Adapting an Evidence-based Approach

to Fit Your Community

Assessing your Community

Implementing & Evaluating

Establishing Goals &

Objectives;Planning for Evaluation

Finding Evidence

Selecting Best Fitting EBAs

Adapting

Where do We Stand?

Session Objectives

• Define adaptation, fidelity, and core elements

• Describe the process and steps for adaptation

• Discuss which changes can probably be made without affecting the effectiveness vs. which cannot

Adaptation

Adaptation: making changes or modifications to fit priority population and local conditions

• Additions

• Deletions

• Substitutions

Fit and Fidelity

Adaptation is a balance between:

Achieving FIT – Make an EBA compatible with your community

Maintaining FIDELITY – Optimize implementation of an EBA as it is prescribed in the original protocol.*

*Rabin, B.A., Brownson, R.C., Haire-Joshu, D., Kreuter, M.W., & Weaver, N.L. (2008) A glossary for dissemination and implementation research in health. J Public Health Management Practice, 14(2), 117–123.

Core Elements

Core Elements: required components that represent the logic mechanisms of change and key delivery steps of an EBA which most likely produce the EBA’s effectiveness

• Core elements include*:

1) Content

2) Delivery mechanisms

3) Methods

*Eke, A.N., Neumann, M.S., Wilkes, A.L., & Jones, P.L. (2006) Preparing effective behavioral interventions to be used by prevention providers: the role of researchers during HIV Prevention Research Trials. AIDS Education & Prevention, 18(4 Suppl A):44-58.

Logic Model of Change: Methods used

Objectives Goal

Reduce CRC morbidity &

mortality

CRC Screening

Free/low cost tests

Determinants

Knowledge

Attitude

Behaviors & Environment

HealthDiscussion

Tailoring

Persuasive communication

Methods

Self-EfficacyModeling

1. Assess fit to consider adaptation

2. Assess the acceptability and importance of adaptation

3. Make final decision of what to adapt

4. Make the adaptation

5. Pretest and pilot test

Steps for Adaptation

9

1. Assess Fit

10

Adaptation Categories Your Community EBA Fit outcomes; adaptation ideasYes, No, Partially;

NotesProgram Outcomes, Goals and Objectives

Health outcomes/ Goal Goal: Outcome:

Behavior objectivesBehavior 1 Sub-behaviorsBehavior 2 Sub-behaviors

Objectives: Outcomes:

Environmental objectives Objectives for actors, facilities:

Outcomes for actors, facilities:

Determinants & Methods

1. Assess Fit

11

Adaptation Categories Your Community EBA Fit outcomes; adaptation ideas

Yes, No, Partially; Notes

Program Outcomes, Goals and Objectives

Health outcomes/ Goal Goal: Outcome:

Behavior objectives

Environmental objectives

Determinants & Methods

Determinant 1 Method…………………………Determinant 2 Method

Determinant 1, related objective, method………………………Determinant 2, related objective, method

Determinant 1 addressed, methods used…………………………Determinant 1 addressed, methods used

1. Assess Fit

2. Assess Acceptability and Importance

Assess acceptability

There is a continuum for adaptation changes:

… should be avoided (red)

To maintain fidelity on core components

…should be made cautiously (yellow)

…safe (green)

Adapted from: Lesesne, C. A., Lewis, K. M., Moore, C., Fisher, D., Green, D., & Wandersman, A. (2007). Promoting Science-based Approaches to Teen Pregnancy Prevention using Getting To Outcomes: Draft June 2007. Unpublished manual.Firpo-Triplett, R., Fuller, T. R. (2012). General Adaptation Guidance: A Guide to Adapting Evidence-Based Sexual Health Curricula. Accessed via http://recapp.etr.org/recapp/documents/programs/GeneralAdaptationGuidanceFINAL.pdf

Red Light Adaptations: Things That Probably Cannot Be

Modified• Methods used

– Change theoretical underpinning;

mechanisms of change

• Content

– Change health topic/behavior addressed

– Add activities that contradict or detract

from the original EBA’s goals

– Delete whole sections or major activities

– Reduce duration and dose

Yellow Light Adaptations: Things That Can Probably Be Changed with

Caution• Content/ methods

– Alter the length of program activities

– Change the order of sessions or

sequence of activities

– Add activities to address other

risk factors or behaviors

– Apply EBA to a different population

• Delivery mechanisms– Change delivery format/ process

– Modify who delivers the program

– Change setting of delivery

– Substitute activities and/or materials

Green Light Adaptations: Things That Can Probably Be Modified

Minor adaptations to increase reach, receptivity and participation

• Update and/or customize statistics and guidelines

• Customize program materials to fit the priority population. E.g., change names, pictures, wording, etc.

