Maria E. Fernandez, PhD Associate Professor of Health Promotion and Behavioral Sciences

1. A Systematic Approach for Program Adaptation Using Intervention MappingThe 4th International Cancer Control CongressRepublic of Korea Maria E. Fernandez, PhD Associate Professor of Health Promotion and Behavioral Sciences University of Texas Health Science Center at Houston

2. ResearchtoAction Who is responsible? Researchers/ program developers, implementers, health service providers, funders? A barrier to translation of intervention research findings for public health benefit is that both developers (often researchers) and practitioners believe that the responsibility for dissemination lies elsewhere.

3. Research to Action • Researchers: I don’t have the training or interest in approaches to enhance dissemination of research products; grant funding does not support such activities. • Practitioners: The responsibility for summarizing and making research products useful lay elsewhere. But if they were easy to find and use we would do it. National Cancer Institute, Center for the Advancement of Health and Robert Wood Johnson Foundation. Designing for dissemination: Conference summary report. 2002.. http://dccps.cancer.gov/d4d/d4d_conf_sum_report.pdf

4. Increase the number of systems providing evidence based cancer control Increase the number of practitioners providing evidence based cancer control Increase the number of individuals receiving evidence based cancer control Bridging the Gap: A Synergistic Model Getting Evidence - Based Cancer Control Interventions Into Practice GOAL: To increase the adoption, reach and impact of evidence - based cancer control Delivery Capacity Science Push Market Pull/ Building the capacity Documenting, Demand of relevant systems to improving, Building a market deliver the and communicating and demand for the intervention the intervention for intervention wide population use - - - ULTIMATE GOAL: Improve population health and well being Orleans, T. NCI Designing for Dissemination Conference, 2002; adapted by Jon Kerner

5. User-based or Community-centered Research to Practice Models • Patient-centered Medical Home (Miller, 2010; Stange, 2010; Stewart, 2010) • Others have noted that community-centered models are needed (Miller and Shinn, 2005) or offered a complex discussion of community capacity (Goodman et al. 1998) Combines Perspectives • Interactive Systems Framework for Dissemination & Implementation (Wandersman, 2008) Source-based Diffusion of Innovation Theory (Rogers,1995) Technology Transfer Model (Backer, 1995) Reach, Efficacy or Effectiveness, Adoption, Implementation and Maintenance RE-AIM Model (Glasgow et al., 2003; Glasgow et al., 2004; Glasgow et al., 2006) Model of Prevention Science (IOM, 1994) Public Health Model (Mercy et al., 1993) Knowledge Management (Graham, 2006, adapted by Kerner, CPAC)

6. Intervention Mapping • Description of a planning process derived from the work of health promotion interventionists • Seems to have stimulated in the field • enhanced attempts to integrate theory and evidence • greater focus on both behavior and environment an ecological planning approach • greater attention to planning for implementation and dissemination

7. Steps of Intervention Mapping • Conduct a needs assessment • Create matrices of change objectives based on the determinants of behavior and environmental conditions • Select theory-based intervention methods and practical applications • Translate methods and applications into an organized program • Plan for adoption, implementation and sustainability of the program • Generate an evaluation plan

8. Three ways Intervention Mapping can advance implementation and dissemination 1. Designing the health education program in ways that enhance its potential for being adopted, implemented, and sustained (IM Steps 1-4) 2. Designing interventions to influence adoption, implementation and continuation (IM Step 5) 3. Using IM processes to adapt existing evidence-based interventions - Categorizing and identifying core elements of programs

9. Using Intervention Mapping to Adapt Evidence-Based Programs

10. The Adaptation Debate • Some authors suggest that when developmental issues and program targets are appropriate, adaptation is seldom or never needed (Elliot and Mihalic, 2004) • Others point out that the formative work to support adaptation is seldom done (Lau, 2006 ) • Nevertheless, in practice… Adaptation Happens.

11. Adaptation may help • Some researchers insist that adaptation is essential and the challenge is to strike a balance between program fidelity and adaptation (Backer, 2001) • Even when higher fidelity was shown to be associated with improved outcomes (Durlak & DuPre, 2008) fidelity was not 100%; adaptation may have added to effectiveness

12. A problem with adaptation • During the adaptation process, planners often choose pieces of programs that are the most appealing or that seem the most feasible, • Usually there is not much input from the community • Little or no process for determining what in a program needs to change and what must stay the same • This can lead to programs that are incomplete with little chance of maintaining impact

13. The Importance of Identifying Essential Program Elements • Variously called core elements, active ingredients, essential elements • Whatever we call them – we • Often do not know what they are • Program descriptions often do not include them Botvin, 2004

14. Retaining Essential Elements Program Active Ingredients are: • Theoretical methods that are intended to change determinants of behavior (of the at-risk group or environmental agents) • Practical applications of methods including delivery channels • Characteristics of program materials and messages • Characteristics of program implementation

15. Adaptation Approaches • Several authors have described processes of disseminating interventions including approaches to adaptation (McKleroy, 2006; Wandersman, 2008) that generally describe the tasks involved. • Planned adaptation models have been proposed (Backer, 2001; Lee et al., 2008)

16. A systematic approach to program adaptation • Intervention Mapping provides a systematic approach that adds detailed how tos to these frameworks. • It can help planners identify and retain the essential elements as programs are translated to new communities and settings.

