commitment to advocacy, self-evaluation, and self-critique aimed at dismantling systemic power imbalances, as exhibited by one’s life-long commitment to learning from the expertise of collaborating community partners and their lived experiences [47,48]. We view cultural humility as particularly important when collaborating with Latinx community members, since concepts such as familismo and machismo can be accompanied with bias and generalized assumptions that differ among each Latinx individual. Valuing a culturally humble lens asks us to consider these constructs in our partnership, but to prioritize getting to know the individuals with whom we partner and learn from.

This investigation enacts an exploratory evaluation case study and conducts an analysis using concurrent mixed methods. Exploratory evaluation case studies serve to identify the procedures that might be efficacious or a hinderance in meeting the identified goals (e.g., facilitating Latinx maternal acceptance of LGBTQ+ youth) [49] and to highlight the standards to consider in developing more replicable, generalizable programs [50]. Studies have identified the value of informing the procedures that researchers should replicate or amend based, to prevent research from making the same mistake multiple times [49]. The researchers in this study explore and identify what factors researchers should account for when conducting culture-responsive programming to facilitate maternal acceptance of LGBTQ+ youth among Latinx mothers. Concurrent mixed methods, on the other hand, aid in conveying generalizable results from statistical findings that are contextualized via culture-specific perspectives from qualitative responses. Using a concurrent mixed methods design permitted the researchers to gather qualitative and quantitative data, conduct independent analyses, and merge these together to learn how the qualitative findings converged with, diverged from, or expanded upon the quantitative findings with culture-specific rationale [51]. Thus, using a concurrent mixed methods design was elected to triangulate the data and yield a rich, intersectional understanding of how the Latinx families perceived the efficacy and acceptability of developed programming.

1.6. Current Study and Research Questions

Given that increased Latinx family acceptance of LGBTQ+ youth is associated with positive outcomes paired with the critical caretaking role of mothers in Latinx culture, it is important that culturally relevant programming exists to facilitate positive outcomes. While the Familias con Orgullo program exists, additional programming should be developed. It is additionally important to inform what goes into developing a culturally relevant programming for Latinx families of LGBTQ+ youth to facilitate future programming efforts. In conducting an exploratory evaluation case study that aims to illustrate the development process and evaluation of outcomes from a brief psychoeducational session, we pose the following research questions:

Process research questions (1) How did researchers use PCSIM to develop the program content? (2) What did the community collaborators want from the programming aimed at facilitating the familial acceptance of Latinx LGBTQ+ youth? While we hypothesize that these PCSIM methods will facilitate the development of culturally relevant programming, hypotheses about the content that will be developed are unknown, as this is an exploratory inquiry.

Evaluation efficacy research questions: (3a QUAN) Does brief programming garner an initial improvement in Latinx mothers’ acceptance of LGBTQ+ youth? (3b QUAL) What concerns do Latinx mothers have about Latinx children identifying as LGBTQ+? We hypothesize that the programming will yield an initial increase in Latinx mothers’ perceived interest in and ability to support and accept their LGBTQ+ children and other LGBTQ+ youth in their community.

Evaluation acceptability research questions: (4a QUAN) How acceptable do Latinx mothers find the brief programming aimed at facilitating their acceptance of LGBTQ+ youth? (4b QUAL) What aspects of this program did Latinx mothers enjoy? and (4c) What aspects of this program would Latinx mothers change? The hypotheses are unknown given the inductive nature of this qualitative inquiry.

Evaluation efficacy and acceptability mixed methods research questions: (1) How do the qualitative findings converge with, diverge from, or expand upon the quantitative findings? (2) While we suspect the findings will converge and expand among the qualitative and quantitative methods, the hypotheses are unknown given the inductive nature of this qualitative inquiry.

2. Materials and Methods

This study is an exploratory evaluation case study that explores the process of using PCSIM methods to develop and implement a culture-responsive brief session with Latinx mothers of LGBTQ+ youth, aimed at promoting maternal acceptance. Exploratory case studies indicate that the enacted programming itself is not intended to be replicated, but informs what researchers can do to yield more generalizable programming in the future [50]. The methods section conveys how the PCSIM-informed session was developed, what the implementation looked like, and what evaluation methods were used to evaluate the session’s initial efficacy and acceptability. The methods are presented over the four phases of PCSIM. The process of developing culture-specific content is highlighted and presented in Phase 2 of PCSIM, while the data analysis for the evaluation process is depicted within Phase 3.

This study also evaluates the efficacy and acceptability of the implemented programming using mixed methods. The researchers document the intentional mixed methods process that guided this study in Figure 1. We review the specific methods used to conduct the qualitative and quantitative analyses in the methods and review how we triangulated the data to yield a mixed methods synthesis. Lastly, we review important considerations for researchers and practitioners seeking to develop sustainable programming when working to promote maternal acceptance among Latinx mothers with LGBTQ+ youth that were learned from this experience.

2.1. The Development Process of Brief Programming Aimed at Promoting Maternal Acceptance of LGBTQ+ Youth Using PCSIM Methods

The researchers used PCSIM to yield culturally relevant programming for mothers seeking to affirm and accept LGBTQ+ youth in their communities and homes via participatory methods [7]. PCSIM consists of four phases: (1) systems entry, (2) culture-specific model development, (3) culture-specific program development, and (4) program continuation and extension. The following sections share how programming was developed, implamented, and evaluated over the four-step process.

