Needs and Attitudes Related to the Adoption of Evidence-Based Practices Among Latinx Mental Health Professionals

Abstract

This study investigated the needs and attitudes toward EBPs among an interdisciplinary sample of mental health professionals in Puerto Rico. An anonymous survey was distributed to social workers, psychologists, and professional counselors (N=237). Using structural equation modeling, four dimensions of attitudes towards EBPs (openness, divergence, appeal, and requirement) were regressed on various individual and organizational factors. Some socio-demographic characteristics, educational opportunities, and organizational factors significantly contributed to specific attitudes related to the adoption of EBPs. Female participants and those working in rural settings scored higher in the openness to innovation dimension. Greater organizational support and graduating from a private institution were associated with more divergence from research, while married individuals and those trained on EBPs scored lower on this dimension. The lack of exposure to EBPs in college and younger age predicted greater interest in the appeal of adopting an EBP intervention (i.e., would adopt an EBP if it made sense). No differences in attitudes toward EBPs were found by professional discipline or work setting (i.e., clinical, community, and schools). Recommendations to increase openness and interest in the appeal of EBPs among Spanish-speaking professional communities in Latin America are highlighted.

Full text

ORIGINAL ARTICLE
Administration and Policy in Mental Health and Mental Health Services Research
https://doi.org/10.1007/s10488-023-01278-7
The adoption and successful implementation of Evidence-
Based Practices (EBPs) in clinical and non-clinical set-
tings to address mental health and health needs are gaining
increased attention (Stadnick, et al., 2020). Eorts to iden-
tify and disseminate these practices in diverse communities,
such as the growing population of Latinxs in the United
States (U.S.), are limited. Puerto Ricans, the second larg-
est group of Latinxs in the U.S., have higher rates of men-
tal health than any other Latinx population in the nation
(Alegría, et al., 2007). The twelve-month prevalence of
mental health and substance use disorders was 19% and
24%, respectively, indicating a clear need to implement
EBPs in Puerto Rico (Canino, et al., 2016).
Research has suggested that Puerto Ricans who engage
in culturally adapted evidence-based interventions have
shown considerable improvements in their clinical needs
(Alegría, et al., 2019; Lee, et al., 2013; Rosselló & Bernal,
Natalia Giraldo-Santiago
ngiraldosantiago@mgh.harvard.edu
1 Disparities Research Unit, Department of Medicine,
Massachusetts General Hospital, 50 Staniford Street, 8th
oor, suite 830, Boston, MA 02114, USA
2 Department of Psychiatry, Harvard Medical School, Boston,
MA, USA
3 Graduate College of Social Work, University of Houston,
Houston, TX, USA
4 Department of Psychiatry & Behavioral Sciences, National
Crime Victims Research & Treatment Center, Medical
University of South Carolina, Charleston, SC, USA
Abstract
Empirically supported interventions are warranted to achieve desired clinical outcomes and improve service delivery.
Thus, eorts to identify, adopt, and implement Evidence-Based Practices (EBPs) are underway across various Latinx com-
munities, including Puerto Ricans, where there is a growing recognition and prevalence of mental health and substance use
disorders. This study investigated the needs and attitudes toward EBPs among an interdisciplinary sample of mental health
professionals in Puerto Rico. An anonymous survey was distributed to social workers, psychologists, and professional
counselors (N = 237). Using structural equation modeling, four dimensions of attitudes towards EBPs (openness, diver-
gence, appeal, and requirement) were regressed on various individual and organizational factors. Some socio-demographic
characteristics, educational opportunities, and organizational factors signicantly contributed to specic attitudes related to
the adoption of EBPs. Female participants and those working in rural settings scored higher in the openness to innovation
dimension. Greater organizational support and graduating from a private institution were associated with more divergence
from research, while married individuals and those trained on EBPs scored lower on this dimension. The lack of exposure
to EBPs in college and younger age predicted greater interest in the appeal of adopting an EBP intervention (i.e., would
adopt an EBP if it made sense). No dierences in attitudes toward EBPs were found by professional discipline or work
setting (i.e., clinical, community, and schools). Recommendations to increase openness and interest in the appeal of EBPs
among Spanish-speaking professional communities in Latin America are highlighted.
Keywords Mental health professionals · Evidence-Based Practices (EBPs) · Mental health services · Implementation
science · Puerto Rico · Latinx providers
Accepted: 29 May 2023
© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2023
Needs and Attitudes Related to the Adoption of Evidence-Based
Practices Among Latinx Mental Health Professionals
NataliaGiraldo-Santiago1,2 · Robin E.Gearing3· ChristianCarr3· RosauraOrengo-Aguayo4· Sarah
C.Narendorf3
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Administration and Policy in Mental Health and Mental Health Services Research
1999). Thus, investigating attitudes towards EBPs is key to
improve service delivery, outcomes, and support their suc-
cessful implementation of these practices in settings where
they are needed the most (Aarons, 2004; Melas, et al., 2012;
Rousseau & Gunia, 2016; Rye, et al., 2019). However, atti-
tudes toward EBPs have been examined mostly in white,
female, and U.S. professional samples (Parrish & Rubin,
2012; Locke, et al., 2019). The study of individual charac-
teristics, educational, and organizational factors associated
with the successful adoption of these practices remains lim-
ited, particularly among Spanish-speaking mental health
professionals residing and practicing in Latin American
communities. To address this critical gap in the eld, there
is a need to increase the number of studies focusing on the
implementation of EBPs among Latinx professionals, an
essential workforce needed to mitigate the rising prevalence
of clinical needs in this population.
