Question Number: 447

Social Science homework help Analyzing Focus Group FindingsImagine that two focus groups have been conducted in an Asian American and immigrant community in a large urban city. The rationale of conducting the qualitative study was because it has been noted that many Asian Americans and immigrants are reluctant to seek mental health services. To further understand this issue, service providers including social workers, counselors, doctors, and nurses were recruited to discuss the barriers in implementing mental health services targeted to Asian Americans and immigrants. After the focus groups were transcribed, two research assistants were hired to conduct a content analysis of the transcripts. Refer to the Week 5 Handout: Content Analysis of Focus Groups (ATTACHED). As the social worker, you have been asked to analyze the focus group data and are charged with working with an advisory board in the community to formulate social work practice recommendations using the ecological model. To prepare for this Assignment, review Week 5 Handout: Content Analysis of Focus Groups (ATTACHED). Submit a 3-4-page report of the following: Discuss the themes found in the Week 5 Handout: Content Analysis of Focus Groups (ATTACHED). Based on this data, what is your analysis of the current barriers to services? Create two social work recommendations to address a current barrier and explain how the recommendation proposed addresses the findings. Discuss how you would collaborate with the research stakeholders (e.g. service providers and community members) to ensure that the data are interpreted accurately and that the practice recommendations made will be culturally appropriate. Critically reflect on your own culture and explain how your cultural values and beliefs may have influenced how you interpreted the focus group data. What specific cultural knowledge do you think you need to obtain to conduct culturally sensitive research with this group?Support the assignment with references using assigned readings and/or additional scholarly literature attached.Week 5 Handout: Content Analysis of Focus Groups 1Research Question 1: What are the barriers in implementing mental health services in the AsianAmerican community?Research Design: Qualitative, DescriptiveResearch Method: Focus groupsPatient Related BarriersSocial Stigma Associated with Mental Illness“….but also a lot of my patients have a fear of going to psychiatrists because of the socialstigma ….” and most of them have financial difficulty and have to pay an additional feeto pay for psychiatry. (DN, pg. 1)Financial Difficulties“….but also a lot of my patients have a fear of going to psychiatrists …. and most ofthem have financial difficulty and have to pay an additional fee to pay forpsychiatry.” (DN, pg. 1)Characteristics of the Asian patientMistrustful of mental health“I found it easier sometimes to refer them to someone else because a lot of timesI find that the Chinese patients are unwilling to open up or trust.” (TPW, pg.2)“we have to see why Asians go to see a health care provider, forget aboutwhether the mental health profession, or even a regular clinician. Why does thepatient see the provider..is it because they have seen a chinese herbalist and havefailed and have used their last efforts to see a western doctor, that will puttremendous expectations on this relationship, as opposed to someone whocomes to see the doctor for the first time and has faith that the Westerndoctor.” (Anthony, pg. 7)Don’t Ask for Assistance“It is hard to get them ask for help and ….. “ (TPW, pg. 2)Patient’s View of Mental Health Provider as Last Resort“we have to see why Asians go to see a health care provider, forget about whether themental health profession, or even a regular clinician. Why does the patient see theprovider..is it because they have seen a chinese herbalist and have failed and haveused their last efforts to see a western doctor, that will put tremendous expectations onthis relationship, as opposed to someone who comes to see the doctor for the first timeand has faith that the western doctor.” (Anthony, pg. 7)Week 5 Handout: Content Analysis of Focus Groups 2Service Provider Related Barriers“Despite all the training I have found that working with Chinese populations there are a lot ofbarriers I am finding that it is not as easy working with them.” (TPW, pg. 2)“Pass the Buck theme”I found it easier sometimes to refer them to someone else because a lot of times I find thatthe Chinese patients are unwilling to open up or trust. (TPW, pg. 2)Lack of training/skills/expertise“….and I find that I struggle with my own skills and I am trying to get some help inbeing a better primary care provider and getting my skills more fine tuned for thepopulation that I work with.” (TPW, pg. 2)“On the Western provider side, we noticed that when a provider is confronted with aWestern patient they are reluctant to enter areas because they are not really sure if thatbehavior is natural to that culture so that while they know pathology on the onehand they are not sure if what they are seeing is pathological. I remember one indianpsychiatrist said that a schizophrenic in india is the same schizophrenic in NY but youknow there are excuses sometimes and avoidance so educating the general providerconcerning what really can be expected is very important.” (MAC, pg. 8)“My comment is very similar, there are very big knowledge gaps for providers andwhat providers bring to the situation…” (JK, pg. 8)Cultural Assumptions“well what you have to think about is other areas, our own cultural biases. There arecertain things that I make assumptions on without even knowing it just because ofwhat I know growing up or and I think these are areas we need to address.”