2.1.1. PCSIM Phase 1: Systems Entry

Systems entry serves to form trusting relationships among the researcher/practitioner leading the program development and the community collaborators and cultural brokers, and building awareness of one’s own worldview [7]. The first author attended a health day event, where service providers with various expertise (e.g., therapists, cardiovascular specialists, and yoga teachers) gathered in a local Detroit community to share free resources and could share about their offered programming with the local community attendees. The first author is a licensed psychologist and attended the event to share the therapeutic programming she offers for supporting LGBTQ+ youth’s mental health and wellness. The programming took place in the parking lot of a Detroit-based community agency serving local Latinx community members and offering housing for displaced youth—many of whom were LGBTQ+. A community leader—who will be referred to as the cultural broker in this manuscript—who worked for the Detroit-based community agency approached the first author and endorsed the families she works with, wanting to learn how to support their LGBTQ+ youth community members. She introduced the writer to a mother in the Latinx local community who also endorsed wanting this programming and encouraged the cultural broker to set up programming with the writer for a group of local mothers. The first author, mother, and cultural broker shared laughter about the first author’s broken Spanish in this initial conversation, but this served to facilitate an initial entry point into a shared interest towards developing programming to promote the family acceptance of LGBTQ+ youth. The mother shared with the first author that the cultural broker had the trust and support of the community to collaborate with the writer in developing programming for a group of Spanish-speaking Latinx mothers. Following this initial conversation, the writer and cultural broker had three more conversations to inform a brief programming session that would be implemented through her community agency and possibly expanded pending its acceptability, efficacy, and what was learned from the experience.

2.1.2. PCSIM Phase 2: Culture-Specific Model Development

Culture-specific model development involves developing an overall understanding—or a working model—of what values should be addressed in the programming. Learning what content should be included in this programming occurred over two 1 h meetings with the cultural broker. The guiding questions of the meeting were, “What information would attendees benefit from in learning how to accept LGBTQ+ youth at home and in the community”? and “How can we make the programming culture-responsive?”. The first author documented critical commentary from the conversations via audit trails, which are a detailed chronology of the research activities’ emerging themes and thoughts on developing models because of the project interactions. She conducted member checks, where she reviewed her findings with the cultural broker to confirm that she was capturing the essence of their conversations [52]. The writer and cultural broker used consensus practices, where the final developed culture-specific model would be considered a product upon which both the cultural broker and first author agreed, exhibiting content that would facilitate the familial acceptance of LGBTQ+ youth and presenting as culturally relevant for the Latinx families with whom the cultural broker worked [53]. As a result of this agreed-upon content, the writer had a documented list of concepts and theories that would be reviewed in the session, which she and the additional authors of this paper developed together and member checked with the cultural broker.

Table 2. Culture-specific model of the necessary content to include in programming.

Qualitative Theme	Summary of Cultural Broker’s Commentary	Included Content to Address Theme in Programming (with Empirical and Evidence Base)
Theme 1: Parents experiencing grief and denial of their children being LGBTQ+	Some parents may not be ready to acknowledge their children are LGBTQ+, or genuinely do not know because their children are not out to them. Some parents have voiced anticipating a grieving process if their children come out as LGBTQ+, where they mourn assumptions of the lives their children would lead (e.g., being married to someone of the opposite sex and having children).	Grief validation to validate their feelings are real. Reframe through cognitive behavioral therapy, and talk about topics not assuming families have LGBTQ+ youth in their homes, but assuming their more general curiosity [23,45]
Theme 2: Need Basic introduction to what is LGBTQ+?	Families know little about the LGBTQ+ community, proper terminology, and need basic myths dispelled.	Psychoeducation: terminology and myth busting! [3,23,45]
Theme 3: What is wrong with LGBTQ+ people? Nothing!	Families have expressed wanting to know if anything is wrong with LGBTQ+ people and why “problems” such as “dressing different” or “being depressed” exist.	Psychoeducation: minority stress theory (stressors and outcomes [3,5,45]
Theme 4: Why are LGBTQ+ youth picked on?	Families have endorsed seeing people they think are LGBTQ+ get bullied in their own community and do not know what to do or why it is happening, besides them being thought of as “different.”	Psychoeducation: bullying as a minority stress [1,5,45] Psychoeducation: how can I help? By being an upstander.
Theme 5: What can we do?	Families have shared not knowing the best way to respond to LGBTQ+ youth, not knowing if it is okay to condone LGBTQ+ identities and want to know how to support. They report wanting their children to be healthy and happy. Parents uncertain how to support their children, while also being uncomfortable and nervous about whether they are doing good by their children and families.	Psychoeducation and affirmative cognitive behavioral therapy recommendations: affirm, listen, and promise unconditional love and willingness to learn [23,26,45]. Authenticity, with beneficent intent and honoring dialectically that two opposites of wanting to support and feeling nervous about doing so can be true at the same time (e.g., “I don’t know what you’re going through and I’m nervous I’ll make mistakes by not saying the right thing, but I want to learn how to support you” [45,54].
Theme 6: Familismo & Machismo	Families want to learn how to incorporate validation of LGBTQ+ youth with conflicting values of religion and machismo.	Acknowledge cultural values as strengths (e.g., familismo). Validate where it may be more challenging to work through affirming LGBTQ+ diversity, and recognize dialectically (e.g., machismo [45,54]).
Theme 7: Brief programming	The cultural broker thought families would benefit from initial brief programming that would evoke thought and willingness to change, prior to families committing to ongoing programming. Endorsed that a “brief” one-time session would be a great starting place.	Brief programming has demonstrated efficacy when the experience is perceived as meaningful and informative [55]. Motivational interviewing could be used to change behavior towards accepting LGBTQ+ youth [56].