• Change ways to recruit and/or engage priority population

Consult Experts to Assess Importance

• EBA experts

• Content experts

• Community representatives

• Organization stakeholders

Final decision making

Image courtesy of Ambro at FreeDigitalPhotos.net

Consult EBA & Content Experts

EBA Experts• Discuss core elements

− Evaluated?− Their beliefs?− Exchange ideas about

potential adaptation

Content Experts• Insight into “core elements” and

need for adaptationImage courtesy of David Castillo Dominici at FreeDigitalPhotos.net

Consult Community & Organization Experts• Discuss fit between CA and EBA with community

experts (include priority population)/ How important is adaptation to achieve fit?

To ensure:• Reach• Acceptability• Feasibility• Effectiveness

• Representatives from organization/ Insight into possibilities for implementation

Image courtesy of Ambro at FreeDigitalPhotos.net

Additional Considerations

Consider pros and cons for adaptation• Re: Adaptations to fit priority population

T Diversity within priority population may be larger than the diversity of the population addressed by EBA

T Stigmatization

T Costs, feasibility

• Re: Adaptations to community and contextT Try to think about possibilities for implementation as is

instead of barriers

3. Make final decision of what to adapt

• Using considerations and stakeholder input, make a final decision of what to adapt

• Think through steps for making the adaptation

4. Make the Adaptation

• Relatively straightforward for “green light adaptations” to priority populationT E.g., Replace graphics, key figures,

pictures, wording

• A bit more complex for “yellow light adaptations” − Select behavioral and/ or determinant objectives

not yet addressed by EBA− Search for methods to address these determinants

(and related behaviors) − Adaptation of delivery mechanisms

5. Pretesting & Pilot testing

Pretest

• Trying out program elements (e.g., materials) with intended end users− Adapted elements− Non-adapted elements

Pilot test

• Tryout implementation to assess fit with community and organization/ coalition

5. Pretesting & Revision

• Trying out program elements (e.g., materials) with intended participants (i.e., priority population)− Adapted elements− Non-adapted elements

• For example test on:− Comprehension− Acceptability− Attractiveness− Cultural relevancy− Potential influence on determinants

5 (cont’). Pilot Testing & Implementation

• Is there an implementation protocol?E.g., manual

/ If not, needs to be developed/ If there is one, adaptation/ addition may be needed

because of adaptations to EBA- Who does

- What, - When,

- Why (motivations, barriers),- and How

5 (cont’). Pilot Testing & Implementation

Pilot testing

• Tryout implementation to assess fit with community and

organization/ coalitionT Adherence to program

protocolT Dose deliveredT Quality of program deliveryT Barriers/ facilitators

*Rabin, B.A., Brownson, R.C., Haire-Joshu, D., Kreuter, M.W., & Weaver, N.L., (2008). A glossary for dissemination and implementation research in health. Journal of Public Health Management Practice, 14(2), pp. 117-123.

Activity: Adaptation Tool for Programs

Activity: Adaptation Tool for Programs

1. Read the program description individually for StairWELL to Better Health

2. Discuss adaptation using the Adaptation Tool in your small group

3. Share what you decided to adapt, why, and how

Activity: Adaptation Tool Activity

Activity: Adaptation Tool for Policy

1. Read the tobacco-free policy descriptions individually

2. Discuss adaptation using the Adaptation Tool in your small group

3. Share what you decided to adapt, why, and how

Next Step: Evaluation

HIGHFIDELITY

LOWFIDELITY

MINOR

ADAPTATIONMAJOR

ADAPTATION

GREATER NEEDFOR EVALUATION

Carvalho, M., Honeycutt, S., Escoffery, C., Glanz, K., Sabbs, D., & Kegler, M. (2013). Balancing fidelity and adaptation: implementing evidence-based chronic disease prevention programs. Journal of Public Health Management and Practice, 19(4), 348-356.

Take-home Points: Importance of Adapting Based on Needs of Community

• Base changes on your community assessment results

• Identify the core elements of an EBA and keep them intact in adaptation

• Work with your community to get their feedback as you make changes

• Get advice from experts including the EBA developers in making yellow and green light adaptations

• The more you adapt, the more you need to evaluate

Questions?