(Ernesto, pg. 7)Systems BarriersPrimary Care is the Access Point for Patients with Mental Disorders“….primary care as sort of the gatekeeper those are the guys that are picking upthe symptoms and so I sort of see that this is a good project to enhance ourunderstanding of this population.” (AN, pg. 2)Changing Financial Systems“Another issue is that there are financial issues that primary physicians often see thatthere is cost shifting going on that psychiatry or whomever else is telling us to do thisnew activity that is really shifting a responsibility” (LR, pg. 4)Week 5 Handout: Content Analysis of Focus Groups 3Changing of Responsibilities“Another issue is that there are financial issues that primary physicians often see thatthere is cost shifting going on that psychiatry or whomever else is telling us to do thisnew activity that is really shifting a responsibility” (LR, pg. 4)Professional Medical/Psychiatry CultureDiffering Cultures and Ideologies Within Medical Profession“one major barrier is that there is a difference in physician culture that an internalistperceives a different way of treating a patient than a family care doctor and thepediatrician looks at it differently than an internalist and that certain cultures when theyhave certain specialty referral systems will feel differently when they specialty referralsystem is used less frequently, and we have found them being treated much differently”(LR, pg.4)Miscellaneous“we tend to forget that the mental health problems are a spectrum, they may not benecessarily psychosis or dementia, manic depression, they may not be a DSM 4 diagnosis,they may be life style related , they are a state of flux it is a spectrum, when a women is havinginfertility when a women loses a pregnancy when a women delivers a baby and it is another girlbut she wanted a boy, or when she delivers a baby it is what she wanted but the constraints, butthe burden is too much, so it can gyn issues it could be ob issues but they are not dsm categoriesand I think that a barrier is that we do not acknowledge the existence of these kinds of things…”(IH, pg. 6)“The other big thing that I think of is the other side of the spectrum which is when we do seethese patients and when we do have the luxuries of identifying these issues that I have justoutlined that we try to squeezed these people into the diagnoses that I just described so wemake it into an anxiety disorder or we make it into a depression when it could be just life stylerelated or cultural related..” (IH, pg. 6) Cultural Adaptation of Interventionsin Real Practice SettingsFlavio F. Marsiglia1 and Jamie M. Booth2AbstractThis article provides an overview of some common challenges and opportunities related to cultural adaptation of behavioralinterventions. Cultural adaptation is presented as a necessary action to ponder when considering the adoption of an evidence-basedintervention with ethnic and other minority groups. It proposes a roadmap to choose existing interventions and a specific approachto evaluate prevention and treatment interventions for cultural relevancy. An approach to conducting cultural adaptations isproposed, followed by an outline of a cultural adaptation protocol. A case study is presented, and lessons learned are shared aswell as recommendations for culturally grounded social work practice.Keywordsevidence-based practice, literatureCulture influences the way in which individuals see themselvesand their environment at every level of the ecological system(Greene & Lee, 2002). Cultural groups are living organismswith members exhibiting different levels of identification withtheir common culture and are impacted by other intersectingidentities. Because culture is fluid and ever changing, the processof cultural adaptation is complex and dynamic. Social work andother helping professions have attempted over time to integrateculture of origin into the interventions applied with ethnicminorities and other vulnerable communities in the UnitedStates and globally (Sue, Arredondo, & McDavis, 1992). Inan ever-changing cultural landscape, there is a renewed needto examine social work education and the interventions socialworkers implement with cultural diverse communities.Culturally competent social work practice is well establishedin the profession and it is rooted in core social work practiceprinciples (i.e., client centered and strengths based). It strivesto work within a client’s cultural context to address risks andprotective factors. Cultural competency is a social work ethicalmandate and has the potential for increasing the effectivenessof interventions by integrating the clients’ unique cultural assets(Jani, Ortiz, & Aranda, 2008). Culturally competent or culturallygrounded social work incorporates culturally based values,norms, and diverse ways of knowing (Kumpfer, Alvarado,Smith, & Bellamy, 2002; Morano & Bravo, 2002).Despite the awareness about the importance of implementingculturally competent approaches, practitioners often strugglewith how to integrate the client’s worldview and the applicationof evidence-based practices (EBPs). When selecting andimplementing social work interventions, practitioners oftencontinue to unconsciously place themselves at the center ofthe provider–consumer relationship. Being unaware of theirpower in the relationship and undervaluing the clients perspective in the selection of EBPs tends to result in a typeof social work practice that is culturally incompetent andnonefficacious (Kirmayer, 2012). This ineffectiveness canbe experienced and interpreted by practitioners in severalways. In instances when clients do not conform to the contentand format of existing interventions, they are easily labeled asbeing resistant to treatment (Lee, 2010). In other cases, whenclients fail to adapt to a given intervention that does not feelcomfortable to them, the relationship is terminated or theclient simply does not return to services. Thus, terms suchas noncompliance and nonadherence may hide deeper issuesrelated to cultural mismatch or a lack of cultural competencyin the part of the practitioner.Culturally grounded social work challenges