From pilot to evaluation to dissemination, this adolescent behavioral intervention for Latinx families continues to grow and evolve by staying culturally connected and creative.
Fifteen-year-old Gabi has been waiting for her mom, Cecilia, to come home from her job as a caregiver. Gabi’s worried about her 13-year-old brother, Darwin, who’s been skipping school. When Cecilia arrives late and tired, Gabi joins her on the couch.
“Mami, we have to talk,” says Gabi.
“You always choose the worst moments!” replies her mother.
“I don’t choose them; they’re the only chance I have,” responds Gabi. “You’re always in a hurry or tired.”
“Okay, tell me what’s bothering you,” says her mother.
“It’s not me, it’s Darwin. It looks like – ”
“Gabriela, I’m sorry, m’ija, but I’m dead tired. Tomorrow I have to take Doña Silvia to the radiologist super early. We’ll talk another time, OK?”
“Yeah, sure. Another time,” says Gabi.
Frustrated and dejected, Gabi sits at her laptop and messages Ramiro, an older man she met on a dating app. “OK, Ramiro. We’re on. When do you want to see me?” Heading off to bed, Cecilia has no idea Darwin’s about to be suspended from school or that Gabi’s planning to meet up with Ramiro.
“Gabi” and “Cecilia” are fictional characters in a telenovela that has been watched by hundreds of parents participating in the online version of Familias Unidas (United Families), an evidence-based prevention program for Latinx parents and their 12-to-16-year-old adolescents. Over eight episodes, the story dramatizes problems that stem from a lack of effective communication between parents and teens. Familias Unidas was co-developed as a face-to-face intervention more than 20 years ago by a team of researchers under the direction of Professor Guillermo “Willy” Prado, Ph.D., who also serves as the University of Miami’s vice provost for faculty affairs and Graduate School dean. Seeking to address factors associated with substance use and HIV sexual risk behaviors among Latinx adolescents, the team worked to empower parents with skills to improve family functioning.
The intervention builds on an ecosystemic model that targets the adolescent’s “three worlds” – family, friends, and school. Over 12 weeks, groups of parents meet eight times to explore each of these worlds. Through a participator y process, facilitators elicit parents’ stories and teach them strategies to communicate effectively with their adolescents, monitor their behavior and schoolwork, and protect them from peer pressure to smoke, drink alcohol, use drugs, or engage in unsafe sexual activities. During four family sessions, facilitators coach parents as they practice new communication skills with their teens.
“Familias Unidas also addresses Hispanic cultural values, acculturation, and stress,” says Prado, who holds faculty appointments in the School of Nursing and Health Studies (SONHS), as well as in UM’s departments of Public Health Sciences and Psychology. “It’s very culturally syntonic.”
“The parents have a great deal in common,” adds long-time clinical super visor and trainer María Tapia, Ph.D. “They arrive complaining that their kids are getting into trouble and speaking disrespectfully. They don’t know what to do or how to communicate.” Tapia, who has trained more than 250 facilitators and currently super vises 100 in the U.S. and Latin America, knows building a supportive network among parents is essential to the program’s success. “They share problems and stories and realize they aren’t alone,” she explains. “They say, ‘The other parents gave me support, relief, tools, and skills.'”
The highly regarded intervention has been delivered in more than 40 middle and high schools throughout Miami-Dade County. But wherever it is implemented, parents affirm that learning to communicate with their teens is one of their most valued outcomes.
“We learned how to draw closer to our kids so they’re able to share the things they’re holding inside,” says parent participant Lidiana Baster. “With these strategies it’s easy to help them.” As parents learn about the developmental and societal challenges teens face, they begin to understand how best to apply the communication strategies they’re also learning.
“It’s not enough to tell us, ‘This is wrong, fix it’ – you need to teach us what to do,” explains “Marta García,”* another parent participant who asked that her real name not be used. “It’s a difficult age; parents are seen as an obstacle, like we’re always going to say no. I learned how to approach my daughter so she won’t see me that way.”
“My son has changed in how he reaches out to me and shares his problems,” agrees Baster. “I feel he’s broken through that barrier and there’s a lot more communication.”
“I liked the program because it teaches you how to interact with your family,” adds Baster’s son Brandon Raymond. “It was easier for me to explain things to my mom.”