17. Using Intervention Mapping to adapt evidence-based programs to new settings and populations

18. Adaptation Example • “World Starts With Me” • Developed to address the sexual and reproductive health and rights needs of secondary school students in Uganda • Adapted for adoption and implementation in Indonesia

20. The Working Group in Indonesia

21. Current Adaptation Activities using IM • Adaptation of an existing EBP developed for Mexican Americans for use in Puerto Rico • Cultivando la Salud (CDC funded intervention program- National Center for Farmworker Health) • Adaptation of a lay health worker delivered small media intervention (Vivir sin Cancer) on HPV/HPV vaccine originally developed for parents of girls in the LRGV • CPRIT funded intervention trial to increase HPV vaccination among Hispanic girls in Houston • Exploring possibility of adapting the intervention for use in Puerto Rico

22. Step 1 – Needs Assessment and Logic Model of the Problem • Adaptation Product: Description of discrepancy between original program logic model of the problem and the model in the new setting (including priority population characteristics). • Adaptation Questions: • What is the logic model and priority population of the problem from the original needs assessment? • What is the logic model and priority population for the adopting site? • Do they match? How are they different?

23. Planning the needs assessment with a logic model adapted from PRECEDE Phase 4 Phase 3 Phase 2 Phase 1 Qualityof LifeIndicators BehavioralFactors HealthProblems Personal and External Determinants (Predisposing, enabling, reinforcing factors) EnvironmentalFactors

24. Determinants influencing breast and cervical cancer screening Original Program- Cultivando la Salud- Mexican Origin women Low levels of • Knowledge of breast and cervical cancer and screening guidelines • Outcome Expectations • Perceived Barriers and Benefits • Attitude (fear of detection, fear of procedure and belief that cancer is incurable) • Low Self-Efficacy • Low Perceived Social Norms • Availability and Accessibility Puerto Rico Low levels of • Knowledge of breast and cervical cancer and screening guidelines (not as low) • Knowledge of availability • Perception of risk • Perceived Barriers and Benefits • Attitude (fear of detection, fear of procedure) • Low Self-Efficacy Environmental Factors differ considerably due to access to care (Reforma – universal coverage in PR vs indigent care in LRGV) Outreach Program

25. Step 2 – Logic Model of Change and Matrices of Change Objectives • Adaptation Product: Matrix of change objectives that should be added to the original program to improve validity the of the change model. • Adaptation Questions: • What behavior and environmental conditions (and their determinants) did the original program target for change? • What should the adopting site seek to change in behavior and environment (and their determinants) that is different from the original program?

26. Matrices of change objectives

27. At Risk Group Theoretic Methods & Practical Strategies Performance Objectives Determinants Behavioral Outcomes Resources Program Activities & Materials Health and Quality of Life Environmental Outcomes Theoretic Methods & Practical Strategies Performance Objectives Determinants Environmental Agent Program Outputs Logic of Change Outcomes Program Inputs

28. Parent versions Vivir Sin Cáncer Program Designed to increase information seeking about HPV and HPV vaccine among Hispanics along the TX-Mexico Border Young Women versions

29. Vivir Sin Cancer Adaptation • Goal is to adapt existing materials so that they fit a new context (Houston urban Hispanics) • Differences in target behaviors: • Original Project: HPV/HPV Vaccine information seeking • New/Adapted Intervention: HPV vaccination • Differences in determinants?

30. Determinants for parents seeking information about hpv and the hpv vaccine Vivir sin Cancer – Mexican Origin Women • Knowledge/awareness of CIS “1-800” number • Knowledge/awareness of CC, HPV and HPV vaccine • Self-Efficacy for calling CIS • Skills for calling CIS • Perceived norms and social norms about calling • Personal preferences about information seeking • Outcome expectation that their questions would be answered • Media and mandate on HPV vaccination Common factors across parents from LRGV and Houston • Attitudes about HPV vaccination • Perceived risk of cervical cancer and HPV (for daughter) • Perceived severity of cervical cancer and HPV (for daughter) • Concerns about cost/Insurance coverage • Concerns about sexual disinhibition Outreach Program

31. Step 3 – Program Theoretical Methods and Practical Applications • Adaptation Product: • Description of theoretical methods or practical applications that should be added to address new change objectives or to make the original methods apply to a different population/context. • Description of essential program elements that must be retained. • Adaptation Questions: • What theoretical methods and practical applications to promote change did the original program include? • What methods and practical applications must be added to match new change objectives or modified to fit the new population?

32. Step 4 – Program • Adaptation Product: Description of recommended changes in the program components and/or delivery. • Adaptation Questions: • How well did the program components and delivery implement the theoretical methods and practical applications? • How well does the program delivery match preferences the new population and context? • What changes in scope and sequence or materials are necessary to deliver new methods and practical applications?

33. Step 5 – Program Adoption and Implementation • Adaptation Product:Description of how program implementation should be changed • Adaptation Questions: • How well was the original program delivered (completeness, fidelity, dose)? • How comprehensive and feasible is the implementation protocol? • What are the implementation performance objectives in the new setting? • Will implementation require additional elements in the new setting?

34. Cultivando la Salud-Adoption Matrix

35. Cultivando la Salud-Implementation Matrix

36. Program Products Breast & Cervical Cancer Training Curriculum • Introduction to the Training • Role of the Lay Health Worker • Reaching Women from Farmworker Families • Finding Breast Cancer Early • Breast Cancer Screening: Barriers and Responses • Pap Test: Barriers and Responses • Teaching Methods • Practices Session Using Program Materials • Resources and Referrals • Evaluation

37. Step 6 – Program Evaluation • Adaptation Product: Evaluation questions including effectiveness and acceptability of new program elements • Adaptation Questions: • What program outcomes and change objectives was the adapted program effective in meeting? And how does effectiveness compare to the original program? • What was the reach, fidelity and completeness of the adapted program? And how does the process evaluation compare to the original program?

38. Summary • Systematic planning models such as Intervention Mapping can guide planned adaptation that can help ensure that • important differences between the original program population and setting are addressed with new program objectives, methods, and practical applications • essential elements of programs are maintained