reflects the culture-specific model developed from these meetings, which informs the mandatory content that would be included in programming. Within this table, themes from the conversations are noted and contextualized via a summary of what the cultural broker identified as important content to include. The researchers paired the content with empirical- and evidence-based practices, to ensure the culture-responsive content could be disseminated with methods that have demonstrated efficacy in facilitating parent acceptance.

2.1.3. PCSIM Phase 3: Culture-Specific Program Development

Culture-Specific Program Development involves implementing and evaluating programming to recursively learn the extent of the program’s cultural relevance, efficacy, and acceptability [7]. Phase 3 occurred with ongoing partnership from community members, the cultural broker and the organization with whom we partnered. To facilitate the program’s implementation, the cultural broker led participant recruitment via various forms of convenience sampling [56]. She posted IRB-approved flyers to their Facebook webpage, included this event on the community group’s calendar, and invited families who she thought would benefit from the session content directly in conversation. At the event, the cultural broker served as a translator, as the researchers who presented spoke English and the primary language of the families attending was Spanish. The session was in-person at the community organization’s center. Prior to families’ participation, they were required to sign informed consent, which was written in English, but read aloud in Spanish.

The programming was facilitated by the first author and supported by authors two and three of this paper. The authors went through training with the first author and were introduced to the cultural broker prior to the program’s implementation to facilitate trust and relationship building [7]. When beginning to pull up the PowerPoint presentation to guide the conversation, the cultural broker began the conversation and presented the families with multiple questions. As conversation seemed to be the preferred mode of content delivery, the authors exhibited recursive flexibility [7] and disregarded the prepared PowerPoint, engaged in semi-conversation, and referenced their list of topics and theories from the culture-specific model to ensure that the agreed-upon content was discussed.

Evaluation Methods and Data Analysis

The researchers evaluated the efficacy and acceptability of the brief programming using qualitative and quantitative methods. Data were gathered via Qualtrics surveys before and after participation in the program. The surveys were written in English, but the cultural broker read the questions aloud in Spanish, and the three researchers assisted participants follow along with the surveys on their phones as they entered their responses. The researchers initially elected to leave the protocols in English to maintain the original form of the surveys, since many mothers spoke both English and Spanish, with Spanish being the preferred language, and since this was an agreed upon approach with the cultural broker. We discuss the limitations of this choice and how we would have the surveys translated into Spanish with the assistance of a formal translator in future programming iterations. Participants were first asked to share demographic information by sharing their age, zip code, gender, and sexual orientation via write-in responses. Participants were also encouraged to respond to open-ended prompts in their preferred language (English or Spanish).

Quantitative Data and Analysis

In evaluating efficacy, participants answered the Parental Acceptance Scale [57]. This scale was a 4-point Likert scale, with responses ranging from always true to never true. This scale was summed and evaluated via a paired t-test to determine whether the families’ attitudes towards their acceptance of LGBTQ+ youth significantly changed following the presentation. In evaluating acceptability, the participants answered three prompts, with a 5-point Likert scale ranging from strongly disagree to strongly agree, which posited: (1) “this program was helpful”, (2) “I liked this program”, and (3) “I would recommend this program to others”. Acceptability questions were evaluated by treating each question as an independent item and reporting the mean and standard deviation values.

Qualitative Data and Analysis

Qualitative responses were gathered from the survey write-in responses [50]. In evaluating efficacy, we asked a qualitative write-in prompt in the pre-test, “What are some current beliefs you hold about the LGBTQ+ community?”. Post-test, we asked the participants via write-in survey prompts, “What belief did you have before this experience, that you learned may have been inaccurate, false, or a misconception?”. Both pre- and post-test, we asked the participants, “What are your concerns for LGBTQ+ youth?” and “What are your hopes for LGBTQ+ Youth?”. In evaluating acceptability, we asked the following write-in prompts: “What did you like about this program today?”, “What was helpful?”, “My favorite part of the programming was”, “My least favorite part of the programming was”, “What would you change about this program?”, and “What was not helpful?”.

The researchers analyzed the qualitative data using a thematic analysis, which refers to using a systematic approach to guide researchers in identifying thematic patterns through a systematic process [57,58]. The first and second authors reviewed the write-in responses independently and developed initial open codes. They came together and conducted consensus coding, where the first and second authors identified the agreed-upon themes that best represented the data [56]. Then, the authors engaged in additional consensus coding for the group codes within the identified themes. Thus, all the coding depicts agreed-upon thematic coding, which was also member checked by community collaborators [57,58].

