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  • Systematic review
  • Open Access
  • Open Peer Review

A systematic review of adaptations of evidence-based public health interventions globally

Implementation Science201813:125

https://doi.org/10.1186/s13012-018-0815-9

  • Received: 22 February 2018
  • Accepted: 10 September 2018
  • Published:
Open Peer Review reports

Abstract

Background

Adaptations of evidence-based interventions (EBIs) often occur. However, little is known about the reasons for adaptation, the adaptation process, and outcomes of adapted EBIs. To address this gap, we conducted a systematic review to answer the following questions: (1) What are the reasons for and common types of adaptations being made to EBIs in community settings as reported in the published literature? (2) What steps are described in making adaptations to EBIs? and (3) What outcomes are assessed in evaluations of adapted EBIs?

Methods

We conducted a systematic review of English language publications that described adaptations of public health EBIs. We searched Ovid PubMed, PsycINFO, PsycNET, and CINAHL and citations of included studies for adapted public health EBIs. We abstracted characteristics of the original and adapted populations and settings, reasons for adaptation, types of modifications, use of an adaptation framework, adaptation steps, and evaluation outcomes.

Results

Forty-two distinct EBIs were found focusing on HIV/AIDS, mental health, substance abuse, and chronic illnesses. More than half (62%) reported on adaptations in the USA. Frequent reasons for adaptation included the need for cultural appropriateness (64.3%), focusing on a new target population (59.5%), and implementing in a new setting (57.1%). Common adaptations were content (100%), context (95.2%), cultural modifications (73.8%), and delivery (61.9%). Most study authors conducted a community assessment, prepared new materials, implemented the adapted intervention, evaluated or planned to evaluate the intervention, determined needed changes, trained staff members, and consulted experts/stakeholders. Most studies that reported an evaluation (k = 36) included behavioral outcomes (71.4%), acceptability (66.7%), fidelity (52.4%), and feasibility (52.4%). Fewer measured adoption (47.6%) and changes in practice (21.4%).

Conclusions

These findings advance our understanding of the patterns and effects of modifications of EBIs that are reported in published studies and suggest areas of further research to understand and guide the adaptation process. Furthermore, findings can inform better reporting of adapted EBIs and inform capacity building efforts to assist health professionals in adapting EBIs.

Keywords

  • Adaptation
  • Intervention
  • Modifications
  • Implementation
  • Evidence-based

Background

Emphasis on evidence-based practice in medicine, public health, and the social services has led to a prominence of the application of practice guidelines and evidence-based interventions or EBIs. When situating an EBI in a new context, public health professionals, or health practitioners who work in community settings, sometimes adapt the EBI during the process of replication [1, 2]. However, in planning and implementing these interventions, there may be mismatches between the original EBI and the characteristics of the population of interest, implementing agency, and/or community [3]. In addition, agencies may lack the resources, funding, or expertise to deliver the EBI as it was originally intended [4]. Consequently, public health professionals often make both intended and unplanned program adaptations to the EBI to better fit the new audience or context.

The concept of program adaptation was originally introduced by Rogers when he defined adaptation as the degree to which an innovation is modified in the process of its adoption and implementation [5]. Other definitions have evolved in the era of translation of EBIs and the emergence of adaptation frameworks (Table 1). These definitions share similar characteristics, including modifying a program to meet the needs of the target population, local circumstances, or new contexts. Some definitions focus on the need to retain the core components or logic of the program [611]. The adaptations could be deletions, additions, or modifications [11]. Some posit that adaptations should be systematic or planned [1214] to involve stakeholder input and to have a more rigorous process in program planning, while the CSAP (Center for Substance Abuse Prevention) framework notes that adaptations could be accidental modifications [11]. Moore and colleagues proposed the schema of timing of adaptation of proactive (planned) vs. reactive [15]. Furthermore, three definitions included modifications related to matching the culture for the new population, “cultural adaptation” [11, 16, 17]. A few definitions specify elements that could be changed such as program components, content, provider, and delivery [11, 14]. Of these definitions, CSAP’s Guidelines for Adaptation [11], Map of Adaptation Process [16, 18], ADAPT-ITT [9], and Research-based Program Adaptation [6] are cited most frequently in the published literature. In summary, although many adaptation definitions share similar characteristics, the most frequently cited ones do not emphasize the same concepts. Thus, it is important to discern how professionals in the field describe their adaptations, why they make modifications and the types of changes that they make, and how they use frameworks to conduct adaptations.
Table 1

Definitions of adaptation

Article

Adaptation definition

Backer (CSAP, 2002) [11]

“The deliberate or accidental modification of the program, including the following:

a. Deletions or additions (enhancements) of program components;

b. Modifications in the nature of the components that are included;

c. Changes in the manner or intensity of administration of program components called for in the program manual, curriculum, or core components analysis; or

d. Cultural and other modifications required by local circumstances.”

McKleroy et al. 2006 [16]

Quotes Rogers’ (1995) definition and the CSAP definition (see above).

Solomon et al. [6]

Modifying an efficacious program to meet the needs of its new target population and community context while retaining fidelity (or adherence) to its core components.

Smith and Caldwell [14]

“Evidence-based programs should not be changed randomly but should be modified based on a careful review of program content, the theoretical underpinnings involved, and the context of the new environment. Four different forms of adaptation need to be considered: structural, content, provider, and delivery.”

Wingood and DiClemente [9]

“The process of modifying an EBI without competing with or contradicting its core elements or internal logic.”

Barrera and Castro, Kumpfer et al. [17, 22]

Developing cultural adaptations or accommodations of EB practices for international transport is a … “process requiring careful assessment of the local political, religious, and economic context as well as the cultural norms and family practices of country and internal ethnic groups. It should be a careful and rigorous process …guided by research and theory.”

Lee et al. [7]

“Inherent in [the process of moving evidence-based programs (EBPs) from research to practice] is the tension between implementing programs with fidelity and the need to tailor programs to fit the target population.”

Card et al. [3]

“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.”

Chen et al. [8]

“Methods of planned adaptation identify differences in the new target population and attempt to make changes to the EBI that accommodate these differences without diluting the program’s effectiveness.”

Rolleri [10]

“The process of making changes to a program in order to make it more suitable for a particular population or for an organization, based upon its capacity. Changes to a program should be made without compromising or deleting the program’s core components.”

Bartholomew et al. [42]

Systematic adaptation requires that planners make adaptation decisions by comparing the logic of change in the EBI with the needs of the new community. Planners should only make changes that correspond with mismatches between the EBI and community needs.

Previous reviews have found that modifications to original EBIs often occur spontaneously when they are adopted into other practice settings [1, 15]. Common reasons for adaptations include responding to participants’ attributes [18, 19], needs [20] or culture [15], constraints such as limited time or resources [15, 1921], issues related to participant recruitment or retention [15], and accommodating practice or setting circumstances/context [20].

Increased development of models and frameworks to guide the adaptation of EBIs began with national EBI dissemination efforts related to disease prevention areas in substance abuse and HIV/AIDS [6, 9, 14] or cultural adaptations to existing programs [7, 22]; these frameworks provide approaches to facilitate adaptation. Escoffery and associates recently conducted a scoping study that found 13 adaptation frameworks [23]. They reported 11 common steps including assess the community, understand the intervention, select intervention, consult with experts, consult with stakeholders, decide what needs adaptation, adapt the original program, train staff, test the adapted materials, implement, and evaluate. These frameworks enhance the translation of evidence-based practices. As Wandersman’s Interactive Systems Framework suggests, supports are necessary to guide the public health system or agencies to adopt and implement new public health interventions [24]. These frameworks assist public health professionals as capacity building tools for a structured adaptation process.