The lack of studies examining the factors aecting the
implementation of EBPs in Latin America could contribute
to the existing health disparities experienced by the growing
Latinx population migrating to the Unites States. Moreover,
understanding the needs and attitudes related to the adop-
tion of scientically rigorous interventions across clinical,
school, and community settings is imperative to increase
the reach of these practices. This is particularly relevant in
Puerto Rico, a territory of the U.S. where the implemen-
tation of EBPs is currently underway across professional
disciplines and diverse settings. Notwithstanding, the lit-
erature indicates that mental health professionals in Puerto
Rico are perceiving mental health services as limited, less
individualized, and more automated as a result of the lack
of supervision and training focused on specialized interven-
tions (Negroni, et al., 2019).
To successfully disseminate and implement EBPs in pro-
fessional communities of Latinxs, individual, educational,
and organizational factors must be studied to understand
how characteristics, experiences, environments inuence
attitudes and behaviors (Meadowcroft, et al., 2018). To
date, only one study has examined knowledge, attitudes,
and behaviors related to EBPs among 132 mental health
professionals and graduate students in Puerto Rico (Rodrí-
guez-Soto, et al., 2015). The study found that only 10% of
participants indicated they were familiar with EBPs, 11%
reported using them regularly, and 13% described having the
necessary skills to use EBPs (Rodríguez-Soto, et al., 2015).
However, this study did not examine how socioeconomic
and organizational factors contribute to attitudes, despite
prior literature suggesting signicant associations with
these factors (Aarons, et al., 2010, 2012; Rye, et al., 2019;
Pitsillidou, et al., 2021). Moreover, dierences in attitudes
toward the adoption of EBPs among social workers, psy-
chologists, and counselors working across practice settings
(i.e., clinical, community, and schools) remain unclear. The
identication of factors contributing to the adoption of EBPs
in school and community settings is increasingly important,
as preventative interventions for marginalized and hard-to-
reach populations ought to be implemented in such settings.
Extensive research has highlighted that a support-
ive organizational climate is associated with more posi-
tive work attitudes (Aarons, 2004; Aarons, et al., 2011),
employee commitment (Islam, et al., 2015), and favorable
views toward adopting EBPs (Aarons & Sawitzky, 2006).
Currently, there is a knowledge gap in how organizational
factors relate to the adoption of EBPs in Puerto Rico, and
whether attitudes towards these practices are impacted by
burnout, a work-related stressor associated with lower use of
EBPs (Wilkenson, et al., 2017). Increasingly, there has been
an interest in examining whether agency type (i.e., public
vs. private agencies) has an inuence on the adoption of
EBPs as some organizations are embracing these practices.
In Puerto Rico, mental health agencies in the public sector
have expressed a commitment to developing public policies
that endorse, support, and disseminate EBPs among mental
health providers (Exc. Order, No. 2013-03). However, the
Mental Health Code of Puerto Rico (2000) requires only
the public sector to provide treatment with a scientic basis.
According to this code, faith-based organizations (e.g., pri-
vate and non-prot organizations) are allowed to engage in
traditional, historical, and spiritual interventions. Inconsis-
tencies in the requirement of EBPs may worsen disparities
in access to eective and much-needed interventions as well
as shape professional attitudes and decisions.
Policies and organizational factors may directly or indi-
rectly inuence provider attitudes related to the adoption of
these practices. For example, a study conducted with a Span-
ish sample of child welfare professionals found that profes-
sionals in private agencies were more likely to adopt EBPs
based on requirements than participants from the public sec-
tor (De Paúl, et al., 2015). Despite policies requiring the use
of EBPs, no identied research has examined whether there
are any dierences in attitudes toward adopting an EBP if
a supervisor, agency, or an island-wide policy is required to
do so by agency type (i.e., working in a public vs. private
agency). Further, less is known about whether other socio-
demographic characteristics (i.e., age, gender, marital sta-
tus) inuence other dimensions of attitudes towards EBPs
(i.e., the appeal of an EBP, divergence from research, and
openness to innovation).
Existing literature in the U.S. indicates that social work-
ers may be at a disadvantage when compared to psycholo-
gists in their orientation toward evidence-based practices
(Parrish & Rubin, 2012). In Puerto Rico, Rivera-Suazo and
Ramos Cruz (2017) commented that social workers are con-
cerned about the emphasis of EBPs on research over other
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Administration and Policy in Mental Health and Mental Health Services Research
types of knowledge and the reductionist approach of these
practices. To our knowledge, this is the rst study to explore
attitudes of EBP adoption among an interdisciplinary sam-
ple of Puerto Rican mental health providers (social workers,
psychologists, and counselors) in diverse clinical and non-
clinical settings.
