Reframing Adaptations in a Post-pandemic World: Building a Roadmap for Implementation Support Practitioners
By Dr. Julia E. Moore, Executive Director
For years, there has been a heated debate about adaptations and fidelity. But, as a result of all of the adaptations people have had to make over the past year, we seem to have moved away from the debate about whether to adapt or not, and shifted towards questions about how to operationalize and plan for adaptations. I would like to believe that even after the pandemic, people will continue to recognize the importance and value of making adaptations.
For now, questions about adaptation seem to be in a very different vein—one of the most common questions was about how to convince stakeholders that adaptations were needed. That is no longer a significant challenge. Instead, people are wondering how to make adaptations that actually work.
Some questions that we at The Center for Implementation (TCI) received when the pandemic hit included:
How could people adapt in-person interventions to be delivered virtually?
Was there a process model to plan for adaptations?
What adaptation framework should they use?
How can people make adaptations without changing their components and changing the effectiveness of the intervention?
How could they make adaptations in a number of weeks or days given the turnaround needed during lockdown?
It was apparent that as a result of how our lives have changed over the course of the pandemic, many of us have been on the receiving end, experiencing poorly executed adaptations. I have a colleague whose son is in kindergarten, and his elementary school teacher tried to deliver the kindergarten curriculum virtually, without making any changes to the content or how she delivers it. The five-year-olds in the class have not been very receptive. Many social service interventions have adapted the mode of delivery to be virtual, but they didn’t consider how some of the recommendations within the intervention rely heavily on things like social support, which were not allowed during lockdowns. Public health guidance and recommendations have often been made generic, casting a wide net, without adapting messaging for different target audiences, despite the fact that barriers to mask wearing or physical distancing are different for marginalized populations working in essential services and office workers, who were not able to work virtually from home. To expedite change, effective interventions have been “adapted” to new settings, particularly from hospitals to long-term care homes, without rigorously or systematically thinking about the contextual differences between these different types of organizations.
Five tips to more systematically plan for adaptations
Around this time, Dr. Alison Metz reached out and asked whether I would do a podcast with her on adaptations. We talked about these exact issues in an episode called, “Providing Implementation Support for Program Adaptations in a COVID-19 Environment”.
From there, TCI developed five tips to help guide implementation practitioners to rapidly plan for adaptations. Based on both my professional and personal experiences with adaptations, it became clear that we need more guidance by asking these five questions and referring to adaptation frameworks. People need a roadmap to plan for adaptations that helps them consider the different factors and facets that adaptations entail.
Adaptation Planning Tip #1: Engage stakeholders
The first tip is to make sure you identify and engage key stakeholders. For example, if you adapt an intervention to a new setting (e.g., from hospitals to long-term care homes) without involving stakeholders who work and live in that setting, you are likely going to miss key factors to consider when making adaptations. While this might seem obvious, many of the adaptation efforts we have seen do not thoughtfully identify and engage key stakeholders.
Adaptation Planning Tip #2: What is the goal of your intervention?
Can you clearly describe the goal of your intervention? What problem are you addressing? What outcomes are you hoping to achieve? This is important for two big reasons. First, as you invite in new stakeholders (tip #1), you will need to clearly define what you are implementing. Second, as you describe what you need to adapt (tip #4) and why (tip #3), it’s very helpful to have a clear description of the intervention pre-adaptation.
Adaptation Planning Tip #3: Understand why you are making adaptations
What problem are you trying to address by making adaptations? What is the reason for your adaptation? Reasons are often grouped into four categories (based on the FRAME framework). Adaptations can occur because: a) the intervention needs to be tailored to different recipients (e.g., language, race/ethnicity, gender identity, motivation and readiness); b) intervention needs to be tailored to different providers (e.g., previous training and skills, preferences, race/ethnicity, perceptions of the intervention or the evidence); c) different/ dynamic organization/setting characteristics might impact implementation (e.g., available resources, technology, time constraints, billing constraints, location, social context); and d) different/dynamic sociopolitical conditions might impact implementation (e.g., existing laws, mandates, policies, funding, political climate).
Adaptation Planning Tip #4: Describe what the adaptations look like
First, are you making adaptations to the WHAT or to the HOW. The WHAT is the evidence-based practice or program, the “thing” you want people to do differently. The HOW includes the implementation strategies you are using to change people’s behavior (e.g., education, champions, reminders, audit and feedback).
What is the nature of the adaptation? Provide a clear description of the adaptation and how it is different than the original intervention. For example, have you changed content to suit a different intervention recipient (e.g., implementing an intervention with new immigrants designed for a different audience) or the context in which you are implementing (e.g., putting a hospital-based intervention in long-term care homes)? Then describe those adaptations – for example, have you added or removed elements, and/or are you restructuring the order in which elements are being delivered?
Adaptation Planning Tip #5: Hypothesize the potential impact of different adaptations
Describe the potential impact of the adaptation. Will it change the effectiveness of the intervention?
What about cultural adaptations?
You’ll notice in the questions above that some of the guidance pertains to cultural adaptations. In a conversation I had with Dr. Ruben Parra-Cardona, he pointed out how most of the implementation science adaptation frameworks focus primarily on contextual adaptations, and while they mention cultural adaptation they don’t delve deeply into the logistics and the differences in the process for making cultural versus contextual adaptations.