Limited research has explored how adaptation occurs in practice. Little is understood about who is involved in adaptation processes, what common types of changes are made to the original program, and what mechanisms are used. This review advances the concept of adaptation and elucidates common adaptation processes in real-world community settings as reported in the published literature. Community settings are defined as various organizations or places in communities such as schools, faith-based organizations, social services or public health agencies, households, or worksites. The research questions for the review were as follows:
  1. 1.

    What are the reasons for and common types of adaptations being made public health EBIs in community settings as reported in the published literature?

     
  2. 2.

    What steps are described to making adaptations to EBIs?

     
  3. 3.

    What outcomes are assessed in evaluations of adapted EBIs?

     

Methods

We followed procedures for systematic reviews based on the Cochrane Handbook of Systematic Reviews of Public Health Interventions [25] and the reporting guideline, Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [26].

Search strategy

We searched Ovid PubMed, PsycINFO, PsycNET, and CINAHL with the assistance of an experienced health sciences librarian. The date of the last search was December 2015. Concepts for the search included adaptation, evidence-based interventions and practice, health behavior, and quality of healthcare. Combinations of the associated MeSH terms were used to develop the initial PubMed search and then adapted to search other databases. The search strategies can be found in Additional file 1. We also manually cross-referenced reference lists of included studies. We downloaded relevant citations into a reference manager software program, EndNote, which facilitated removing duplicate citations identified in the multiple databases. We exported the resulting composite library into an Excel file for documentation of the title and abstract review process.

Eligibility criteria

The project team created an Eligibility Assessment Checklist restricting included articles to those reporting primary studies published in English after 1995 and that examined the adaptation process or outcomes of an adapted evidence-based intervention (public health program or policy). Programs are defined as a combination of strategies designed to create behavior change or improve health status and policies are rules, regulations, or actions related to a health goal or service. These adaptations reported could be proactive (purposeful) or reactive. Articles were excluded if they did not describe the adaptation methods or if the full-text article was unable to be located after an exhaustive search. We combined articles reporting different aspects of the same EBI, e.g., the evaluation findings and the adaptation process.

Screening

Two trained reviewers (CE, HU) independently screened titles and abstracts after duplicates were removed, using the Eligibility Assessment Checklist. We selected potentially relevant abstracts for a full-text review conducted independently by the two trained reviewers. The first author resolved any disagreement between the reviewers.

Study quality assessment

We assessed study quality of the articles based on their use of a theory or adaptation framework, and in the case of those that included an evaluation, we assessed the rigor of the design. We used these variables descriptively, however, and did not differentiate studies based on these variables.

Data abstraction and analysis

We reviewed the articles of EBI adaptations for six categories of variables: (1) characteristics of the original and adapted EBI (name, disease/topic, population and setting), (2) reason(s) for adaptation, (3) type(s) of modifications, (4) steps (tasks) in adaptation described by the authors, (5) reference to an adaptation framework, and (6) measures of implementation and intervention outcomes (see definitions in Additional file 2). In addition, we described how they presented the EBI adaptations made in the articles. We used a structured data abstraction form designed in Excel 2016 to record the extracted information. We used Stirman and associates’ typology of modifications [1], the adaptation steps identified in the scoping study of adaptation frameworks [23], and implementation outcomes defined by Proctor and colleagues [27]. Context modifications were defined as changes to format, location, or personnel delivering the intervention, while content modifications were changes to the intervention materials, procedures, or delivery. In coding adaptation steps, we combined consulting with stakeholders and experts and had an “other” option, resulting in nine named steps. For each study, we examined bias in the study through documentation of participants (e.g., selection, generalizability), study design, and inadequate results reporting. Two trained reviewers (CE, HE, RW, ME, PDM, EL) independently coded the included articles. Discrepancies were discussed and adjudicated by the larger team.

Data synthesis and presentation

We presented summaries of study-specific adaptation reasons, steps, types of adaptations, and outcome measures with descriptive statistics across studies. We described the original and adapted EBI, the study population, reasons for adaptations, the name of adaptation frameworks, and examples of adaptations qualitatively.

Results

We found 543 unique citations that yielded 45 articles reporting 42 distinct program adaptations after the two levels of screening (Fig. 1). Main reasons for exclusion were a lack of description of the adaptation process or methods, not being a public health program or policy, and not being a primary study (e.g., protocol, review).
Fig. 1
Fig. 1

Flow diagram of reviewed articles

Adaptation characteristics

Publication years of the primary citations are from 2003 to 2014, and common disease topics included HIV/AIDS, mental health, substance abuse, and chronic illnesses (Table 2). Many of these studies had non-experimental designs (k = 27, 64.3%), and the remainder had experimental (k = 12, 28.6%) or quasi-experimental (k = 3, 7.1%) designs. Thirty-six adaptations included an evaluation. Most (k = 26, 61.9%) reported on adaptations that took place in the USA, and one EBI was adapted in three locations (USA, Africa, and Asia). Other EBIs were adapted in Africa (k = 4), Asia (k = 5), Europe (k = 3), Canada (k = 1), the Caribbean (k = 1), and Australia (k = 1).
Table 2

Characteristics of included reports, reasons for adaptation, and frameworks

First author, year

Original EBI name (adapted EBI name) study design

EBI disease/topic

Reason for adaptation

Target population/setting

Adaptation framework (if mentioned)

Original (author)

Adapted

Reijneveld, 2003 [53]

Healthy & Vital (no change)

Experimental—RCT

Physical inactivity/poor physical and mental well-being

Cultural appropriateness

New population

People aged ≥ 65 in welfare services in the Netherlands

Turkish immigrants aged ≥ 45 in welfare services in the Netherlands

N/R

Komro, 2004 [54]

Project Northland (Project Northland Chicago)

Experimental—RCT

Alcohol use

Cultural appropriateness

New population

New community

Mostly white, 6th–8th grade students in rural NE Minnesota, USA

Culturally diverse 6th–8th grade students in Chicago, IL, USA

N/R

Sarkisian, 2005 [55]

Empowerment: Facilitating a Path to Personal Self-Care (N/R)

Non-experimental

Diabetes

Cultural appropriateness

New population

Younger, mostly Caucasian patients with diabetes in the USA

African Americans and Latinos aged ≥ 55 with diabetes in public health diabetes and geriatrics clinics and senior centers in South Los Angeles, CA, USA

N/R

Tsey, 2005 [56]

Family Wellbeing (no change)

Non-experimental

Teasing, bullying, fighting, low self-esteem, truancy

New population

New community

Adults in Aboriginal Australia (Tsey [57])

Students in 2 primary schools in remote indigenous communities in Cape York Peninsula, far north Queensland, Australia

N/R

Villarruel, 2005 [58]

Be Proud! Be Responsible! (¡Cuídate!)

Experimental—RCT

HIV

Cultural appropriateness

New population

African American adolescents aged 13–18 from community-based agencies in Philadelphia, USA

Inner-city Latino adolescents aged 10–19 in Philadelphia, PA, USA

N/R

Belanksy, 2006 [59]

Integrated

Nutrition Education Program, INP

(Integrated Nutrition and Physical Activity Program, INPAP)

Non-experimental

Nutrition and physical activity

Cultural appropriateness

New community

Elementary school children in a school setting in Denver, USA

2nd and 3rd grade students in a rural, biethnic, low-income county in south-central Colorado, USA

N/R

Hitt, 2006 [60]

Project RESPECT

(N/R)

Non-experimental

HIV/STD

New population

New community

Heterosexual individuals aged ≥ 14 attending 5 public STD clinics in the USA (Kamb [61])

MSM, IDU, and heterosexual individuals attending either a local health department or a CBO for prevention counseling services in Texas, USA

N/R

Somerville, 2006 [62]

Popular Opinion Leader, POL (Young Latino Promotores, YLP)

Non-experimental

HIV

Cultural appropriateness

New population

White gay men in gay venues frequented predominantly by whites in midsized southern cities in the USA

Latino migrant MSM aged 18–30 in Texas and California USA-Mexico border communities

