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Emerald Group Publishing Limited
Copyright © 2012, Emerald Group Publishing Limited
Article Type: Editorial From: Journal of Children’s Services, Volume 7, Issue 4
It is becoming increasingly common for countries to import evidence-based programmes (EBPs) that were developed elsewhere. EBPs are going global.
This is understandable. Take substance abuse problems, which are increasing among adolescents worldwide. One of the most effective interventions in this area is the Strengthening Families Programme (SFP). It has been estimated to reduce the proportion of adolescents using alcohol by 18 per cent, while a ten-year follow-up when participants were 22 years old suggested reductions in lifetime mental health diagnoses of up to 300 percent compared with the control group. It appears on several lists of EBPs, including Blueprints for Healthy Youth Development and a recent compendium developed by the UN Office on Drugs and Crime. Surely programmes like SFP should be disseminated widely – including internationally?
Not according to everyone. Many EBPs, SFP included, were developed in the USA, and there is scepticism that they will work elsewhere: families in each country have unique needs, translating materials and re-filming videos is expensive, and why import when you can develop home-grown products? So runs the sceptics’ case. Similar arguments could apply to the value of, say, importing to Spain a programme developed in Norway.
There is good reason to be cautious. There are many successes in the cross-national transfer of programmes but there are also failures. The Incredible Years BASIC parenting programme shows consistent evidence of impact across several countries, including Norway, Ireland, Wales and England as well as the USA, where it originated. By contrast, multisystemic therapy performed only a little better than regular services in the UK, whereas in Sweden young people receiving regular services did just as well.
Why does importing progammes not always work? One explanation centres on poor fidelity of implementation in the new setting or the use of a different research design from the original evaluation. The services received by the control group in the new setting may also be better than they were in the evaluation in the original setting. Then there is the nature of the problem being addressed, and its risk and protective factors, which may be different in the new site. There may also be important cultural differences between countries in terms of values (e.g. gender roles, an individualist or collectivist orientation) or behaviour norms (e.g. accepted ways of parenting) that limit the programme’s “fit” in the new setting.
A connected hypothesis holds that programme transportability is likely to be affected by the extent to which careful programme adaptation is undertaken. In this edition of the Journal, Gregory A. Aarons and colleagues discuss the challenge of adapting programmes for use in different service settings and call for more research into the process of adapting programmes and the impact of adapted versions of programmes. We agree. In this context, it is interesting to note the work of a team from Stockholm University that examined nine models for adapting programmes for a new cultural group (Ferrer-Wreder et al., 2012).
The Stockholm team interpreted “adaptation” as any change to any aspect of the programme – omissions, add-ons or modifications to programme logic, processes, materials, or support structures. The majority of models reviewed originate from mental health prevention or therapy literatures, with others from HIV intervention and drug prevention literature. All were concerned with adapting a programme for a new cultural, racial, or ethnic group. Some models were generic, others specific to a programme. Several had a domestic orientation, for example focusing on American sub-cultural groups, while others had a more international outlook.
Three types of model were identified. “Step models” tell adapters what to do and in what order. A less prescriptive approach specifies which areas to consider when making programme adaptations. “Stacked” models start by setting out areas or themes to consider but then “stack” steps on top of these.
A good example of a step model was developed by Kumpfer et al. (2012) in relation to SFP. It sets out ten steps, starting with a needs assessment to determine risk and protective factors in the new setting, and then moving through an iterative process in which local implementers work with family members and the programme developer to make and test adaptations. An example of a stacked model is the model of intervention cultural sensitivity (ICS). This requires adapters to consider a programme’s deep structure, in other words the etiological basis of the programme. This is important, it is argued, for achieving impact. The ICS also requires modifying surface structure – language, materials, medium of presentation. This is critical for feasibility – whether practitioners will deliver the programme, and whether users will use it.
There is considerable variability between the nine theoretical models examined in terms of what was considered an adaptation. Surface structure changes are widely accepted as necessary, but changes to deep structure are more controversial. Underlining the seriousness of tinkering with a programme’s deep structure, Ferrer-Wreder et al. (2012, p. 167) argue that “if adaptations of such a potentially profound nature are undertaken, then they should be pursued in an effectiveness trial context, be based on direct empirical evidence (e.g. etiologic studies of the new target group), and be conducted in collaboration with program developers”.
The difference between changing content and delivery is also a recurring theme. Changes to programme content may be necessary if consumers need or want certain content not offered by the original programme, but usually it is the form of delivery that needs to change – using lay workers instead of professionals, delivering material via the internet rather than in school classrooms, holding sessions in a community centre not a social services office (Kumpfer et al., 2012). In other words, adapt the characteristics of delivery personnel and the channel and location of delivery.
The models reviewed by Ferrer-Wreder et al. (2012) are fairly consistent in recommending collaboration with programme developers and community members. By contrast, they vary in terms of the nature of the empirical research deemed necessary to support adaptations. Some models have empirical illustrations of their feasibility. Others have produced adapted programmes which are then tested in a randomised trial. Some stress the importance of adaptations being guided by etiological studies of the new target population. Future research could usefully compare different versions of the same programme adapted to different degrees against a control group. It should also compare cultural adaptation models and test whether some models work best for some types of programme.
In all of this, patience will be essential. As Ferrer-Wreder et al. (2012, p. 167) put it, “Effectiveness trials should not be bypassed in the rush to disseminate programs, and can serve as an occasion for program developers and stakeholders to come together to make the cultural adaptation of existing EBIs [evidence-based interventions] the focus of rigorous scientific study and thereby expand promising EBIs’ global generalizability and public health impact”.
Nick Axford, Michael Little
Ferrer-Wreder, L., Sundell, K. and Mansoory, S. (2012), “Tinkering with perfection: theory development in the intervention cultural adaptation field”, Child Youth Care Forum, Vol. 41, pp. 149–71
Kumpfer, K.L., Magalhães, C. and Xie, J. (2012), “Cultural adaptations of evidence-based family interventions to strengthen families and improve children’s developmental outcomes”, European Journal of Developmental Psychology, Vol. 9 No. 1, pp. 104–16