Current Study
This study aimed to examine mental health providers’ atti-
tudes towards the adoption of EBPs using a four-dimen-
sional approach that included (1) the intuitive appeal of
EBPs, (2) requirements for the use of EBPs, (3) openness
to innovation, and (4) perceived divergence from research-
informed practices. The rst research objective sought to
investigate whether mental health professionals’ socio-
economic (e.g., age, gender, marital status, income, high-
est degree accomplished) and educational factors, such as
the type of university attended (e.g., public vs. private) and
learning experiences in graduate school were associated
with the four dimensions of attitudes towards the adoption
of evidence-based practices (EBPs). Moreover, this study
sought to understand whether perceived organizational sup-
port, training, agency location (e.g., urban vs. rural), type
of organization (e.g., private vs. public), work setting (e.g.,
clinical vs. community and school settings), and emotional
exhaustion inuenced mental health professionals’ attitudes
toward EBPs in each of the four dimensions. Lastly, this
study examined whether dierences existed in each dimen-
sion of attitudes towards EBPs based on professional disci-
pline (i.e., social workers vs. psychologists and professional
counselors).
Methods
Data Collection
This study used a cross-sectional design and convenience
sampling method. An anonymous online Qualtrics survey
was distributed in social media Facebook groups and shared
with professional associations of social workers, psy-
chologists, and counselors in Puerto Rico. This study was
approved by the institutional review board at the Univer-
sity of Houston. Data were collected online and in person,
between October and December 2021. The online Qualtrics
survey was sent to 8,645 individuals, posted on private
social media groups of 15,282 professionals, and presented
in person at a conference in PR comprising 322 social
workers. The response rate via an email invitation through
three professional associations and online private Facebook
groups yielded a 1.34% and 1%, respectively. The in-person
data collection yielded a response rate of 30%.
Participants
A convenience sample of practicing and licensed social
workers, psychologists, and professional counselors in
Puerto Rico was recruited through email correspondence
via the following associations: (1) Professional Counselors
Association (CPCR), (2) Psychology Association of Puerto
Rico (APPR), and the (3) College of Social Work Profes-
sionals (CPTSPR). Social workers were also recruited at
an in-person conference in Ponce, Puerto Rico, in Octo-
ber 2021. A total of 299 individuals completed the survey.
Sixty-two of the online survey responses were removed and
deleted from the analysis as the survey completion time was
under ve minutes or survey was identied to be completed
by individuals outside of PR.
Measures
Socio-economic factors included age, gender, income, and
marital status. Educational factors included degree (masters,
doctorate degree, or something else), university type (pub-
lic vs. private), and exposure to EBPs in graduate studies
(see Table 1). Professional predictors included occupation,
number of jobs, and years of experience (Table 2). Work-
related factors included perceived organizational support,
type of agency (private vs. public), work setting (clinical,
school, and community), training on EBPs, and perceived
suitability of EBPs for the Puerto Rican population (see
Table 3).
Evidence-based Practice Attitude Scale (EBPAS-15)
Attitudes towards EBPs were examined with the original
measure of EBPAS-15 (Aaron, 2004). This brief and prag-
matic measure was preferred to gain a more nuanced under-
standing of the barriers and facilitators of EBPs. The 5-point
Likert scale ranged from (0) to a very great extent to (4) not
at all. The EBPAS scale was conceptualized in four lower-
order factors or subscales rather than higher-order factors
or the total scale score. These dimensions were requirement
to engage in EBP, the appeal of an EBP, openness to inno-
vation, and divergence from research. The appeal of EBPs
examined the extent to which professionals would adopt a
new practice if it was intuitively appealing and made sense
(ω = 0.71). The requirements for the use of EBPs centered
on the extent to which a provider would adopt a new prac-
tice based on it being required by their agency, supervisor,
or island-wide (ω = 0.91). Openness to innovation was the
third dimension of attitudes that explored professionals’
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Administration and Policy in Mental Health and Mental Health Services Research
condence intervals. Moreover, a variety of sample size
scenarios and criteria were evaluated using Monte Carlo
simulation per Muthén and Muthén (2002).
Additionally, a conrmatory factor analysis was con-
ducted to estimate the measurement model for the latent
variables in step one. In step two, structural regressions
were estimated, while factor loadings were specied and
xed based on the results of step one. Due to the non-nor-
mal distribution of some measurement indicators, as well
as limited response categories (ve), maximum likelihood
estimation was used with robust standard errors and t indi-
ces (Rhemtulla et al., 2012). Monte Carlo simulation and
model estimation were performed using Mplus 8. Sensitiv-
ity analyses were performed to ensure that individual cases
were not exerting undue inuence on parameter estimates or
model t indices (Pek & MacCallum, 2011).
Missing data were handled using maximum likelihood.
Missingness for most variables was low (< 5%), although
some exhibited higher amounts of missing data, includ-
ing indicators for learning about EBPs during university
studies (11%), work setting (18%), and EBP suitability
(20%). Several correlates of missingness for these variables
were included in the model, thus supporting the missing
at random assumption necessary for maximum likelihood
(Enders, 2010).
