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Different Strokes for Different Folks? Contrasting Approaches
to Cultural Adaptation of Parenting Interventions
Anilena Mejia
1
&Patty Leijten
2,3
&Jamie M. Lachman
2
&José Ruben Parra-Cardona
4
#Society for Prevention Research 2016
Abstract Relevant achievements have been accomplished in
prevention science with regard to disseminating efficacious
parenting interventions among underserved populations.
However, widespread disparities in availability of parenting
services continue to negatively impact diverse populations in
high-income countries (e.g., the USA) and low- and middle-
income countries. As a result, a scholarly debate on cultural
adaptation has evolved over the years. Specifically, some
scholars have argued that in diverse cultural contexts, existing
evidence-based parenting interventions should be delivered
with strict fidelity to ensure effectiveness. Others haveempha-
sized the need for cultural adaptations of interventions when
disseminated among diverse populations. In this paper, we
propose that discussions on cultural adaptation should be con-
ceptualized as a Bboth-and,^rather than an Beither-or^pro-
cess. To justify this stance, wedescribe three distinct parenting
intervention projects to illustrate how cultural adaptation and
efficacy of evidence-based interventions can be achieved
using contrasting approaches and frameworks, depending on
cultural preferences and available resources of local contexts.
Further, we suggest the need to develop guidelines for consis-
tent reporting of cultural adaptation procedures as a critical
component of future investigations. This discussion is relevant
for the broader public health field and prevention science.
Keywords Cultural adaptation .Health disparities .Parenting
interventions .Low- and middle-income countries .Ethnic
minorities
Relevant achievements have been accomplished in the pre-
vention field with regards to disseminating culturally relevant
and efficacious mental health interventions among ethnically
diverse populations (Castro, Barrera, and Holleran Steiker
2010; Updegraff and Umaña-Taylor 2015). However, wide-
spread mental health disparities continue to negatively impact
diverse populations in high-income countries (HIC), as well as
low- and middle-income countries (LMICs) (Collins et al.
2011). Addressing mental health disparities worldwide has
been recognized as a pressing priority by leading organiza-
tions such as the Society for Prevention Research (Hawkins
et al. 2015) and the Institute of Medicine (2009). International
initiatives such as the global mental health movement have
historically advocated for increased access to evidence-based
services, particularly in LMICs (Patel and Prince 2010).
However, as efforts expand across cultures (e.g., Matos,
Bauermeister, and Bernal 2009), so do inherent dilemmas re-
garding the extent to which mental health interventions re-
quire contextual adaptation without compromising interven-
tion effectiveness.
A highly promising area within the global mental health
movement refers to the dissemination of efficacious parenting
interventions based on their demonstrated capacity to prevent
physical, behavioral, and emotional difficulties in children and
youth (Institute of Medicine 2009). Parenting interventions
have been shown to be effective in reducing child maltreat-
ment and child behavior problems, as well as improving the
*Anilena Mejia
amejia@indicasat.org.pa
1
Instituto de Investigaciones Científicas y Servicios de Alta
Tecnología (INDICASATAIP), Clayton Edificio 219, Ciudad del
Saber, Panamá
2
University of Oxford, Oxford, UK
3
University of Amsterdam, Amsterdam, Netherlands
4
Michigan State University, East Lansing, MI, USA
Prev Sci
DOI 10.1007/s11121-016-0671-2
quality of parenting practices and overall family well-being
(Barlow, Coren, and Stewart-Brown 2002;Barlow,Smailagic,
Ferriter, Bennett, and Jones 2010). However, the literature on
their effectiveness among underserved and ethnically diverse
populations continues to be underdeveloped (Knerr, Gardner,
and Cluver 2013; Mejia, Calam, and Sanders 2012). Thus, it is
key to increase access to evidence-based parenting interven-
tions among underserved populations and to understand the
best approaches in design and service delivery that are neces-
sary to achieve this goal (Ward, Sanders, Gardner, Mikton,
and Dawes 2016).
The Concept of Cultural Adaptation
Cultural adaptation has been defined as Bthe systematic mod-
ification of an evidence-based treatment or intervention
protocol to consider language, culture, and context in such a
way that it is compatible with the client’s cultural patterns,
meanings, and values^(Bernal et al. 2009; p.362). Cultural
adaptation is often understood as the adaptation of an existing
intervention. However, it is also possible to extract compo-
nents of existing evidence-based interventions (Chorpita,
Daleiden, and Weisz 2005) to create new culturally tailored
parenting program manuals (e.g., Lachman et al. 2016a,b).