Mixed Methods Analysis: Triangulation

This investigation used mixed methods to evaluate Latinx mothers’ experiences of the program to quantitatively identify if they endorsed changes from pre- to post-test, identifying how acceptable they found the programming and pairing the quantitative values with the qualitative context. Using mixed methods is recommended when conveying a culture-specific perspective (e.g., Latinx, Spanish-speaking mothers of LGBTQ+ youth), as measures may not be normed or intended for use with diverse participants. The quantitative and qualitative data were analyzed together via triangulation, a strategy that identifies how data converge with or build upon each other. The researchers used the recommended methods of triangulation [51]. The authors used a joint display to compare the qualitative and quantitative data, which identified via consensus coding where data converged, diverged, or expanded upon each other [58,59]. Mixed methods were not used to convey the researcher’s perceptions of the program development and implementation process, as this process was documented via audit trails [52].

2.1.4. PCSIM Phase 4: Program Continuation, and Extension

Program Continuation and Extension aims to sustain programming to continue yielding positive outcomes for its recipients and LGBTQ+ youth who may benefit from programming, to transcend the research partnership [7]. This programming occurred as an exploratory case study to inform future efforts towards producing replicable, sustainable programming and outcomes. The first author has an ongoing relationship with the community agency, where she has conducted professional developments with staff to develop their cultural competencies and skillsets in the areas covered within the culture-specific model of this programming, which, within this organization, can be generalized to productive conversations between staff and mothers that can facilitate their acceptance of LGBTQ+ youth. The PowerPoint created to inform this programming was also shared with the agency so they would be able to disseminate information without the researchers. Additionally, the learned content from this program development, implementation, and evaluation effort will be used to inform the writer’s ongoing development of sustainable, generalizable programming after exploring what worked within this investigation.

3. Results

The results depict the efficacy and acceptability of the findings endorsed among the mothers who participated in the brief PCSIM-informed therapeutic programming. The programming took place over a two-hour session and all the contents of the culture-specific model were addressed. The results first present the demographic information of the families who participated in programming. Next, researchers review the efficacy and acceptability qualitative and quantitative findings. A mixed methods synthesis is offered in the discussion of the qualitative and quantitative data.

3.1. Participant Demographics

A total of n = 16 participants were present for the programming. Of these participants, n = 16 identified as women and were predominantly mothers. The participants in this study ranged in age from 14 to 55 years old (mean = 38 years old). The participants ethnically identified as Hispanic (n = 4), Latina (n = 4), or Hispanic and Latina (n = 3). There were two participants who responded with “Mexico/Mexicana”, one participant who responded with “Detroit”, and two participants did not answer this question. When asked what their sexual orientation was, the participants answered heterosexual (n = 5), none (n = 1), and bisexual (n = 1). The primary spoken language of the participants included Spanish (n = 9) or Spanish and English (n = 4). Four participants did not answer this question.

3.2. Efficacy Findings

3.2.1. Efficacy Quantitative Findings

The quantitative findings assessed the families’ perceived ability to accept their LGBTQ+ children. In reflecting on clinical significance, the ratings of parent acceptance improved (via a noted decrease in scores) across all parent acceptance prompts except for the prompt, “I require that other family members respect my child’s identity.” These findings do not indicate that statistical significance was reached, likely due to the small sample size. In

Table 3. Efficacy outcomes: paired t-test and descriptive statistics regarding acceptance of LGBTQ+ youth.

Prompts	Pre-Test n	Pre-Test Mean (SD)	Post-Test n	Post-Test Mean (SD)	T Value	Sig
1. I talk with my child about their LGBTQ+ identity.	13	2.31 (1.25)	7	1.29 (0.76)	2.05	0.09
2. I support my child’s LGBTQ+ identity even if I feel uncomfortable.	12	2.17 (1.19)	7	1.14 (0.38)	2.05	0.86
3. I advocate for my child when they are mistreated because of their LGBTQ+ identity.	12	1.67 (1.07)	7	1.14 (0.38)	1.08	0.32
4. I participate/attend LGBTQ+ events to support my child.	11	2.45 (1.44)	7	1.57 (1.13)	2.17	0.08
5. I require that other family members respect my child’s identity.	11	1.00 (0.00)	7	1.14 (0.38)	--	--
6. I support my child’s gender expression, even if it is not typical.	12	1.25 (0.62)	7	1.14 (0.38)	1.00	0.36
7. I believe my child can have a happy future as an LGBTQ+ adult.	9	1.33 (1.00)	7	1.14 (0.38)	−1.00	0.37
8. I welcome my child bringing other LGBTQ+ people to my home.	10	1.40 (0.96)	7	1.00 (0.00)	--	--

Note. -- indicates t-tests did not execute output due to data assumptions not being met for these two questions. Likert values, to contextualize the mean the mean: 1 = Always True, 2 = Often Times True, 3 = Sometimes True, and 4 = Never True.

, the paired t-test efficacy findings are presented.

3.2.2. Efficacy Qualitative Findings

The qualitative efficacy findings are documented in

Table 4. Participant qualitative responses (direct quotes from survey write-in prompts), pre- and post-test.

