# Presentation: 164427

## Fidelity vs. Adaptation and Cultural Tailoring in Substance Abuse Prevention ProgramsChris Ringwalt, DrPHringwalt@pire.orgGrants to Reduce Alcohol Abuse Technical Assistance ConferenceAlbuquerque, N.M.Jan. 15, 2008

## Fidelity

- By self-report, only 15% of teachers follow curriculum guides “very closely”
- Teachers tend to:
- Omit key points, entire activities and lessons
- Add content, some of which may be inappropriate
- Tell personal anecdotes
- Fail to implement challenging strategies that entail risk of losing control of the class

## Specific examples from the literature

- 1/3 of schools delivered only half of lessons specified
- Teachers failed to use role plays and teach family communication skills
- One-third of teachers rated as low implementers
- Teachers averaged 2/3rds of curriculum’s points and objectives
- 70% of prescribed activities implemented
- Only 1/4th of teachers taught program in year 2
- 3/4ths of steps in session attempted; additions & deletions much more common than modifications

## Importance of fidelity

- Fidelity *repeatedly and consistently* linked to achievement of outcomes
- Effects of prevention programs generally robust across ethnic/cultural groups
- Standard and culturally focused LST worked equally well with Hispanic & African-American (AA) populations
- ALERT did (at least) as well with Hispanic and AA as with white populations
- Project Smart did equally well with Hispanic and white populations

## So why support adaptation?

- Because it’s an appealing idea
- Teachers will do it regardless
- as they seek to be responsive to the culture of their students, schools, and classrooms
- as they internalize and become comfortable with the curriculum
- Adaptation as a type of reinvention will promote program diffusion, enhancing:
- adoption by gatekeepers, champions
- penetration (reach)
- sustainability

## Cultural adaptations should be sensitive to:

- Students’ primary language and idioms
- Match between teaching strategies used and cultural norms & characteristics
- Norms and values, e.g.
*African Amerians*: communality, religiosity, intuition
*Hispanics*: respect for elders, familismo, simpatia, fatalismo
*Chinese*: loss of face
*American Indians*: spirituality, reverence for family, cooperation, connectedness

## So what about core components?

- Can they be identified with confidence, even by the developer?
- Has the program been tested implementing components only?
- Core components for successful and unsuccessful programs look similar
*Each* brick laid, and *how* it is laid, may be critical to the success with which the wall is built

## Many types of adaptation...

- Delete, modify, add content
- Delete, modify, add instructional strategies
- Cultural tailoring

## Cultural tailoring

- Definition:
-     “The process of developing or modifying interventions or materials to ensure their conformity to pertinent characteristics of the population targeted”

## Key conceptual components of cultural tailoring

*Surface structure/peripheral strategies*: enhancing congruence between superficial program aspects and audience characteristics, e.g.:
- Familiar people, images, locations
- Idioms, phrases, language

## More

*Deep structure/sociocultural strategies*: “inner workings” of population’s mores, values, history, physical environment, spirituality, environment, collective psychology, e.g.:
- Sensitivity to stress, coping, social support
- Appeals to self-image, approval of family or friends
- Communication bearing cultural freight, e.g. use of “talk stories” among Hawaiian children

## More

*Evidential strategies*: the judicious presentation of pertinent empirical information to a population, e.g.:
- Degree to which substance use is normative in the community
- Specific advertising practices in a community
- Local policies and practices supporting or inhibiting substance use

## More

*Teaching methods*, e.g.:
- Use of multi-dimensional teaching aids
- Seating arrangements
- Singing, talking circles, meditation, music
- Drawings, illustrations, demonstrations
- Use of wait time when asking questions
- Manifesting appreciation for students’ cognitions and their need to be respectful

## Brief case example using PY/PM

- Gathered representatives from three tribes in NE Nebraska
- Omaha – two elders, language teacher, community members
- Santee - elder & language teacher
- Winnebago - two elders, language teacher
- Curriculum developer attended meetings to ensure modifications consistent with key objectives; *served as final arbiter*

## Conclusion	

- Process worked reasonably well
- Effects difficult to measure
- Recommended to program developers for their consideration, with caveats....

## Questions for you	

- Have you adapted your program?
- How did you decide it needed to be adapted?
- How did you go about doing so? Was the process intentional? unintentional? both?
- How do you know your adaptations were congruent with program goals?
- What did you do?
- Did it seem to work?  How do you know?