This process is not traditionally encompassed under the um-
brella of cultural adaptation research, although it often utilizes
its tools and frameworks. Our conceptualization of cultural
adaptation in this paper is broad, as it includes a case example
of extracting evidence-based principles to create a new par-
enting program manual responsive to local context.
Relevant conceptual frameworks and tools have been
developed to inform cultural adaptation studies. For example,
Resnicow et al. (2000) differentiate between surface-anddeep-
structure adaptations. Specifically, surface-level adaptations re-
fer to changes in materials or activities of the intervention in order
to fit specific characteristics of the target population (e.g., lan-
guage, music). In contrast, deep-structure adaptations involve
addressing deeper cultural, social, or historical factors that influ-
ence the life experiences of the target population. In Resnicow
et al. (2000) framework, cultural adaptation is understood as a
continuum ranging from relatively minor changes to interven-
tions (e.g., translation of materials), to deeper structural adapta-
tions (e.g., changes in the content).
Bernal et al. (1995) Ecological Validity Model (EVM) in-
cludes eight well-defined and interrelated dimensions: (a) lan-
guage, (b) persons, (c) metaphors,(d) content,(e) concepts, (f)
goals, (g) methods, and (h) context. The dimension of
language refers to the adaptations that are required to achieve
multiple expressions of linguistic relevance with the target
populations (e.g., vocabulary used by interventionists). The
dimension of persons highlights the need to match ethnicity
and native language of clients with research staff involved in
recruitment and intervention delivery efforts. Metaphors refer
to symbols and concepts that represent an alignment with the
cultural values and experiences of targeted populations.
Content consists of ensuring that themes align with the clients’
socio-cultural worldviews. Goals are closely related to content
in that the objectives of interventions must match the experi-
ences and expectations of target populations. Finally, context
and methods refer to the importance of considering the con-
textual characteristics of communities and social enclaves in
which populations live (context) and the ways in which all
phases of intervention activities (e.g., recruitment, delivery)
will be informed accordingly (methods).
The cultural adaptation framework proposed by Barrera
and Castro (2006) consists of four adaptation stages identified
as (a) information gathering, (b) preliminary adaptation de-
sign, (c) preliminary adaptation tests, and (d) adaptation
refinement. These stages integrate both top-down and
bottom-up approaches. That is, although cultural adaptation
might start with initial efficacy trials (i.e., top-down ap-
proach), active input is permanently sought from the targeted
groups in order to ensure cultural relevance. As a result, there
is a continuous process of adaptation at multiple levels aimed
at achieving cultural relevance (i.e., bottom-up). To ensure
rigor of the adaptation process, interventions must ultimately
be evaluated (Barrera and Castro 2006).
Whereas the aforementioned frameworks have distinct fea-
tures, they also have clear commonalities. For example, all
models emphasize the importance of cultural relevance.
Cultural relevance can be defined as ensuring that intervention
components and procedures remain syntonic with the cultural
values and day-to-day experiences of target populations
(Castro, Barrera, and Martinez 2004). Achieving cultural rele-
vance is a necessary goal to ensure feasibility of implementa-
tion as well as change on target outcomes (Bernal et al. 1995).
The Fidelity versus Cultural Adaptation Debate
Historically, tensions between intervention fidelity and popu-
lation fit have been central to the prevention field. This paper
focuses specifically on the cultural adaptation debate as it
refers to parenting intervention research.
The Society for Prevention Research (SPR) has provided
an intellectual platform for a scientific debate on fidelity ver-
sus cultural adaptation. Some scholars originally suggested
that evidence-based mental health interventions should be
adapted and tailored to diverse populations in order to achieve
optimal engagement, cultural satisfaction, and overall inter-
vention impact (Castro et al. 2004). On the other hand, critics
have argued that modifications to original efficacious inter-
ventions can diminish the impact of core ingredients and
mechanisms of change (Elliott and Mihalic 2004). These
scholars support strict fidelity and adherence to original
Prev Sci
interventions in order to ensure efficacy and effectiveness
(Elliott and Mihalic 2004; Chambless and Ollendick 2001).
Empirical evidence informing this debate continues to be
generated. For example, meta-analytic studies on cultural ad-
aptation of mental health interventions indicate that culturally
adapted interventions are more efficacious than interventions
without cultural adaptations (Benish, Quintana, and Wampold
2011; Griner and Smith 2006; Sundell, Beelmann, Hasson,
and von Thiele Schwarz 2015). Unfortunately, research is
scarce in the field of parenting interventions specifically.
One meta-analytic study did not corroborate the need for cul-
tural adaptation (Gardner, Montgomery, and Knerr 2015).
