Culturally Adapted Evidence Based Interventions: Issues to Consider. The following paper introduces the issue of cultural adaptations to evidence based treatments (interventions and practices), some issues (fidelity, erosion of effectiveness), challenges in the design of the adaptations, as well as briefly discussing the processes and frameworks in the extant literature that have been used for cultural adaptations. INDEX Introduction pp. 1 3 Fidelity adaptation dilemma pp. 3 4 Challenges Involved in the Design of Cultural Adaptations What procedures should intervention developers follow when conducting a cultural adaptation? pp. 4 6 Are cultural adaptations developed from the original evidence based interventions justifiable? p. 6 What is the evidence that cultural adaptations are effective? pp. 6 7 How can within group cultural variations be accommodated in a cultural adaptation? p. 7 REFERENCES pp. 8 9 Appendix A, A Map of Adaptation Process for EB Behavioral Interventions p. 10 Appendix B, cont. p. 11 Appendix C, cont. p. 12 Appendix D, cont. p. 12 Appendix E; CSAP Finding the balance: Program fidelity and adaptation pp. 13 14 Appendix F; Issues surrounding the definition of culture. p. 15 Appendix G; Professional contexts affecting the design of cultural adaptations p. 16 Appendix H, Adaptation of a Parenting Management Training program pp. 17 18 1 Culturally Adapted Evidence Based Interventions: Issues to Consider.
Introduction. Health departments and community based organizations increasingly are required to implement evidenced based behavioral interventions (McKleroy, Galbraith, Cummings, Jones, Harshbarger, Collins, Gelaude, and Carey, 2006). Often, if not always, the implementing agency s setting or target population is different than those in the original implementation and evaluation studies. Because of the above, the implementation of evidence based practices has resulted in a dynamic tension between the scientific top down approach that demands fidelity in the implementation of evidence based practices (standardized statements that account for larger social patterns nomothetic) and the case wise bottom up approach that demands sensitivity and responsiveness to each person s unique needs (focused on individual cases or eventsideographic) (Gonzalez Castro, Barrera, Holleran Steiker, 2010). This tension has resulted in research and literature that attempts to resolve that tension via cultural adaptations. In support of the case for cultural adaptations, a 2007 review by Mak, Law, Alviderez, & Perez Stable of 379 funded clinical trials research (National Institute of Mental Health) between 1995 and 2004 found that fewer than half of the studies provided basic information on race and ethnicity, and that all ethnic groups except Whites and African Americans were underrepresented. For a brief discussion on cultural issues, please refer to Appendix F. According to McKleroy et al. (2006) Rogers defined adaptation in 1995 as the degree to which an innovation is changed or modified by a user in the process of its adoption and implementation. In 2002, the Center of Substance Abuse Prevention added or deliberate or accidental modification of a program to that definition. Innovation in the above is equivalent to an evidence based intervention. The terms evidence based intervention, evidence based practice, or evidence based programs are interchangeable in this paper. Gonzalez Castro et al. (2010) reviewed the literature on cultural adaptations. They state that cultural adaptation involves a planned, organized, iterative, and collaborative process that often includes the participation of persons from the targeted population for whom the adaptation is being developed. They quote Resnicow and colleagues (2000) who found that there may be surface structure adaptations and deep structure adaptations. Surface structure adaptations involve changes in original materials or activities that address observable and superficial aspects of a target population s culture, such as language, music, food, clothing, and related observable aspects. By contrast, deep structure adaptations involve changes based on deeper cultural, social, historical, environmental, and psychological factors that influence the health behaviors of members of the targeted population. 2 Culturally Adapted Evidence Based Interventions: Issues to Consider.
