1. Adapting an EBI Program to Fit
Your Community
Talking Points:
This session covers the concept of adapting an evidence based approach. It will also describe steps in the adaptation process.
The Cancer Prevention and Control Research Network is supported by Cooperative Agreement Number 3 U48 DP S8 from the Centers for Disease Control and Prevention’s Prevention Research Centers Program and the National Cancer Institute. The content of this curriculum is based upon findings and experiences of workgroup members and does not necessarily represent the official position of the funders. 

2. Where Do We Stand? Establishing Goals & Objectives
Assessing your Community
Finding EBI
Selecting Best Fitting EBI
Adapting EBI
Talking Points:
This part of the session about adaptation continues to work with community assessment outcomes, and the detailed comparison between it and the EBI selected.
After considering the need and acceptability for adaptation, you might
choose to implement the EBI as is if it is a good fit
decide to go back to selection – namely, if so much adaptation is needed that it might reduce the effectiveness
or adapt the EBI to your local context and population, if required and acceptable, before using the EBI in practice.
Implementing & Evaluating
*Adapted from Brownson et al. (2017). Evidence-Based Public Health. 3rd ed. New York, NY: Oxford University Press.

3. 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
Talking Points:
This session will cover:
Adaptation, fidelity, and core elements
Steps for adaptation
Which changes can probably be made without affecting the effectiveness.

4. Adaptation
Adaptation: making changes or modifications to fit priority population and local conditions
Additions
Deletions
Substitutions
Talking Points:
Adaptation involves changes or modifications to an evidence-based intervention program (during adoption and implementation), so that it better fits the needs of a particular population and context.  
These changes can include additions, deletions, and substitutions.   (Rabin B.A., Brownson R.C., Haire-Joshu D., Kreuter M.W., & Weaver N.L., 2008) 

5. Fit and Fidelity Adaptation is a balance between:
Achieving FIT – Make an EBI program compatible with your community
Maintaining FIDELITY – Implement an EBI program as it is prescribed in the original protocol.*
Talking Points:
During adaptation you might be taking away elements, however, that contributed to the approach’s effectiveness.
Therefore, it is the balance between adaptation to achieve fit with your community, and fidelity to maintain core elements of a program or strategy (in other words “optimizing implementation of an EBI as it is prescribed in the original protocol”) that would make the EBI succeed in a new setting or not.
Though, how do you know which elements are crucial for the EBI’ effectiveness, and in other words, should not be adapted?
In planning implementation, we need to strategically plan what adaptations are needed to increase fit without jeopardizing fidelity to 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.

6. Core Elements
Core Elements: required components that represent the mechanisms of change and key delivery steps of an EBI that most likely produced the EBI’s effectiveness 
Talking Points:
We might describe core elements as the required components that represent the logic mechanisms of change and key delivery steps of an EBI which are most likely to produce its effectiveness.
Core components relate to:
Content is what is being delivered or taught via the EBI’ core methods. (e.g., different types of CRC screening tests and their pros and cons)
Delivery mechanisms refers to the logistics and how an EBI is delivered. Including the setting, format and channels used, the providers etc.
Methods are how to change the behavior or environment and are very likely to be core to the EBI’ effectiveness
Determining which elements are core elements is often an educated guess.
The system we present gives you some guidance.
*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.

7. Steps for Adaptation 5. Pretest and pilot test 4. Make the adaptations
1. Assess fit and consider adaptation
2. Assess the acceptability and importance of adaptation
3. Make final decisions about what and how to adapt
4. Make the adaptations
5. Pretest and pilot test
Talking Points:
And now time for action; how does the adaptation process look?
As mentioned before, decision making for adaptation uses the detailed comparison between your community assessment and the EBI. Outcomes on fit can be used to generate ideas for adaptation.
Then assess whether each adaptation idea is acceptable and how important it is to make this adaptation in order to achieve fit.
Use the acceptability and importance of each adaptation to make final decisions about what to adapt and how before actually doing the adaptations and testing them.
To help go through the first three steps, for making adaptation decisions that maintain probable core elements *See next slide

8. Assess Fit

9. Know Your Community Strengths and assets Culture and traditions
Leaders and trusted individuals
Social roles and norms
Physical environment
Talking Points:
Important to seek stakeholder input throughout the process! Know your community. One size does not fit all, people and place matter.
Example: Program for the elderly in urban communities may not work for the elderly in rural communities (where transportation, resources, healthcare access, and social support, etc. are not as easily accessible).

10. 2. Assess Acceptability and Importance
Talking Points:
The second part of the tool concerns balancing the acceptability of adaptations with the actual need for or importance of adaptations.
In the next couples of slides, we will review considerations for completing the worksheet.