N/R

NIMH Collaborative HIV/STD Prevention Trial Group, 2007 [38]

Community Popular Opinion Leader (C-POL) (no change)

Experimental—RCT

HIV/STD

Cultural appropriateness

New community

Populations vulnerable to HIV risk behavior in the USA

Individuals aged 18–49 at food markets with individually owned stalls in Fuzhou, China and individuals aged 18–30 in the following settings; wine shops in slums in Chennai, India; gathering points of young, high-risk people in barrios in Lima, Chiclayo, and Trujillo, Peru; trade school dorms in St. Petersburg, Russia; and retail establishments in rural Zimbabwe

N/R

Tsarouk, 2007 [63]

Reconnecting Youth (RY) (no change)

Non-experimental

Substance abuse and HIV transmission

Cultural appropriateness

High-risk students aged 14–18 in the USA

Russian adolescents aged 14–17 with poor school performance and mild behavioral problems in schools in Moscow, Russia

N/R

Beattie, 2008 [64]

Swim and Survive, and Infant Aquatics (Water Safety in the Bush)

Non-experimental

Water safety/drowning

Cultural appropriateness

New community

Infants, children 5–14 years, and parents in Australia

Children and adults in rural and remote Australian communities

N/R

Cornelius, 2008 [28]

Sisters Informing Sisters on Topics about AIDS, SISTA (Women Informing Women on Topics about AIDS, WIWTA)

Non-experimental

HIV/AIDS

New population

New community

Young African American girls in heterosexual relationships in San Francisco, USA (DiClemente [65])

African American women ≥ 50 in heterosexual relationships who frequent churches located in low-income areas of North Carolina, USA

N/R

Gitlin, 2008 [30]

Chronic Disease Self-Management Program, CDSMP (Harvest Health, HH)

Chronic disease self-management

New population

New community

Middle-class white patients aged ≥ 40 in community-based sites in the USA (Lorig [66])

African Americans aged ≥ 60 with chronic condition(s) in a senior setting in Philadelphia, PA, USA

N/R

Lerdboon, 2008 [67]

Vietnamese Focus on Kids (Exploring the World of Adolescents, EWA)

Non-experimental

HIV/AIDS

Cultural appropriateness

New community

Adolescents in Khanh Hoa Province, Vietnam

Adolescents aged 15–21 in both rural and urban Vietnam

N/R

Steiker, 2008 [29]

Keepin’ It REAL (Refuse, Explain, Avoid, and Leave)

(N/R)

Quasi-experimental

Substance abuse prevention

Cultural appropriateness

New population

New community

Middle school youth in the USA

Adolescents aged 14–19 in high risk, unique community settings in Texas, USA

Castro - cultural adaptation

Burgio, 2009 [68]

Resources for Enhancing Alzheimer’s Caregiver Health, REACH II

(REACH OUT, Offering Useful Treatments)

Non-experimental

Alzheimer’s disease

Implementation ease/feasibility

In-home Alzheimer’s caregivers in USA cities

Alzheimer’s caregivers in Area Agencies on Aging in Alabama, USA

N/R

Fiscian, 2009 [69]

Making Proud Choices

(N/R)

Non-experimental

HIV/AIDS

Cultural appropriateness

New population

New community

Minority adolescents in the USA

Adolescent girls aged 10–14 in a church-affiliated junior secondary school in Ghana

N/R

Mueller, 2009 [31]

¡Cuídate! (no change)

Non-experimental

HIV/AIDS

New community

Latino youth aged 13–18 in Northeast Philadelphia schools, USA

Latino youth in a urban

high school in Denver, CO, USA

N/R

Pekmezi, 2009 [70]

Individually tailored physical activity print intervention (Seamos Activas)

Experimental—RCT

Physical inactivity and related chronic illnesses

Cultural appropriateness

New population

Sedentary adults in the USA

Overweight/obese Latinas aged 18–65 with low income and acculturation in Providence, RI, USA

N/R

Stevens, 2009 [71]

REACH II (Support Teams for Caregivers)

Non-experimental

Alzheimer’s disease or dementia

Implementation ease/feasibility

Family caregivers of patients with Alzheimer’s disease or dementia in 5 USA cities

Family caregivers of patients with Alzheimer’s disease or dementia in Texas, USA

RE-AIM and REP

DePue, 2010 [72]

Project Sugar 2, PS2 (Diabetes Care in American Samoa)

Experimental—RCT

Type 2 diabetes

Cultural appropriateness

New population

Urban African Americans aged ≥ 25 with diabetes in Baltimore, USA

Individuals aged ≥ 21 with type 2 diabetes in American Samoa

Lau’s framework for cultural adaptation

Domenech Rodriguez, 2011 [73]

Parent Management Training—Oregon Model, PMTO (Criando con Amor: Promoviendo Armonía y Superación, CAPAS)

Experimental—RCT

Parenting

Cultural appropriateness

New population

Divorcing mothers with sons in 1st–3rd grades in a medium-sized city in the Pacific NW, USA (Forgatch [74])

Spanish-speaking Latino parents or relatives who co-parent in rural Utah, USA

CAP and EVM

Poulsen, 2010; [39] Vandenhoub, 2010 [75]

Parents Matter! (Families Matter!)

Non-experimental

HIV

Cultural appropriateness

New community

African American parents of preteens aged 9–12 in a controlled clinical setting in the USA

Families with children aged 9–12 in Asembo, rural west Kenya

MAP

Sadler, 2010 [76]

“Cancer Clinical Trials: The Basics” and “Conversemos un rato: Información para combatir el cáncer en su comunidad” (N/R)

Non-experimental

Breast cancer

Cultural appropriateness

New population

Individuals with cancer in the USA

African American/Hispanic American women, or women from diverse communities with breast cancer in California, USA

N/R

Rotheram-Borus, 2011 [77]

Project TALC (LA Project TALC in Los Angeles, Family to Family in Thailand, Mentor Mothers in South Africa)

Non-experimental

HIV

Cultural appropriateness

New community

Parents living with HIV and their children or caregiver supports in New York City, USA

Parents living with HIV and their children or caregiver supports in the USA (Los Angeles, CA), Thailand, and South Africa

CQI

Cardona, 2009 [78]

Parent Management Training—Oregon Model, PMTO

(N/R)

Non-experimental

Parenting/mental health

Cultural appropriateness

New population

New community

Divorcing mothers with sons in 1st–3rd grades in a medium-sized city in the Pacific Northwest, USA (Forgatch [74])

Latino immigrant parents with children aged 6–12 with mild behavioral problems in Detroit, MI, USA

EVM

Feinberg, 2012 [79]

Problem-Solving Treatment (Problem-Solving Education)

Experimental—RCT

Depression

New population

Adults with depression in general practices in Oxford, United Kingdom (Gath [80])

Mothers with limited incomes and high rates of depression in 3 settings where they receive services in Massachusetts, USA

Backer’s 6-step approach

Castro’s cultural adaptation

Parker, 2012; [81]

Chen, 2013 [82]

Arthritis Self-Help Program, ASHP

(no change)

Non-experimental

Arthritis

Cultural appropriateness

New population

Condense program

Younger, mostly non-Hispanic white adults in the USA

African American, Hispanic, and non-Hispanic white older adults attending senior centers in New York City, NY, USA

M-PACE

Reid, 2012 [83]

Cognitive Behavioral Stress Management (CBSM) (no change)

Non-experimental

Substance abuse, sexual behavior, and HIV

Cultural appropriateness

New community

Drug abusers

HIV-positive substance abusers in recovery in Trinidad and Tobago

N/R

Rosati, 2012 [84]

Family Matters (Thai Family Matters)

Experimental—RCT

Alcohol, tobacco, and other drug use

Cultural appropriateness

New community

Parents and children in the USA

Adolescents aged 13–14 and their parents in Bangkok, Thailand

N/R

Tomioka, 2012 [85]