Adaptations vary greatly in range and depth. For example, an adaptation of a CBT (cognitive behavior treatment) group therapy intervention for African American women at the Depression Clinic in San Francisco (Kohn et al., 2002) adapted the program by adding four modules concerned with healthy relationships, spirituality, African American family issues, and African American female identity (Gonzalez Castro et al., 2010). Another study adapted CBT group therapy to increase engagement with low income participants of Spanish, African American, and Asian or American Indian background by adding outreach supplemental case management, targeting problems in housing, employment, recreation, and relationships with family and friends (Miranda et al., 2003). Lau (2006) discusses adaptations to Parenting Management Training (PMT) programs. Apparently, sometimes the adaptations are as basic as including material and cultural family values in their manuals and modifying graphic material to depict ethnically similar families. But the adaptations have also included community network recruitment, ethnic matching provider, conducting groups in churches and other community locations, and addressing basic living needs. For a detailed process of cultural adaptation to a PMT, please refer to Appendix H. Fidelity adaptation dilemma. On the one hand, intervention researchers spend years developing, refining, and testing the efficacy of the theory based and structured intervention, recommending that it be administered with high fidelity to the intervention procedures as designed. On the other hand, if interventions lack relevance and fit with the needs and preferences of a specific subcultural group (an intervention consumer mismatch) or within diverse ecological conditions, then certain adaptations are usually necessary. Castro et al., 2004, developed a table that shows the possible sources of mismatch (Gonzalez Castro, 2010, p. 222): a. group characteristics, b. program delivery staff, and c. Administrative/community factors. The general adaptation strategy is to identify specific sources of intervention consumer mismatch and then to introduce specific adaptive elements and activities that affect each of these sources of mismatches in order to enhance relevance and fit. This paper will discuss other adaptation strategies below. Concerns over erosion of intervention effectiveness. Efficacy measures how well an intervention works when tested within the control conditions under which it was designed. Effectiveness, on the other hand, measures how well the intervention works when it is applied in real world setting. The effectiveness of the evidence 3 Culturally Adapted Evidence Based Interventions: Issues to Consider.
based intervention should be defined in relation to the population with which it was tested; I.e. the statement of efficacy should be of the form that, program or policy X is efficacious for producing Y outcomes for Z population, (Flay et al., 2005, p. 154). Cultural adaptations goal is to further the effectiveness of the intervention beyond the population with which it was tested. The Center for Substance Abuse Prevention (CSAP) developed guidelines that emphasize striking a balance between adaptation and fidelity to the original intervention during the adaptation process. Please refer to Appendix E. Challenges Involved in the Design of Cultural Adaptations Gonzalez Castro et al. s (2010) analysis of the issues and challenges involved in the design of cultural adaptations to original evidence based interventions resulted in four questions: a) What procedures should intervention developers follow when conducting a cultural adaptation? There are a variety of similar stage models with similar stages for conducting a cultural adaptation of an evidence based intervention. Gonzalez Castro el al. (2010, pp. 225 226) discuss the adaptation models of Kumpfer et al. (2008), McKleroy et al. (2006) and Wingood and DiClemente (2008). The authors distilled the basic pathways for planning and conducting cultural adaptations which involve variations of the following four stages (Gonzalez Castro et al.,2010): (1) Information gathering; review of the literature to understand common and unique risk factors and conduct focus groups to assess perceived positives and negatives of the original evidence based intervention. (2) Developing preliminary adaptation designs; develop recruitment strategies and modify the intervention based on information gathered in step 1. (3) Conducting preliminary tests of adaptation; pilot test the modified recruitment intervention and assessment procedures and (4) Adaptation refinement; modify the intervention based on pilot results and subject the intervention to a full evaluation with quantitative and qualitative data to evaluate the efficacy of the adapted intervention. (Barrera and Castro, 2006) For the two arenas in which adaptations occur, please refer to appendix G. Domenech, Rodriguez and Wieling (2004) propose a three phase Cultural Adaptation Process Model that includes a) studying the relevant literature, establishing a collaborative relationship with community leaders, gathering information from community members on needs and interests; b) drafting a revision of the intervention, soliciting input from community members, and pilot testing; and c) integrating the lessons learned from the preceding phase into a revised intervention that could be used and studied more broadly. 4 Culturally Adapted Evidence Based Interventions: Issues to Consider.