Qualitative Prompt	Pre-Test Themes and Direct Quotes	Post-Test Themes and Direct Quotes
What are some current beliefs you hold about the LGBTQ+ community?	Theme: LGBTQ+ youth are normal and typical   “They are kind and regular people like any other.” Theme:   “No se, I don’t know”   “No se nada” Translation: I do not know anything.   “No se” Translation: I don’t know.   “I am new to this.” Theme: LGBTQ+ Youth are neat!   “I think they are pretty neat.”	NOT ASKED
What belief did you have before this experience, that you learned may have been inaccurate, false, or a misconception?	NOT ASKED	Theme: LGBTQ+ as a Choice   “That being gay was a choice.”   “I understand that their sexualities are not just a choice, and they are not confused.” Theme: Gender Expression and Clothing   “Crossdressing would mean they are gay.”   “That dressing as the opposite sex does not make you gay or lesbian.” Theme: Gender and Sexual Orientation as Different Constructs and Experiences   “I didn’t know that sexual orientation is different.” Theme: I had incorrect information   “Tenga informacion muy incorrectas” Translation: I had a lot of incorrect information.   “La falta infomacion” Translation: [I had] lacking information.
What are your concerns for LGBTQ+ youth?	Theme: The stressors to which LGBTQ+ individuals are exposed   “My concern is that they are attacked without a cause.”   “Lo respeto” Translation: Their respect   “I’m concerned for those who come out to their parents and they kind don’t care about them anymore.” Theme: I don’t know and want to learn No se (I don’t know) Si me interesa quiero aprender	Theme: The stressors to which LGBTQ+ individuals are exposed, and corresponding adverse outcomes   “The harassment”   “La maltrado” Translation: The maltreatment   “That they are misunderstood.”   “Que no sean aceptadas. Que tengan ideas suicidal” Translation: That they aren’t accepted. That they have suicidal ideation.   “Their depression and anxiety” Theme: Concerned with how I talk about LGBTQ+ topics with my kids   “How to talk with her [my daughter]”
What are your hopes for LGBTQ+ youth?	Theme: More acceptance of LGBTQ+ youth and less discrimination   “That they are accepted in society like everyone else.”   “Que no sean descrimimados” Translation: That they are not discriminated against. Theme: Equity   “Que tengan las mismas oportunidades para salir Adelante” Translation: That they have the same opportunities to get ahead. Theme: LGBTQ+ Youth Mental Health   “My hopes are that they feel happy and confident.” Theme: That I can learn more   “Quiero aprender mas” Translation: I want to learn more.   “Pues tengo 4 hijos y quisiera aprender” Translation: Well, I have four children, I would like to learn.	Theme: More Acceptance of LGBTQ+ youth   “That everyone learns to respect them.”   “To be treated like normal people.”   “That more people get inform and learn to accept the lgbtq+ community.”   “Más aceptacion” Translation: More acceptance Theme: Equity   “Las mismas oportunidades como cualquier persona” Translation: [That they have] the same opportunities as anyone. Theme: LGBTQ+ Youth Mental health   “That they are happy and confident.” Theme: Protect my kids   “To be able to defend her” [my daughter]

and organized by the qualitative prompts that participants answered in the survey. Table 4 depicts the qualitative data via themes and direct quotes that illustrate each theme. This commentary defines the themes presented in the table.

Pre-test, the families were asked in the survey to share, “What are some current beliefs you hold about the LGBTQ+ community? What are some current beliefs you hold about the LGBTQ+ community?” Three themes were identified: Theme 1 was “LGBTQ+ Youth are normal and typical”, meaning that the mothers already recognized their LGBTQ+ community members as typical prior to attending the session. Theme 2 was “No se, I do not know”, which referenced participants having limited knowledge about the LGBTQ+ community prior to the programming. Theme 3 was “LGBTQ+ youth are neat”, reflecting participants’ enthusiasm towards the community.

Post-test, the participants were asked a different prompt, “What belief did you have before this experience, that you learned may have been inaccurate, false, or a misconception”? Four themes were discussed. Theme 1 was “LGBTQ+ as a Choice”, where mothers shared that they originally thought there was a choice and freedom to elect to be part of the LGBTQ+ community but learned through the programming that this is not a choice for youth or adult community members. Theme 2 was “Gender expression and clothing”, referred to community members’ conflation of gender expression with implications on sexual orientation; and dispelling the accidental use of the terminology, “crossdressing”. Theme 3, “Gender and Sexual Orientation as Different Constructs and Experiences” more specifically addressed the conflation of gender and sexual orientation. Theme 4, “I had incorrect information” reflected on families’ recognition that they had limited and incorrect information on the LGBTQ+ community prior to attending programming.

Pre- and post-test, the participants were asked “what are your concerns for LGBTQ+ youth?”. Mothers reflected on a similar theme, “The stressors to which LGBTQ+ Individuals are exposed”, both pre- and post-test, where they shared their concern about youths’ lack of respect and exposure to discriminatory behaviors from others. However, post-test, the mothers also mentioned their concern in this code about the impact these experiences may have on LGBTQ+ youths’ mental health outcomes. A unique theme that appeared in pre-test results was mothers’ general reflection on not knowing enough about the community, depicted as the theme, “I don’t know and want to learn”. Post-test, mothers reflected on the potential concerns they had for communicating with their own children who may be LGBTQ+ community members via the theme, “Concerned with how I talk about LGBTQ+ topics with my kids”.