Chronic Disease Self-Management Program, CDSMP

(Ke Ola Pono)

Non-experimental

Chronic disease self-management

Cultural appropriateness

New population

Adults aged ≥ 40 with chronic diseases in community-based sites in California, USA (Lorig [66])

Asians and Pacific Islanders with chronic diseases in Hawaii, USA

CDC’s adaptation traffic light

Danielson, 2013 [33]

Sistas Informing, Healing, Living, and Empowering, SiHLE

(SiHLEWeb)

Non-experimental

HIV/STD

Cultural appropriateness

Implementation ease/feasibility

African American adolescents in community health agencies in the USA (DiClemente [65])

Community-dwelling traditionally underserved African American girls aged 13–18 in the Southeast USA

N/R

Fasula, 2013 [86]

Project Safe (Project POWER)

Non-experimental

HIV/STD

New population

New community

African American and Mexican American

women in STD clinics in in San Antonio, USA (Shain [87])

HIV-negative women with sentences up to 14 months due to be released within 6 months in North Carolina women’s prison facilities, USA

MAP

Parker, 2013a; [88]

Parker; 2013b [89]

Healthy Living Project (Supporting Youth and Motivating Positive Action, SYMPA)

Non-experimental

HIV/AIDS

New population

New community

Adults living with HIV in the USA

Youth aged 15–24 living with HIV/AIDS in Kinshasa, Democratic Republic of the Congo

ADAPT

Wainer, 2013 [90]

Reciprocal imitation training (RIT)

(no change)

Non-experimental

ASD

Implement in new community setting

Make program more widely accessible

Individuals working with children with ASD, including parents, in the USA

Individuals working with children with ASD, including parents, in the participants’ homes and research lab in the Midwestern USA

N/R

Williams, 2013 [91]

Adherence Through Home Education and Nursing Assessment, ATHENA

(N/R)

Experimental—RCT

HIV/AIDS

Cultural appropriateness

New population

New community

European, African and Hispanic individuals with a high prevalence of substance abuse and mental illness for whom ARV therapy was prescribed in the northeastern USA

Patients living with HIV/AIDS receiving ARV therapy from the Hunan China CARES clinical program in rural south central China

Castro’s cultural adaptation

Baydala, 2014 [92]

Life Skills Training, LST (Nimi Icinohabi)

Quasi-experimental design

Substance abuse

Cultural appropriateness

New population

Elementary, middle, and high school students, including ethnic minority youth in the USA

Aboriginal school-age children in Central Alberta, Canada

N/R

Broning, 2014 [93]

Strengthening Families Program for Parents and Youth 10–14, SFP 10–14 (Familien Stärken)

Experimental—RCT

Substance abuse

Cultural appropriateness

New community

Adolescents aged 10–14 and their caregivers in rural economically deprived regions in Iowa, USA

Adolescents aged 10–14 and their caregivers in socially deprived urban districts in Hamburg, Schwerin, Hanover and Munich, Germany

N/R

Cariou, 2014 [94]

Pool Cool

(no change)

Non-experimental

Skin cancer

New population

Implementation ease/feasibility

Aquatics instructors, kids aged 5–10, parents and other pool users in Hawaii and Massachusetts, USA (Glanz [95])

Children and adolescents aged 2–17 enrolled in swim lessons at the Payette Municipal Pool, rural Idaho, USA

N/R

Reback, 2014 [96]

Gay-specific cognitive behavioral therapy, GCBT (Getting Off: A Behavioral Treatment Intervention for Gay and Bisexual Male Methamphetamine Users)

Experimental - RCT

Methamphetamine use/HIV

New community

Methamphetamine-using gay and bisexual men in a controlled clinical setting in the USA

Methamphetamine-using MSM in a community-based HIV prevention setting in Los Angeles, CA, USA

N/R

Riggs, 2014 [32]

Family Overweight: Comparing Use of Strategies, FOCUS (Family Wellness Program, FWP)

Non-experimental

Pediatric obesity

Implementation ease/feasibility

New community

Obese children and their parents in the USA (Saelens [97])

Obese children aged 6–12 and their parents in primary care clinics near Seattle, WA, USA

N/R

Tu, 2014 [98]

Clinic-based educational program to promote CRC screening among Chinese immigrants (N/R)

Quasi-experimental

Colorectal cancer screening

New population

Implementation ease/feasibility

Chinese immigrant in a community health center in the metropolitan area of Seattle, USA (Tu [99])

Vietnamese patients of community health centers in the metropolitan area of Seattle, WA, USA

Diffusion of innovations theory

N/R not reported, ASD autism spectrum disorder, ARV antiretroviral, CAP cultural adaptation process, CBO community-based organization, CQI continuous quality improvement, EVM ecological validity model, IDU injection drug user, M-PACE Method for Planned Adaptation through Community Engagement, MAP Map of Adaptation Process, MSM men who have sex with men, RE-AIM Reach, Effectiveness, Adoption, Implementation and Maintenance, REP Replicating Effective Programs, STD sexually transmitted disease

Reasons for adaptation

The most common reasons for adaptation included the need for a culturally appropriate program (k = 27; 64.3%), a new target population (k = 25; 59.5%), and a new community setting (k = 24; 57.1%) (Table 2). Less common reasons for adaptation were the desire to improve ease and feasibility of implementation (k = 6; 14.3%), attempting to make the program more widely accessible (k = 1; 2.4%), and trying to condense the original intervention (k = 1; 2.4%).

Types of modifications

Authors reported making an average of 3.4 (SD = 0.90, range 2–5) different types of adaptations with a mode of 3 (Table 3). All 42 (100%) reported some modification of the EBI content. The form this took usually included tailoring (k = 39; 92.9%) or adding elements (k = 30; 71.4%). For example, Cornelius and associates modified HIV prevention videos originally tested with young pregnant women to be relevant to older African American women [28]. In the adaptation reported by Steiker, the study team added four new videos to accompany the curriculum and rewrote scenarios used in the workbooks to incorporate local culture [29]. In the EBI adapted by Gitlin and associates, a moment of silence was added at the beginning of each session to recognize spiritual practices and their importance to participants [content modification-adding elements [30]]. More than half of the authors reported shortening the original EBI as one of the adaptations made. For the 42 programs, some teams described adapting the intervention content by shortening it (k = 13; 31.0%), removing elements (k = 12; 28.6%), loosening the structure (k = 10; 23.8%), lengthening the program (k = 9; 21.4%), substituting modules or activities (k = 7; 16.7%), or integrating other approaches to the intervention (k = 5; 11.9%).
Table 3

Summary of adaptation characteristics reported in peer-reviewed literature (EBIs), k = 42

Adaptation characteristics

Studies reporting characteristic

k (%)

Type of modification

 Content

42 (100%)

  Tailoring

39 (92.9%)

  Adding elements

30 (71.4%)

  Shortening

13 (31.0%)

  Removing elements

12 (28.6%)

  Loosening structure

10 (23.8%)

  Lengthening

9 (21.4%)

  Substitution

7 (16.7%)

  Integrating other approach

5 (11.9%)

  Reorder elements

4 (9.5%)

  Integrating intervention

2 (4.8%)

  Departing

2 (4.8%)

  Repeating elements

1 (2.4%)

 Cultural modification

31 (73.8%)

  Context

40 (95.2%)

   Population

33 (78.6%)

   Setting

29 (69.0%)

   Other

3 (7.1%)

  Delivery

26 (61.9%)

   Deliverer

16 (38.1%)

   Mode/medium

14 (33.3%)

   Other

4 (9.5%)

  Training

16 (38.1%)

  Evaluation

19 (45.2%)

  Change to core elements

4 (9.5%)

Reasons for adaptation

  Cultural appropriateness

27 (64.3%)

  Focus on new target population

25 (59.5%)

  Implement in new community setting

24 (57.1%)

