External Validity of SIs Flashcards
How can we improve accessibility and outcomes of evidence-based social interventions in culturally diverse populations?
Culture is a complex and multidimensional construct
o Over 100 varied definitions of culture (Baldwin and Lindsley, 1994)
o Can be differentiated from “race” and “ethnicity” (but sometimes terms are used interchangeably)
o Race tends to assume a biological basis can be applied to classifying humans, yet there is more genetic variation within races than between races; race more of a social construct than a biological one
o Ethnicity attempts to further differentiate racial groups according to lineage (e.g., country of origin, location, religion, language); like race, it carries its own historical, political and social baggage
o Knowing someone’s ethnic identity or national origin does not reliably predict beliefs and attitudes
Culture is a general system of behaviors, beliefs, values, symbols shared by a group of people, and learned and transmitted through participation in group life
o Everyone has a culture: it is not just the group a person is born into; it can evolve and involve multiple spheres
o Cultures are not static: they grow and evolve in response to new circumstances, challenges and opportunities;
o Culture is not deterministic: different people take on and respond to the same cultural expectations in different ways
o Cultural “differences” are complicated by differences in status and power between (and within) cultures
Cultural adaptation
o “The systematic modification 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)
NB: Cultural adaptation may take place:
o Within countries – adaptation with minority groups means considering issues such as discrimination, immigration (or not), poverty; differing levels of disadvantage, power between groups (compare: Australia, NZ, Sweden, UK, USA, Estonia, Malaysia – incredible variation in histories and policies…)
o Between countries – may involve ‘majority’ groups; may or may not be differing levels of disadvantage and power; contextual differences often huge—term ‘transportability’ often used
WHY IS CULTURAL ADAPTATION IMPORTANT?
Ecological validity argument
o Much of the research supporting EBIs is said to have been conducted in white middle-class populations or in high-income countries; findings may not generalise to other groups (which EBIs?)
o Poor acceptability of “evidence-based” or ‘imported’ approaches shown in some communities (Lau, 2006): e.g., high dropout
Evidentiary argument
o Griner and Smith (2006): Meta-analysis of culturally adapted mental health interventions; effect sizes (d = 0.45) suggest moderately strong benefit of culturally adapted interventions
o Interventions targeted to a specific cultural group were more effective than those for mixed groups
o But note: conflicting evidence, e.g., Huey et al., 2008; 2012; Gardner et al., 2016
Ethical argument
o Potential adverse effects arising from interventions that ignore or minimise cultural issues
- Or could just be ineffective?…
ADAPTATION FRAMEWORKS
Types/functions of cultural adaptation frameworks (see Baumann et al., 2015 for a review)
o To inform modification to content of the intervention
- e.g., Ecological Validity Model (Bernal et al., 1995)
o To inform the process of adaptation
- e.g., decisions about when to adapt, how to adapt, and which stakeholders should be involved (e.g., Ferrer-Wreder et al., 2012; Backer, 2002)
Cultural adaptation is a relatively new development in intervention science
o No single set of agreed-upon best practices for adapting EBIs
o Various frameworks for cultural adaptation have been proposed; they typically integrate community perspectives with existing theory and evidence-based practice elements
o Aim to “strike a balance between community needs (for adaptation) and scientific integrity” (incorporating EB principles and fidelity to these) (Domenech-Rodríguez and Wieling, 2004)
- Balance is tricky, e.g., in Gottfredson (2002) SFP trial in DC, adaptations helped engagement, but intervention was not effective
o Need to critically consider costs as well as benefits of cultural adaptation
- When needed?
- Apart from cost and time, are there other drawbacks?