Specifically, Gardner et al. (2015) study suggested that origi-
nal and generally nonadapted parenting interventions were
more effective when transported to countries that did not share
the contextual and cultural characteristics of the countries in
which the interventions were originally developed. These
findings indicate that regardless of cultural differences, par-
enting interventions can be efficacious when transported to
new contexts if delivered with fidelity. However, findings
from this meta-analysis must be considered with caution as
it only included 11 studies.
The fidelity versus adaptation debate continues to be rele-
vant, but empirical evidence supporting either side of the argu-
ment remains inconclusive. A major limitation is that proce-
dures to make parenting interventions relevant and appropriate
in diverse cultural settings have not been systematically
documented in most trials. Gardner et al. (2015) meta-
analysis could not include any information on whether inter-
ventions were adapted or not, because adaptations were not
reported in the original papers. BIn situ^modifications (i.e.,
adaptations that are not systematically planned but rather occur
in the moment or in vivo) are often not measured throughout
service delivery (Miller-Day et al. 2013). Other meta-analyses,
such as Sundell et al. (2015), use a dichotomous approach to
adaptation (i.e., adapted versus nonadapted). This fits with the
tendency of the field to use an Beither-or^approach (i.e., strict
fidelity versus complete adaptation).
In this paper, we intend to move beyond this approach and
take a closer look at the broad range of adaptations that can be
conducted depending on available resources in specific con-
texts. In other words, we propose that a way to move forward
the fidelity versus adaptation debate refers to understanding
cultural adaptation as a Bboth-and^rather than an Beither-or^
process. We present insights from three cases of parenting
interventions evaluated with diverse populations in contrast-
ing settings. These cases are used to illustrate that cultural
adaptation can be a flexible process, should be informed ac-
cording to existing local resources, and remain responsive to
specific cultural contexts. That is, cultural adaptation can in-
tegrate fidelity to original components accounting for inter-
vention efficacy, while ensuring high cultural relevance.
Furthermore, as the cases demonstrate, the path to achieving
efficacy and cultural relevance is not rigid and can be under-
taken with diverse procedures.
Three Contrasting Cases Demonstrating Diversity
in Cultural Adaptation Research
In this section, we present two case examples of culturally
adapted parenting interventions implemented with Latino
populations in contrasting international settings (Panamá and
the USA). A third case, while not strictly an adaptation of a
specific parenting intervention, modified evidence-based prin-
ciples and components that are common to most parenting
program manuals within a South African cultural context.
All cases have in common the aim of reaching parents in a
culturally sensitive way. Each used a different approach to
reach this aim and was carried out independently (i.e.,
Panamá, USA, and South Africa). Resembling the Resnicow
et al. (2000) conceptualization of cultural adaptation, the first
two cases illustrate contrasting approaches to cultural adapta-
tion that ranged from surface-level (e.g., refinement of mea-
sures, translation) to deep-structure adaptations (e.g., revised
content, qualitative studies). The third case is an illustration of
a culturally focused process. Although this intervention inte-
grates common principles and approaches from evidence-
based parenting interventions, a context and culture-specific
program manual was developed to fully respond to the cultur-
al experiences of the target population.
Tab le 1summarizes how activities undertaken in each pro-
ject align with frameworks previously discussed (i.e.,
Resnicow et al. 2000; Bernal et al. 1995; Barrera and Castro
2006). Table 2delineates the research design of each case and
the main findings.
Case Number 1: Checking for Cultural Relevance Prior
Adaptation
In this case, cultural relevance checks were conducted before
deciding to invest in a cultural adaptation process. The cultural
relevance and initial efficacy of the Triple P Positive Parenting
Program (Sanders 2012) was assessed with families from
high-risk low-income communities in Panamá City, Panama.
Most families had a monthly income below US$300, were
seeking help to deal with child behavioral difficulties, and
self-identified as mestizos or African descendants. Triple P
is an intervention originally developed in Australia with
strong evidence of efficacy according to multiple studies in
diverse contexts (Nowak and Heinrichs 2008). However, this
was its first evaluation in a LMIC.
Prior to adaptation, cultural relevance checks were con-
ducted with both parents (n= 120) and potential facilitators
of the intervention (i.e., school-based practitioners; n=80).
This is in line with the information gathering stage from
Prev Sci
Barrera and Castro’s framework (2006). The rationale for
assessing cultural relevance prior adaptation was that modifi-
cations might not be needed if local communities considered
the original content as relevant and appropriate. Therefore,
Mejia and colleagues decided to show a sample of program
materials (i.e., videos and workbooks from the Triple P Every
Parent Survival Guide) to a group of parents and local
practitioners. An instrument previously published by Metzler
et al. (2011) was used for measuring consumer preferences.