  Improve ease and feasibility of implementation

6 (14.3%)

  Make program more widely accessible

1 (2.4%)

  Condense program

1 (2.4%)

Outcomes

 Implementation

  Acceptability

28 (66.7%)

  Fidelity

22 (52.4%)

  Feasibility

22 (52.4%)

  Adoption

20 (47.6%)

  Sustainability

11 (26.2%)

  Other

5 (11.9%)

 Behavioral/program

  Behavior

30 (71.4%)

  Practice

9 (21.4%)

  Knowledge

7 (16.7%)

  Self-efficacy

5 (11.9%)

  Environment

4 (9.5%)

  Well-being/health

3 (7.1%)

  Attitudes

3 (7.1%)

  Skills

3 (7.1%)

  Communication

2 (4.8%)

  Policy

0

  Other

4 (9.5%)

 Individual satisfaction

11 (26.2%)

Nearly all of the adaptations (k = 40; 95.2%) described modifying context, and 31 (73.8%) included cultural modifications. Most context modifications included making changes to the original EBI by adapting it to fit with the new intervention population (k = 33; 78.6%) and setting (k = 29; 69.0%). Mueller and colleagues, for example, adapted a curriculum originally delivered in community agencies and after-school programs to a school setting [31]. Over half of the adaptations included changes to the delivery of the original intervention (k = 26; 61.9%), either by modifying the role of the personnel delivering the intervention (k = 16; 38.1%) or by adapting the format or channel of delivery (k = 4; 33.3%). Masters-level research interventionists, for instance, delivered the family-based behavioral pediatric obesity treatment rather than medical staff in the intervention reported by Riggs and colleagues [32]. In the EBI adapted by Danielson and team, a web-based delivery platform was used instead of small group sessions [33]. Fewer authors reported modifying procedures for training personnel (k = 16; 38.1%) or for evaluating the program (k = 19; 45.2%). Four (9.5%) studies described changing what they regarded as core elements of the original EBI.

Patterns of adaptation types

The most common combinations were content, context, and delivery (k = 9), and content and context (k = 8) (Fig. 2). Content and context were part of all other combinations; four other combinations only had one study each.
Fig. 2
Fig. 2

Common patterns of types of adaptations across studies

For content adaptations, the classifications reported varied greatly. However, some patterns emerged with certain content combinations, including tailoring, adding elements, and cultural modifications (k = 5); tailoring, adding elements, loosening structure, and cultural modifications (k = 4); tailoring, adding elements, lengthening, and cultural modifications (k = 3); and tailoring and cultural modifications.

Steps in adaptation

Each of the nine steps derived from the scoping review of evaluation frameworks [23] is represented in most of the adaptations (combining consulting with experts and stakeholders), with fewer reporting selecting the EBI (k = 23; 54.8%) and pilot testing (k = 24; 57.1%) (Table 3); 37 (88.1%) conducting a community assessment; 37 (88.1%) preparing new materials; 35 (83.3%) implementing the adapted intervention; 32 (76.2%) evaluating the adapted intervention; 31 (73.8%) determining needed changes based on action step assessments; 31 (73.8%) training staff members; and 30 (71.4%) consulting stakeholders or experts before adapting the materials (Fig. 3). Overall, the average number of steps was 6.7 (range 3–9, mode = 7). Of the 37 authors who reported conducting community assessments, 21 (56.8%) held focus groups with community members, 12 (32.4%) conducted interviews with key informants and stakeholders, five (13.5%) formed and consulted with community advisory boards or steering committees, and two (5.4%) administered a survey to get community feedback. Ten of these (27.0%) used a combination of methods to collect community input and assess need.
Fig. 3
Fig. 3

Steps taken in the adaptation process across studies

Use of adaptation frameworks

The authors of less than half of the reports named a pre-existing adaptation framework as guiding the adaptation process (k = 15; 35.7%) (Table 2). Most frameworks were mentioned once; the Ecological Validity Model, Map of the Adaptation Process, and Cultural Adaptation Framework were referenced twice.

Intervention outcomes

Of the 36 reports that included an evaluation, most authors reported measuring program acceptability (k = 28; 66.7%), fidelity (k = 22; 52.4%), and feasibility (k = 22; 52.4%) (Table 3). With respect to implementation outcomes, most authors reported evaluating program acceptability (k = 28; 66.7%), fidelity (k = 22; 52.4%), and feasibility (k = 22; 52.4%). Several studies also reported assessing the adoption/implementation (k = 20; 47.6%) and sustainability of the program (k = 11; 26.2%). Numerous authors also reported measuring behavioral and program outcomes. The majority reported measuring behavioral outcomes (k = 30; 71.4%), while a smaller number measured changes in practice (k = 9; 21.4%), knowledge (k = 7; 16.7%), self-efficacy (k = 5; 11.9%), or environment (k = 4; 9.5%). Only a few studies included assessments of changes in well-being (k = 3; 7.1%), attitudes (k = 3; 7.1%), skills (k = 3; 7.1%), or communication (n = 2; 4.8%). Lastly, 11 (26.2%) of the evaluations included satisfaction with the adapted intervention as an outcome (Table 4).
Table 4

Characteristics of the adaptations (k = 42)

First author, year

Adaptation type1

Specific modifications

Adaptation steps2

Evaluation outcomes (k = 36)

Modification/adaptation example

1

2

3

4

5

Content

Context

Delivery

1

2

3

4

5

6

7

8

9

10

Reijneveld, 2003 [53]

x

x

x

x

x

Tailoring

Adding elements

Lengthening

Substitution

Cultural modification

Population

Deliverer

Other

x

x

 

x

x

x

x

x

x

 

Acceptability

Fidelity

Examples regarding safety excluded cycling because few Turkish immigrants cycle

Komro, 2004 [54]

x

x

x

  

Tailoring

Adding elements

Cultural modification

Setting

Population

Mode/medium

Deliverer

x

x

x

x

x

x

x

x

  

Acceptability

Fidelity

Audiotape vignettes re-taped with African American and Hispanic actors

Sarkisian, 2005 [55]

x

 

x

  

Tailoring

Adding elements

Lengthening

Cultural modification

Setting

Population

x

 

x

 

x

     

Acceptability

Expanded focus to more explicitly include family members

Tsey, 2005 [56]

x

x

x

  

Tailoring

Shortening

Loosening structure

Setting

Population

Mode/medium

Deliverer

x

      

x

x

 

Acceptability

Adoption

Sustainability

Individual satisfaction

Students interviewed their role models, explaining why they looked up to that person

Villarruel, 2005 [58]

x

x

 

x

x

Tailoring

Adding elements

Cultural modification

Population

x

x

x

x

x

x

x

x

x

 

Acceptability

Individual satisfaction

Presented the view of machismo that incorporated the values of caring for and protecting others, so condom use could be presented as consistent with machismo

Belanksy, 2006 [59]

x

x

 

x

x

Tailoring

Adding elements

Shortening

Cultural modification

Setting

Population

x

 

x

x

x

x

x

x

x

 

Lessons simplified so that they could be completed during the 1-h classroom period

Hitt, 2006 [60]

x

x

 

x

 

Tailoring

Loosening structure

Setting

Population

x

x

x

x

x

x

 

x

x

 

Acceptability

Adoption

Fidelity

Feasibility

Sustainability

Individual satisfaction

Intervention protocols and supporting materials (tools) were tailored for local circumstances

Somerville, 2006 [62]

x

x

 

x

x

Tailoring

Adding elements

Substitution

Integrating other approach

Cultural modification

Setting

Population

x

x

x

x

x

x

x

x

x

 

Acceptability

Fidelity

Other

Individual satisfaction

A variety of successful Latino-focused HIV prevention training programs were integrated into the adapted intervention

