How to Adapt Effective Programs for Use in New Contexts

How to Adapt Effective Programs for

Use in New Contexts

Josefina J. Card, PhD,Julie Solomon, PhD, Shayna D. Cunningham, PhD

A wide variety of underused effective HIV prevention programs exist. This article describes sources for obtaining such effective programs and issues to consider in selecting an existing effective program for use with one’s priority population. It also discusses seven steps involved in adapting an effective program to meet the needs of a new context while preserving core components (what made, or is believed to have made, the intervention effective in the first place) and best practices (characteristics common to effective programs). Although the examples presented are from the HIV prevention field, the seven-step framework is applicable to the adaptation of effective programs in other health promotion and disease prevention arenas.

Keywords: effective programs; program selection; program replication; program adaptation;HIV/AIDS; best practices; program model;program goals and objectives; core components

During the past two decades, a wide variety of effective HIV prevention programs have been developed and implemented. These programs use diverse approaches, such as one-on-one or couples counseling, small-group education and skills building, community-wide outreach, and social marketing. Collectively, they have been shown to be capable of preventing or reducing risky behaviors leading to the transmission of HIV among persons from a wide range of cultural and social backgrounds and a wide range of priority populations, such as men who have sex with men, women, youth, HIV-positive individuals, and members of particular racial or ethnic groups (Card, 2001;

Card, Lessard, & Benner, 2007; Centers for Disease Control and Prevention [CDC], 2001; Crepaz et al., 2006; Kirby, 2007; Lyles et al., 2007). Using these wellestablished, effective programs can save time and money while increasing the likelihood of achieving successful outcomes (Card, 2001; Kraft, Mezoff, Sogolow, Neumann, & Thomas, 2000). Replication is the process of reimplementing an established program in a new context in a way that maintains fidelity to core goals, activities, delivery techniques, intensity, and duration of the original study. Ideally,

the established program would be replicated “as is” in the new setting, with no changes to the original. Oftentimes though, there are mismatches (discrepancies) between the characteristics of the new priority population, implementing agency, or local community and those of the original program. For example, the language, images, and examples in the original program may be outdated, or they may not be culturally appropriate for the new priority population’s needs. Particular objectives, approaches, or activities may be too politically charged or controversial for the new local community. Or they may be irrelevant in the new setting. It is also possible that an agency may lack the funding, staffing, expertise, or other resources that are needed to implement the program as it was originally designed and implemented (Bell et al., 2007; Kelly et al., 2000; Solomon, Card, & Malow, 2006; Stanton et al., 2005). Adaptation is the process of altering a program to reduce mismatches between its characteristics and those

of the new context in which it is to be implemented or used. Increasingly, studies have shown that it is possible to adapt existing, efficacious HIV programs for new contexts and keep the successful outcomes of the original program (e.g., Gaydos et al., 2008; Lightfoot et al., 2007). Doing so however requires careful planning and execution, as it is possible to make changes that enhance a program’s cultural appropriateness, local acceptance, and feasibility, while undermining its effectiveness in changing risky behaviors. This article details a set of science-based pragmatic steps in adapting an existing, empirically validated intervention to better suit a new context, while preserving what made—or is believed to have made—it effective in the first place. Although its examples are drawn from the HIV prevention and care field, its principles and methods are extendable to the adaptation of other effective health promotion and disease prevention interventions, such as those in the teen pregnancy, substance abuse, violence, and obesity areas. The steps described below are intended to be readily implemented by program staff in everyday service provision contexts, such as community clinics and social service agencies. Other adaptation models that address both adaptation and fidelity use similar principles but are much more involved, making them more appropriate for clinical trials or academic–community collaborations (McKleroy et al., 2006; Solomon et al., 2006; Tortolero et al., 2005; Wainberg et al., 2007; Wingood & DiClemente, 2008).

>OVERVIEW OF THE ADAPTATION PROCESS

In our framework, the adaptation process consists of the following seven steps: (1) Select a suitable effective program; (2) gather the original program materials; (3) develop a program model; (4) identify the program’s core components and best-practice characteristics; (5) identify and categorize mismatches between the original program model or materials and the new context; (6) adapt the original program model, if warranted; and (7) adapt the original program materials. These steps have been synthesized from a review of the scientific literature on the adaptation of teen pregnancy, sexually transmitted infection (STI), and HIV prevention programs .

The step framework encourages practitioners to make culturally competent changes to a program to better suit a priority population, but only when needed and only when certain constraintssuch as adherence to the original program’s theory of change and core components as well as to the literature on best practicesare met. Ideally, a variety of key stakeholders—including local community leaders, program staff, and members of the priority population—will be involved throughout the adaptation process. Having a diverse, representative committee

conduct (or at least oversee) adaptation-related activities will help to ensure that all stakeholder interests

are considered and respected, that the program that is ultimately planned and implemented is maximally culturally

competent, and that there is an increased likelihood of successful implementation and positive outcomes

(Card et al., 2007; Card, Solomon, & Berman, 2008).

Step 1. Select a Suitable Effective Program

Step 2. Gather the Original Program Materials

Step 3. Develop a Program Model

Step 4. Identify the Program’s Core Components and Best-Practice Characteristics

Step 5. Identify and Categorize Mismatches Between the Original Program Modelor Materials and the New      Context

Step 6. Adapt the Original Program Model, if Warranted

Step 7. Adapt the Original Program Materials

>SUMMARY

The replication of effective interventions is fraught with tension between maintaining fidelity to the original program while being sensitive to the culture and needs of the new priority population and implementation context. This article describes a step-by-step framework for practitioners to use to select and make changes to existing, evidence-based HIV prevention programs to better suit the needs of new contexts, while preserving the theory of change and core components that made them effective in the first place. Other adaptation models that address both intervention fit and fidelity use similar principles but are much more involved (McKleroy et al., 2006; Solomon et al., 2006; Tortolero et al., 2005; Wainberg et al., 2007; Wingood et al., 2008).

The current framework is geared toward practitioners in resourcelimited settings for whom such approaches may not be feasible. Among its unique and salient features is that it offers specific points of consideration (e.g., questions to consider when selecting a program to implement or when adapting program materials) and examples (e.g., types of mismatches that may be encountered and addressed) to facilitate decision making at each step. As with other models, practitioners who use this framework are encouraged to document their decisionmaking process concerning any changes made to an existing intervention as well as to conduct and disseminate the results of process and outcome evaluations of the adapted program, as implemented in their new setting. This will not only benefit the organization that undertook the adaptation but the entire field of translation research and practice as well.

NOTE

1. Several reviews have identified programs that have shown

positive results in reducing behavioral risks for HIV among youth

(Alford, Cheetham, & Hauser, 2005; Kirby, Laris, & Rolleri, 2005;

Paul-Ebhohimhen, Poobalan, & van Teijlingen, 2008) and adults

(Bollinger, Cooper-Arnold, & Stover, 2004; Eke et al., 2002; Hong

& Li, 2009; Shahmanesh, Patel, Mabey, & Cowan, 2008) in developing

country settings. Although examples in this article are U.S.-

based, the adaptation principles and processes described here can

be applied to programs irrespective of their place of origin or

replication locale.