Results
Descriptive
The total sample for analysis was 237 participants. As
detailed in Table 1, the sample identied predominately as
female (83.4%) and Puerto Ricans (96.2%), with a mean
age of 42.83 (SD = 11.64). Almost half of the participants
were social workers (n = 45.6%), followed by psycholo-
gists (29.1%) and professional counselors (25.3%). Mean
scores on each dimension of attitudes towards EBPs (intui-
tive appeal, requirements for the use, openness to innova-
tion, and perceived divergence from research-informed
practices) are presented across key individual, educa-
tional, and organizational factors in Table 1. The EBPAS
total mean scores was 2.69 (SD = 0.52). Mean values on
the appeal, requirement, and openness dimensions were
higher among providers with a master’s degree than those
with a doctorate degree. Similarly, those working in public
agencies and schools had higher mean scores in all dimen-
sions when compared to those working in communities or
clinical settings. Table 2 presents the professional charac-
teristics and socio-economic needs of the sample. Table 3
presents organizational characteristics of the sample and
experiences with EBPs. Despite a majority of professionals
willingness to try new interventions (ω = 0.83). Lastly, per-
ceived divergence of EBP focused on the extent to which
providers perceived research-based interventions as not
clinically useful and less important than clinical experience
(ω = 0.68). The divergence subscale was reverse coded for
higher scores to indicate less favorable attitudes towards
research. More details about the reliability estimates of the
study measures are presented in the results section and the
following publication (Giraldo-Santiago, 2022).
Perceived Organizational Support (POS-8)
POS referred to employees’ perception concerning the
extent to which the organization values their contribu-
tion and cares about their well-being (Eisenberger, et al.,
1986). The POS-8 scale was an abbreviated version of the
POS − 21 item scale developed by Eisenberger. This study
adapted the Spanish Version by Ortega (2003) from a 7- to
a 5-point Likert scale ranging from strongly disagree (1) to
strongly agree (5). Negatively worded items were reverse
coded for higher scores to represent greater perceived orga-
nizational support. The reliability coecient of POS in this
study was 0.89.
Emotional Exhaustion (EE)
A three-item subscale obtained from the 9-item Maslach
Burnout Inventory (MBI) was used in this study (Maslach
& Jackson, 1981). This variable was continuous and mea-
sured at an interval level with a Likert scale ranging from
never (1) to every day (6) on the following items: (1) I deal
very eectively with the problems of my patients; (2) I feel
I’m positively inuencing other people’s lives through my
work, and (3) I feel exhilarated after working closely with
my patients. The emotional exhaustion subscale had an esti-
mated reliability of 0.87.
Statistical Analysis
Structural equation modeling (SEM) was used because
measurement error is controlled for when estimating struc-
tural regressions (Bollen, 1989), unlike naïve approaches
such as sum scores. Given the relatively limited sample size
(n = 237), a series of Monte Carlo simulations (Muthén &
Muthén, 2002) were performed to assess the quality of the
estimates and decide whether full SEM (i.e., simultaneous
estimation of the measurement and structural parts of the
model) was feasible or if a two-step, small sample SEM
technique was required (Rosseel, 2020). Results of the sim-
ulations revealed that a two-step procedure would minimize
bias in the parameter estimates and standard errors as well
as maximize coverage of parameter estimates with 95%
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Administration and Policy in Mental Health and Mental Health Services Research
received EBP education in their graduate program (75%),
only 49% reported having knowledge on how to access
EBP resources. Only 56% had received training on EBPs in
the year prior to the survey. Three-quarters (75.1%) of the
Table 1 Mean and standard deviations on each dimension of attitudes towards the adoption of EBPs by predictors
Predictors Appeal Requirements Openness Divergence EBPAS Total*
n (%) M SD M SD M SD M SD M SD
Gender
Female 196 (83) 2.66 0.78 2.36 1.02 3.10 0.76 1.40 0.84 2.70 0.52
Male 39 (17) 2.75 0.84 2.56 0.96 2.71 0.85 1.52 0.87 2.63 0.55
Occupation
Social Workers 108 (46) 2.69 0.84 2.55 0.98 3.10 0.77 1.50 0.88 2.71 0.49
Psychologists 69 (29) 2.64 0.80 2.22 1.10 3.08 0.84 1.31 0.85 2.69 0.60
Counselors 60 (25) 2.72 0.68 2.35 0.96 2.94 0.75 1.41 0.78 2.67 0.50
Marital Status
Single 91 (39) 2.63 0.79 2.38 1.07 3.10 0.80 1.42 0.85 2.68 0.53
Married 144 (61) 2.71 0.79 2.41 0.97 3.01 0.79 1.42 0.85 2.69 0.52
Education
Master’s degree 149 (63.4) 2.72 0.80 2.50 1.02 3.10 0.77 1.43 0.87 2.73 0.53
Doctorate 62 (26.4) 2.66 0.76 2.16 0.96 3.03 0.82 1.36 0.83 2.65 0.54
Something else 24 (10.2) 2.48 0.79 2.35 0.97 2.85 0.84 1.55 0.74 2.54 0.45
University attended
Public 43 (18) 2.94 0.77 2.68 0.92 2.97 0.73 1.29 0.74 2.83 0.55