Pre- and post-test, the participants were also asked “What are your hopes for LGBTQ+ youth?”. Three similar themes were mentioned at both time points. The first similar theme called for “More acceptance of LGBTQ+ youth and less discrimination”, where the participants reflected on society learning how to accept and affirm youth as opposed to invoking discrimination. Another theme mentioned at both time points was “Equity”, where the families reflected on wanting LGBTQ+ youth to have the same access to resources and health as anyone else. The last similar theme at both time points called for “LGBTQ+ Youth Mental Health”, where mothers wanted LGBTQ+ youth to be happy and well. Pre-test, the theme “That I can learn more” conveyed mothers’ hope of learning more information to know how to support LGBTQ+ youth, where the new theme post-test, “Protect my kids”, reflected on the families’ more focused interest in learning how to support their own children with more individualized support.

3.3. Acceptability Findings

3.3.1. Acceptability Quantitative Findings

The quantitative results of the acceptability data indicate that the programming was regarded as highly acceptable. Where a score of 1 on the acceptability prompts indicated “strongly disagree” and a 5 indicated “strongly agree”, the mean acceptability scores ranged from a mean of 4.43 to 4.57, with a standard deviation of 1.13 across all three questions.

Table 5. Acceptability outcomes: means and standard deviations of participants’ satisfaction with programming.

Quantitative Prompt	Respondents (n)	Mean (Standard Deviation)
This program was helpful.	7	4.57 (1.13)
I liked this program.	7	4.43 (1.13)
I would recommend this program to others.	7	4.57 (1.13)

Likert values, to contextualize the mean: 1 = Strongly Disagree, 2 = Disagree, 3 = Neither Agree nor Disagree, 4 = Agree, and 5 = Strongly Agree.

shows the specific quantitative acceptability findings.

3.3.2. Acceptability Qualitative Findings

The qualitative efficacy findings are documented in Table 5 and organized by the qualitative prompts answered in the survey. Table 5 depicts the qualitative data via themes and direct quotes that illustrate each theme. This commentary defines the themes presented in the table.

The qualitative prompt, “What did you like about today’s program?” yielded four themes. The first, “Everything”, indicated that the parents liked everything about the programming. The second theme, “Learning LGBTQ+-specific content” referred to mothers’ appreciation for learning LGBTQ+-specific content from the brief session. The third theme, “How to support my child” reflected on the mothers’ appreciation for the content provided that helped them learn how to be a valuable presence for their LGBTQ+ child. The last theme, “Authentic expression by parents” reflected mothers’ appreciation for each others’ vulnerability and realness.

The qualitative prompt, “What was helpful?” yielded three themes: “Everything”, “LGBTQ+-specific” and “Process of programming”. “Everything” referred to the participants finding everything about the programming helpful. “LGBTQ+-specific” referred to the participants finding the LGBTQ+ content they learned helpful. Lastly, the theme “Process of programming” referred to the factors the participants described as helpful in the way the facilitators facilitated the programming.

The qualitative prompt, “My favorite part of the program was” yielded three themes: “Everything”, “Process of programming”, and “Presentation of digestible content”. The theme “Everything” referred to mothers’ referencing everything as being their favorite part of the programming. The theme “Process of programming” referred to participants’ perceptions of the methods facilitators used in programming. The theme “Presentation of digestible content” referred to the mothers’ appreciation for the content being presented in ways that were digestible and understandable and in ways that exhibited sensitivity to their family values and worldview.

The qualitative prompt, “My least favorite part of the program was” yielded two themes: “Nothing” and “Process of programming”. “Nothing” referred to the participants experiencing minimal unfavourability during the programming experience, while “Process of programming” referred to what participants did not like about how the facilitators ran the programming. Lastly, the qualitative prompt, “What was not helpful?” yielded two themes: “Nothing” and “Getting more individualized guidance”. “Nothing” referred to the mothers being satisfied with their experience, while the theme “Getting more individualized guidance” referred to the mothers hope for more individualized consultation on how to approach LGBTQ+-specific concerns within their individual family units.

Table 6. Acceptability post-test prompts, themes, and corresponding direct quotes.

Qualitative Prompt	Pre-Test Themes and Direct Quotes
What did you like about today’s program?	Theme: Everything   “Everything” Theme: Learning LGBTQ+-specific content   “I liked that we learned a bit more about LGBT+” Theme: How to support my child   “Explanation on how to support my child.” Theme: Authentic Expression by Parents   “That everyone expressed their true beliefs”
What was helpful?	Theme: Everything   “Everything” Theme: LGBTQ+-specific   “I learned about how gender and gender expression are different.” Theme: Process of Programming   “The way we got out questions answered”
My favorite part of the program was	Theme: Everything   “Everything” Theme: Process of Programming   “My favorite part is when we talked about it as a group.”   “Asking questions”   “Learning.”   “The support they gave.” Theme: Presentation of Digestible Content   “The way everything was explained into words we could understand and relate
My least favorite part of the programming was	Theme: Nothing   “Nothing” Theme: Process of Programming   “Make it more organized based on the questions.”
What was not helpful?	Theme: Nothing   “Nothing. I loved it.”   “Everything was helpful.” Theme: Getting more individualized guidance   “Ayudarme a mi si me encontrara en una situacion” Translation: Helping me if I find myself in a situation.

presents specific quotes conveying the families’ specific thoughts on each theme.

3.4. Mixed Methods Convergence of Findings: Triangulated Qualitative and Quantitative Efficacy and Acceptability Data

We merged our mixed methods findings via a joint display in

Table 7. Joint display of Latinx mothers’ experience of programming.