Across multiple randomized trials, Familias Unidas has been shown to significantly improve family functioning and communication, reduce cigarette and alcohol use, and increase condom use. The intervention has been recognized by the Substance Abuse and Mental Health Ser vices Administration, the Centers for Disease Control and Prevention (CDC), and the National Institute of Justice. According to the prestigious Blueprints Registry, it is one of only 54 interventions meeting the strictest scientific standard of evidence, and the only one recognized for Latinx youth. In addition, the National Academy of Medicine (formerly the Institute of Medicine) cited Familias Unidas as an evidence-based intervention ready for wide-scale dissemination.
Going Virtual with ‘eHealth Familias Unidas’
In 2012, the team began testing an online adaptation of Familias Unidas in partnership with the UM School of Communication. Parents watch the telenovela and follow the lives of Cecilia, Gabi, and their family and friends, who are portrayed by professional actors. The scripts were written by Luis Santeiro, the Cuban-American playwright known for the classic 1970s public television sitcom ¿Qué Pasa, USA?
“The telenovela resonates with Hispanic families because it’s syntonic with our culture; we all grew up watching them,” says Yannine Estrada, Ph.D., SONHS research assistant professor and Familias Unidas director of research, who served as principal investigator of the CDC-funded “eHealth” online adaptation under Prado’s mentorship. “Parents love it. Each episode maps on to one of the inter vention topics and ends with a cliffhanger that engages parents to watch the next one. Some even binge watch.”
The telenovela is followed by a video featuring Tapia facilitating a parent group. To ensure a participatory experience, Tapia introduces interactive exercises for parents watching at home. Using a telehealth model, facilitators also coach parents through four live family sessions.
“The online format offers greater accessibility, flexibility, and convenience, making it easier for parents everywhere to participate,” says Estrada. “It also supports wider dissemination to communities beyond South Florida.”
National and Hemispheric Impact
As Familias Unidas has gained visibility, it has generated appeals to bring the intervention to communities across the United States and Latin America. Building on an impressive platform of evidence and recognition, Prado and his team are disseminating Familias Unidas into real-world settings.
“We’re taking the intervention out of the research lab and translating it to practice,” he explains.
Tapia has trained and supervised clinicians implementing Familias Unidas in Providence, Rhode Island, and Chester County, Pennsylvania, nurturing strong community partnerships. Now, the team is preparing to disseminate the program in Brooklyn and Rochester, New York.
“Familias Unidas has filled a great void in parent-adolescent relationships, bringing tools that have enriched their communication,” says Luis Rodríguez, master trainer and clinical super visor at CYC (Children and Youth Cabinet) in Providence. “It has empowered many parents from our Hispanic community.”
“We’re amazed by the incredible outcomes for our families,” adds Johnna Goodridge, director of prevention for Family Ser vice of Chester County. “I have yet to see a program with such impactful dynamics in family functioning. Familias Unidas has become our number one resource in serving our Hispanic community.”
Because the team transitioned Familias Unidas to an online platform years ago, they were well-positioned to continue delivering the program during the COVID-19 pandemic.
“We’re especially grateful that the University of Miami’s dedicated team led the way for us to offer Familias Unidas online since the start of the pandemic,” says Goodridge. “It provided a lifeline for many of our families in the face of stress and isolation.”
In 2019, the Chilean government officially adopted Familias Unidas as a prevention program for families with at-risk adolescents. Delivered through Sistema Lazos, a program of the undersecretary for crime prevention, Familias Unidas is being implemented in 20 communities across Chile, with a goal of 40 by 2022.
“Familias Unidas has significantly impacted thousands of families since its large-scale implementation in Chile,” says Marcelo Sánchez Ahumada, managing director of the San Carlos de Maipo Foundation and principal investigator of Familias Unidas en Chile. “It has become public policy in our country as an intervention proven to positively impact the lives of Chilean adolescents and their families.”
To date, Familias Unidas has also reached families in Ecuador and Central America. The intervention’s success in Chile demonstrates its immense potential to impact families and public policy on a hemispheric scale.
Familias Unidas continues evolving to address community needs. With rates of overweight and obesity among Hispanics climbing to alarming levels, in 2016 Prado and his team developed Familias Unidas for Health and Wellness, which led to an NIH-funded randomized trial of 280 families in partnership with Miami-Dade Parks and Recreation. Sessions focused on preventing obesity through diet and physical activity, and families learned healthier ways to prepare traditional Latin American meals.
Last year, Prado and his team collaborated with Behar-Zusman, Ph.D., SONHS professor and associate dean for research, to begin focusing on the needs of sexual minority youth, an at-risk population with high rates of depression, anxiety, and suicide ideation. A grant from the Sylvester Comprehensive Cancer Center funded formative research to pilot test the new intervention, called Familias con Orgullo (Families with Pride), which addresses parent-adolescent communication, emotional regulation, and managing the coming out process.