11. Assess Acceptability of Adaptations
There is a continuum for adaptation:
… should be avoided (red) To maintain fidelity on core components …should be made cautiously (yellow) …safe (green)
Talking Points:
The assessment of acceptability of adaptation can be done using the traffic light system, a guide to adaptation developed with funding from the Centers for Disease Control and Prevention.
They describe the acceptability of adaptation as a continuum:
Red light adaptations should be avoided to maintain fidelity on core components.
Yellow light adaptations should be made with caution.
Green light adaptations are mostly safe.
Ask the Audience:
You might ask how many are familiar with these guidelines and recognize them.
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

12. Red Light Adaptations: Components that Probably Cannot be Modified
Methods
Change theoretical underpinning; mechanisms of change
Content
Change health topic/behavior addressed
Add activities that contradict or detract from the original EBI's goals
Delete whole sections or major activities
Reduce duration and dose
Talking Points:
Red light adaptations concern, for example, changing the methods used, or deleting content, changing or contradicting behaviors or content addressed.
These adaptation ideas are not recommended while it seems required to ensure reach, receptivity, effectiveness or feasibility of the EBI.
You are then left with two options:
Try to make a red light adaptation into a yellow light adaptation,
Or, as suggested before, go back to your EBI with basic fit to see whether another EBI might be more suitable

13. Yellow Light Adaptations: Components that Can Probably be Changed with Caution
Methods and content
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 the EBI to a different population
Delivery mechanisms
Change delivery format/process
Modify who delivers the program
Change setting of delivery
Substitute activities and/or materials
Talking Points:
Yellow light adaptations concern adaptations of methods and content, but instead of deletion or contradiction, use addition of methods or content. Some packaged programs may have suggestions of these yellow and green adaptations in their implementation protocols.
However, cautious with adapting the delivery mechanisms. For example, the influence of program deliverers may go through several pathways – e.g., when it is a peer, or key person this may create receptivity, we might unconsciously tailor messages, etc. On the other hand, expertise of health professionals might have played an important role.
Also be careful with changing delivery formats.
And always try to keep elements of the program that fit.

14. Green Light Adaptations: Components 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 such as changing names, pictures, wording, etc.
Change ways to recruit and/or engage priority population
Talking Points:
Green light adaptations are more superficial adaptations to the EBI, mostly to make it fit to your population; to increase reach, receptivity, and participation.
For example, you can tailor or update content such as statistics, use other names and colors, pictures, and wording.
You might also adapt the recruitment of your priority population, for instance use more active strategies – a direct approach, versus more passive ones via media.

15. Example: FLU-FIT Program
Core Elements:
Mailed announcements
Clinic posters to advertise program
Algorithms for patient flow and for using electronic medical records to assess iFOBT/FIT eligibility
Script to introduce iFOBT/FIT with flu shots to patients
Visual aids when offering iFOBT/FIT
Multilingual materials to explain why colorectal cancer screening is important, written instructions, and video instructions (can play on computer at location)
Pre-addressed and pre-stamped mailing pouches
Log sheet to record flu shots and iFOBT/FIT kits dispensed
Clinic nursing staff – 1 to 2 hours of staff training are required initially, with periodic brief review and reinforcement of program by a practice team leader or supervisor
*You can change the example to one most relevant to the audience.
Talking Points:
Let’s walk through using the Adaptation Guidance Tool with a program example
This one is for the FLU-FIT/FOBT Program.
Here are the required core elements of this program.

16. Adaptation Quiz
You would like to replicate the FLU-FIT Program for use for worksite in a rural community (where the local health department serves as clinic staff). Would the following adaptions be:
A. Red, B. Yellow, or C. Green
Add worksite logo to announcements and poster materials?
Eliminate log sheet to record flu shots and iFOBT/FIT/kits dispensed?
Have a staff person who is an excellent trainer and is familiar with the program to conduct required clinic staff training?
Play the videos for participants on a TV instead of a computer?
Include patients in the program outside of the age category?
Talking Points:
Opportunity for audience to move around room – either stand to vote or go to a corner of the room to vote.
Green
Red
Yellow

17. Assess Importance of Adaptations
Consult Experts
EBI experts
Content experts
Community representatives
Organization stakeholders
Talking Points:
Throughout the whole project – from the community assessment on – but especially when considering the importance of adaptation and making final decisions on adaptation, the input of experts is strongly recommended.
Content experts, for instance health promotion researchers, might be able to both take a look at whether your plan may harm core elements, as well as whether adaptation seems needed to reach your goals and objectives.
The community can give insight into which changes seem really needed for achieving reach, receptivity, and effectiveness among your priority population versus which might be less needed.
While the organization and partners might brainstorm whether adaptation is really required to enable implementation.
These together can form the basis of your adaptation decisions; what to adapt and how.
Do EBI experts think your proposed adaptation is a big deal?
Integrate input into
final decision making

