Community, Culture, and Service Contexts in Implementation Research

1. Community, Culture, and Service Contexts in Implementation Research Luis H. Zayas, Ph.D. Improving Implementation Research Methods for Behavioral and Social Science, Silver Spring, MD 20 September 2010

2. Adaptation for Communities • Assumption: That we are implementing ESTs/EBPs based on good science • Premise: Adaptation must consider ethnicity and culture of clients • Premise: Cultural/ethnic adaptation not enough • Service contexts determine what adaptation is needed and how much • Adapted ESTs/EBPs do not work same across diverse communities or service settings

3. Multiple Services Context • Service Sector (e.g., child welfare, education, juvenile justice, health, mental health) • Region and geography (e.g., part of the country; rural/urban) • Organizations and institutions (e.g., gov’t; non-profit; multi-service orgs; small CBO) • Providers (e.g., professional/paraprofessional; culture/ethnicity; disciplines) • Clients, consumers, patients(e.g., culture; age; immigrant; legal status)

4. Types of Adaptation • Adaptation: broad term describes adjustments and modifications. • Targeting: adaptation of service at the population, community, and organization level that considers local characteristics • Tailoring: adaptation of treatment/intervention at the family or individual level • Clinical tailoring: unique constellation of issues brought by individual (personalized)

5. Policy ecologies • Political context: Implementation as involving all legislative and advocacy efforts that support goals. • Regulatory/payer context:Monitors type of care delivered. States influence by paying via contractual requirements. • Organizational context: Where clinicians deliver interventions to consumers (and need administrative buy-in and support) (Raghavan, Bright, & Shadoin, 2008)

6. Community capacity: Factor for implementation success; e.g., awareness and definition of problems, readiness to act, resources, social capital, leadership Organizational level capacity: Agency leadership, attitude, hierarchy, vision, commitment, size, and structure Individual level capacity: Provider attitudes, training, skills and knowledge, as well as motivation to adapt and implement ESTs/EBPs. (Guerra & Knox, 2008; Wandersman et al., 2008) Capacity

7. Incorporates policy ecologies, capacity issues, service- or intervention-adaptations; cultures Service levels Sector of care Region and geography Communities Service organizations and their programs and providers Clients Framework for Multiple Service Levels

10. Political, social, economic climate: Historical trends and events National funding policies: federal and state administrations (whose in power?) National priorities: changes in economy and competing priorities Macro-Forces: Broad Service Level

12. Sector of care: What is the sector of care and what are the social issues it addresses (e.g., child welfare, juvenile justice, education, mental health, substance abuse) Region and geography: Differences in communities (e.g., urban/rural; diverse or homogeneous; remote/isolated reservations) Regulatory and Regional Levels

14. Organizations (adaptation) What type of organization is it? Multi-site? Number and diversity of programs? What is the institutional culture? Programs (targeting adaptations) What is the managerial expertise and process? What are the levels of collaboration among programs? What is the culture across programs? Reflect the administrative culture? Community and Organizational Level, I

15. Providers (tailoring adaptations) What is the staff mix (professional-paraprofessionals; disciplines)? What are individual and collective capacities? What is the training on and acceptance of ESTs/EBPs? Communication among staff? How reflective of community and clients are providers? Community and Organizational Level, II

16. Clients (tailoring; clinical tailoring) Neighborhood level factors Culture, ethnicity, language, age span, family types Mandated to service? Legal status? Community and Organizational Level, III

17. Adaptation as part of implementation science Multiple service levels affect adaptation (targeting and tailoring) Policy ecology; community-organizational-provider capacity influence ultimate implementation Each service level, capacity level, and ecology has differential influence on the cultural adaptation of the evidence-based intervention Conclusion

18. Acknowledgements • Jennifer Bellamy and Enola Proctor (chapter co-authors) • Administration for Children and Families • Office of Planning, Research, and Evaluation • NIMH and NICHD: conference grant on adapting parenting and family interventions

19. Email: Lzayas@wustl.edu