Parents were firstly presented with sample materials of the
intervention and then asked to rate these materials and its
content. Metzler et al. (2011) instrument has no cutoff scores,
but ratings can range from 7 to 15 for utility, 9 to 17 for
relevance, and 4 to 10 for interest. In this study, utility ratings
averaged 13.41 (SD = 1.71), relevance ratings averaged 16.37
(SD = 2.34), and interest ratings averaged 9.24 (SD = 0.96)
(Mejia, Calam, and Sanders 2014a). Local practitioners
showed comparable scores. In a scale from 1 to 5, utility
ratings were M=4.58 (SD=0.65), interest ratings were
M= 4.46 (SD = 0.67), familiarity ratings were M=4.25
(SD = 0.88), and acceptability ratings were M=4.42
(SD = 0.86) (Mejia et al. 2014b).
These findings indicated to researchers that the intervention
was culturally relevant in its original form, and thus, an exten-
sive adaptation process of the content was not undertaken.
However, superficial-structure adaptations (Resnicow et al.
2000) were conducted, specifically (1) translating materials
into Spanish and (2) having the intervention delivered by a
local facilitator. Nevertheless, a posteriori reflections sug-
gested that un-measured adaptations were conducted in situ
by the facilitator in order to ensure cultural fit during delivery.
For example, the facilitator used culturally relevant metaphors
to introduce specific skills and reflect on local challenges. An
icebreaker activity was introduced at the start of the session,
which is a common practice in this culture to prompt interac-
tion between participants.
After exploring cultural relevance, a pilot efficacy trial was
conducted with 108 parents of children 3 to 12 years old
(Mejia, Calam, and Sanders 2015). Primary outcome measure
was child behavioral difficulties as reported by parents using
the Eyberg Child Behavior Inventory (Eyberg and Pincus
1999). Effect sizes were d= 0.52 at post-intervention,
d= 0.42 at 3 months follow-up, and d= 1.09 at 6 months fol-
low-up. As recommended in the preliminary adaptation tests
stage from Barrera and Castro’sframework(2006), a qualita-
tive study was conducted after the trial with a group of parents
that took part in the intervention (n= 25). Qualitative results
confirmed cultural relevance of the original program manual.
However, some further adaptations were suggested at this
point, specifically including additional support for dealing
with neighborhood violence and poverty.
In summary, Mejia and colleagues opted for establishing
cultural relevance of an original parenting program manual
Tab l e 1 Procedures undertaken in each case example according to cultural adaptation frameworks
Case Examples Resnicow et al. (2000) Bernaletal.(1995) Barrera and Castro (2006)
Superficial-
structure
adaptations
Deeper-
structure
adaptations
Language Person Metaphor Content Goals Methods Context Information
gathering
Preliminary
adaptation
Preliminary
adaptation
test
Adaptation
refinement
Case 1: checking cultural relevance
of Triple P in Panamá
✓✓✓✓ ✓✓✓
Case 2: differential cultural
adaptations of PMTO for Latinos
in the US
✓✓✓✓✓✓✓✓✓✓ ✓✓✓
Case 3: adapting evidence-based
principles to develop the
Sinoyuyo parenting program in South
Africa
✓✓✓✓✓✓✓✓✓✓✓✓
Prev Sci
Tab l e 2 Description of each project
Case 1: checking cultural relevance of Triple P in Panama Case 2: differential cultural adaptations of PMTO for
Latinos in the US
Case 3: adapting evidence-based principles to develop
the Sinovuyo parenting program in South Africa
Research design 1. Quantitative surveys with parents and practitioners
2. Pilot RCT
3. Qualitative interviews
1. Differential cultural adaptation RCT to compare CA
versus CE
1. Identification of evidence-based parenting program components
2. Qualitative evaluation with parents and service providers
3. Pilot RCT
Target audience Parents of children 3 to 12 years in high-risk low-income
neighborhoods in Panama City
First-generation Latino parents of children4to12yearsin
Detroit, Michigan
Low-income, isiXhosa-speaking parents of children aged 2
to9yearsinSouthAfrica
Intervention Triple P single-session discussion group delivered over 2 h +
two 15-min telephone support sessions
CA consisted of the adaptation of core PMTO components.
CE consisted of CA plus two culturally focused sessions
Sinovuyo Caring Families Program, a 12-session group-
based parenting program
Intervention aims To reduce child externalizing difficulties and improve
parenting skills
To increase quality of parenting skills and reduce child
internalizing and externalizing difficulties
To reduce the risk of child maltreatment, improve positive
parenting, and reduce child externalizing difficulties
Outcomes 1. Parent-reported child behavioral difficulties, parenting
practices and parental stress
1. Quality of parenting skills
2. Parent-reported child externalizing and internalizing
difficulties
1. Parent-reported harsh parenting, positive parenting, and
child externalizing difficulties.