Beyond the above general stages in cultural adaptation, there is Lau s well documented and reviewed approach for evidenced based treatment adaptation (Lau, 2006) which involves two arms. 1. One is the Contextualizing Content arm, so that the adapted intervention accommodates the distinctive contextual factors related to the presenting problem in the target community. This may involve the addition of novel treatment components to target this group s specific risk processes, or the addition of components to mobilize group specific protective factors. Alternatively, treatment content may be altered in order to target symptom presentation patterns than require distinctive intervention elements. 2. Her second arm of adaptation involves Enhancing Engagement when the evidence based treatment strategies have demonstrably low social validity with the target group. Enhancing engagement includes contextualizing content to be more reflective of the participants experiences as well as reframing the purpose of treatment to one that is more culturally acceptable (e.g. educational versus therapeutic). Lau cites Castro et al (2004) who state that the main challenge is to design adaptations that increase engagement in a standard EBT approach without undermining the therapeutic value of the original intervention. Bernal et al (1995) designed a framework of eight overlapping dimensions to be juxtaposed with a process such as Lau s (above). The dimensions are: language, persons, metaphors, content, concepts, goals, methods, and context. This framework operationalizes the two arms of contextualizing content and engagement proposed by Lau by providing the culturally informed scaffolding needed to isolate or select the target problems in a target group. These target issues are consistently stated in the literature of cultural adaptations as risk or resilience, or evidence of threats to an evidence based treatment s social validity. The content of the eight dimensions focus or direct the adaptations to contextualizing content or to enhancing participant engagement. It provides the sociocultural knowledge needed for the adaptation. Lau (2006) goes on to say that adaptations to evidence based practices or treatments are predicated on basic behavioral research that addresses the distinctive socio cultural patterns of risk, resilience, and presentation of mental health problems as well as the attitudes towards common mental health treatment in diverse communities. She support s Castro et al s (2004) notion that well intentioned adaptation efforts that are not informed by data may fall into a category of being culturally appealing but scientifically indefensible. The Center for Disease Control has developed a map of adaptation process. Please refer to Appendices A, B, C, and D. 5 Culturally Adapted Evidence Based Interventions: Issues to Consider.
When tackling cultural adaptations, McKleroy et al. (2006) stress the importance of beginning with evidence based interventions that have been shown to be effective; maintaining fidelity to the core elements of the effective evidence based interventions; conducting systematic assessments of the current status of the target population s risk factors, behavioral determinants, and risk behaviors; as well as assessing systematically the agency s capacity, the potential for collaborations with other partners, and the need for cultural proficiency. They define cultural proficiency as a way of being that enables both individuals and organizations to respond effectively to people who differ from them. Their approach emphasizes the importance of the implementers practical experience with the target population and agency capacity, while still emphasizing maintaining fidelity to the core elements, theory, and internal logic of the original intervention. Lastly, besides documenting the adaptation process and evaluating outcomes, they stress drawing on the strengths of the community and implementers experience in the field by integrating feedback loops throughout the adaptation process. b) Are cultural adaptations developed from the original evidence based interventions justifiable? Research so far suggests that generally, yes, when the original intervention exhibits one of four types of diminished effects (Gonzalez Castro et al.,2010): (1) Ineffective client engagement, (which can be assisted with the RE AIM; Reach, Adoption, Implementation, Maintenance model, Glasgow, Vogt, Boles, 1999). According to Mariñez Lora & Atkins (2009), there are factors that can help identify specific barriers to engagement with an evidence based treatment and its component parts. These are knowledge and attitudes about seeking mental health treatment, acceptability and feasibility of the therapeutic procedures used, along with the participants perceptions of the relevance, effectiveness, and demands placed on them. (2) Unique risk or resilience factors in a subcultural group. That is, the cultural adaptation need not be indiscriminate, but instead respond to particular clinical problems emerging within a distinct set of risk and resilience factors in a given community, Low, 2006, p. 297. (3) Unique symptoms of a common disorder (in the target population of the real world practice) that the original evidence based intervention was not designed to influence, and (4) Poor intervention effectiveness in a particular subcultural group. c. What is the evidence that cultural adaptations are effective? Most of the research on cultural adaptations has been conducted with treatments or practices for children and 6 Culturally Adapted Evidence Based Interventions: Issues to Consider.