“It’s the first family intervention for Latinx sexual minority youth who have recently disclosed to their parents,” says Prado. “This is a population where there is so much need. Almost 50 percent of kids in our pilot study reported suicide ideation, and many reported suicide attempts.”
Fostering Latinx Adolescent Mental Health
Most recently, Prado and longtime collaborator C. Hendricks Brown, Ph.D., a professor at Northwestern University, were awarded a four-year, $3.05 million grant from the National Institutes of Health’s National Institute of Mental Health for an effectiveness implementation trial that will bring an enhanced online intervention, “eHealth Familias Unidas for Mental Health,” to 468 Latinx families at 18 primary care sites throughout South Florida with an eye toward sustainability.
The study will explore whether the clinics are able to deliver the intervention on their own over the long term. “We know Familias Unidas is effective, so this study is all about implementation,” explains Prado. “We’re looking at sustainment as one of our primary outcomes.”
With a focus on fostering mental health, the study team will also evaluate the intervention’s effectiveness in preventing or reducing symptoms of depression and anxiety, suicide ideation and behavior, and drug misuse among Latinx adolescent participants, one of the largest and fastest-growing youth populations in the U.S. They’ll also explore the role parental depression, family communication, and adolescent externalizing behaviors such as drug misuse play in the intervention.
“Interventions designed to interrupt the effects of mental health disorders and other poor outcomes are imperative for maximizing health among Hispanic youth,” says Prado. “Until now, evidence-based preventive interventions such as Familias Unidas and eHealth Familias Unidas have largely been tested in schools and delivered by research staff. Evaluating these interventions in real-world studies of primary care delivered by clinic staff, and understanding the implementation processes that help or hinder their integration in systems, is key to improving mental health and reducing disparities in the U.S.”
The study will use a new iteration of the telenovela, and the team is adapting the original scripts to include more explicit conversations about adolescent anxiety, depression, and suicidality. Two award-winning filmmakers at the UM School of Communication, professors Sanjeev Chatterjee and Ed Talavera, will collaborate in the production of the new videos.
“Now that we’re targeting new outcomes and focusing on new populations, we’re re-recording the telenovelas to include mental health, and one of the characters will be a sexual minority youth,” says Prado, a step that will make the telenovela even more relevant and inclusive.
Familias Unidas has undergone a remarkable 20-year journey, from a face-to-face intervention in schools to online program accessible to families everywhere and adaptable for emerging needs. But those who know him best say the journey couldn’t have happened without Prado’s unique brand of collaborative leadership. They are quick to praise his dedication to mentoring and to ensuring the team’s ongoing professional development.
“Dr. Prado is a wonderful mentor to staff and students, and always credits the success of Familias Unidas to his team,” says Tapia. “He allows us to work independently, but we rely on his leadership and vision. We have confianza—we trust and care about each other.”
“He holds us to high standards and motivates us to do the hard work, and he values our input and puts it into action,” adds Estrada. “But he’s also lively and energetic, and he makes it fun for us.”
In 2020, the journey led Prado and his team to a new home at the School of Nursing and Health Studies, where they are ready to take Familias Unidas in new directions. With Prado at the helm, they will continue adapting the intervention to address generational changes and emerging community and hemispheric needs.
Meanwhile, in the final episode of the telenovela, Gabi’s mother, Cecilia, joins a Familias Unidas group and learns to communicate with her teens. By then, the real-life parents following the story have been practicing their own new skills and are beginning to see positive changes. The program is so transformational, parents often talk about their lives “before” and “after” Familias Unidas.
“Familias Unidas teaches us how to use our resources, together—which is the name of the program,” says García. “Families get together and—it’s love.”
“I definitely recommend this program and hope it reaches many families,” adds Baster. “Once you know what actually works, your life changes.”
Dr. Prado and SONHS would like to acknowledge the rest of the Familias Unidas team, including research support senior manager María Velázquez, biostatistician Tae Kyoung Lee, doctoral students Alyssa Lozano and Devina Dave, and research assistants María Alfaro and Rosalba Serralta. The Familias Unidas team would also like to thank past research assistants, students, and postdoctoral fellows, as well as community partners, for their contributions. Finally, they want to acknowledge the thousands of families whose participation in this research made possible the program’s dissemination to other cities and families in the U.S. and Latin America.