A Model for Adapting Evidence-based Behavioral Interventions to a New Culture: HIV Prevention for Psychiatric Patients in Rio de Janeiro, Brazil

Columbia University, New York, New York, United States
AIDS and Behavior (Impact Factor: 3.49). 10/2007; 11(6):872-883. DOI: 10.1007/s10461-006-9181-8


As in other countries worldwide, adults with severe mental illness in Brazil have elevated rates of HIV infection relative
to the general population. However, no HIV prevention interventions have been tested for efficacy with psychiatric patients
in Brazil. We conducted participatory research with local providers, community leaders, patient advocates, and patients using
an intervention adaptation process designed to balance fidelity to efficacious interventions developed elsewhere with fit
to a new context and culture. Our process for adapting these interventions comprised four steps: (1) optimizing fidelity;
(2) optimizing fit; (3) balancing fidelity and fit; and (4) pilot testing and refining the intervention. This paper describes
how these steps were carried out to produce a Brazilian HIV prevention intervention for people with severe mental illness.
Our process may serve as a model for adapting existing efficacious interventions to new groups and cultures, whether at a
local, national, or international level.

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Available from: Milton L Wainberg, Sep 06, 2015
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    • "Methods to adapt evidence-based HIV intervention have been duly noted in the literature (e.g., McKleroy et al., 2006; Wainberg et al., 2007; Wechsberg et al., 2010; Wingood & DiClemente, 2008). McKleroy et al. (2006), Wainberg et al. (2007), Wingood and DiClemente (2008), and Wechsberg et al. (2010) report similar adaptation processes of evidencebased HIV interventions. An overview of these adaption processes includes (a) assessing the needs of the target population who is at risk of HIV through focus groups and interviewers with key stakeholders in the community; (b) choosing an appropriate HIV intervention; (c) eliciting the opinions of the target population and key stakeholders on the intervention; (d) using the knowledge gained from the focus groups and interviews that adapt the intervention while keeping with the fidelity of the core elements and characteristics of the original intervention; (e) having members of the target population, key stakeholders, and experts in HIV interventions give feedback on the adapted intervention; and (f) training staff to implement the intervention so that the efficacy of the intervention can be determined. "
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    ABSTRACT: The convergence of the high prevalence of HIV incidence among African American adolescent and adult women along with substance use and risky sexual behavior among university students necessitates the development of a HIV intervention specifically addressing culture, gender, and college factors for female African American university students. The woman-focused HIV intervention was chosen for adaptation because it has been shown to be efficacious with reducing risk for African American women who use alcohol and drugs, and has been successfully adapted 7 times. The target population was African American college women enrolled at a historically Black university who use alcohol and other drugs, and who engaged in risky sex behaviors. To understand and assess the needs of this population, we conducted four focus groups with African American college women, two in-depth interviews with faculty, and a combination of in-depth interviews and focus groups with student affairs and health staff that were analyzed using content analysis. From this analysis, several themes emerged that were used to adapt the intervention. Emerging themes included challenges related to identity and societal stereotypes, lack of knowledge about sexual health (i.e., negotiating safer sex) and the function of female and male anatomies, high incidents of pregnancy, negative consequences related to alcohol and marijuana use, and the need to incorporate testimonies from college students, media enhancements, and role-plays to convey intervention messages. After the preliminary adaptation, 11 college women reviewed the adapted intervention and provided positive feedback. Plans for future research are discussed.
    Full-text · Article · Oct 2012 · SAGE Open
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    • "Table 1 integrates health intervention adaptation activities delineated in systematic stage models (Barrera & Castro, 2006; Kumpfer et al., 2008; McKleroy et al., 2006; Wingood & DiClemente, 2008). HIV/AIDS has been the subject of more stage models for the cultural adaptation of interventions than any other health condition (Card, Solomon, & Cunningham, 2011; Dévieux, Malow, Rosenberg, & Dyer, 2004; Dworkin, Pinto, Hunter, Rapkin, & Remien, 2008; Kelly et al., 2000; McKleroy et al., 2006; Solomon, Card, & Malow, 2006; Tortolero et al., 2005; Wainberg et al., 2007; Wingood & DiClemente, 2008), in part because of National Institutes of Health directives that called for such adaptations (Bell et al., 2007). A critical aspect of cultural adaptation stage models is that they integrate " top-down " and " bottom-up " approaches. "
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    ABSTRACT: Objective: To reduce health disparities, behavioral health interventions must reach subcultural groups and demonstrate effectiveness in improving their health behaviors and outcomes. One approach to developing such health interventions is to culturally adapt original evidence-based interventions. The goals of the article are to (a) describe consensus on the stages involved in developing cultural adaptations, (b) identify common elements in cultural adaptations, (c) examine evidence on the effectiveness of culturally enhanced interventions for various health conditions, and (d) pose questions for future research. Method: Influential literature from the past decade was examined to identify points of consensus. Results: There is agreement that cultural adaptation can be organized into 5 stages: information gathering, preliminary design, preliminary testing, refinement, and final trial. With few exceptions, reviews of several health conditions (e.g., AIDS, asthma, diabetes) concluded that culturally enhanced interventions are more effective in improving health outcomes than usual care or other control conditions. Conclusions: Progress has been made in establishing methods for conducting cultural adaptations and providing evidence of their effectiveness. Future research should include evaluations of cultural adaptations developed in stages, tests to determine the effectiveness of cultural adaptations relative to the original versions, and studies that advance our understanding of cultural constructs' contributions to intervention engagement and efficacy. (PsycINFO Database Record (c) 2012 APA, all rights reserved).
    Full-text · Article · Jan 2012 · Journal of Consulting and Clinical Psychology
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    • "In our framework, the adaptation process consists of the following seven steps: (1) Select a suitable effective program; (2) gather the original program materials; (3) develop a program model; (4) identify the program's core components and best-practice characteristics; (5) identify and categorize mismatches between the original program model or materials and the new context ; (6) adapt the original program model, if warranted; and (7) adapt the original program materials. These steps have been synthesized from a review of the scientific literature on the adaptation of teen pregnancy, sexually transmitted infection (STI), and HIV prevention programs (Bell et al., 2007; Dévieux, Malow, Rosenberg, & Dyer, 2004; Dworkin, Pinto, Hunter, Rapkin, & Remien, 2008; Kelly et al., 2000; Kirby, 2007; McKleroy et al., 2006; Solomon et al., 2006; Stanton et al., 2005; Tortolero et al., 2005; Wainberg et al., 2007; Wingood & DiClemente, 2008). The step framework encourages practitioners to make culturally competent changes to a program to better suit a priority population , but only when needed and only when certain constraints­ such as adherence to the original program's theory of change and core components as well as to the literature on best practicesare met. "
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    ABSTRACT: A wide variety of underused effective HIV prevention programs exist. This article describes sources for obtaining such effective programs and issues to consider in selecting an existing effective program for use with one's priority population. It also discusses seven steps involved in adapting an effective program to meet the needs of a new context while preserving core components (what made, or is believed to have made, the intervention effective in the first place) and best practices (characteristics common to effective programs). Although the examples presented are from the HIV prevention field, the seven-step framework is applicable to the adaptation of effective programs in other health promotion and disease prevention arenas.
    Full-text · Article · Oct 2009 · Health Promotion Practice
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