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 Health Discussion Tailoring Persuasive communication Methods Self-Efficacy Modeling

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

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1. Assess Fit 10 Adaptation CategoriesYour CommunityEBAFit outcomes; adaptation ideas Yes, No, Partially; Notes Program Outcomes, Goals and Objectives Health outcomes/ GoalGoal:Outcome: Behavior objectives Behavior 1 Sub-behaviors Behavior 2 Sub-behaviors Objectives:Outcomes: Environmental objectivesObjectives for actors, facilities: Outcomes for actors, facilities: Determinants & Methods

1. Assess Fit 11 Adaptation CategoriesYour CommunityEBAFit outcomes; adaptation ideas Yes, No, Partially; Notes Program Outcomes, Goals and Objectives Health outcomes/ GoalGoal: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 Unpublished manual. Firpo-Triplett, R., Fuller, T. R. (2012). General Adaptation Guidance: A Guide to Adapting Evidence-Based Sexual Health Curricula. Accessed via

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 adaptation Image 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 ̶Diversity within priority population may be larger than the diversity of the population addressed by EBA ̶Stigmatization ̶Costs, feasibility Re: Adaptations to community and context ̶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 population ̶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/ coalition ̶Adherence to program protocol ̶Dose delivered ̶Quality of program delivery ̶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

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 HIGH FIDELITY LOW FIDELITY MINOR ADAPTATION MAJOR ADAPTATION GREATER NEED FOR 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),

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?