practitioners tosee themselves as the other and to recognize that the responsibility of cultural adaptation resides not solely on the clients butinvolves everyone in the relationship (Marsiglia & Kulis,2009). In order to do this, practitioners need to have accessto interventions or tools that are consistent with the culturallygrounded approach. A culturally grounded approach starts withassessing the appropriateness of existing evidence-based interventions and adapting when necessary, so that they are more1 Southwest Interdisciplinary Research Center (SIRC), School of Social Work,Arizona State University, Phoenix, AZ, USA2 School of Social Work, University of Pittsburgh, Pittsburgh, PA, USACorresponding Author:Jamie M. Booth, School of Social Work, University of Pittsburgh, 2117Cathedral of Learning, 4200 Fifth Avenue, Pittsburgh, PA 15260, USA.Email: jmbooth2@outlook.comResearch on Social Work Practice2015, Vol. 25(4) 423-432ª The Author(s) 2014Reprints and permission:sagepub.com/journalsPermissions.navDOI: 10.1177/1049731514535989rsw.sagepub.comrelevant and engaging to clients from diverse cultural backgrounds, without compromising their effectiveness. This processof assessment, refinement, and adaptation of interventions willlead to a more equitable and productive helping relationship.The ecological systems approach provides a structure forunderstanding the importance of cultural adaptation in socialwork practice. Situated on the outer level (macro level) ofthe ecological system, culture frames the norms, values, andbehaviors that operate on every other level: individual beliefsand behaviors (micro level), family customs and communication patterns (mezzo level), and how that individual perceivesand interacts with the larger structures (exo level), such asthe school system or local law enforcement (Szapocznik &Coatsworth, 1999). In this approach, the relationships betweenindividuals, institutions, and the larger cultural context withinthe ecological framework are bidirectional, creating a dynamicand rapidly evolving system (Bronfenbrenner, 1977; Gitterman,2009). The bidirectional nature of relationships is an importantconcept to consider when discussing the cultural adaptationof social work interventions for two reasons: (1) regardlessof the setting, in social work practice, the clients and thesocial workers engage in work partnerships in which both parties must adapt to achieve a point of mutual understanding andcommunication and (2) culture is in constant flux, as individuals interact with actors and institutions which either maintainor shift cultural norms and values over time.Although culturally tailoring prevention and treatmentapproaches to fit every individual may not be feasible, culturally grounded social work may require the adaptation ofexisting interventions when necessary while maintaining thefidelity or scientific merit of the original evidence-basedintervention (Sanders, 2000). This article discusses the needfor cultural adaptation, presents a model of adaptation froman ecological perspective, and reviews the adaptations conducted by the Southwest Interdisciplinary Research Center(SICR) as a case study. The recommendations section connects the premises of this article with the existing literatureon cultural adaptation and identifies some specific unresolvedchallenges that need to be addressed in future research.Empirically Supported Interventions (ESIs) inSocial Work PracticeEBP has become the gold standard in social work practice andinvolve the ‘‘conscientious’’ and ‘‘judicious’’ application ofthe best research available in practice (Sackett, 1997, p. 2).It is commonly believed that utilizing EBP simply requires thepractitioner to locate interventions that have been rigorouslytested using scientific methods, implement them, and evaluatetheir effect; however, EBP acknowledges the role of individuals and relationships in this process. EBP requires the integration of evidence and scientific methods with practicewisdom, the worldview of the practitioner, and the client’sperspectives and values (Howard, McMillen, & Pollio, 2003;Regehr, Stern, & Shlonsky, 2007). The clinician’s judgment andthe client’s perspective are not only utilized in the selection ofthe EBP intervention; they are also influential in how the intervention is applied within the context of the clinical interaction(Straus & McAlister, 2000). Achieving a balance between boththe client and the practitioner’s perspective in the application ofESIs is essential for bridging the gap between research and practice (Howard et al., 2003). However, the inclusion of the clinician’s judgment and the client’s history potentially muddlesthe scientific merit of the intervention being implemented. Thisis the fundamental tension and challenge when implementingEBP and a key reason why the gap between research and practice exists (Regehr et al., 2007).The attraction of EBP is clear; locating and potentiallyutilizing empirically tested treatment and prevention interventions allow social workers to feel more confident that theywill achieve the desired outcomes and provide clients withthe best possible treatment, thereby fulfilling their ethicalresponsibility (Gilgun, 2005). Despite this clear rationale, theutilization of EBP is limited (Mullen & Bacon, 2006) andwhen it is applied, research-supported interventions may notbe implemented in the manner the authors of the interventionintended.This lack of treatment fidelity when implementing EBPmay be due to practitioner’s awareness that the evidencegenerated by randomized control trials (RCTs) may not beapplicable to the diverse needs of their clients or adequatelyaddress the complexity of the clients’ life (Webb, 2001;Witkin, 1998). Practitioners have natural tendency to adaptinterventions to better fit their clients (Kumpfer et al.,2002). Some adaptations are made consciously, but others aremade quickly during the course of implementation and basedon clinical