2. Observational assessments of positive parenting, harsh
parenting, positive child behavior, and negative child behavior
Process evaluation
(if any)
Not conducted Not conducted Qualitative and quantitative assessments of cultural
acceptability, implementation fidelity and quality of
delivery, and participant involvement (enrolment,
attendance, and dropout)
Significant results Cultural relevance by parents: utility of intervention M=13.41
(SD = 1.71, range 7–15); relevance of intervention M=16.37
(SD = 2.34, range 9–17); interest level with materials
M=9.24(SD=0.96,range 4–10)
Efficacy on child behavior difficulties: compared to control,
d= .52 at post-intervention; d= .42 at 3-month follow-up,
and d= 1.09 at 6-month follow-up
Qualitative results:
(i) Cultural context in which families live. Included codes on
economic difficulties, living in a dangerous world,
struggling in balancing parenting and work, and using tough
communication patterns
(ii) Appropriateness of the intervention. Included codes on
relevance of content and materials, physical resemblance
of actors in videos, socio-economic differences with parents in
videos, and recommendations for delivery (e.g., reaching more
community members, facilitator having contact with child)
Efficacy on child internalizing difficulties:Comparedto
CA and control, CE effects were d=−0.5 at post-
intervention; d=−0.9 at 6-month follow-up
Efficacy on child externalizing difficulties:Comparedto
CA and control, CE effects in fathers were d=−0.6 at
post-intervention; d=−1.0 at 6-month follow-up
Cultural relevance by parents:
Out of a total score of 100, overall satisfaction M=94.22
(SD = 5.12), ability to meet parent goals M=89.55
(SD = 8.27), format of delivery M= 94.41 (SD = 11.97),
appropriateness of parenting skills M= 96.00 (SD = 5.81),
quality of delivery M= 98.62 (SD = 3.24), group
supportiveness M= 97.24 (SD = 3.79)
Efficacy on positive parenting:
Compared to control, d= 0.63 for parent report; d=0.57for
observational assessments
Qualitative results:
(i) Participant involvement
Included codes on structural and programmatic components
used to support participation and engagement
(ii) Implementation feasibility
Included codes on strengthening fidelity and competency
by community facilitators
(iii) Cultural acceptability
Includes codes on receptivity to existing parenting practices,
resistance to introduction of new practices, and the
importance of contextualizing content within a local
cultural framework
Participation rates 85 % of those recruited participated in the intervention 87 % of those recruited were retained (84 % of fathers) 85 % of those recruited participated in the intervention
Prev Sci
instead of conducting a priori adaptations. According to
Barrera and Castro’s(2006) framework, this can be defined
as an information gathering stage. Survey data prior to the trial
suggested high cultural relevance of the intervention in this
setting, and thus, only superficial-structure adaptations were
conducted (Resnicow et al. 2000). These adaptations were test-
ed in a pilot trial, and following the trial, some further recom-
mendations were collected through qualitative interviews (i.e.,
preliminary adaptation tests as referred to by Barrera and
Castro 2006). This approach might be appropriate in contexts
where resources are not available for deeper-structure adapta-
tion. Some in situ cultural adaptations took place during deliv-
ery, which suggests a need for developing instruments to keep
track of such processes when working across cultures.
Case Number 2: Differential Cultural Adaptation
In this case, two differentially culturally adapted versions of
the Parent Management Training—The Oregon Model
(PMTO
R
)—were evaluated with low-income Latino/a immi-
grants residing in Detroit, Michigan. The original PMTO in-
tervention was developed with a majority of Euro-American
parents (Forgatch, Patterson, DeGarmo, and Beldavs 2009).
The first adapted version of PMTO for Latino/a families
was developed and piloted by Domenech-Rodriguez et al.
(2011) with parents in the southwest (n= 85). This version is
known as CAPAS-Criando con Amor,Promoviendo Armonia
ySuperación(Raising Kids with Love, Promoting Harmony
and Growth; CA). Adaptations were conducted according to
the Ecological Validity Model (Bernal et al. 1995). Materials
and language were adapted for appropriateness and relevance
with the Latino culture (language). Bilingual Latinos were in
charge of recruitment, data collection, and delivery (persons).
Culturally rich phrases and raps were incorporated throughout
the intervention (metaphors). The dimension of content guid-
ed the adaptation by identifying and addressing Latino values
in materials and sessions. Goals of the PMTO intervention
were reframed to ensure adequate match with the Latino cul-
ture (goals). For example, the promotion of discipline was
framed according to respeto and family harmony (i.e.,
familisimo). Finally, adaptations were made to ensure respon-
siveness to contextual challenges faced by the target commu-
nity (context and methods). For example, mid-week support
calls were dropped, as these were perceived as intrusive
(Domenech-Rodriguez, Baumann, and Schwartz 2011).