families (Gonzalez Castro et al., 2010). The authors state that the evidence for the effectiveness of cultural adaptations is promising, but mixed. It appears that culturally adapted interventions are approximately as effective as the original evidence based intervention. Ideally, the adapted intervention would provide a significant increment of improvement on targeted outcome measures, although few studies have conducted direct comparisons of this effect. For example, Lau (2006) states that outcomes associated with adaptations to parent management training are typically equivalent or only slightly better than standard versions. The issue remains of the worthiness of the cost and effort involved in designing and evaluating adaptations if the effect size, and thus the effectiveness, on targeted outcomes are approximately equal to those obtained in the under the original evidencebased interventions (Gonzalez Castro et al.,2010). Two meta analyses published after Gonzalez Castro et al s, 2010 article, by Benish, Quintana, and Wampold (2011) and by Smith, Domonech, Rodriguez and Bernal (2011) provide support for cultural adaptations. d. How can within group cultural variations be accommodated in a cultural adaptation? The problem of within group variations can be addressed by (Gonzalez Castro et al., 2010) specifically identifying the subgroup within the target population and by adapting the interventions to that subgroup. (5) Population segmentation, which involves more narrowly defining the targeted subcultural group (attenuating within group variability), and (6) Adaptive interventions of various types (please refer to pp. 225 to 228 Gonzalez Castro et al., 2010). To conclude, Mariñez Lora and Atkins, 2009, quote Hill et al, (2007) and Miranda et al., (2005) as having said that clinicians routinely make adaptations to evidence based treatments to better meet the needs of the populations they serve. This has suggested a gap between science and practice that can be understood as a gap between evidence based practices and practice based adaptations (Mariñez Lora & Atkins, 2009). For the last 20 years, there has been a growth of efforts to culturally adapt evidence based interventions. There are now processes and frameworks that facilitate cultural adaptations to guide clinicians, supervisors, managers, and stakeholders to make evidence informed adaptations that are consistent with cultural norms. 7
REFERENCES Addis, M. E., Cardemil, E. V. (2006). Does manual isolation in group therapy outcomes? Psychotherapy manuals can improve outcomes. In Evidence Based Practice In Mental Health: Debate And Dialogue on the Fundamental Questions, Ed. J. C. Norcross. L. E. Beutler, R.F. Levant, pp. 131 140. Washington, DC: American Psychological Association. American Psychological Association. Presidential Task Force Evidence Based Practice. (2006). Evidencebased practice in psychology. American Psychologist, 61, 271 285. Barrera, M., Jr., Castro, F., G. (2006). A heuristic framework for the cultural adaptation of interventions. Clinical Psychology Scientific Practice, 15, 311 316. Benish, R. G., Quintana, S., & Wampold, B. E. (2011). Culturally adapted psychotherapy and the legitimacy of myth: A direct comparison meta analysis. Journal of Counseling Psychology, 58, 279 289. Bernal, G., Bonilla, J., & Bellido, C. (1995). Ecological validity and cultural sensitivity for outcome research: Issues for the cultural adaptation and development of psychosocial treatments with Hispanics. Journal of Abnormal Child Psychology, 23, 67 82. Castro, F. G., Barrera, M. Jr., Martinez, C. R. (2004). The cultural adaptation of prevention interventions: resolving tensions between fidelity and fit. Prevention Science, 5, 41 45. Center for Substance Abuse Prevention (2001). Finding the balance: Program fidelity and adaptation in substance abuse prevention. (Conference 2002) Domenech Rodriguez, M., Wieling, F. (2004). Developing culturally appropriate evidence based treatments for interventions with ethnic minority populations. In Voices of Color: First Person Accounts of Ethnic Minority Therapists, ed. M. Rastogi, E. Wieling, pp. 313 333. Thousand Oaks, CA:Sage Glasgow, R. E., Vogt, T, M., Boles, S. M. (1999). Evaluating the public health impact of health promotion interventions: the RE AIM framework. American Journal of Public health, 89, 1322 1327. Gonzalez Castro, F., Barrera, M., Holleran Steiker, L. K. (2010). Issues and Challenges in the Design of Culturally Adapted Evidence based Interventions. Annual Reviews, Clinical Psychology, 6, 213 39. Hill, L. G., Maucione, K. & Hood, B. K. (2007). A focused approach to assessing program fidelity. Prevention Science, 8, 25 34. Miranda, J., Bernal, G., Lau, A., Kohn, L., Hwang, & LaFromboise, T. (2005). State of the science on psychosocial interventions for ethnic minorities. Annual Review of Clinical Psychology. 1, 113 142. Kazdin, A. E. (2008). Evidence based treatment and practice: new opportunities to bridge clinical research and practice, enhance the knowledge base, and improve patient care. American Psychologist, 63, 146 159. 8 REFERENCES