judgment (Bridge, Massie, & Mills, 2008; Castro,Barrera, & Martinez, 2004). ESIs, however, can only beexpected to achieve the same results as those observed whenoriginally tested, if they are implemented with fidelity orstrict adherence to the program structure, content, and dosage(Dumas, Lynch, Laughlin, Phillips Smith, & Prinz, 2001;Solomon, Card, & Malow, 2006). Although adaptations aretypically made in response to a perceived need, when theyare not done systematically, based on evidence and with thecore elements of the intervention preserved, the efficacy thatwas previously achieved in the more controlled environmentmay not be replicated (Kumpfer et al., 2002). Informal adaptation has the potential for compromising the integrity ofthe original intervention, thus negating the value of the accumulated evidence that supports the intervention’s effectiveness. This tension between fidelity and fit has generated aneed foESIs is locating interventions that have been designed for andtested with a given cultural group. However, the limited availability of culturally specific interventions with strong empirical support may create barriers to this approach. Despite theprogress that has been made to date, most ESIs are developedfor and tested with middle-class White Americans, with theassumption that evidence of efficacy with this group can betransferred to nonmajority cultures, which may or may notbe the case (Kumpfer et al., 2002).For example, a prevention intervention with Latino parentsfound that assimilated, highly educated Latino parents wereresponsive to the prevention interventions presented to them,while immigrant parents with less education were less likelyto benefit (Dumka, Lopez, & Jacobs-Carter, 2002). This highlights the differential effects of an intervention based on cultureas well as a clear need for a more culturally relevant intervention for immigrant parents. Despite a clear need for adaptationin some circumstances, there is a strong risk of compromisingthe effectiveness of the ESI when unstructured cultural adaptations are implemented in response to perceived cultural incongruence (Kirk & Reid, 2002; Kumpfer & Kaftarian, 2000;Miller, Wilbourne, & Hettema, 2003; Solomon et al., 2006).For that reason, when culturally and contextually specific interventions exist with strong evidence, it is certainly preferable toselect that intervention; however, in the absence of an ESIdesigned and tested for the population being served, adaptationmay be a more viable and cost-effective option for scientifically merging a client’s cultural perspectives/values and theESI (Howard et al., 2003; Steiker et al., 2008). Systematicallyadapting an intervention may increase the odds that the treatment will achieve similar results than those found in morecontrolled environments by minimizing the amount of spontaneous adaptations that the practitioner feels that they mustmake to communicate within the client cultural frame(Ferrer-Wreder, Sundell, & Mansoory, 2012).Cultural adaptation may not only preserve the ESI’s efficacy but also enhance the results attained in clinical trials(Kelly et al., 2000). Culturally adapted interventions have thepotential to improve both client engagement in treatment andoutcomes and might be indicated when either rates fall belowwhat could be expected based on previous evidence (Lau,2006). In an evaluation of a culturally adapted version ofthe Strengthening Families intervention, there was a 40%increase in program retention in the culturally adapted versionof the intervention (Kumpfer et al., 2002). Although outcomeswere not found to be significantly better in the adapted versionof the intervention, the increase in retention is a significantimprovement. Improving retention expands the intervention’spotential to reach and impact individuals who would nottypically remain in treatment. Despite the lack of differencein outcomes in the Strengthening Families intervention, someevidence has emerged that culturally adapted interventionsnot only increase retention but are also more effective. In arecent meta-analysis, culturally adapted treatments had agreater impact than standard treatments, produced better outcomes, and were most successful when they were culturallytailored to a single ethnic minority group (Smith, DomenechRodrı´guez, & Bernal, 2010).Adapting interventions in partnership with communities alsoenhances the community’s commitment to the implementationand the chances that the program will be sustained overtime(Castro et al., 2004). For example, efforts to adapt HIV prevention programs by modifying the messages and protocolsin order for them to sound and feel natural or familiar intellectually and emotionally to individuals, families, groups, andcommunities have improved the communities’ receptiveness,retention, outcomes, and overall satisfaction, in addition toretaining high levels of fidelity (Kirby, 2002; Raj, Amaro,& Reed, 2001; Wilson & Miller, 2003).Finally, cultural adaptation is advantageous because itallows the social worker to address culturally specific riskfactors and build on identified protective factors. In the caseof Latino families, differential rates of acculturation betweenparents and youth appear to be a risk factor for substance useand delinquency among youth, indicating that family-basedinterventions may be the most culturally relevant intervention(Martinez, 2006). In addition to a source of risk, culturalnorms that place a high value on family loyalty are protectivefactors against a variety of negative outcomes (German,Gonzales, & Dumka, 2009; Marsiglia, Nagoshi, Parsai, &Castro, 2012). Identifying risk and protective factors uniqueto a community and addressing these within an interventionhave the potential to increase the efficacy of the intervention.The importance of EBP and culturally competent practicehas created tension in the field of social work. Evidencehas landed support to both claims: (1) interventions are