Dr. Parra-Cardona is featured below in this month’s spotlight, highlighting the differences between contextual and cultural adaptations and providing some guidance on how to think differently about cultural adaptations.
Adaptation Is Not Necessarily Cultural Adaptation
By Ruben Parra-Cardona, Ph.D., Associate Professor, Steve Hicks School of Social Work; Area Director for Research, Latino Research Institute; The University of Texas at Austin
I am a cultural adaptation researcher who recently joined the implementation science (IS) field. After 15+ years of conducting cultural adaptations of evidence-based parenting interventions, I was confused by the many ways in which IS researchers referred to the term adaptation. I slowly understood that they mostly referred to adaptation within the context of IS frameworks and theories. Thus, I would like to express my views on what cultural adaptation is, as a way of increasing conceptual clarity about these critical constructs.
The cultural adaptation-fidelity debate
Back in the early 2000s, a scholarly debate unfolded, known as the “cultural adaptation-fidelity debate.” On one hand, fidelity researchers challenged the need to culturally adapt evidence-based interventions with demonstrated effectiveness. According to these scholars, the greatest risk associated with the cultural adaptation of efficacious interventions is that significant changes to the core components of original interventions can threaten treatment fidelity and effectiveness. These researchers also affirmed that there was limited empirical evidence demonstrating the benefits of cultural adaptations. 1
On the other hand, cultural adaptation scholars argued that implementing interventions without adapting according to key factors such as poverty, historical racism and segregation, language barriers, and distrust towards institutions; represented a form of scientific imperialism. These scholars also clarified that whereas surface-level adaptations primarily center on adapting interventions by focusing on issues such as language and cultural fit of interventions materials, deep-level adaptations are conducted according to a deep understanding of relevant cultural and contextual experiences lived by target populations. 2
Approaches to cultural adaptation
In our own program of research, we have devoted 12 years to the cultural adaptation of the evidence-based intervention known as GenerationPMTO.© The first cultural adaptation of GenerationPMTO for Latina/o immigrant populations was conducted by Domenech Rodríguez and colleagues. 3 The initial adaptation was conducted by following the premises of a well-established cultural adaptation model known as the Ecological Validity Model (EVM) 4 , which offers a guide to researchers to adapt interventions according to eight dimensions: (a) language, (b) persons, (c) metaphors, (d) content, (e) concepts, (f) goals, (g) methods, and (h) context.
In a subsequent study, we conducted a randomized controlled trial with low-income Latina/o families with children ages 4-12. Specifically, we compared an adapted version of GenerationPMTO exclusively focused on parent training components, in contrast to an enhanced adapted version in which we overtly addressed immigration-related challenges, racism and discrimination, and biculturalism. Efficacy indicators illustrated that the adapted intervention in which we overtly addressed issues of racism and cultural challenges, had the most statistically significant improvements for child internalizing (e.g., anxiety) and externalizing behaviors (e.g., conduct problems). Parents also reported that the enhanced cultural adaptations helped them identify how contextual stressors such as racism and cultural conflicts, negatively impacted their daily parenting practices. 5
In summary, whenever I hear IS researchers use the term adaptation, I immediately think about the need to ask ourselves key clarifying questions. For example, “to what extent our recruitment strategies are informed by a deep understanding of what is like to be a person of color in the US?”, “are intervention manuals informed by a deep understanding of the pervasive forms of discrimination that low-income Latinas/os continue to experience in this country?”…If we cannot respond these questions with complete clarity, it is likely we have engaged in the realms of adaptation and surface-level cultural adaptation, but not deep-structure cultural adaptation. Such conceptual clarity is essential to continue to embrace the journey towards social justice in the evolving IS field.
References
Elliot, D. S., & Mihalic, S. (2004). Issues in disseminating and replicating effective prevention programs. Prevention Science, 5, 47-53.
Castro, F. G., Barrera, M., & Martínez, C. R. (2004). The cultural adaptation of prevention interventions: Resolving tensions between fidelity and fit. Prevention Science, 5, 41-45.
Domenech Rodríguez, M. M., Baumann, A. A., & Schwartz, A. L. (2011). Cultural adaptation of an evidence based intervention: From theory to practice in Hispanic/a community context. American Journal of Community Psychology, 47, 170-186. doi: 10.1007/s10464-010-9371-4
Bernal, G., Jimenez-Chafey, M. I., & Domenech Rodríguez, M. M. (2009). Cultural adaptation of treatments: A resource for considering culture in evidence-based practice. Professional Psychology: Research and Practice, 40, 361-368. https://doi.org/10.1037/a0016401
Parra-Cardona, J. R., Bybee, D., Sullivan, C. M., Domenech Rodríguez, M. M., Dates, B., Tams, L., & Bernal, G. (2017). Examining the impact of differential cultural adaptation with Latina/o immigrants exposed to adapted parent training interventions. Journal of Consulting and Clinical Psychology, 85, 58-71. https://doi.org/10.1037/ccp0000160
These articles were featured in our monthly Implementation in Action bulletin! Want to receive our next issue? Subscribe here.