NIMH Collaborative HIV/STD Prevention Trial Group, 2007 [38]

x

x

 

x

x

Tailoring

Cultural modification

Other

x

x

x

x

x

x

x

x

x

x

Adoption

Fidelity

Feasibility

Sustainability

Specific messages used in training were based on findings that emerged from the ethnography with each site’s populations

Tsarouk, 2007 [63]

x

x

   

Tailoring

Removing elements

Shortening

Substitution

Cultural modification

Other

x

 

x

 

x

x

x

 

x

 

Acceptability

Feasibility

Individual satisfaction

Some of the support behaviors, such as applauding in response to a group member’s participation, were removed because teens said that it is not a natural expression of support in this informal situation

Beattie, 2008 [64]

x

x

  

x

Tailoring

Removing elements

Shortening

Integrating other approach

Cultural modification

Setting

Population

x

 

x

x

x

  

x

x

 

Acceptability

Adoption

Sustainability

Some sites used a swim camp model, with several days of training provided often on two or three occasions and typically at a central point for families

traveling long distances

Cornelius, 2008 [28]

x

x

   

Tailoring

Adding elements

Removing elements

Lengthening

Substitution

Setting

Population

x

x

   

x

    

Used videos that included information about HIV in older women

Gitlin, 2008 [30]

x

x

x

  

Tailoring

Adding elements

Cultural modification

Setting

Population

x

 

x

x

 

x

 

x

x

 

Acceptability

Adoption

Fidelity

Feasibility

Sustainability

Other

Individual satisfaction

Introduction of moment of silence at the beginning of each session to recognize spiritual practices and their importance to participants

Lerdboon, 2008 [67]

x

x

   

Tailoring

Adding elements

Integrating other approach

Cultural modification

Setting

x

x

x

x

x

x

x

x

x

 

Acceptability

Adoption

Feasibility

Gender-specific

components were integrated throughout the curriculum through a story line about an

adolescent boy and girl growing up in a fictional Vietnamese family, as well as gender-specific scenarios, activities and messages

Steiker, 2008 [29]

x

x

   

Tailoring

Adding elements

Cultural modification

Setting

Population

x

 

x

 

x

x

x

x

x

 

Acceptability

Adoption

Fidelity

Created four new videos, one for each prevention strategy: refuse, explain, avoid and leave

Burgio, 2009 [68]

x

x

x

x

x

Tailoring

Removing elements

Shortening

Setting

Population

Mode/medium

Deliverer

x

 

x

x

x

x

 

x

x

 

Acceptability

Adoption

Fidelity

Feasibility

Individual satisfaction

Reduced number of home visits and shortened time span of the intervention

Fiscian, 2009 [69]

x

x

x

 

x

Tailoring

Adding elements

Removing elements

Lengthening

Reorder elements

Integrating other approach

Cultural modification

Setting

Population

Mode/medium

x

 

x

x

x

x

 

x

x

 

Acceptability

Fidelity

Individual satisfaction

Modified role-play stories to use African names and settings and simplified scripts to a sixth-grade reading level

Mueller, 2009 [31]

x

x

   

Adding elements

Lengthening

Substitution

Loosening structure

Setting

x

 

x

x

x

x

 

x

  

Acceptability

Feasibility

Sustainability

Individual satisfaction

Adapted from community agency or after-school programs to be integrated into existing school curriculum

Pekmezi, 2009 [70]

x

x

  

x

Tailoring

Cultural modification

Population

x

 

x

  

x

x

x

x

 

Acceptability

Feasibility

Individual satisfaction

Intervention materials and research measures were translated into Spanish through an iterative process involving both translation and back-translation

Stevens, 2009 [71]

x

x

x

 

x

Tailoring

Adding elements

Deliverer

 

x

x

x

x

x

 

x

x

 

Fidelity

Support teams for caregivers were created

DePue, 2010 [72]

x

x

x

x

x

Tailoring

Adding elements

Loosening structure

Cultural modification

Setting

Population

Mode/medium

Deliverer

x

x

x

x

x

x

x

x

x

 

Adoption

Feasibility

Incorporated local cultural features in flipcharts, including quotes from focus groups, culturally relevant examples of healthy behaviors, local sources of stress, and effective local coping strategies

Domenech Rodriguez, 2011 [73]

x

x

x

  

Tailoring

Adding elements

Loosening structure

Cultural modification

Setting

Population

Deliverer

x

x

x

x

x

x

x

x

x

 

Acceptability

Fidelity

Feasibility

Individual satisfaction

Sayings, or dichos, were incorporated generously into treatment manual as parents used them during the parent training sessions

Poulsen, 2010 [39]

Vandenhoubt, 2010 [75]

x

x

x

  

Tailoring

Adding elements

Substitution

Cultural modification

Setting

Population

Other

Mode/medium

Deliverer

x

x

x

x

x

x

x

x

x

x

Acceptability

Adoption

Fidelity

Sustainability

Individual satisfaction

Owing to low literacy rates among local adults, drawings were used to illustrate messages that were originally conveyed through text on posters and handouts

Sadler, 2010 [76]

x

    

Tailoring

Adding elements

Shortening

Reorder elements

Cultural modification

Population

Deliverer

x

    

x

x

   

PowerPoint voice over changed to be in the first person instead of third to inspire comradery and motivation for women battling cancer together through clinical trials

Rotheram-Borus, 2011 [77]

x

x

x

  

Tailoring

Adding elements

Removing elements

Shortening

Substitution

Integrating intervention

Repeating elements

Cultural modification

Setting

Population

Mode/medium

Deliverer

x

    

x

x

x

x

 

Other

The intervention content and framing was adapted to resonate with Buddhist values and idioms around “sound body and sound mind”, as well as Thai values around the importance of family and community in health and well-being

Cardona, 2009 [78]

x

x

x

  

Tailoring

Adding elements

Loosening structure

Cultural modification

Setting

Population

Other

x

x

x

x

x

x

 

x

x

 

Acceptability

Adoption

Fidelity

Feasibility

Individual satisfaction

Substituted a booster session with a session on “Parenting between two cultures” to add relevance to Latino immigrant families

Feinberg, 2012 [79]

x

x

x

x

 

Tailoring

Removing elements

Integrating intervention

Cultural modification

Setting

Population

Mode/medium

Deliverer

Other

x

x

x

x

x

x

x

x

  

Acceptability

Fidelity

Feasibility

Individual satisfaction

Reframed the focus of the intervention from prevention of depression to learning new skills to deal with everyday stress, with an emphasis on parenting

Parker, 2012 [81]

Chen, 2013 [82]

x

x

x

  

Tailoring

Adding elements

Removing elements

Lengthening

Reorder elements

Cultural modification

Population

Mode/medium

x

x

x

 

x

x

    

Acceptability

Adoption

Fidelity

Feasibility

Created “action plan for sustainability” to link participants with exercise/disease self-management programs in neighborhood

Reid, 2012 [83]

x

x

   

Tailoring

Adding elements

Departing

Cultural modification

Setting

Population

Other

x

 

x

x

x

x

x

x

  

Acceptability

Adoption

Fidelity

Feasibility

Individual satisfaction

Sociocultural norms, values, beliefs, and myths were applied to role-play scenarios and exercises

Rosati, 2012 [84]

x

x

   

Tailoring

Adding elements

Loosening structure Cultural modification

Setting

Mode/medium

x

x

 

x

 

x

 

x

x

 

Acceptability

Adoption

Fidelity

Feasibility Individual satisfaction

Added a unit targeting adolescent dating and sexual behavior after conducting focus groups with Thai parents

Tomioka, 2012 [85]

x

x

 

x

x

Tailoring

Adding elements

Lengthening

Cultural modification

Population

x

x

x

x

 

x

 

x

x

 

Acceptability

Adoption

Fidelity

Feasibility

Sustainability

Individual satisfaction

Added opening session with a prayer, a 6-month reunion, and provided certificate of completion