Top down vs. bottom up approaches
o Top down: Universal approach that views an original intervention as applicable across all cultural groups and not in need of modification
o Bottom up: Culture-specific approach that emphasises sensitivity and responsiveness to distinctive cultural features
ADAPTATION FRAMEWORKS: Content frameworks
o To inform modification to content of the intervention
- e.g., Ecological Validity Model (Bernal et al., 1995)
Barrera et al. (2013)
o Surface Structure (or “Presentation Strategies”)
- Bilingual and bicultural materials and staff
- Translation/back-translation of materials
- Inclusion of lifestyle elements, such as food, music
- Delivery of the intervention in group settings
- Situating the intervention in safe settings familiar to participants
- Incorporation of culturally familiar formats and activities
- Inclusion of culturally important role models
o Deep Structure (or “Content Strategies”)
- Incorporation of cultural values in intervention design or implementation (e.g., ‘time-out’ in Norway)
- Involvement of the family in interventions
- Adjustment of materials to literacy level of participants
- Use of social support and networks
Ecological Validity Model
o Originally developed with Latino populations (Bernal et al., 1995)
o Identifies 8 “culturally sensitive” elements for adaptation:
- (1) Language: Does the user understand language, idioms and words used?
- (2) Persons: Is the user comfortable with the similarity (or difference) in the cultural identity of the provider?
- (3) Metaphors: Are cultural symbols and concepts used appropriately?
- (4) Content: Does the user feel that the intervention acknowledges his/her cultural values and traditions?
- (5) Concepts: Are intervention concepts framed within cultural context? Is the user in agreement with problem definition and intervention rationale?
- (6) Goals: Are intervention goals framed within adaptive cultural values of the patient? Does the user agree with the goals of treatment?
- (7) Methods: Do intervention methods fit with the user’s expectations and preferences?
- (8) Context: Does the intervention consider contextual issues such as migration and acculturation stress, social supports, family relationships and access barriers?
ADAPTATION FRAMEWORKS: Process or method frameworks
o To inform the process of adaptation
- e.g., decisions about when to adapt, how to adapt, and which stakeholders should be involved (e.g., Ferrer-Wreder et al., 2012; Backer’s steps model, 2001)
Adaptation methods
o Increasing consensus in the literature towards iterative, phased adaptation process; broadly, this involves the following phases:
- Phase 1: Assess beneficiary needs
- Phase 2: Identify relevant strategies and model intervention
- Phase 3: Evaluate and refine intervention acceptability and feasibility
o Vellakkal and Patel (2015): Program for Effective Mental Health Interventions in Under-resourced Health Systems (PREMIUM)
o Barrera et al. (2013): Cultural Adaptations of Behavioral Health Interventions: A Progress Report
Community engagement informs all stages of adaptation
o (1) Identify clinical/community needs
o (2) Select intervention types
o (3) Select specific EB strategies, then develop intervention model
o (4) Assess acceptability, perceived feasibility of identified components
o (5) Field testing and refining intervention – feasibility study, refine, then RCT
CASE EXAMPLE: Developing a brief parenting psychoeducation intervention in Burundi (Jordans et al., 2011)
o Setting: Central African nation affected by civil war along ethnic lines; resulted in 250,000-300,000 deaths and 880,000 displaced people
o Peace accords in 2003, but high levels of poverty and “damaged social and moral fabric due to violence” act as main risk factors for mental health problems
o Project involved (i) mapping and selection of existing local and global intervention components based on expert and community stakeholder perspectives, and (ii) controlled evaluation
Phase 1 – Assessing needs (qualitative study)
o Explored:
- (i) Necessity and relevance of family-based care
- (ii) Stakeholder views of and recommendations for intervention content and delivery methods
o Data collection methods (used local researchers):
- Focus group discussions with children, teachers, parents, facilitators of existing psychosocial programmes (n=99)
- Key informant interviews with clergy, healers (n=11)
- Group discussions with parents around specific case vignettes related to milestones, discipline and poverty (n=68)
- Semi-structured interviews with children involved in existing programmes, and parents (n=25)
o “Community sensitisation meetings” used for initial purposive sampling, followed by snowball sampling
Phase 2 – Identifying and prioritizing types of interventions (lit review and expert consultation)
o Aim: to generate field-tested intervention modalities in LMIC settings
- Expert panel assembled to further generate & rank intervention options
- Followed existing criteria and guidelines for priority setting (Child Health and Nutrition Research Initiative)
- Process involved (i) gathering technical experts, (ii) systematic listing of intervention options, and (iii) scoring options by pre-defined criteria
