• By Dartington SRU
• Posted on Sunday 18^th May, 2014

The habits of highly effective programme adapters

As evidence-based programmes go global, programme adapters are looking for guidance on how to make imported programmes work. There is a natural desire to benefit from good programmes developed in other countries. But while there are many successes with importing programmes, there are also failures. So what are the secrets of successful adaptation?

There are several reasons why a “proven” programme might fail in a new setting. Perhaps it uses a different research design from the original study. Maybe the fidelity of implementation is poor, or adaptations for the new context undermine the way the programme works. Or it could be that cultural differences mean that the programme doesn’t appeal.

In this context, a team from Stockholm University examined nine models for adapting programmes for a new cultural group. They interpreted “adaptation” as any change to any aspect of the programme – omissions, add-ons or modifications to programme logic, processes, materials or support structures.

Most of the models come from mental health prevention or therapy literatures, with others from HIV intervention and drug prevention literature. All are concerned with adapting a programme for a new cultural, racial, or ethnic group.

Some models are generic, others specific to a programme. Several have a domestic orientation (for example, focusing on American sub-cultural groups), while others have a more international outlook.

But despite their diversity, they share a focus on the value of collaboration, the need to take systematic steps in selecting an intervention to adapt, and the importance of taking empirical studies into account.

The Stockholm-based team, led by psychologist Laura Ferrer-Wreder, distinguished between three types of models.

Step models and content models

“Step models” are prescriptive. They tell adapters what to do and in what order.

One model, for example, focuses on Multisystemic Therapy, a family therapy designed to benefit troubled adolescents with conduct or substance misuse problems. The adaptation model is designed for cross-national adaptation.

A pre-implementation phase involves engaging stakeholders and getting them to consider the programme’s fit with the new host community’s social and cultural characteristics. Stakeholders assess potential threats to effectiveness and consider solutions.

This is followed by a clinical phase, when materials are translated into local languages and minor modifications are made to materials and processes. Changes to the training process are also encouraged, to take account of customs and norms.

A second type of model – a “content model” – specifies which areas or themes to consider when making programme adaptations. It is less prescriptive than a step model.

Stacked models

The third type of model, a “stacked model”, combines the step model and content model. It starts by setting out areas or themes to consider, but then “stacks” steps on top of these. A good example is a model of intervention cultural sensitivity (ICS), which originated in the substance misuse field.

The ICS approach requires adapters to consider the programme’s deep structure – in other words, the way the programme seeks to set a sequence of changes in motion in order to affect a specified problem. For instance, some drug prevention programmes call for changing teenagers’ ideas about drug use as a way to change their drug use behaviour. Getting the deep structure right, it is argued, is important for achieving impact.

The model also requires modifying the programme’s surface structure – language, materials, and the medium of presentation. Getting these right is critical for feasibility – whether practitioners will deliver the programme, and whether users will use it.

The nine models differed widely in terms of what was considered an adaptation. Surface structure changes are widely accepted as being necessary, but changes to deep structure are more controversial.

Underlining the seriousness of tinkering with a programme’s deep structure, Ferrer-Wreder and colleagues argue that “if adaptations of such a potentially profound nature are undertaken, then they should be pursued in an effectiveness trial context, be based on direct empirical evidence… and be conducted in collaboration with programme developers.”

The habits of effective programme developers

All of the models reviewed advocate best practices in adaptation, notably collaboration with programme developers and community members. They also agree that adaptations should be supported by good evidence – but they disagree about what types of evidence are necessary.

Some models, for instance, call for evaluations of a programme’s feasibility in a new context. Others suggest that an adapted programme should then be tested in a controlled trial. Some stress that adaptations should be guided by studies of the new target population.

Future research could usefully compare different versions of the same programme adapted to different degrees against a control group. It should also compare cultural adaptation models – like the nine reviewed by Ferrer-Wreder and colleagues – and test whether some models work best for some types of programmes.

As evidence-based programmes go global there is a need to allow for adaptation while ensuring that programmes’ benefits are realised. Here, the authors urge patience and care:

“Effectiveness trials should not be bypassed in the rush to disseminate programmes, and can serve as an occasion for programme developers and stakeholders to come together to make the cultural adaptation of existing EBIs [evidence-based interventions] the focus of rigorous scientific study and thereby expand promising EBIs’ global generalisability and public health impact.”

Ferrer-Wreder, L., Sundell, K., & Mansoory, S. (2012). Tinkering with perfection: theory development in the intervention cultural adaptation field. Child Youth Care Forum, 41, 149-171.