18. 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 the EBI
Stigmatization
Costs, feasibility
Re: Adaptations to community and context
Think about possibilities for implementation as-is instead of barriers
Talking Points:
You should consider counterarguments for adaptation- e.g., with regard to adaptations towards the priority population
Diversity within priority population;
Differences between community assessment and EBI with regard to population may be smaller than differences within your own priority population
Adaptations may only create a perfect fit for part of your priority population, but misfit for other parts; in some cases non-adaptation may be able to fit – to a lower degree – a broader part of your population
e.g., low acculturated subgroup vs. high acculturated subgroup
Stigmatization (for example, having only pictures of African-Americans on your HPV brochure might be interpreted as meaning that only African-Americans get HPV)
Costs and feasibility of changes may be barriers to changes
Because of these costs & feasibility, and attempts to maintain fidelity, when thinking about adaptations to community and context. try to think about possibilities for implementing as is, without adaptations

19. 3. & 4. Make the Decision and Adapt
Relatively straightforward for “green light adaptations” to priority population
E.g., Replace graphics, key figures, pictures, wording
More complex for “yellow light adaptations”
Select objectives for determinants and behavioral/environmental factors not yet addressed by EBI program
Search for methods to address these determinants (and related behaviors)
Adaptation of delivery mechanisms
Talking Points:
Some of these adaptations might be quite straightforward. For example the replacement of graphics and other key figures, pictures and wording.
Others might be more complex. For instance yellow light adaptation with regard to adding behavioral objectives or intervening on more determinants. For these the method table provided before can be useful. Search for methods that address the determinants and related behaviors that were not addressed by the original program.

20. 5. Pretest and Pilot Test Pretest Pilot Test
Try out program elements (e.g. materials) with intended end users.
Can include adapted elements and non-adapted elements.
Pilot Test
Implement the EBI on a small scale to assess fit with community or organization.
Talking Points:
Finally, we would like to recommend always testing the adapted components first with the end users – your priority population – and those responsible for the implementation, before broader implementation. Also pretesting the components that were not adapted may be useful, particularly when you were not really sure whether adaptation was needed or not.
For this purpose qualitative data collection is especially useful, such as focus groups, interviews or observations. This enables assessing why and how the adapted approach fits or not; what will provide a basis for how to revise the program (adaptations) if necessary.

21. Pretest and Revise
Try out program elements (e.g. materials) with intended end users from your priority population
Adapted elements
Non-adapted elements
For example, test:
Comprehension
Acceptability
Attractiveness
Cultural relevancy
Influence on determinants
Talking Points:
Pretesting is trying out the messages of the adapted program products or new program elements with the intended participants before final production.
You can also pre-test non-adapted elements, if you are not sure whether they fit the priority population.

22. Pretest and Revise Is there an implementation protocol (manual)?
If not, needs to be developed
If there is one, adaptations/additions may be needed because of adaptations to the EBI
Who does
What,
When,
Why (motivations, barriers)
How
Talking Points:
Elements of the implementation protocol (e.g., manUal) may need to also be adapted and pilot tested.
There may be slight changes in the who, what, when, why, and how of the key process steps. For example, the type of person who delivers the intervention may be somewhat different in the original EBI from who is available in your community. More training may need to be added to account for this staff capacity difference.

23. Pilot Test
Implement the EBI on a small scale to assess fit with community or organization
For example, assess:
Adherence to program protocol
Dose delivered
Quality of program delivery
Barriers/facilitators
Talking Points:
Pilot testing is trying out the program as it will be implemented with both the implementers and the intended participants prior to the actual implementation.
You will be able to learn much more about the delivery of the program and whether it works. If not, you will have time to make changes.
*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

24. Take-home Points
Base modifications to the EBI on your community assessment findings
Identify and retain the EBI’s core elements 
Seek feedback and advice from representatives of your priority population
Seek advice from experts including the EBI developers to make yellow and green light adaptations 
The more you adapt, the more you need to re- evaluate effectiveness
Talking Points:
Here are some key concepts for this session:
Base changes on your communities’ needs
Consider the core elements with every adaptation you make
Work with your community to get their feedback as you make changes
Get advice from experts including the program developers or experts
The more you adapt, the more you need to evaluate

25. Questions?
Ask the Audience:
Do you have any questions?

26. References
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.
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.
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