Private 194 (82) 2.63 0.78 2.34 1.02 3.05 0.80 1.45 0.87 2.66 0.51
Agency type
Public 135 (57) 2.76 0.76 2.50 0.99 3.10 0.77 1.46 0.82 2.74 0.53
Private 102 (43) 2.58 0.81 2.28 1.01 2.96 0.80 1.37 0.88 2.63 0.50
Type of setting
Clinical 52 (26) 2.63 0.82 2.28 1.01 3.03 0.86 1.46 0.92 2.64 0.61
School 86 (44) 2.80 0.73 2.48 0.99 3.10 0.74 1.40 0.80 2.77 0.50
Community 59 (30) 2.64 0.82 2.46 0.98 2.92 0.76 1.68 0.82 2.59 0.47
Total sample 237 (100) 2.68 0.79 2.40 1.01 3.03 0.79 1.42 0.85 2.69 0.52
Note. * Divergence subscale was reverse scored to compute EBPAS total scores
Table 2 Professional characteristics and socio-economic needs of the
sample
Variable Values (Percentages)
Income
Less than 20 K 18 (7.7)
$21,000–30,000 77 (32.9)
$31,000–40,000 61 (26.1)
$41,000–50,000 33 (14.1)
$51,000–60,000 19 (8.1)
More than 61 K 17 (7.3)
Prefer not to answer 10 (4.3)
Number of jobs
One job 132 (56.2)
Two jobs 69 (29.4)
Three jobs 22 (9.4)
Four jobs or more 12 (5.2)
Years of experience
Less than a year 10 (4.2)
1–3 years 34 (14.3)
4–6 years 28 (11.8)
7–9 years 27 (11.4)
More than 10 years 138 (58.2)
Table 3 Organizational characteristics and exposure to EBPs
Variables Values (Per-
centages)
Emotional exhaustion in the workplace (mean, SD) 2.94 (1.35)
Perceived Organizational Support (mean, SD) 3.11 (0.83)
Work Location
Rural 121 (51.7)
Urban 113 (48.3)
Received training on EBP in the last year
Yes 133 (56.1)
No 104 (43.9)
Perceived EBP suitability for Puerto Ricans
Yes 178 (75.1)
No 15 (6.3)
I don’t know 44 (18.6)
EBP exposure in graduate school
Yes 161 (75.2)
No 53 (24.8)
Know how to access EBPs
Yes 117 (49.4)
No 120 (50.6)
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Administration and Policy in Mental Health and Mental Health Services Research
Structural Model
Structural regression results are presented in Table 5. Ini-
tially, all structural paths were freely estimated. Next, a
likelihood ratio test was performed to simultaneously test
all predictors that failed to achieve signicance in the ini-
tial model: χ
2
∆
(84) = 86.64, p = .40. Therefore, these paths
were constrained to zero in the nal model. Furthermore, an
omnibus test of all remaining eects achieved signicance:
χ
2
∆
(12) = 86.85, p < .001. This indicates the paths that were
freely estimated achieved signicance not only individu-
ally, but also as a set. These omnibus tests were conducted
to provide stronger tests than the single degree of freedom
tests shown in Table 5 and to guard against Type I error
ination. To aid interpretation, standardized coecients
(b*) were fully standardized for continuous predictors and
partially standardized for ordinal or binary predictors. This
means that the standardized estimates can be interpreted as
the predicted dierence in the outcome (in SD units) for a
one-SD unit dierence in continuous predictors, or a one-
unit dierence in ordinal or binary predictors.
Table 5 presents the signicant and non-signicant indi-
vidual- and organizational-level factors across the four
dimensions of attitudes towards the adoption of evidence-
based practices (EBPs). Three predictors were signicant for
the requirement to engage in EBP subscale (e.g., “I would
adopt a new intervention as long as it was required by my
supervisor”). Older respondents tended to score lower on
the Requirements subscale. For one-standard-deviation unit
dierence in age (approximately 12 years), the predicted
score was lower by 0.22 SD units. The relationship was also
negative for income. For one-unit dierence in the ordinal
predictor, the predicted dierence in the subscale score was
0.12 SD units. Finally, years of experience were positively
related to requirements subscale scores, with a one SD unit
dierence in experience (measured ordinally) correspond-
ing to a 0.19 SD unit dierence in predicted scores. The
model explained approximately 7% of the variance in the
Requirements subscale.
For the appeal subscale (e.g., “I would adopt a new
therapy or intervention as long as it made sense to me”),
three predictors achieved signicance. Age was once again
inversely related, but with a smaller eect size (b* = − 0.13)
than the requirement subscale. Older respondents tended to
score lower on the Appeal subscale. As with the require-
ments subscale, years of experience was positively related
to appeal, with a one-unit dierence in experience corre-
sponding to an increase in predicted appeal of 0.25 SD units
Finally, exposure to EBPs in graduate school was associated
with lower scores on the appeal subscale (0.29 SD units).
The model explained 10% of the variance in the Appeal
subscale. For the openness to innovation subscale (e.g., “I
sample reported perceiving EBPs as suitable for the Puerto
Rican population.
Measurement Model
To achieve an acceptable t for the latent-variable measure-
ment model, minor modications were necessary. Residual
correlations were added for the reverse-worded items on the
POS scale and for EBPAS items 9 and 10 owing to similar
item wording. Global t was χ2(277) = 431.44, p < .001;
RMSEA = 0.05, 90% CI [0.04, 0.06]; CFI = 0.95; TLI = 0.94.
