Sticking with the evidence, but adapting the programming

In this field of HIV/AIDS support, advocacy and prevention, it’s not unusual to hear talk about “the gap” between research and programming. Committed and educated researchers dedicate years to figuring out what works through pilot projects, evaluation and trials.  When they come up with something effective, it’s understandably frustrating to watch organizations, community groups and governments making programming decisions that seem to ignore the evidence that they’ve worked so hard to produce.  Ideally, where we have evidence that a particular HIV-prevention program works, we should be trying to use this evidence-based programming as widely as possible … shouldn’t we?  As it turns out, individuals, groups and governments regularly make choices based on factors other than evidence of effectiveness – prejudice, religion, personal preference, perceived public opinion, etc.  How can we make the best use of evidence-based programming in the context of our specific communities?

I recently learned from CATIE (the Canadian AIDS Treatment Information Exchange) about a fascinating American project called DEBI (the Diffusion of Effective Behavioral Interventions Project).  DEBI’s goal is to make HIV prevention programs that have been proven effective in a research study, available to other organizations.  At the time of writing, DEBI provides online tools for more than 25 population-specific individual-level and group-level “Interventions”, and they support organizations to implement them in their own communities.  This sounds fantastic (and I think it is!) but there are actually some challenges to using evidence-based programming, and in particular, to adapting it for effectiveness in another community (geographical, cultural, ethnic, etc).

While we want to change a program to meet the needs of each community (called program adaptation), we need to keep it “the same” enough that it doesn’t lose its effectiveness (called program fidelity).  The clearest examples of this challenge come from programs that are adapted to accommodate (real or perceived) cultural differences.  Let’s say for example that there is an effort to implement an evidence-based parenting program in a group for whom physical punishment is the generally accepted norm.  Complete program fidelity would mean taking a hard-line anti-hitting approach, but this is alienating the participants so that they are not participating.  “I was smacked and it didn’t hurt me,” say the parents.  Studies and experience have shown that if the program was adapted to “tone down” this key message, more people would come, but the program would lose its effectiveness – the parents would still hit their kids.  Miguelina German of Arizona State University decided not to compromise this core component of the program.  Instead, she and her colleagues adapted it by creating some new materials containing a compilation of the available evidence that hitting is not only ineffective but can lead to a further deterioration in a child’s behaviour.  The parents accepted this and the program had a higher success rate without compromising retention.  (Thanks to Prevention Action for this example.)

In this 2007 article, Connor, Small and Cooney from the University of Wisconsin-Madison provide an excellent overview of the challenges of balancing program fidelity and adaptation.  They list acceptable adaptations, including modifying vocabulary, replacing images, replacing cultural references, and adding relevant, evidence-based content as in the example above.  Risky or unacceptable adaptations include reducing the number of sessions or length of program, eliminating key messages or removing topics, changing the theoretical approach, and using inadequately trained staff or volunteers.

To read CATIE’s informative introduction to program adaptation, with an example of a Canadian adaptation of one of DEBI’s programs, visit their publication Prevention in Focus.

-Miriam

This was posted on Friday, September 3rd, 2010 at 9:30 am and is filed under Education & Resources, HIV Prevention, Research . Feel free to respond, or trackback. Read our comments policy.

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