Lau, A. S. (2006). Making the case for selective and directed cultural adaptations of evidence based treatments: examples from parent training. Clinical Psychology: Science and Practice, 13, 295 310. Kohn, L. P., Oden, T., Muñoz, R. F., Robinson, A. Leavitt, D., (2002). Adapted cognitive behavioral group therapy for depressed low income African American women. Community Mental Health Journal 38:497 504. Kumpfer, K. L., Alvarado, R., Smith, P. & Bellamy, N. (2002). Cultural sensitivity and adaptation in family based prevention interventions, Prevention Science, 3, 241 246. Kumpfer, K. L., Pinyuchon, M., Mel, A. T., Whiteside, H. O. (2008). Cultural adaptation process for international dissemination of the Strengthening Families Program. Eval. Heath Prof, 31, 226 239. Mak, W. W., Law, R. W. Alviderez, J., & Perez Stable, E. J. (2007). Gender and ethnic diversity in NIMHfunded clinical trials: review of a decade of published research. Administration Policy in Mental Health, 34, 497 503. Mariñez Lora, A., Atkins, M. S. (2009). Evidence Based treatment in practice based cultural adaptations, chapter 12 in a book McKleroy, V. S., Galbraith, J. S., Cummings, B., Jones P., Harshbarger, C., Collins, C. Gelaude, D., Carey, J. W., & ADAPT Team (2006). Education and Prevention, 18, Supplement A, 59 73, Miranda, J., Nakamura, R., & Bernal, G. (2003). Including ethnic minorities in mental health intervention research: A practical approach to a long standing problem. Culture, Medicine & Psychiatry, 27, 467 486. Resnicow, K., Soler R., Braithwait, R.L., Ahluwalia J.S., Butler J. (2000). Cultural sensitivity in substance abuse prevention. Journal of Community Psychology, 28, 271 290. Smith, T. B., Domenech Rodriguez, M., & Bernal, G. (2011). Culture, Journal of Clinical Psychology, 67. 166 175. Wingood, G. M., DiClemente, R. J. (2008). The ADAPT ITT Model: a novel method of adapting evidencebased HIV interventions. Journal Acquired Immune Deficiency Syndrome 47 (Suppl. 1): S40 46. 9 REFERENCES
APPENDIX A Map of Adaptation Process: A Systematic Approach for Adapting Evidence-Based Behavior ral Interventions 10 REFERENCES
11 REFERENCES APPENDIX B
APPENDIX C APPENDIX D 12 REFERENCES
APPENDIX E CSAP Finding the balance: Program fidelity and adaptation in substance abuse prevention, 2002. Conference Edition, Center for Substance Abuse Prevention. Guidelines for Balancing Program Fidelity/Adaptation 1 - Identify and understand the theory base behind the program. Published literature on the program should provide a description of its theoretical underpinnings; if not, an inquiry to the program developer may yield this information. This may or may not include a logic model that describes in linear fashion how the program works. The theory and logic model are not in themselves core components of a program, but they can help identify what the core components are, and how to measure them. This step also identifies core values or assumptions about the program that can be used to help persuade community stakeholders of the program s fit and importance for their environment. 2 Locate or conduct a core components analysis of the program. This will provide implementers with a roster of the main program ingredients, and at least some sense of which components are essential to likely success and which are more amenable to modification, given local conditions. In essence, core components analysis represents a bridge between developer and implementer, and between fidelity and adaptation. Ideally, the program developer or a third party will already have conducted the core components analysis. If not, with good information about the program, an implementer can at least approximate this informally. CSAP, through its National Center for the Advancement of Prevention, is undertaking a large-scale core components analysis of effective and model programs. Checking to see if a selected program is in the database of CSAP s National Registry of Effective Prevention Programs (NREPP) is a first step in determining the status of a core components analysis. For online access to this database, go to www.samhsa.gov/csap/modelprograms/. 3 Assess fidelity/adaptation concerns for the particular implementation site. This step means determining what adaptations may be necessary, given the target population, community environment, political and funding circumstances, etc. 4 Consult as needed with the program developer to review the above steps and how they have shaped a plan for implementing the program in a particular setting. This may also include actual technical assistance from the developer or referral to peers who have implemented the program in somewhat similar settings. 5 Consult with the organization and/or community in which the implementation will take place. This is a process to allow fears and resistance to surface, build support for the program, and obtain input on how to do the implementation successfully. 13 REFERENCES