Local t indices revealed a few localized strains on model t,
but the model was retained as there were no remaining theo-
retically sound modications to improve t. Factor loadings
ranged from 0.51 to 0.92. Using a multiple indicators and mul-
tiple causes CFA approach (Brown, 2015; Oort, 1998), there
was no evidence of dierential item functioning as a function
of language of the survey instrument. The reliability of each
latent variable was estimated using CFA results (McNeish,
2020), which accounted for the correlated error terms. The reli-
ability estimates and 95% condence intervals for the EBPAS
subscales are presented in Table 4.
Subscale correlations for the EPBAS are shown in
Table 4. The openness, appeal, and requirements subscales
were signicantly and positively intercorrelated. The cor-
relation between the appeal and requirements subscales was
high at 0.79, just below the threshold for establishing dis-
criminant validity (Brown, 2015). Thus, there was a high
degree of correspondence between adopting interventions
based on intuitive appeal and direction from authorities.
Interestingly, there was a moderate, positive correlation
between divergence from research and appeal, indicating
respondents who stated intuition was important to their
adoption of an intervention were also more likely to down-
play the importance of research informed interventions.
Relatedly, the association between openness to innovation
was moderately negatively correlated with willingness to
diverge from research.
Table 4 EBPAS Subscale Reliability and Intercorrelations
1. Required
to Engage in
EBPs
2. Appeal of
Intervention
3. Openness to
Innovation
4. Diver-
gence from
Research
0.91 [0.88,
0.94]
0.71 [0.62,
0.78]
0.83 [0.79,
0.87]
0.68 [0.61,
0.75]
1. 1
2. 0.79, p < .001 1
3. 0.26, p = .001 0.39, p < .001 1
4. 0.14, p = .09 0.26, p = .006 − 0.20, p = .03 1
Note. Reliability estimates and 95% CIs shown beneath subscale
names
1 3

Administration and Policy in Mental Health and Mental Health Services Research
Table 5 Structural Regression Model: Organizational, Individual, and Educational Predictors of EBPAS four dimensions
Required to Engage in EBPs Appeal of Intervention Openness to Innovation Divergence from Research*
R2 = 0.07, p = .02 R2 = 0.10, p = .008 R2 = 0.08, p = .007 R2 = 0.10, p = .009
Predictors bSE p b*bSE p b*bSE p b*bSE p b*
Organizational Factors
Org. Support n.s. n.s. n.s. 0.15 0.07 0.03 0.15
Training on EBP n.s. n.s. n.s. -0.45 0.15 0.00 -0.44†
Rural work location n.s. n.s. 0.40 0.13 < 0.001 0.38†n.s.
Agency type n.s. n.s. n.s. n.s.
Clinical setting n.s. n.s. n.s. n.s.
Community setting n.s. n.s. n.s. n.s.
Ind. and Educational Factors
Age -0.02 0.01 0.00 -0.22 -0.01 0.01 0.05 -0.13 n.s. n.s.
Female n.s. n.s. 0.54 0.16 0.00 0.51†n.s.
Married n.s. n.s. n.s. -0.37 0.15 0.01 -0.35†
Private university n.s. n.s. n.s. 0.32 0.15 0.01 0.31†
Income -0.13 0.04 0.00 -0.12†n.s. n.s. n.s.
Years of experience 0.20 0.06 0.00 0.19†0.26 0.06 < 0.001 0.25†n.s. n.s.
EBP in College n.s. -0.31 0.14 0.03 -0.29†n.s. n.s.
Emotional Exhaustion n.s. n.s. n.s. n.s.
Psychologists n.s. n.s. n.s. n.s.
Counselors n.s. n.s. n.s. n.s.
Master’s degree n.s. n.s. n.s. n.s.
Doctoral degree n.s. n.s. n.s. n.s.
Number of jobs n.s. n.s. n.s. n.s.
Note. b = unstandardized parameter estimate. b* = standardized parameter estimate. SE = standard er ror. p = two-tailed p-value
† = b* standardized only on the outcome due to the predictor being binary or ordinal
* higher scores on the divergence subscale indicate less favorable attit udes towards research
1 3

Administration and Policy in Mental Health and Mental Health Services Research
professionals. Eorts to disseminate and support the adop-
tion of these practices in Spanish-speaking and underserved
communities could reduce the existing health and mental
health disparities experienced by the growing Latinx popu-
lation in the United States. The following sections discuss
signicant factors associated with specic dimensions of
attitudes related to the adoption of these practices.
Dimensions of Attitudes Towards Evidence-Based
Practices
Openness to innovation. Providers’ willingness to follow
treatment manuals is important to improve treatment out-
comes and services (Greenhalgh, et al., 2004). In this study,
female practitioners were more open to innovation than
males, consistent with prior studies suggesting that females
perceive EBPs as more suitable (Rye, et al., 2019) and that
male providers report greater barriers in the implementa-
tion of EBPs (Pitsillidou, et al., 2021). Findings should be
interpreted carefully, as a prior study using the same mea-
sure (EBPAS-50) with a Spanish sample found no signi-
cant dierences in gender (De Paul, et al., 2015) and males
were under-represented in this sample (26.4%). Further
research could examine the role of “Marianismo,” a Latinx
value characterizing females with greater responsibility to
nd ways to take care of those around them, and whether
openness to new practices may be inuenced by this cul-
tural factor. Another interesting nding was that those in
rural settings were more open to innovation, suggesting a
greater interest in EBP-related knowledge in a setting where
resources and competencies are lacking (Hisham, et al.,
2018). The implementation of EBPs may be more success-
ful in rural regions of Puerto Rico as a result of their favor-
able attitudes and openness to innovation. Cost-eective,
easy-to-sustain, and culturally adapted interventions should
be considered when translating science to under-served and
under-resourced communities and settings.