moreeffective when implemented with fidelity (Durlak & DuPre,2008) and (2) interventions are more effective when they areculturally adapted because they ensure a good fit (Jani et al.,2008). These different perspectives highlight the tension inthe field between implementing manualized interventionsexactly as they were written versus to adjusting them to fit thetargeted population or community (Norcross, Beutler, &Levant, 2006). Although this debate is far from resolved, theories of adaptation have been developed that allow theresearcher/practitioner to adjust the fit without compromisingthe integrity of the intervention (Ferrer-Wreder et al., 2012).If the cultural adaptation is done systematically, it has thepotential for maximizing the benefit of the fit, as well as thebenefit of the ESI, thus providing a strategy that addressesmany of the concerns surrounding EBP’s applicability insocial work practice (Castro et al., 2004).An Emerging Roadmap for Cultural AdaptationCultural adaptation is an emerging science that aims ataddressing these challenges and opportunities to enhance theeffectiveness of interventions by grounding them in the livedexperience of the participants. Strategies and processes to systematically adapt interventions while insuring a more optimalcultural fit without compromising the integrity of scientificmerit have been proposed and are beginning to be testedMarsiglia and Booth 425(La Roche & Christopher, 2009). The first step in all adaptationmodels is determining that the cultural adaptation of an intervention should be perused. Adaptation of an ESI is indicated when(1) a client’s engagement in services falls below what isexpected, (2) expected outcomes are not achieved, and (3) identified culturally specific risks and/or protective factors need tobe incorporated into the intervention (Barrera & Castro, 2006).Once the determination is made to conduct an adaptation,there are a variety of models that one could follow all of whichfall into two categories: content and process (Ferrer-Wrederet al., 2012). Although most current adaptation models havemerged the discussions regarding the content that should bemodified and process by which this modification takes place,it is useful to consider them separately.Content models identify an array of domains that may becrucial to address when conducting an adaptation. The ecological validity model, for example, focuses on eight dimensionsof culture: language, persons, metaphors, content, concepts,goals, methods, and social context (Bernal, Jime´nez-Chafey,& Domenech Rodrı´guez, 2009). The cultural sensitivity model,also a content model, identifies two distinct content areas: deepculture, which includes aspects of culture such as thought patterns, value systems, and norms, and surface culture, which refersto elements, such as language, food, and customs (Resnicow,Soler, Braithwaite, Ahluwailia, & Butler, 2000). Proponents ofthe cultural sensitivity model argue that both aspects of cultureshould be assessed and potentially addressed if areas of conflictor incongruence between the culture and the intervention areidentified (Resnicow et al., 2000). Surface adaptations allow theparticipants to identify with the messages, potentially enhancingengagement; while, deep culture adaptations ensure that theoutcomes are impacted (Resnicow et al., 2000).Castro, Barrera, and Martinez (2004) and Castro, Barrera,and Steiker, 2010 have proposed a content model that identifiesa set of specific dimensions—at the surface and deep levels—that are essential to consider in the adaptation process: cognitive, affective, and environmental. Cognitive adaptations areconsidered when participants cannot understand the contentthat is being presented due to language barriers or the use ofinformation that is not relevant in an individual’s culturalframe. Vignettes given by the original intervention, for example, may not be relevant to the participants or may be offensivedue to spiritual or religious taboos. The content may create anegative reaction from the participants which in turn may blocktheir ability to hear and integrate the message. It is that contentthat needs to be modified while the core elements of the intervention are respected. Affective-motivational adaptations areindicated when program messages are contrary to culturalnorms and values, creating a resistance to change within theindividual (Castro, Rawson, & Obert, 2001). Environmentalfactors (later referred to as relevance) make sure that the contents and structure are applicable to the participants in theirdaily lived experience (Castro et al., 2010).While content models of adaptation tell adaptors where tolook for cultural mismatch, process models provide a framework for making systematic assessments of cultural match,adjustments to the original intervention, and tests of the adaptations effectiveness. At a minimum adaption process, modelsfollow two systematic steps: (1) identifying mismatchesbetween the original intervention and the client’s culture and(2) testing/evaluating changes that have been made to rectifythese disparities (Ferrer-Wreder et al., 2012).Most process models of adaptation begin with building apartnership or coalition with members of targeted community(Castro et al., 2010; Harris et al., 2001; Wingood & DiClemente, 2008). Sometimes the ESI that will be adapted isselected at this stage; however, more information is often gathered about the targeted population before selecting the intervention that would provide the best fit (Kumpfer, Pinyuchon,Teixeriade de Melo, & Whiteside, 2008; Mckleroy et al.,2006; Wingood & DiClemente, 2008). Whether the intervention has yet to be selected, extensive formative research is conducted to assess the etiology of the social problem that is thetarget of the intervention, possible population-specific risksand protective factors, and measurement equivalence to insureand accurate evaluation of intervention outcomes (Harris et