- Participants selected based on experience in psychosocial and mental health work for children in LMIC
- Expert panel (n=60): first round further generation of options; second round prioritization based on set of criteria (Acceptability; Feasibility; Effectiveness)
Phase 3 – Identifying specific elements of intervention (systematic review)
o Reviewed academic literature to determine common practice elements of evidence-based interventions for conduct and mood problems
o Drew on existing database that distilled evidence-based interventions into constituent elements—context and delivery
Phase 4: Assessing acceptability and feasibility of identified components (stakeholder assessment)
o Stakeholder assessments conducted to assess cultural acceptability and feasibility of all components generated in previous steps
o Respondents included care manager, service providers and potential beneficiaries (n=40)
Results—Stakeholder assessment
o Strong endorsement for selected components
o In addition, stakeholders provided suggestions on how to implement the intervention strategies:
- e.g., respondents recommended training teachers and community workers in addition to health workers, follow-up through home-visits, and reinforcing family ceremonies as a way of strengthening networks
o While acceptance was high, respondents commented that it was difficult for parents to give time because of the loss of productivity that comes with joining interventions
o Respondents therefore emphasised the need to start with raising parental awareness and creating willingness to participate in interventions…
o …then adaptation and finalisation of intervention protocol
Summary and conclusions
o One size does not fit all
- Through cultural adaptations it may be possible to go beyond the one-size-fits-all approach and modify interventions at multiple levels (e.g., deep vs. surface; 8 ecologically valid domains)
- Or some interventions may be culturally flexible, so the adaption happens at the level of each participant (see Barrera et al., 2013; also Incredible Years parenting a possible example)
o Community engagement is important across all phases of cultural adaptation, from needs-assessment through to implementation
o Potential for cultural adaptations to enhance engagement, outcomes and sustainability of interventions, but issues of fidelity require careful attention
What are the key barriers and facilitators to scaling up evidence-based social interventions?
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Is research knowledge easily translated into policy and practice? Discuss, with examples.
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If brief interventions for alcohol misuse are cost-effective, should they be implemented universally?
Cost-effectiveness analyses:
o Conditions: where two interventions for the same condition are differentially effective on the same consequences and differentially costly
o Consequences: ‘natural units’ or ‘clinical units’ (e.g., months of school year gained in reading ability, number of deaths averted)
o Comprehension: which intervention gives us the best bang for the buck?
o …these are often questions of incremental cost-effectiveness analyses
o How much more an intervention costs divided by how much more effective it is
o How much more effective is an intervention compared to how much more it costs?
What can randomized trials tell us about taking evidence to scale?
Taking evidence ‘to scale’: what does this mean?
o Widespread implementation (across services…high uptake, reaching much of target population…)
o Dissemination – broad
o Diffusion of an evidence-based intervention
o Efficacy, Effectiveness, Diffusion, Population-level approaches (aim to influence/change rate of problem in whole population)
Going to scale – why important?
o Growing number of evidence-based interventions
o Evidence-based interventions often have firm science base – studies of prevalence, theory + risk factors, mediators, effectiveness
o But what use if effective interventions don’t reach large parts of the population?
o Need for impact at level of public health / wellbeing – potential for prevention of social problems
o Growing demand from donor organizations (e.g., USAID) and governments for effective programming
What is needed before scale-up? (Society for Prevention Research (SPR) Standards of Evidence (New Generation) – Gottfredson et al., 2015)
o Intervention must meet criteria for “effectiveness” AND have:
- Clear cost information (set-up costs and ongoing costs)
- Materials with information on activities and optimal methods of delivery (manuals)
- Training and supervision processes (from facilitator – coach – trainer)
- Technical assistance (project preparation, implementation, Monitoring and Evaluation – M/E)
- Fidelity tools
- Systems for documenting adaptations
- Monitoring systems with feedback loops
- System to support planning and monitoring of client recruitment
- [Scale up efforts should be rigorously evaluated]
Key considerations
o Macro-level:
- Buy-in from governments etc. for sustainability (understand constraints; current programming)
- Delivery systems (social services, education)
- Stability of targeted site (conflict zone?)