Finding	Quantitative Statistic Result	Qualitative Experiences	Converge, Diverge, Expand
Acceptability	Mean value ranged from 4.43–4.57, meaning participants found this program helpful, likable, and worth recommending.	Mothers liked learning about LGBTQ+-specific content, how to support their children.	Converge
		Mothers wanted more organization and more time to process individualized problem solving for their specific family units.	Diverge
		Mothers appreciated attendees’ authenticity and vulnerability, sharing their experiences in session. Facilitators were viewed as answering questions effectively and in digestible ways.	Expand
Efficacy	Paired t-tests were not significant, indicating limited generalizability about efficacy. Descriptively, and of clinical significance, all mean rating scores decreased, meaning families’ scores were more skewed in their perceived ability to accept their LGBTQ+ youth compared to the post-test.	Mothers endorsed wanting the best for their children, for them to feel happy and confident, and that they do not want them to have to experience hardships and stressors related to their LGBTQ+ identity.	Converge
		Mothers endorsed learning that being LGBTQ+ is not a choice, that opting for diverse gender expression does not mean someone is gay, and that gender and sexual orientation are different constructs. Families learned that LGBTQ+ youth are susceptible to depression and suicidal ideation due to stressors and not because there is something wrong with them. Mothers endorsed having minimal knowledge of LGBTQ+ community members and endorsed a lot of knowledge they originally thought was incorrect.	Expand

Note: Converge is where qualitative and quantitative data align and inform each other. Diverge is when qualitative and quantitative data indicate conflicting content. Expand is where qualitative data builds on quantitative data, beyond commenting on the same finding.

, which serves to present the corresponding qualitative and quantitative data together to inform how these findings converge (agree) with, diverge (disagree) from, and expand (offers new information) upon each other [51,58,59]. Table 7 shows the triangulation of the qualitative and quantitative data.

4. Discussion

We know that family acceptance, particularly maternal acceptance, is one of the strongest predictors of LGBTQ+ youth mental health and wellness outcomes [3]. In Latinx communities, where the values of familismo, machismo, and religion value mothers’ role as caregivers and may present as both strengths and barriers to facilitating familial and maternal acceptance [38,39], it is important that researchers and practitioners have information to help inform them on how to produce culture-responsive programming to support mothers in accepting their LGBTQ+ youth [7]. While programs such as Familias con Orgullo exist [45], this study presents a PCSIM-informed development, implementation, and evaluation of brief programming with Latinx mothers to encourage their acceptance of LGBTQ+ youth and community members. Using an exploratory evaluation case study allowed the researchers to identify what should be replicated in future program development and what should be amended to yield sustainable, generalizable programming [49]. Using mixed methods additionally allowed us to enact a culture-responsive protocol for evaluating the Latinx mothers’ experiences of programming by contextualizing the quantitative findings with the qualitative findings [58]. The following discussion reflects on the triangulated, mixed methods findings in the evaluation of the implemented programming. Following this discussion, the researchers reflect on the strengths and limitations of this investigation, to inform future efforts towards seeking to build sustainable programming to facilitate Latinx maternal acceptance of LGBTQ+ youth.

In the acceptability evaluation findings, the qualitative findings converged with the quantitative findings, which indicated a high acceptability, where the mothers indicated that they liked learning the LGBTQ+-specific content that the facilitators presented. The LGBTQ+-specific content presented aligned with endorsed content that the cultural broker shared would be beneficial to present in the PCSIM-developed culture-specific model [7] and aligned with recommendations from previously implemented programming (e.g., [45].) The findings also converged, as mothers indicated they appreciated the content that conveyed how to accept and support children in their community. The content presented on how to affirm and accept these children aligned with recommendations from previous family-based interventions (e.g., [23]) and incorporated familismo values among Latinx community members, an endorsed value by participating community members [28,29]. The qualitative results expanded upon the acceptability ratings, as the families commented on the shared content and described it as easy to understand and as being sensitive to their family values [7]. The mothers also endorsed appreciating each other’s ability to be vulnerable in a brief session, which appeared to contribute to the participants’ openness to learning the content and recognizing how the content may relate to their own lives. Qualitative acceptability responses diverged from the high quantitative ratings where mothers wanted more organization and time to process individual situations within their family units.

Efficacy quantitative findings did not yield a statistical significance, however, the descriptive statistic findings indicated a shift in ratings towards a greater likeliness of accepting their LGBTQ+ children by mothers. In noting this shift towards a greater acceptance, qualitative findings converged, where mothers endorsed wanting the best for their children, for them to have access to the same experiences and rights as everyone else, and for them to be happy and void of poor mental health. Mothers’ endorsed understanding of the minority stress theory and how it could impact their youth [1]. In expanding upon their hope for children’s acceptance, mothers reflected on the knowledge gained from this experience. Mothers shared it was helpful to learn that being LGBTQ+ is not a choice, that gender and sexual orientation are different constructs, and that there is nothing inherently wrong with LGBTQ+. Offering mothers psychoeducation via terminology and dispelling myths aligned with research that has described these components as a critical practice in facilitating family acceptance [3,23,45].