al.,2001). Some information about the target community may begained by reviewing relevant literature; however, interviews,focus groups, and surveys are also used to collect primary dataabout the social and cultural context that may impact the outcome of the intervention or conflict with the program’s messages/implementation strategies.At this point in the process, some adaptation models recommend making changes based on the formative research(Domenech-Rodriguez & Wieling, 2004; Harris et al., 2001), whileothers suggest implementing the intervention with minimalchanges and assessing the need for further adaption. In an innovative approach, the Planned Intervention Adaptation model suggestsmaking significant changes to one version of the interventionwhile making minimal changes to another and implementing themboth simultaneously to test the differential effects (Castro et al.,2010; Ferrer-Wreder et al., 2012; Kumpfer et al., 2008).Regardless of the level of adaptation, the modified intervention is pilot tested and based on the outcomes subsequentadaptations are made (Ferrer-Wreder et al., 2012). Once afinal adaptation has been made, further testing takes placein effectiveness trials. Across all theories of adaptation, theprocess is iterative with refinements made to the interventionat every stage based on the evidence generated in the priorstage (Domenech-Rodriguez & Wieling, 2004). Regardlessof the depth of changes made, the adapted intervention mustbe rigorously tested to ensure that the effects of the originalESI are preserved after changes have been made.Case Study: Adaptations of Keepin’it REAL(KiR)adaptation model utilized at SIRC is an expanded versionof the Barrera and Castro (2006) model as illustrated byFigure 1.KiR is the flagship empirically supported treatment SIRC(Marsiglia & Hecht, 2005). KiR is a manualized schoolbased substance abuse prevention program for middle schoolstudents. It was designed to (a) increase drug resistance skillsamong middle school students, (b) promote antisubstance usenorms and attitudes, and (c) develop effective drug resistanceand communication skills (Gosin, Dustman, Drapeau, &Harthun, 2003). It was created and evaluated in Arizonathrough many years of community-based research funded bythe National Institutes on Drug Abuse of the National Institutes of Health. It is a model program listed under SubstanceAbuse and Mental Health Services Administration’s NationalRegistry of Evidence-Based Programs and Practices. There isstrong evidence about the efficacy of the intervention withmiddle school Mexican American students (Marsiglia, Kulis,Wagstaff, Elek, & Dran, 2005), however the communityidentified need to reach out to younger students and to students of other ethnic groups generated a set of adaptationefforts summarized in Figure 2.As Figure 2 illustrates, KiR was adapted for fifth-grade students (Harthun, Dustman, Reeves, Marsiglia, & Hecht, 2009)following the SIRC adaptation model and an RCT was conducted to test whether the effects of the intervention increasedby intervening earlier (fifth grade vs. seventh grade). Studentswho received the intervention in both the fifth and seventhgrade were no different in their self-reported use of alcoholand other drugs than students who received the interventiononly on the seventh grade (Marsiglia, Kulis, Yabiku, Nieri,& Coleman, 2011). This effort did no yield the expectedresults but provided evidence from a developmental perspective that starting earlier was not cost effective.The second adaptation presented in Figure 2 was alsocommunity-generated and supported from the evidence gathered during the initial RCT of KiR. Urban American Indian(AI) youth were not benefiting from KiR as much as otherchildren (Dixon et al., 2007). Following the principles ofcommunity-based participatory research, a steering group,including leaders from the local urban AI community andschool district personnel in charge of AI programs, wasformed to guide the adaptation process. In addition to engaging community members and setting up a structure to ensurea collaborative partnership, before beginning the adaptationprocess, formative information was collected by consultingthe literature to identify culturally specific risks and protective factors and focus groups. Focus groups were conductedwith both Native American adults and youth to explore culturally specific drug resistance strategies that were frequentlyapplied by urban Native American youth (Kulis & Brown,2011; Kulis, Dustman, Brown, & Martinez, 2013).Based on this information, collected in conjunction withfour Native American curriculum development experts, KiRwas adapted, and while maintaining its core elements, thecontent and structure were changed to be more culturally relevant to Native American youth (Kulis et al., 2013). Changesto the curriculum included (1) new drug resistant strategiesthat were identified by the AI youth as being more culturallyrelevant to them, (2) lesson plans designed to teach strategiesin a more culturally relevant way, (3) more comprehensivecontent focusing on ethnic identity (a protective factor identified in the literature), and (5) a narrative approach in teachingcontent (Kulis et al., 2013). In the initial pilot test of theintervention, results showed an increase in the use of REALstrategies indicating a promising effect. Based on pilot testfeedback, the intervention has been further adapted andimplemented on a larger scale through an RCT. The researchteam at SIRC is currently in the process of developing aIdentificationof EBP withcommunity.PreliminaryadaptationPilot-testingof theadpatedversionIntegration ofthe results.Furtheradaptation ifneededRCTof the finaladaptedversionCommunityEngegament& NeedsAssessmentFigure 1. The SIRC adaptation model (Barrera & Castro, 2006).Note. SIRC ¼ Southwest Interdisciplinary Research Centre.keepin't REALPhoenix efficacytrial: EBPN = 6,035(1997-2002)Adapted with Jalisco-Mexicomiddle schoolsN = 431(2011-2013)Adapted with Phoenix urban AmericanIndian middle schoolsN = 247(2007-2012)Adapted with Phoenix 5th gradersN = 3,038(2003-2008)Figure 2. The SIRC family of adapted interventions.Note. SIRC ¼ Southwest Interdisciplinary Research Centre.Marsiglia and Booth 427parenting component to this intervention using the processesthat were established in the development of the youth version.Implementing and adapting KiR for the Mexican context isthe most recent adaptations done at SIRC. Collaborators inJalisco-Mexico identified Keepin’ it as an ESI suitable forMexico. The initial review of the intervention resulted in a‘‘surface’’ adaptation consisting mostly of translating themanuals from English to Spanish and changing some of thevignettes that were not appropriate for Mexico. The Jaliscoteam recruited two middle schools to participate in a pilotstudy of the initial adapted version of KiR. The schools wererandomized to control and experimental conditions. Implementers (teachers) and student participants participated inthe regular classroom-based intervention for 10 weeks andwere also a part of a simultaneous intensive review processof the intervention through focus groups. The overall levelof comfort and satisfaction with the intervention was high andthe pre- and posttest survey results were also favorable. Themain concern for teachers and students was the videos thatillustrate the REAL resistance strategies. The original videoswere dubbed into Spanish, but the story lines, the music, andeven the clothing felt foreign to the youth in Jalisco. As aresult, new scripts and new videos were produced by and foryouth in Jalisco. This method of adaptation did not change thecore elements of the original intervention but did addressaspects of deep culture (Steiker et al., 2008). Because theyouth wrote and acted in the videos, they were able to construct scenarios that accurately reflected their cultural normsand values.The results of the pilot also provided additional feedback toedit the content and format of the manuals. See Figure 3 forthe pilot results on alcohol, cigarette, and marijuana use.The results of the pilot were very promising and identifiedfemale students at a greater risk. Females in the control group(not receiving the intervention) reported the greatest increase insubstance use between the pre- and posttest. The pilot resultsillustrate the need for the cyclical and continuous adaptationprocess. This case study highlights the need to conduct a genderadaptation in addition to an ethnic or nation of origin adaptation. With the adapted manual and the new videos, the binational team of researchers is applying for funding to conductan RCT in Mexico of the revised intervention now called‘‘Mantente REAL.’’Adaptation in Social Work PracticeThe previously discussed models, including the SIRC model,are based on collaborations between practitioners and researchers, where researchers take the lead in the formative assessments, adaptations, and evaluations of effectiveness. In manysocial work practice settings, this process might look different,although it is recommended that regardless of the setting, apartnership with the intervention designers is developed ifsignificant modifications are going to be made to the originalintervention. The Centers for Disease Control and Prevention(CDC) has devised a set of practical guidelines for practitionersadopting an ESI and strongly discourages adaptors to changethe deep structures of the intervention (McKleroy et al., 2006).In the CDC model, as in the SIRC model, the adaptationprocess starts with the selection of an ESI that best matches thepopulation and context (Solomon et al., 2006). The selection ofan intervention is based on an initial assessment of the targetedpopulation and an exploration of possible intervention variations (Ferrer-Wreder et al., 2012). Assessments of the population can be made through a review of the literature and byconducting interviews with key informants or focus groupswith potential participants. The initial assessment of the population should go beyond potential participants’ ethnicities toinclude multiple and intersecting identities. Cultural adaptationfrequently starts and stops with the identification of race, without examining how age, gender, sexual orientation, religion,acculturation, and geography shape culture. The lack of suchidentification information could potentially impact the participants’ experience with the intervention (Wilson & Miller,2003). A thorough assessment includes consideration for bothdeep and surface culture, as well as population-specific risksand protective factors (Solomon et al., 2006). During this initial00.10.20.30.40.50.60.70.80.9Wave 1 Wave 2Wave 1 Wave 2Wave 1 Wave 2Alcohol FrequencyMale (E)Male (C)Female (E)Female (C)00.050.10.150.20.250.30.350.40.45Cigarette FrequencyMale (E)Male (C)Female (E)Female (C)00.050.10.150.20.250.30.350.40.45Cigarette AmountMale (E)Male (C)Female (E)Female (C)Figure 3. Pilot results of ‘‘Mantente REAL.’’428 Research on Social Work Practice 25(4)phase, social workers strive to find the best possible fit becausethe fewer modifications they make, the less likely the fidelity ofthe intervention will be compromised in the adaptation process.After the intervention is selected, the practitioner thoroughlyevaluates the theoretical underpinnings of the intervention andassesses the intervention in light of the cultural norms and valuesof the clients being served (Green & Glasgow, 2006). Thepractitioner then systematically works to reconcile any mismatches between the intervention and the participants’ livedexperiences without altering the core components of the intervention or features of the intervention that are responsible forthe intervention’s effectiveness (Green & Glasgow, 2006;Kelly et al., 2000; Solomon et al., 2006). When it is determined that elements of deep culture need to be changed andthese changes have the potential of altering