Danielson, 2013 [33]

x

x

x

 

x

Tailoring

Shortening

Loosening structure

Departing

Setting

Population

Mode/medium

    

x

x

 

x

x

 

Adoption

Fidelity

Feasibility

Other

Individual satisfaction

Used a web-based delivery platform instead of small group sessions with 10–12 girls

Fasula, 2013 [86]

x

x

x

x

 

Tailoring

Adding elements

Shortening

Lengthening

Loosening structure

Cultural modification

Setting

Population

Deliverer

x

x

x

x

x

x

x

   

Several intervention elements were added to increase participants’ risk awareness, knowledge, and skills related to substance use, including a group discussion about the pros and cons of substance use, how drugs/alcohol contribute to sexual risk, and strategies for avoiding risk

Parker, 2013a [88]

Parker, 2013b [89]

x

x

x

  

Tailoring

Adding elements

Removing elements

Shortening

Integrating other approach

Cultural modification

Setting

Population

Mode/medium

x

x

x

x

 

x

x

x

x

 

Acceptability

Feasibility

Changed delivery from individual to group so there was peer reinforcement content

Wainer, 2013 [90]

x

x

x

x

x

Shortening

Loosening structure

Setting

Mode/medium

   

x

 

x

x

 

x

 

Acceptability

Fidelity

Feasibility

Therapists completed the online training program on computers in their homes or in the research lab

Williams, 2013 [91]

x

x

x

x

 

Tailoring

Adding elements

Cultural modification

Setting

Population

Deliverer

x

x

x

x

x

 

x

x

  

Adoption

The culturally adapted intervention took a more deliberate and structured approach to including the family in discussion and planning

Baydala,2014 [92]

x

x

  

x

Tailoring

Adding elements

Lengthening

Cultural modification

Population

x

x

x

x

x

x

x

x

x

 

Acceptability

Adoption

Fidelity

Feasibility

Sustainability

Elders suggested inclusion of lessons that embraced Aboriginal spirituality, such as an activity on healing the worried mind where students were encouraged to take their worried mind to Waka

(God/Creator) and engage in wacigebi (prayer)

Broning, 2014 [93]

x

x

   

Tailoring

Cultural modification

Population

   

x

  

x

x

x

 

Intervention was translated and adapted to German culture, taking into account family-based interventions are especially culture-sensitive regarding role-model behavior, values and norms

Cariou, 2014 [94]

x

x

 

x

x

Tailoring

Adding elements

Removing elements

Setting

Population

x

x

x

x

x

x

 

x

x

x

Adoption

Sustainability

Other

Eliminated optional poolside activities and retained the few that were feasible based on available resources

Reback, 2014 [96]

x

x

x

x

x

Tailoring

Adding elements

Removing elements

Shortening

Reorder elements

Cultural modification

Setting

Deliverer

x

 

x

x

x

x

 

x

x

 

Adoption

Feasibility

Sustainability

Gay-specific cultural references were updated to maintain cultural relevancy (i.e., exchanging references to telephone dating lines with references to social networking web sites)

Riggs, 2014 [32]

x

 

x

 

x

Adding elements

Shortening

Mode/medium

Deliverer

x

x

  

x

x

x

x

x

 

Acceptability

Fidelity

Feasibility

Masters-level research interventionists delivered treatment rather than medical staff

Tu, 2014 [98]

x

x

x

x

x

Tailoring

Removing elements

Population

Deliverer

   

x

 

x

 

x

x

 

In-person education from health educator was deleted

1Adaptation type: (1) content, (2) context, (3) delivery, (4) training, and (5) evaluation

2Adaptation steps: (1) community assessment, (2) selection, (3) determine level of change, (4) train staff, (5) consult stakeholders/experts, (6) prepare materials, (7) pilot, (8) implement, (9) evaluate, and (10) other

Presentation of adapted elements

The authors used a variety of formats to present their adaptation processes. All 42 adaptations were described in the article’s narrative, while others also used tables and figures to present certain elements. Seventeen (40.5%) included a table of the adaptations or modifications made. Three adaptations (7.1%) illustrated the adaptation process with a figure, and two (4.8%) included a side-by-side comparison of the adapted and original EBIs.

Discussion

This study presents findings based on a systematic review of published reports of adaptations of 42 EBIs. We present a systematic characterization of reasons for adapting EBIs, types of modifications made, steps taken during adaptation, reference to existing adaptation frameworks, and the constructs measured in evaluations of the adapted EBIs. In our review, the most common reasons for adaptation were to be relevant to a particular culture or new population, and to implement a program in a new setting. A previous study by Moore also found cultural adaptation to be a common reason for adaptations among evidence-based grantees, although less frequently (43% compared to our 64%) [15]. Higher frequency reasons in Moore’s study were related to resource constraints or logistics: lack of time (80%), limited resources (72%), difficulty retaining participants (71%), and resistance from implementers (64%) [15].

Among our included reports, all adaptation teams, or individuals involved in the research or adaptation, conducted content modifications, most commonly tailoring, adding or removing elements, and shortening. In their review of 32 published descriptions of interventions implemented in routine care or community settings, Stirman and colleagues also found the same four content modifications most frequently reported [1]. Consistent with the Stirman review, we found that context modifications were the next most frequently mentioned type of adaptation for either the program population or setting. Stirman, however, also found that format changes were frequently described [1]. In our review, delivery modifications were described in the majority of the studies, with training and evaluation modifications much less common. It is unclear whether these did not occur or were less often reported. Moore’s review found slightly different frequencies of modifications, with more reports of changes related to logistics such as changes in delivery and dose, and much less frequent content changes [15].

Like Krivitsky, we also found that 29% reported removing elements [34]. This type of adaptation should be explored more because of its implications for reducing the fidelity to program core elements and potentially reducing the EBI’s effects [35]. Additionally, four studies explicitly described changing the core elements of the original EBI. This is an area of concern because the integrity of the original program could have been jeopardized. More research is needed to understand why the elements were deleted and if the program implementers (i.e., researchers, community planners) consulted others before undertaking this change. The low reporting of changes to core elements may be because it is difficult to identify what the core elements are in an EBI. They may include elements that are readily adapted such as delivery or content. However, unless the original developers of the program or health-related online clearinghouses or resources where they are housed clearly describe them, it is often difficult for planners to identify them. Therefore, considerations of fidelity are critical when making decisions about what to adapt [36]. In a systematic review by Gearing and colleagues of 24 meta-analyses and review articles focusing on fidelity over the past 30 years, the authors identified core components of fidelity including design, training, and monitoring of intervention receipt and suggested that greater attention is needed to document threats to fidelity that remain underreported [37]. While this is true for any implementation effort, it is even more important to consider when making and reporting adaptations. Of particular note in our findings, while many authors reported changes to the delivery of the EBI, including who delivered it, there were fewer who reported adapting training or monitoring of that delivery.

Although cultural modification is not part of Stirman’s taxonomy of adaptation modifications, we found that almost 75% of the authors described their adaptation in this way. Because cultural adaptations would almost always require some adaptation related to population and context, it is likely that authors in the Stirman review reporting adaptations to content, context, and new populations were, at least in some cases, making cultural adaptations. More clarity in definitions of what is meant by each type of adaptations is needed.

Our review uses a new taxonomy of steps or tasks for adaptation derived from a scoping study of existing frameworks [23]. We looked for nine steps or tasks and found that two adaptations reported all of the steps [38, 39], with the mean number being seven. Thus, most adaptation teams completed the majority of the steps. Overall, we found that most reported community assessment, preparation of materials, implementation, evaluation, and engaging stakeholders/experts as part of a program planning process. The least common step was selection of the EBI. This may be because some program staff may have already decided on the EBI a priori and did not undertake a process to review candidate EBIs and select one.