Divergence from Research. Marital status has yielded
mixed ndings regarding its predictive power in relation to
EBP implementation (Alshammari, et al., 2021). Being mar-
ried was a predictor of adopting of EBPs (Aynalem, et al.,
2021), whereas single providers were more likely to diverge
from research. Additionally, those who graduated from pri-
vate institutions had greater attitudes of divergence towards
research compared to those at public institutions. Despite
the benets of private education increasing access to and
completion of academic programs, it is possible that these
advantages are not necessarily translating to acquiring high-
quality education (Douzet, 2006). The ndings of this study
raise concerns about the rapid increase of private programs
and privatization of graduate education in Latin America, a
phenomenon that may compromise the quality of education
would try a new therapy/intervention even if it were very
dierent from what I am used to doing”), two predictors
were signicant. On average, workers located outside a
metropolitan area reported higher openness to innovation
(0.38 SD units). Female respondents also reported higher
openness (0.51 SD units). The model explained 8% of vari-
ability in openness to innovation.
Four predictors achieved signicance for the divergence
from research subscale (e.g., “Clinical experience is more
important than using manualized therapy/interventions”).
Those reporting more organizational support were more
likely to express divergent attitudes from research-based
interventions, with a one-SD unit dierence in support cor-
responding to a 0.15 SD unit dierence in subscale scores. In
contrast, those who reported being trained on EBPs scored,
on average, 0.44 SD units lower in divergence (meaning
they were more amenable to research-informed interven-
tions). Those who attended private universities tended to
score higher in divergence (0.31 SD units), while mar-
ried respondents tended to score lower on the divergence
subscale (0.35 SD units), indicating that they had more
favorable attitudes toward engaging in research-informed
practices. Emotional exhaustion, work setting (being in a
clinical vs. school or community vs. school), agency type
(public vs. private), and number of jobs did not predict any
dimensions of attitudes towards the adoption of EBPs.
Discussion
This study examined attitudes towards EBPs among a sam-
ple of Puerto Rican mental health professionals, and the indi-
vidual, educational, and organizational predictors of various
dimensions of EBP adoption. No dierences were found in
attitudes of appeal, requirement, openness to innovation,
and divergence from research dimensions across work set-
tings (e.g., clinical vs. school or community vs. school),
agency type (public vs. private), and professional occupa-
tion (e.g., social workers vs. psychologists vs. counselors).
In other words, attitudes toward adopting scientically
driven interventions were favorable among this interdis-
ciplinary sample working in both clinical and non-clinical
settings. The total EBPAS mean score in this study (2.69)
was slightly lower and less favorable towards EBPs when
compared to U.S. based (2.90; Choi, et al., 2023) and inter-
national samples (2.92; Santesson, et al., 2020). Meanwhile,
gender, income, marital status, rurality, perceived organiza-
tional support, among other factors were associated with
specic attitudes of EBP adoption. The ndings contribute
to the growing literature suggesting the need to successfully
disseminate these practices, specically among underserved
communities and populations, such as Latinx mental health
1 3

Administration and Policy in Mental Health and Mental Health Services Research
EBPs in graduate school had lower scores in the appeal of
an intervention, suggesting the need to further examine the
attitudes of educators integrating EBPs into educational cur-
ricula and students’ learning experiences.
Lastly, social workers and counselors did not dier in their
attitudes toward EBPs with psychologists (Aaron, et al., 2010;
Parrish and Rubin, 2012), a signicant nding and advance-
ment in the eld of psychotherapy, which has been dominated
by psychologists in Latin America. This openness to innova-
tion among social workers may be supported by several educa-
tional initiatives that are worth mentioning. In Puerto Rico, the
clinical practice appears to be advancing with the development
of the rst Doctorate in Social Work program, and the grow-
ing accreditation of psychology programs on the island. More-
over, the Council of Social Work Education (CSWE, 2015) has
developed a list of resource guides as well as Educational Pol-
icy and Accreditation Standards (EPAS) to guide practitioners
and educators in the identication, analysis, and implementa-
tion of evidence-based interventions in multiple settings and
populations.
Future research could study the challenges related to
the sociocultural, historical, and political factors inuenc-
ing attitudes towards EBPs, as few of these practices have
been found to be ecacious with a Puerto Rican subsample
(Alegría, et al., 2019; Lee, et al., 2013; Rosselló & Bernal,
1999). Similarly, the ecacy of historical, traditional, and
faith-based practices used and recognized by the Code of
Mental Health of Puerto Rico (2000) for the treatment of
substance use disorders should be carefully examined prior
to their dissemination.