core elements ofthe curriculum, the evidence previously found for effectiveness may be negated indicating the need to retest the intervention in an RCT (see Figure 4 ).Although some interventionists have explicitly identifiedcore components that must be preserved to ensure effectiveness, others have not. In the case when they are not explicitlystated, it becomes the implementer’s responsibility to uncoveraspects of the intervention that cannot be changed or removed.Identifying the theory of change (i.e., cognitive behavioraltheory, reasoned action, and communication competency) isthe most practical way of identifying core elements, althoughcontacting the authors and conducting experiments are alsopossibilities (Solomon et al., 2006).After the intervention has been adapted to reconcile anyconflicting mismatches, a pilot test is recommended of theadapted intervention with a small group of participants (atleast N ¼ 10) using pre- or postsurveys and focus groups(McKleroy et al., 2006). Any information gleaned from thisdata will be used to further incorporate any adaptations intothe intervention.The extent of adaptation must be determined by the level ofmismatch between the intervention and the population beingserved (Barrera & Castro, 2006). Frequently, cultural adaptations only address surface aspects of culture while neglectingthe deeper messages being communicated in the intervention.This is not necessarily bad practice. It is possible that changing the language, photographs, and the scenarios in an intervention is all that is needed to make it culturally relevant.There are, however, situations in which this is not sufficient(Resnicow et al., 2000). As mentioned previously, surfaceadaptation allows participants in the program to identifythemselves with the intervention, but it could fail to addressthe larger cultural norms that may be impacting the targetbehaviors or decision-making process. If it is determined thatsignificant and/or deep changes are needed, the developers ofthe intervention need to be contacted and asked to assist thesocial worker in the process. It should be remembered that anychanges have the potential to compromise the intervention’seffectiveness and need to be implemented with extreme caution. Social workers adapting interventions should documentall changes made to the original intervention and systematically evaluate the outcomes in order to ensure that the desiredresults are being achieved.RecommendationsSocial work ethics clearly instruct social workers to provideculturally competent practice and to implement interventionswith the best possible evidence of efficacy. Due to the vastdiversity in the human family, these imperatives can be in conflict. This conflict highlights many of the questions that stilllinger in the discussion of the value of implementing socialwork interventions with fidelity versus adapting them to betterachieve a cultural fit. It has been suggested that one way to rectify this tension is to adapt interventions in a systematic mannerbased on scientifically validated methods. Despite the apparentclarity of this task, the adaptation process can be challenging.The theories of adaptation that have emerged in several different fields put forward similar processes of adaptation. Thesemay require an extensive assessment of the etiology of socialproblems, an understanding of the deep theoretical structureof the original intervention, and rigorous evaluation that maybe beyond the capacity of individual practitioners. To this end,more work needs to be done to build the capacities of socialworkers and social work agencies for utilizing and conductingFigure 4. The continuum of adaptation: Balancing the fidelity and fit.Marsiglia and Booth 429rigorous research that would enable them to reliably adaptsocial work research theories and practices. In the absence ofneeded resources, social workers are encouraged to buildrelationships with research institution that can help them systematically assess and adapt interventions, so that they canprovide the most culturally competent services. When adaptations cannot be reliably implemented, efforts need to be madeto identify interventions that have been previously adaptedand tested with a given population, such as those in the SIRCmodel, and implement them with fidelity. With the everexpanding number of rigorously tested, culturally specific,and culturally grounded interventions, it may seem feasibleat some point to have an ESI for every population in everycontext; however, the dynamic nature of culture and the vastdiversity among humans ensure that cultural adaptation willcontinue to be a likely necessity in the future.Authors’ NoteThis article was previously presented at the conference on Bridgingthe Research and Practice gap: A Symposium on Critical Considerations, Successes and Emerging Ideas, sponsored by the University ofHouston Graduate College of Social Work, Houston, TX, April 5–6,2013. This article was invited and accepted by the Guest Editor of thisspecial issue, Danielle E. Parrish, PhD The content of this article issolely the responsibility of the authors and does not necessarily represent the official views of NIMHD or the NIH.Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect tothe research, authorship, and/or publication of this article.FundingThe authors disclosed receipt of the following financial support for theresearch, authorship, and/or publication of this article: This researchwas supported by the National Institute on Minority Health and HealthDisparities (NIMHD) of the National Institutes of Health (NIH GrantP20MD002316-05, to Flavio F. Marsiglia, principal investigator).ReferencesBarrera, M., & Castro, F. G. (2006). A heuristic framework for thecultural adaptation of interventions. Clinical Psychology: Scienceand Practice, 13, 311–316.Bernal, G., Jime´nez-Chafey, M. I., & Domenech Rodrı´guez, M. M.(2009). 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