The Escoffery classification from a review of adaptation frameworks seems applicable to real-world adaptation and could be used by others as a taxonomy for describing adaptation steps [23]. However, there are details that may be nuanced that are important to understand for the field both in describing adaptation steps and for informing future adaptations of the same EBI. For example, some reports include information about which components of the intervention were pilot tested and what decisions were made based on assessment finding, who the stakeholders were, and how they were engaged. Additionally, specific details about who is involved in the adaptation process (stakeholders, target population, program deliverers, health promotion, and behavioral scientists) and who makes the final decisions on what changes to make are critical to document. This information could be very important in interpreting reasons for specific adaptations and informing subsequent ones for future EBI implementation.

Capacity building efforts can assist practitioners to document the process in more detail and be deliberative or proactive with adaptations. The Cancer Prevention and Control Research Network (CPCRN) has modules on program selection of EBIs and adaptation with tools that help practitioners to document the discussion and decisions related to those processes in their Putting Public Health Prevention into Practice training [40]. In addition, the new online decision support tool, IM ADAPT, walks public health professionals through a systematic process to create a logic model for the adapted EBI and a selection adaptation, implementation, and evaluation plan based on intervention mapping [41, 42].

Among those reports that included an evaluation, the most common outcomes were acceptability, fidelity, and feasibility. This is not surprising since acceptability and feasibility of an intervention is often associated with program adoption [27]. Only one third reported the use of an adaptation framework to inform their process. This number is surprisingly low. Adaptation frameworks would provide guidance and rationale for this process and should be used. Many frameworks exist, but perhaps program planners may not be aware of them [34] or may not know how to follow them without training or technical assistance. Due to the limited research on program adaptation, there also may not be the emphasis on adaptation models and frameworks. There needs to be increased dissemination and education on these frameworks to offer assistance with recommended steps in program adaptation.

Implications

Through a search of the published literature, this is the first systematic review of adapted evidence-based public health interventions internationally. Findings from the present study lead to important implications for the field of implementation science. First, many of the reasons for adaptation focus on either a change of population or setting, while the most common modifications were related to content, context, and delivery. Program developers of EBIs could anticipate program adaptation, instead of only adoption, and provide technical guidance in making modifications in their implementation protocols (or facilitator’s manual) or program website. Recognizing that it is likely that successful programs will be adapted, program developers should also provide guidance about the theory and mechanisms of change that were used in the intervention and where possible design flexibility to match various contexts and populations [43]. They also can serve as expert consultants to help in the adaptation process as recommended as part of adaptation steps in adaptation frameworks [11, 16, 44] or our scooping study [23]. In addition, they could support a community of their EBI adopters by making adapted versions available or offering contacts for practitioners implementing the same program. Due to the low reporting of use of adaptation frameworks, the frameworks could be more widely disseminated to inform future adaptation efforts.

Research on best methods to document program adaptation is warranted to better understand whether it is best to describe and code adaptations based on document reviews of adaptation plans, published articles or reports, interviews of the adaptation team, or all of the above. Each of these methods has limitations, but implementing them all may not be practical for research studies. Finally, we found a variety of styles in reporting the reasons, modifications made, and process of adaptation. Standardization of reporting elements on program adaptation would guide professionals in describing their changes to EBIs and advance the field. Through this process of better reporting on adaptations, practitioners and program planners can better understand the reasons for adaptation, the adaptation process, and results to inform their own practice. Currently, TREND and Standards for Reporting Implementation Studies (StaRI) statement only ask researchers to report on adaptation in general or adaptation results [45, 46]. Other critical elements of adaptations that we have identified (i.e., reasons, types of adaptations, steps taken) are not mentioned or delineated. There is a growing body of literature of adaptation taxonomies that could be recommended for some of these elements, including types of modifications [1, 47], reasons, timing and valence [15, 47], frameworks employed, and steps taken [23]. Creation of detailed reporting standards for program adaptation will result in commonalties for describing adaptations in the published and gray literature and will advance the field of implementation science in terms of producing adaptation data for further analysis.

Future research could explore planned versus unplanned adaptations and patterns of program modifications and the reasons for that happening. We present some early findings of patterns of modifications made to public health EBIs, but there is scarce understanding of them. In addition, further evaluations of adapted interventions are required to determine if adapted versions are as effective as the original program or other adapted versions. In this study, over 60% of the adaptation reports were non-experimental (i.e., observational, pilot program, post-test only) and less than one third were experimental. It is important for the field to have more rigorous evaluations of adapted programs to understand their outcomes and if their effects are comparable, better, or worse than the original EBI. Some preliminary research suggests that adapted versions of interventions are not associated with worst outcomes [48]. The evaluations also could inform if different types or combinations of modifications (e.g., content and context) impact effectiveness as well. Researchers also should determine critical adaptation elements to record and standardize across studies. Finally, while there have been repositories of evidence-based programs for public health practice such as the National Registry for Effective Programs and Practices [49] and Research Tested Intervention Programs (RTIPs) [50], there is no clearinghouse for adapted programs for the field to understand the issues around external validity of EBIs. Chambers recommends the creation of an adaptome to catalog adapted programs and their results to share with the field to potentially address this gap [51].

Several limitations exist for this study. Although we searched for relevant articles of adapted EBIs, it is likely that some articles were overlooked based on our search strategy. For example, we did not review gray literature for adapted EBIs. In addition, we limited our studies to those that focus on public health interventions and excluded clinical interventions. Additionally, our data on adaptations made and outcomes were limited to the authors’ description in the article and were not augmented with other data (e.g., surveys of authors). Although we had two raters to increase the reliability of the data abstracted, some of the modifications may have been underreported if the authors fail to report on that aspect (i.e., training) or may not have fully implemented the program yet (i.e., evaluation). Finally, while our review included adapted interventions globally, we did not review articles in languages other than English. However, we were able to find 16 studies in international settings. A limitation of this study is that we did not confirm with the authors that all of the adaptations made were reported; for example, some could have not reported on unplanned adaptation since some were not yet implemented. It is helpful for planners to document all adaptation, both planned and unplanned [52], for other practitioners to learn from this process. Finally, this review is becoming dated, especially in an area with a much active research and reporting.

Conclusion

This review offers a practical examination of adaptation across multiple programs and program types that were  implemented in community settings. It reports systematically on reasons for adaptation, types of modifications, and steps of adaptations for public health EBIs in public health practice. Adaptations are occurring in natural settings for a variety of reasons, and commonly, adaptations are made to intervention content or context. A few steps were used across adaptation teams in the process of adaptations, but the science of adaptation is still an emerging area of study in implementation science. More critical appraisal of intervention adaptations and their outcomes could assist with EBI transferability to increase the scale up and spread of EBI to increase population health impact.

Abbreviations

CPCRN: 

Cancer Prevention and Control Research Network

EBIs: 

Evidence-based interventions

MeSH: 

Medical Subject Headings

Declarations

Acknowledgements

We are grateful to Danielle Reece, Shuting Liang, and Scott Decker for their contributions during the data abstraction phase of this study.

Funding

This research was supported in part by the Increasing Reach and Implementation of Evidence Based Programs for Cancer Control, National Cancer Institute grant (R01-CA163526) and the Cancer Prevention and Control Research Network (3 U48 DP005017-01S8). The content of this paper is solely the responsibility of the authors and does not necessarily represent the official views of the funding agency. No financial disclosures were reported by the authors of this paper.

Availability of data and materials

Please contact the authors for data requests.

Authors’ contributions

All authors were involved in various stages of the study design. CE conceptualized the study, and MEF, MH, and PDM helped to design the study questions and abstraction tool. CE, EL, EB, and HU wrote the first draft. All abstracted the articles, assisted with the data interpretation, and commented on the subsequent drafts of the paper. All authors read and approved the final manuscript.

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Rollins School of Public Health, Emory University, 1518 Clifton Road, Atlanta, GA 30322, USA
(2)
University of Texas School of Public Health, 7000 Fannin, Ste 2522, Houston, TX 77030, USA

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