- Capacity of training partners to support scale-up
o Micro-level
- Achieving and maintaining fidelity
- -> Addressing a diversity of needs (context, severity, delivery method) – surface/substantial adaptations – are core components still intact?
- -> Ongoing supervision to maintain fidelity
- Recruitment and engagement (provision of incentives – vouchers, meals, transport)
Four challenges in meeting the demand for tested and scalable programmes to reduce violence against children
- Evidence is expensive:
a. Establishing evidence requires substantial time and resources to meet international standards of effectiveness - Thresholds for evidence differ:
a. Implementing agencies often require different thresholds for evidence before scaling up that are less scientifically rigorous than WHO-Inspire or Blueprints - Adaptation may be required:
a. Implementation across contexts may require adaptation to fit local cultures and to integrate within existing delivery systems - Considerations beyond delivery:
a. Beyond delivery there are other components organizations need in order to deliver a program, including budget, fidelity, M/E and accreditation
Cartwright and Munro introduce some concerns about how to interpret RCTs, arguing that they are by themselves typically “insufficient to meet the needs of policy or practice decision makers” (Cartwright and Munro, 2010, p. 265, as cited in Cowen et al., 2017)
“The primary result of an RCT is a judgment about the effectiveness of a treatment in producing an outcome in the study population, although the contribution of other factors to the outcome is unknown. The purpose of RCTs in the context of EBP is to help estimate the effectiveness of a treatment in a target population or populations different from the one on which the experiment was conducted, which raises questions about whether and when such inferences are warranted” (Cowen et al., 2017)
Cartwright and Munro, 2010 (p. 262) trace three kinds of causal claims (as cited in Cowen et al., 2017):
1. It-works-somewhere claims: treatment T causes outcome O somewhere, under some conditions (e.g., in study population X, administered by method M)
- Capacity claims: T has a (relatively) stable capacity to promote O, so that it can be expected to do so widely
- It-will-work-for-us claims: T would cause O in population Q if administered as directed by policy P (i.e., effectiveness claims)
“RCTs are immediately relevant for estimating the first type of causal claim, since they tell us whether (or the degree to which) the intervention influenced the targeted outcome in the population enrolled in the experiment”
“RCTs’ relevance for the other two types of causal claims is indirect and incomplete. Whether a treatment can be assumed to be relevant to a given untreated population depends on a fabric of other knowledge”
o “The second type of claim requires enough theoretical, empirical, and conceptual knowledge to support the claim that what happens in one or a handful of study settings will happen widely”
o “For the third type of claim, there must be good reason, both theoretical and empirical, to warrant the assumption that the RCT population and the target are alike in just the right ways to support the same causal pathways from intervention to outcome”
“Moving from the first to the second or third types of claim, then, requires a great deal of knowledge that cannot be warranted by the RCT itself. The problem is that ‘this kind of complicated causal reasoning is hard, even if we are prepared to be rough in our approximations and figure out ways to tolerate uncertainties’ (Cartwright and Munro, 2010, p. 263)” (Cowen et al., 2017)
“Some interventions will work only because of very special circumstances; they can work in some places but don’t have a widespread potential to succeed. Even those that have widespread potential do not operate on their own; they will work only when the requisite support factors are in place, or some suitable substitute for them” (Cowen et al., 2017)
“Supposing that a particular intervention has relatively wide potential to improve targeted outcomes, we have identified two specific kinds of information that need to be acquired if we are to predict how successful the intervention would be in a new context: [1] what the support factors are and how they are distributed in the new context and [2] how to ‘de-abstract’ or ‘contextualize’ generalizations”
- “Support factors are those factors required for the intervention to work in the context in question. We need to know that they (or an appropriate substitute) will be in place at the right time and to the right degree”
- “General truths – claims that apply consistently in new and different contexts – tend to use fairly abstract concepts…Knowledge formulated in abstract concepts is only of use in practice if we know, for the situation at hand, how to ‘de-abstract’ or ‘contextualize’ it”
- -> “…it is helpful to be able to lump together interventions that differ in a variety of ways but all satisfy the same abstract description, so long as that description is relevant”
- -> “…human beings are affected by heterogeneous motivations, which is one commonly cited reason for the difficulty the social sciences have in coming up with general theories that hold reliably across individuals. Yet, lumping under more abstract descriptions does improve strength of warrant, so long as the descriptions are relevant (Simpson 2017), so it is not surprising that researchers and EBP sites try to do so”
What criticisms can be made of the ‘evidence-based paradigm’ as applied to social interventions?