6 Develop an overall implementation plan based on these inputs. Include a strategy for achieving and measuring fidelity/adaptation balance for the program to be implemented, both at the initial implementation and over time. By addressing all of the complex stages of implementation, such a plan can increase the opportunities for making choices that shape a program, while maintaining good fidelity. 14 REFERENCES
APPENDIX F The issues surrounding the definition of culture as it relates to cultural adaptation. For a systemic analysis of culture and the evolution of its related concepts please refer to Gonzalez Castro et al, 2010, pp. 216 218. Gonzalez Castro et al (2010) address concepts of culture and cultural frameworks, population segmentation, subcultural groups, the structure of culture as a collection of cultural elements, and systemic ecological models of culture (shift from culture as a stable entity toward culture as a dynamic entity that exhibits multiple influences across time and ecological levels), and cultural change and acculturative adaptation (acculturation stressors and familial and social context that erode native culture, family values, attitudes, and behaviors). Gonzalez Castro et al, 2010, when discussing cultural relevance and cultural adaptation quote Castro, Barrera and Martinez, 2004. An intervention developer must develop a deep structure understanding of a subcultural group s culture in order for it to be culturally relevant. An effective consumer responsiveness high in cultural relevance would be characterized by i) comprehension: understandable content matched to linguistic/educational/developmental needs of the consumer group, ii) motivation: content that is interesting and important to this group; and iii) Relevance: content and materials that are applicable to participants everyday lives. 15 REFERENCES
APPENDIX G Professional contexts affecting the design of cultural adaptations. There are two arenas in which the design of cultural adaptations takes place. a) One arena is the distinction between what the adaptation applies to. Does it apply to a particular treatment (evidence based treatment) or to a practice (evidence based practice)? According to Kazdin (2008) there are two approaches to the application of research evidence: evidence based treatments (EBT) and evidence based practice (EBP). i) EBT refers to specific interventions of techniques, such as cognitive therapy for depression, that have produced therapeutic change as tested in clinical trials. ii) In contrast, the American Psychological Association 2005 Presidential Task Force on Evidence based Practice defined evidence based practice (EBP) in psychology as the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences, (American Psychological Association, 2006, p. 273). However, Gonzales Castro et al (2010) note that there is a continuum between the two (EBTs and EBPs) and that the boundaries often blur. b) The other arena for the design of cultural adaptations is in the fidelity to manuals. The ongoing concern is the extent to which clinicians actually utilize the results of clinical research to guide their clinical interventions. This is because some clinicians have been skeptical about the clinical applicability of certain evidence based interventions, especially when the procedures have been incorporated into a treatment manual. According to Addis and Cardemil (2006), well constructed treatment manuals have been described as not rigid and, to the contrary, affording therapists flexibility, and allowing discretionary decision making under a series of dialectics that encourage i) balancing adherence to the treatment manual versus clinical flexibility, and ii) Balancing attention to the therapeutic relationship versus attention to therapeutic techniques. The question remains of when does flexibility in adaptation merge into misadaptation or inappropriate change in the prescribed procedures. 16 REFERENCES
17 REFERENCES APPENDIX H
18 REFERENCES