Implications
This is the rst study in Latin America to identify the pre-
dictive role of individual characteristics, educational expe-
riences, and organizational factors on attitudes of EBP
adoption among Latinx mental health professionals. Over-
all, the ndings suggest that mental health professionals had
favorable attitudes about EBP adoption but lacked access to
training, and organizational support had a negative impact
on attitudes of divergence from research-informed interven-
tions. Future research could examine the mechanism by
which organizational support facilitates attitudes toward
adoption, and the actual use and implementation of these
practices. Moreover, this study has implications for research
that focuses on strengthening EBP education in Puerto Rico.
The examination of educational curricula within graduate
programs and the inclusion of EBP-related coursework,
eld-based learning, and hands-on educational experiences
is warranted (Pritzker & Giraldo-Santiago, 2022). Nonethe-
less, the ndings of this study speak to a growing openness
towards these practices across professional groups working
related to EBPs and learning experiences. Another interest-
ing and unique nding was that divergence from research
was greater among providers perceiving a more supportive
organization. In contrast to prior research (Aarons & Sawit-
zky, 2006), this study highlights the unique role of orga-
nizational context in PR, as it seems like providers with
little support, organizational structure, and guidance may
rely more on research (EBPs) on their own than those in a
supportive organization. Interestingly, more than half of the
sample reported not knowing how to access EBPs, and more
than a quarter had not received EBP training in the previous
year. Attitudes of divergence from research could be mini-
mized with the provision of resources (e.g., training and
supervision) focused on how to evaluate and adapt EBPs to
Puerto Ricans and Latin American communities (Bernal &
Domenech Rodríguez, 2012).
Adopting EBPs based on Requirement. Younger profes-
sionals and those with more years of experience were more
likely to adopt EBPs if they were required by their orga-
nization. Consistent with a study by Rodríguez-Soto et al.
(2015), favorable attitudes towards EBP were observed
among younger adults. However, the mean scores on the
requirement subscale were lower among those with a doc-
torate degree when compared to those with a master’s degree
and divergence from research was greater among those with
less educational attainment (e.g., masters and other types of
degrees, not a doctorate). Professionals with greater income
are less likely to adopt EBP based on requirement. It is pos-
sible that professionals in leadership positions, with greater
income and age, may be less exposed to direct clinical ser-
vices and interactions with EBPs. Yet, a concerning nd-
ing. Contrary to our hypothesis, no dierences in attitudes
toward adopting EBPs based on requirements were found
across public vs. private agencies and emotional exhaustion
had no inuence in attitudes. Qualitative research is rec-
ommended to explore barriers and facilitators in the imple-
mentation of EBPs across professional groups, settings,
and organizations. Similarly, quantitative research could
examine whether specic attitudes towards EBP is associ-
ated with the actual use and adoption of these practices (e.g.,
behaviors).
Adopting EBPs based on Appeal. The Appeal dimension
assessed the extent to which the provider would adopt an
EBP if it was intuitively appealing and it made sense. Older
providers and those with less years of work experience
scored signicantly lower in their attitudes towards EBPs
based on their appeal. It is important to note that age and
years of experience on the Appeal and Requirement dimen-
sions performed in dierent directions. This could be due
to the ordinal way years of experience was measured (see
Table 2), which limited our ability to interpret the continu-
ous nature of this variable. Conversely, those exposed to
1 3

Administration and Policy in Mental Health and Mental Health Services Research
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in clinical, community, and school settings, as no dier-
ences were found in any of the dimensions of attitudes.
Limitations
This study has some limitations that should be considered
in light of its potential implications. First, the sample used
in this study was small and vulnerable to response biases
given the low response rates. However, a sample size larger
than expected was gathered, achieving a power above
0.80. Second, dierences across individual agencies were
not explored, which led to the aggregation of data and the
inability to conduct a multilevel analysis. Despite these
limitations, the self-reported individual and organizational
factors were helpful to inform further studies focused on
the adoption and implementation of EBPs. Third, ndings
should be interpreted carefully as Cronbach’s reliability
analysis showed that Divergence from research and Appeal
of EBPs subscales had the lowest reliability 0.68 and 0.71,
respectively. Although this was acceptable reliability, it was
not ideal. A careful examination of EBPAS scale reliability
is an important next step in addressing the lack of measures
to evaluate implementation outcomes in Latin America.
Conclusions
Mental health providers in Puerto Rico are facing signi-
cant challenges in the adoption of EBPs, steaming from
socio-economic characteristics, educational experiences,
and work-related factors that may become a barrier for the
quality and eectiveness of services provided to the Latinx
community. This study advances the knowledge and under-
standing of barriers and facilitators in the adoption of EBPs
in Puerto Rico, an underserved and under-resourced terri-
tory of the U.S. lacking a solid infrastructure to promote
research, education, and practical solutions to identify, tai-
lor, and implement culturally adapted EBPs.
Acknowledgements The principal investigator gratefully acknowl-
edges the support from the College of Social Work Professionals in
Puerto Rico (CPTSPR), the Professional Counselors Association
(CPCR), and the Psychology Association of Puerto Rico (APPR) in
the recruitment of mental health professionals for this study.
Funding This project was supported by the Substance Abuse and
Mental Health Service Administration (Grant no: SM083355).
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