Emerald Group Publishing Limited
To adapt or not to adapt?
Article Type: Editorial From: Journal of Children's Services, Volume 9, Issue 4
To adapt or not to adapt? This question has received much attention in prevention science in recent years as programme developers, providers and evaluators consider how best to transfer evidence-based programmes (EBPs) that have been tested in one place or with one population to another. It has been the subject of several previous articles in the Journal of Children's Services and also a handful of editorials (e.g. Axford and Little, 2009; McDonald et al., 2012).
This edition features two papers on the theme, one concerning Triple P (looking at participant satisfaction and parent and child outcomes) and the other on SafeCare (examining client experiences of delivery and perceptions of adherence to core components). Both provide robust empirical evidence on the extent to which these programmes could be successfully adapted. Their starting point is that EBPs are not extensively tested with minority populations. This has fuelled a concern about the extent to which impact generalises across cultures.
Both papers concern Latinos, the largest minority group in the USA. They examine ways of addressing the unique linguistic, cultural, attitudinal, social-political barriers these families face to establishing relationships with providers and engaging in services. Broadly, the authors conclude that with some cultural modifications it was possible to implement these particular programmes successfully. Systematic changes during implementation were made without diluting core components, participants liked the programmes, and, where measured, positive outcomes were achieved.
They also raise an interesting question: is adaptation necessary? The theory is that adaptations such as matching participants and providers and addressing special topics relevant to the cultural group in question will improve user engagement and satisfaction and, ultimately, outcomes. Yet as the authors acknowledge, neither study establishes if the programme might have been successful without adaptation. Studies that test adapted vs non-adapted versions of programmes are arguably needed.
This, in turn, prompts a further question: how much testing of cultural adaptations is necessary? It is not realistic to test each adaptation with all cultural groups defined by race/ethnicity, geography, country of origin, language, dialect and so forth, so where to stop?
Such questions have particular resonance in Europe, and not just because the issue is magnified by virtue of having 28 countries in the European Union alone (with considerable diversity within many of them). Critics often use the notion of “cultural unfeasibility” to oppose the import to Europe of EBPs originating in North America. A recent report on this issue by Gregor Burkhart (2013) is important, then, because it cites experience showing that such programmes are both feasible and effective (at least in non-Nordic countries) but that hard work is needed to adapt them to the culture and context.
Burkhart looks at four well-known drug misuse prevention programmes: Preventure, Good Behaviour Game, Strengthening Families Programme and Communities that Care. Using data derived from questionnaires completed by 18 people involved in adapting and implementing the programmes in 12 European countries, he shows that all were successfully adapted to a European environment in content (e.g. wording, names, examples, images) and structure (e.g. organisation, training, staff time, length of sessions). Three points are particularly helpful.
First, he concludes that programmes need to adapt to two main constituents of environment, namely culture and context. He defines “culture” in terms of a country's values, beliefs, language use, traditions and informal norms, and “context” in relation to social and political organisation – service systems, professional traditions, formal norms (legislation), and so on. Both condition each other: they interact. For example:
[…] the level of social capital (trust in fellow citizens and respect for community values) appears to be higher in societies with historical traditions of self-governing communes and city states than in societies anciently ruled by monarchies and with large feudal landholdings […] The religious divide of Europe has strongly enhanced these cultural differences because the rise of Protestantism from the 16th century onwards yielded decisive importance to the idea of self-governance. The political self-organisation of communities accordingly became (and is now) more important in countries with predominantly Protestant traditions, such as the Netherlands, Nordic counties and North America (p. 8).
Second, Burkhart further concludes that in the four programmes studied, adaptations to culture primarily affected the content of the programme materials whereas adaptations to context required a modification of the protocols. In the case of SFP in Greece, for instance, minority ethnic families from the original DVDs were substituted with Filipinos to represent immigrants (an adaptation of content to account for cultural differences), while a shortage of funding and infrastructures led to shortened activities and the absence of childcare provision resulted in children younger than the original target group attending sessions (adaptations of the protocol to account for context).
Third, he contends that it is more challenging to adapt programmes to context than to culture. This is especially the case if the programme rests more on social capital and community organisation than on neurobehavioural theories. Many North American programmes, he suggests, rely heavily on social control mechanisms, such as competition, setting and reinforcing rules and introducing norms. These are more acceptable in states with higher social capital in society:
Today, community-based and environmental prevention are clear and accepted concepts in societies with self-government traditions and are core principles of many North American programmes. In many European societies, however, community-based prevention has either no meaning or no translation, or is understood as the activities of municipal agencies and administrations, not necessarily implying civic engagement. Likewise, environmental prevention in the form of smoking and alcohol regulations or strong community norms seems to be better accepted and agreed upon in traditionally self-governance societies where social control is acceptable, than in other European countries, where it is denounced as paternalistic and coercive (p. 9).
Unanswered questions remain about the added value of adaptation, but for what it is worth our view is that replication is copying, and effective copying always involves adaptation: if you copy something exactly, it does not work, but equally if you copy something badly it does not work. Somewhere between these lies a ‘sweet spot’. But where is that exactly? One hypothesis is that effective copying occurs when there are, as necessary, small but fundamental changes to the core (effectively the logic model) and many superficial changes to the adaptable (what makes programmes sell and deliverable). The debate about adaptation will continue.
Axford, N. and Little, M. (2009), “You can customise it – just make sure the wheels stay on”, Journal of Children's Services, Vol. 4 No. 1, pp. 2-3
Burkhart, G. (2013), “North American Drug Prevention Programmes: are they feasible in European cultures and contexts?”, EMCDDA Thematic Papers, Publications Office of the European Union, Luxembourg
McDonald, L., Coover, G., Sandler, J., Thao, T. and Shalhoub, H. (2012), “Cultural adaptation of an evidence-based parenting programme with elders from South East Asia in the US: co-producing Families and Schools Together – FAST”, Journal of Children's Services, Vol. 7 No. 2, pp. 113-27