4.1. Researcher’s Reflection on Using a PCSIM-Informed Approach to Develop Programming

Using a PCSIM-informed approach paired with a lens of cultural humility was critical to our developed programming. The researchers view the combination of a culturally humble lens and using PCSIM to develop, implement, and evaluate culture-responsive programming as a helpful systematic approach to collaborating with communities [7,47]. Most important to PCSIM are the forged relationships among researchers and community members, which have the potential to engage families who may be resistant to care given their potential previous experiences of medical mistrust exposure [10]. Having the initial support from the mom we met at the health fair, the community agency leaders supporting and hosting this event, and the cultural broker who served as a genuine support to the facilitators and community members via translating content to eliminate communication barriers, this all contributed to the facilitators and families being able to share in an effective brief experience.

The facilitator’s relationship with the cultural broker was particularly important, as we were able to collaborate and create a culture-specific model [7]. The culture-specific model included content that needed to be discussed in the programming, which was a combination of what the cultural broker conveyed as local community members’ culture-specific values and their needs in supporting their LGBTQ+ youth, with the existing, relevant empirical- and evidence-based practices found in Table 2. Through building the culture-specific model, the cultural broker endorsed a preference for brief programming to evoke initial minor changes for families and to give mothers time to digest content prior to committing to more intensive, ongoing programming. Once in the program—which was initially prepared as a psychoeducational presentation—mothers began talking and asking questions and endorsed preferring conversation to a presentation. Given the recursive and iterative nature of PCSIM, the facilitators were able to consult the culture-specific model to ensure that the critical content was reviewed, and were able to transition to meet the culture-specific preferences [7]. We were additionally able to have meaningful conversation thanks to the cultural broker’s skills as a translator and as a highly engaged and trusted community leader.

In partnering with the cultural broker to plan for the programming, the facilitators developed their cultural knowledge-base about the Latinx values of machismo, familismo, and religious ideals. Learning these values guided how the messaging could effectively call for accepting LGBTQ+ youth. What was critical in forging these relationships and yielding cultural relevance in the programming was enacting our lens of cultural humility [47]. We leaned cultural humility to learn about the values of the individuals with whom we shared the room, and what mattered to them as people- rather than recognizing the room as a collective whole. In working with culture-specific communities, it is helpful to have an awareness of their general values to inform a base level of competency, and to values the expertise of community collaborators in their individual lived experiences, to further promote cultural relevance.

4.2. Researcher’s Reflection on Limitations and Future Directions of the Program Development, Implementation, and Evaluation

It is beneficial to consider the limitations in conducting research, especially when studies may not be carried out as intended, so researchers can learn how to account for what went wrong moving forward [49]. There are several limitations to this study and opportunities to learn from that the researchers acknowledge. Specifically, our sample was small and consisted of 16 participants in total, n = 7 of whom completed the post-test survey. This was a convenience sample from a local community, and many needed to leave the programming to attend to personal obligations. While the programming was 2 h, the survey extended beyond the 2 h mark and the mothers had to leave the training. Moving forward, we would seek to complete all the programming components within the allotted timeframe. The retention from pre- to post-test reflects the participants having lives outside of the study, and we need to value attendees’ time, which presents as a limitation to the generalizability of the results from this study.

Additionally, while we adhered to the culture-specific model developed in collaboration with the cultural broker, the recursive, iterative nature of PCSIM led the researchers to change the presentation methods from a psychoeducational PowerPoint to a psychoeducational conversation. Thus, the systematic intent was changed, and this resulted in an amended protocol. This transition aligned with PCSIM programming by amending the protocol to meet the requested format by the mothers, and we would repeat this process again. While our initial intent was to conduct a pilot study of a systematically developed brief presentation, we would, in the future, conduct an exploratory session when developing the programming to ensure that the programming is what families want. Having the insight that mothers were looking for a conversational format has helped us reconsider a more conversational format, which can be replicated and generalized in future programming. In the future, we would also collaborate more closely with community members in addition to cultural brokers to yield a greater understanding of what culturally responsive programming would look like, so fewer changes would occur in real time.

Lastly, while the cultural broker also served as a translator and facilitated our rapport with the families, some messaging was not translated verbatim, as the cultural broker further aligned the messaging to resonate with the families. In future studies, we would seek to have verbatim translation services provided by a third-party translator to effectively evaluate which program messages were effective or which would need additional culture-specific considerations. We also left the surveys in the English language as the cultural broker was prepared to provide translation in live-time. Nevertheless, we recognize the barrier of having surveys in a language that is not the first language of our participants and, despite planning to read the prompts out loud, the reliability and validity of the quantitative results is questionable. In the future, we would work with a translator to ensure the surveys are written in the primary language spoken by our participants.

5. Conclusions

Using PCSIM and in valuing a culturally humble framework, the researchers collaborated with a Latinx cultural broker, community organization, and community to develop culturally responsive programming and learned from this exploratory experience. Programming exists for Latinx families to facilitate their acceptance of LGBTQ+ youth (e.g., Familias con Orgullo), but additional programming is needed to meet Latinx family needs via a brief facilitation, particularly for mothers. This was an exploratory evaluation case study and offers critical information on developing more sustainable, generalizable programming. This study contributes an applied methodological example of how to partner with mothers and yield culture-responsive programming to address intersecting Latinx values in learning to affirm their LGBTQ+ youth. Furthermore, the mixed methods approach informed culture-specific insight into how the acceptability and efficacy findings converged, diverged, and expanded on each other to convey the importance of valuing collaborative culture-specific community perspectives as equal partners and experts in the PCSIM process.