Building on CAPAS, Parra-Cardona and colleagues devel-
oped a culturally enhanced intervention known as BCAPAS-
Enhanced (CE)^(Parra Cardona et al. 2012; Parra-Cardona
et al. 2009). Specifically, the first CE session provided an
overall framework for the intervention focused on Latino cul-
ture, immigration, and biculturalism. This session helped par-
ents reflect on themes such as life as a Latino/a immigrant,
coping with racism and discrimination, and living between
two worlds (biculturalism). The last session focused on reflec-
tions about biculturalism and how the PMTO intervention
offers specific parenting tools to families that are conductive
to achieve biculturalism. In addition, each core PMTO com-
ponent throughout the intervention was introduced according
to immigration- and culturally focused reflections informed by
findings from a previous qualitative study (n= 83 parents).
Discrimination was identified as a salient theme in the quali-
tative study. Therefore, parents were asked to identify the
extent to which daily immigration-related stressors, such as
discrimination or work exploitation, increased the risk they
would engage in punitive limit settings practices with their
children due to accumulated stress and frustration.
Evaluation of CA and CE was informed by principles of
community-based participatory research (Fraenkel 2006). In
collaboration with community leaders, feasibility and initial ef-
ficacy of the two adapted interventions were examined.
Families (n= 103) were randomly allocated to one of three con-
ditions (i.e., CA, CE, or wait-list control), and outcomes were
measured at baseline, post-intervention, and 6-month follow-up.
In terms of feasibility, an overall retention rate of 87 % of
participating families was achieved. Participants in the CA and
CE interventions reported high satisfaction with all intervention
components with no statistically significant differences be-
tween adapted interventions (Parra Cardona et al. 2012). On a
scale from 1 to 5, satisfaction ratings across all sessions aver-
aged 4.52 (SD = 0.062) in CA and 4.57 (SD =0.05)in CE.
In terms of efficacy, multilevel growth modeling was chosen
as analytic strategy to explore differential efficacy of the two
versions. When compared to CA, a main effect for CE was
found for child-internalizing behaviors as measured with the
Child Behavior Checklist (CBCL; Achenbach 2009)atpost-
intervention (d=−0.5) and at 6-month follow-up (d=−0.9).
CE effects for child externalizing behaviors (also measured with
the CBCL) were found only for fathers at post-intervention
(d=−0.6) and follow-up (d=−1.0) (Parra-Cardona et al. 2015).
In summary, this project consisted of a long-term process of
adaptation which focused on expanding the original CA inter-
vention according to salient immigration and cultural experi-
ences reported by the targeted population. This is one of the
few reported trials testing differential cultural adaptation using
a three-group design. Although this design is relevant for the
study of cultural adaptation processes and mechanisms, scal-
ing up differently adapted interventions might present chal-
lenges. It might not be cost-effective or feasible to implement
different versions of an intervention at a large scale.
Case Number 3: Adapting Evidence-Based Principles
and Approaches for a Local Context
In this case, an evidence-informed, culturally relevant par-
enting program was developed and tested in order to reduce
the risk of child maltreatment in low-income South African
Prev Sci
families with children 2 to 9 years old (Lachman et al.
2016a,b). In contrast to the two preceding approaches, this
study did not target a specific pre-existing parenting inter-
vention for adaptation. Instead, the primary goal consisted
of examining the transferability of core intervention com-
ponents and principles of evidence-based parent manage-
ment training to a South African cultural context. This de-
cision was made partially due to high licensing fees and
unwillingness of original developers to sanction the inde-
pendent adaptation of existing evidence-based parenting
programs (Mikton 2012). Furthermore, although there were
many local parenting programs being implemented in South
Africa at the time of the study, a review demonstrated that
none were developed according to evidence-based theoret-
ical frameworks associated with parenting program effec-
tiveness (Wessels and Ward 2015).
The process of intervention development resembled proce-
dures in case no. 2, primarily in its community-based ap-
proach of collaborative research (Fraenkel 2006). Lachman
and colleagues developed the parenting intervention in three
stages. Firstly, authors started by identifying core evidence-
based parenting program components in systematic reviews
(e.g., Barlow et al. 2010), distillation studies (e.g., Chorpita
et al. 2005), implementation studies (Snell-Johns, Mendez,
and Smith 2004), and meta-analyses (e.g., Barlow et al.
