Implement an Evidence Based Program

Section 4.2

Adapting Programs to Local Needs and Preferences While Maintaining Fidelity

Before determining which changes can be made to a given program without endangering fidelity, it is wise to reconsider your selection. Adapting the program could ultimately require more resources than would be required to implement the program as originally designed. How well does the program meet your organizational needs and the needs of your audience? Will it appeal to your audience? Does it target relevant outcomes? If an alternative program that requires little or no adaptation is available, now is the time to consider changing courses and implementing it instead.

It is a good idea to contact the developer of the program to discuss proposed adaptations. The program developer will be able to tell you which adaptations have been made before. He or she will also be able to elaborate on the theories and assumptions that influenced the program’s development. Getting input from the developer is the best way to ensure that any adaptations made to the program are appropriate. The contact information for program developers can be found on databases of EBPs, including those discussed under Identifying Evidence-Based Interventions.

In general, adaptations can be made to two aspects of a program: key elements (or components) and characteristics. Key elements or components are the “active ingredients” of a program—the components that generate the positive outcomes. Characteristics of a program are the appearances and features that distinguish a program. Characteristics can usually be adapted without influencing program outcomes. However, great caution should be exercised when adapting key elements. As noted earlier, the program developers are best suited to make adaptations to key elements. Table 4 provides examples of program adaptations and indicates the degree of caution that must be exercised when making each adaptation. Keep in mind that though characteristics can often be adapted without changing outcomes, you may still need permission from the program developer to make changes in order to adhere to copyright laws.

Table 4 - Program adaptations
Types of Program Adaptations
Adaptation Adapt cautiously Adapt carefully Adapt Freely
Removing or changing topics X
Replacing or modifying cultural references X
Reducing the number, length, or frequency of sessions X
Changing fonts and font size X
Replacing images to reflect the ethnic and cultural makeup of your audience X
Eliminating key messages or skills training X
Using personnel without adequate training or qualifications X
Modifying language (e.g., translating or changing words to increase readability) X
Reducing the number of materials and resources given to participants X
Adding contact information for your organization and local resources X
Targeting a different audience X
Changing aesthetic elements to make the program more appealing to your audience X
Updating health statistics and other science-based information to reflect current findings X

What if your organization has committed to implementing a given program and you realize that fidelity may be threatened because you need to adapt several key elements to make the program suitable for your audience? You are not necessarily trapped; there are a few courses of action to consider. First, get in touch with the program developers. They will be able to provide insight into the impact the adaptations will have on outcomes. Additionally, the developers may be interested in working with you and collecting data to evaluate the impacts of the adaptations on program outcomes, as this would contribute to the program’s evidence base. Second, find additional resources. Adaptations are often necessary because of resource limitations (e.g., limited funding, insufficient staff, inadequate facilities). If this is the case for you, then reevaluate your funding options and your opportunities for partnerships with organizations that have the resources you lack (see Obtaining Funding and Establishing Partnerships for more information). Finally, you can select an alternative program. While this is a difficult choice if you have already invested time and money into a program, it is important to consider the consequences of moving forward with a program that will be implemented without fidelity due to extensive adaptations.

Glossary of Terms

Toolkit Glossary

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Adaptation– Making changes to an evidence-based program in order to make it more suitable for a particular organization and/or audience.

Baseline – A starting point. In evidence-based programming, the term “baseline” is usually used in the context of data collection, where baseline data is data collected before a program is implemented.

Credentials – A testimony of qualification, competence, or authority issued to an individual by a third party. Examples of credentials include academic diplomas, academic degrees (e.g., MSW, MPH, PhD), licenses (e.g., MD, RN, LCSW), certifications (e.g., CHES, CPR, first aid), and security clearances.

Evidence – Facts or testimony in support of a conclusion, statement, or belief. In some settings, individuals may refer to “levels of evidence” or “types of evidence.” These terms will have specific definitions unique to the setting in which they are used. When referring to evidence-based programs, the term “evidence” is generally used to describe the findings or results of program evaluation studies.

Evidence-based program – A program that has been thoroughly evaluated by researchers who determined it produces positive outcomes.

Fidelity – The extent to which a program is being implemented as its developers intended for it to be.

Implementation – Putting into action or carrying out a program.

Instrument – A measurement tool. Instruments can take many forms including biomedical equipment (e.g., glucometer, blood pressure monitor, weight scale), pencil and paper tests, questionnaires, and interviews. A thermometer is an instrument used to measure body temperature. Likewise, a survey is an instrument that can be used to measure anxiety.

Medicaid – A publically-funded health insurance program for individuals who have low incomes and fall into certain categories of eligibility.

Objectives – Specific, measurable steps that can be taken to achieve goals.

Peer review – When experts review a professional’s performance, research, or writings. Peer review is a way that qualified professionals self-regulate their professions. Performance, research, or writings that pass the peer review process have increased credibility or trustworthiness.

Program champion – An individual who advocates for a program.

Quality assurance- A collection of planned, systematic activities applied to ensure that the components of a program are being implemented well.

Secondary data – Previously collected data that is being used for a purpose other than that for which it was originally collected.

Theory of behavior change – An attempt to explain how and why people change their behaviors. Researchers typically generate theories of behavior change from research in the fields of psychology, education, health, and other social sciences. When developing evidence-based programs, researchers will select a theory or components from several theories to guide program development.

Audience – The individuals for whom you implement your program. Depending on your setting, these individuals may also be referred to as a target population, population of interest, or clientele.

Buy-in – Typically used in the business world, buy-in refers to a financial exchange. In the context of health programs, the buy-in of stakeholders (community members, organizational leaders, participants, etc.) is generally non-financial. It involves their acceptance of a concept, idea, or proposal.

Data – A collection of facts, such as measurements and statistics.

Evidence-based practice – When clinicians (e.g., doctors, nurses) base their healthcare treatment decisions on the findings of current research, their clinical expertise, and the values/preferences of their patients.

Evidence-informed practice or program – A practice or program that is guided by theories and preliminary research. While there is some indication that these practices and programs produce positive outcomes, the evidence is too weak to refer to them as evidence-based. These are sometimes referred to as “promising” or “emerging” practices and programs.

Goals – General, non-measurable intentions or outcomes.

Incentives for participation – Factors that motivate an individual to take part in a program. Organizations sometimes provide incentives to encourage participants to begin and/or remain enrolled in a program. Common incentives include gift cards and program t-shirts.

Intervention – Organized efforts to promote health and prevent disease. This term is used because the efforts intervene, or come between, an individual and a negative health outcome in an attempt to prevent or delay the negative outcome. “Intervention” and “program” are often used interchangeably.

Interventionist – An individual who implements or carries out the components of a program.

Lay leaders – Individuals who do not have formal healthcare credentials who are trained to lead evidence-based programs.

Medicare – A publically-funded health insurance program for adults over age 65 and individuals with certain disabilities or health conditions.

Partnership – A cooperative relationship between two or more organizations that collaborate to achieve a common goal through the effective use of knowledge, personnel, and other resources.

Primary data – Original or new data being collected for a specific research goal.

Protocols - Predefined procedural methods. Examples include detailed program implementation procedures, required equipment, required data collection instruments with detailed instructions for administration, and recommended safety precautions.

Readiness – The degree to which an organization is prepared or ready for something.

Stakeholder – Any individual or group that has a stake or interest in a program.

Translation – The process of taking a program originally implemented in a controlled, laboratory-like setting and making it suitable for implementation in the community.

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