2002). Existing protocols of parenting interventions that have
demonstrated effectiveness in multiple contexts were also
reviewed, such as the Incredible Years (Webster-Stratton
2001), Parent Management Training-Oregon (Forgatch et al.
2009), and the Triple P Positive Parenting Program (Sanders
2012). This stage developed theory of change and logic
models that specified core evidence-based components com-
mon to efficacious parenting programs (e.g., improving posi-
tive parenting behavior and reducing harsh and violent disci-
pline in order to reduce child behavior problems and improve
child socio-emotional regulation).
The second stage was a qualitative evaluation to assess
local stakeholders’perceptions regarding parenting inter-
vention content necessary for inclusion. Focus groups with
service providers (n= 4; 29 participants) plus interviews
(n= 11) and focus groups (n= 10; 86 participants) with
low-income parents examined the suitability of evidence-
based parenting intervention components, the potential
need for additional culturally specific content, and barriers
to implementation and participation. Thematic analyses
identified three themes consistent with components found
in evidence-based parenting programs (e.g., managing child
behavior problems, addressing corporal punishment, and
building positive relationships with children). Results also
found additional themes specific to a low-income context
(e.g., child safety in high-crime communities, involving fa-
thers in parenting, and communicating about HIV/AIDS)
(Lachman et al. 2016a,b).
In the third stage, the research team convened a series of
workgroups to assess the relevance of evidence-based parent-
ing intervention components for the target population
(Lachman et al. 2016a,b). The workgroups also examined
the extent to which local contextual factors might affect the
integrity of evidence-based parenting principles. These
workgroups resulted in the design and manualization of a
new evidence-informed, locally relevant parenting program
called the Sinovuyo Caring Families Program.This12-ses-
sion, group-based parenting program incorporates core com-
ponents of evidence-based interventions previously described,
as well as content specific to a sub-Saharan African context
including communicating about HIV/AIDS and parental mor-
tality and child safety in highly violent communities. Finally,
the program is framed within a culturalcontext of constructing
aBrondavel^or traditional hut common in many sub-Saharan
African cultures. Based on Hanf’s work on parent manage-
ment training (Hanf 1969), program content focuses on build-
ing mud walls (i.e., positive parent-child relationships) before
adding a thatch roof (i.e., limit-setting and nonviolent disci-
pline strategies) to their Brondavel of support.^
The parenting intervention was subsequently piloted in a
randomized controlled trial (n= 68). Process evaluation
measures included attendance registers, fidelity checklists
derived from the newly developed parenting program man-
ual activities, client satisfaction surveys, and qualitative fo-
cus groups with parents and community facilitators (n=8).
Findings demonstrated that the parenting intervention was
feasible in active participation by low-income families (en-
rolled parents attended an average of 8.5 out of 12 sessions)
and implementation fidelity by community facilitators
(93.0 % of the manualized activities were delivered).
Qualitative data also suggested that the cultural framing of
intervention content was identified as a critical element in
overcoming initial barriers to engagement and participation
(Lachman et al. 2016a,b). Initial efficacy results showed
medium intervention effects for parent-reported positive par-
entingasmeasuredwiththeParentingofYoungChildren
Scale (McEachern et al. 2011) in comparison to controls
(d= 0.63). Observational assessments also found significant
intervention effects for frequency of child-led play
(d= 0.57). The program manual was revised, and the content
was strengthened; specifically, (1) sessions on nonviolent
discipline were added and (2) a parent handbook was devel-
oped. A full-scale randomized controlled trial is currently
taking place (n= 296 families).
In summary, this approach demonstrated the utility of
using community-oriented tools to develop a parenting pro-
gram that integrates evidence-based core components. The
project was part of a larger research initiated by the World
Health Organization and UNICEF called Parenting for
Lifelong Health. This initiative is committed to developing
evidence-based and affordable parenting programs to
Prev Sci
prevent child maltreatment and improve child well-being in
LMICs (Ward et al. 2014). As a result, all program materials
were made freely available using Creative Commons copy-
right licensing that allows for free distribution of the program
while restricting adaptation without the permission of the
original authors.
Discussion
Research trying to identify how to offer culturally relevant and
efficacious parenting interventions continues to evolve. By
discussing three distinct examples, we make a case for ac-
knowledging the complexities involved when attempting to
reach diverse populations living in contrasting contexts in a
culturally sensitive way. The three approaches discussed re-
sulted in high rates of participant satisfaction with the inter-
ventions, high rates of engagement and retention, and positive
effects on family well-being. The promising findings from the
three case examples support the argument that responding in a
culturally sensitive manner can be achieved successfully ac-
cording to diverse approaches (Baumann et al. 2015). Thus,
the process of cultural adaptation can be perceived as a con-
tinuum of possibilities ranging from few and targeted adapta-
tions that entail minimal costs, to more comprehensive and
expensive approaches (Castro et al. 2004).
Details about cultural adaptation as provided in Table 1
are often missing in publications. This might be in part be-
cause cultural adaptation often occurs without researchers
or clinicians being fully aware of the process. Some authors
have referred to this process as Bin situ^or Bin-vivo^mod-
ifications (Miller-Day et al. 2013;Mooreetal.2012).
Future efforts could aim to develop user-friendly methods
and instruments to record adaptations throughout interven-
tion delivery.
In addition, journals often do not ask for detailed reporting
of possible alterations of the original intervention. Although
SPR guidelines recommend reporting implementation fidelity
procedures to ensure adherence to original interventions and
protocols (Gottfredson et al. 2015), there is no consensus on
whether to—or how to—report types and procedures for cul-
tural adaptation. These guidelines could be modeled on rec-
ommendations similar to the ones described in CONSORT
(Schultz et al. 2010) and TREND (Fuller, Pearson, Peters,
and Anderson 2012), which are international guidelines seek-
ing to create uniformity in the reporting procedures of ran-
domized and nonrandomized evaluations (Armstrong et al.
2008). The nonpharmacological extension of CONSORT sug-
gests that authors should provide a Bdescription of the differ-
ent components of the interventions and,when applicable,
descriptions of the procedure for tailoring the interventions
to individual participants^(Boutron, Moher, Altman, Schulz,
and Ravaud 2008). No further guidelines are provided in
CONSORT about which elements of cultural tailoring proce-
dures should be discussed. Such guidelines can increase
transparency and consistency in the reporting of cultural ad-
aptations that currently tend to happen Bin situ^and without
systematic documentation.
Another critical issue in the context of cultural adapta-
tions is that some interventions may be more flexible than
others and may require less formal adaptations. More spe-
cifically, an alternative to adaptations (e.g., inbuilt changes
to an intervention) might be to focus instead on sensitivity
(e.g., inbuilt flexibility of an intervention). Thus, evidence-
based interventions can have explicit inbuilt flexibility that
allows both therapists and parents to adjust parenting tech-
niques according to their specific cultural values and
norms (e.g., Webster-Stratton 2009). Culturally sensitive
interventions may be particularly versatile for diverse con-
texts and LMICs where families are experiencing continu-
ous political, economic, and social transformation (Bonell,
Fletcher, Morton, Lorenc, and Moore 2012).
Other important questions about the needs and effects of
cultural adaptations remain unanswered. It would be inter-
esting to explore the impact of different levels of cultural
adaptation on intervention effectiveness (Castro et al.
2010). Although our case no. 2 is an example of such
efforts, these types of studies are scarce, mainly because
large dissemination of differently adapted versions requires
substantial resources. A disagreement remains on whether
comprehensive cultural adaptation processes are cost-
effective and sustainable given the limited resources avail-
able for such procedures, especially in LMICs (Wainberg
et al. 2007). There is still a need to develop models that are
culturally sensitive but that are capable of achieving high
implementation feasibility, and cost-effectiveness, particu-
larly when considering dissemination in LMICs (Solomon,
Card, and Malow 2006; Stanton 2005).
Concluding Remarks
We presented three case examples to show how different,
and sometimes even contrasting, approaches to cultural
adaptations can lead to effective parenting interventions
that are well-received by diverse families. We highlighted
the need for a more nuanced thinking about cultural ad-
aptations, moving from a dichotomous Beither-or^per-
spectivetoaninclusiveBboth-and^approach. We offered
multiple ways to consider adaptation in an attempt to
broaden this important discussion beyond the current
thinking. Finally, we discussed the need for developing
reporting guidelines to increase insight into the process
of cultural adaptation and its effects on parenting inter-
vention effectiveness.
Prev Sci
Compliance with Ethical Standards The three case examples de-
scribed in this paper received ethical clearance from the committee of
the sponsor academic institution.
Disclosures of Conflict of Interest AM worked as a Postdoctoral
Research Fellow from May 2016 until December 2016 at the Parenting
and Family Support Centre (PFSC; University of Queensland), which
receives royalties from the dissemination of the Triple P Positive
Parenting Program around the world. She is not a member of staff at this
institution anymore, is not a contributing author in any of the program
variants and has never received any royalties from Triple P. JML is a co-
developer of the Sinovuyo Caring Families Program. He is also the
Executive Director of Clowns without Borders South Africa, the partner
organization responsible for implementation of the program. PL and
JRPC have no conflicts of interest to declare.
Informed consent Informed consent was collected from all partici-
pants in the three case examples.
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