What is Evidence-Based Practice (EBP)?
o “…the conscientious [ethical, effective, honest], explicit [transparent, auditable], and judicious [considered, prudent] use of current best evidence [as rigorous as possible, subject to updating] in making decisions about the care of individual [people]…integrating individual clinical expertise with the best available external clinical evidence from systematic research” (Sackett et al., 1996, p. 71)
o “Without clinical expertise, practice risks becoming tyrannized by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual [person]. Without current best evidence, practice risks becoming rapidly out of date, to the detriment of [people]” (Sackett et al., 1996, p. 72)
Common objections to EBP:
o Ignores clinical expertise
o Ignores client values and preferences
o Is a cookbook approach
o Is simply a cost-cutting tool
o Is limited to clinical research
o Cannot be done; is an ivory-tower concept
o Results in ‘therapeutic nihilism’
- i.e., a contention that it is impossible to cure people or societies of their ills through treatment…In medicine, it was connected to the idea that many “cures” do more harm than good, and that one should instead encourage the body to heal itself (Michel de Montaigne; Jacob Stegenga)
o Assumes that professionals are rational agents
o Can always find evidence for a favored point of view
Potential for harm:
o Conscientious study design, sufficient funding, proper execution, and the best of intentions do not necessarily culminate in an ‘effective’ intervention, or act as sufficient deterrents against undesirable outcomes—the potential for harm must be considered from the outset, and any hypothesized ‘harm-inducing’ mechanisms scrupulously monitored throughout the duration of the intervention (see: McCord, 2003 discussion of Cambridge-Somerville Youth Study)
Does the intervention work or not?
o Wrong question to be asking – should be extended to specify those particular outcomes/populations we are interested in, as compared to the control group (PICO framework)
o “Unless social programs are evaluated for potential harm as well as benefit, safety as well as efficacy, the choice of which social programs to use will remain a dangerous guess” (McCord, 2003)
Dark logic models
o Ethical imperative to consider the potential for harm in advance (a priori) and to design our evaluations to appropriately assess for any such iatrogenic outcomes or mechanisms
In her examination of the negative outcomes of the Cambridge-Somerville Youth Study and a host of other crime prevention programmes shown to ultimately cause harm, Joan McCord advocates an approach to assessing social interventions that takes into account more than mere efficacy, also looking into the safety measures and possible iatrogenic effects of a programme, her aim being to demonstrate that simply asking whether an intervention ‘works’ fails to adequately capture crucial considerations related to propensity for harm (McCord, 2003)
Should researchers fail to systematically collect, critically appraise, and appropriately analyze all the available data concerning a question of interest, harm may very well be introduced into subsequent social interventions through sheer ignorance of what presently constitutes best practice
Alongside limitations in the existing state of knowledge, ignorance constitutes a driving factor of ‘unexpected consequences of conduct’ in purposive social action, as defined by Robert K. Merton (Merton, 1936)
By prohibiting the use of a placebo in cases where there already exists a demonstrably effective alternative, equipoise reduces the potential for ‘doing harm’ to members of a trial’s control group
Skepticism among some regarding the ability of evidence-based practice to effectively navigate ‘real life,’ on-the-ground scenarios:
o Martyn Hammersley (2005) contends that the unequivocal distinction promoted by Iain Chalmers between research evidence and the lived experience of practitioners serves to erroneously suggest that research should always supersede practitioner opinion
o HOWEVER, evidence-based practice can coexist with clinical expertise, and though Hammersley may be correct in asserting that “value judgments” (Hammersley, 2005, p. 94) infiltrate research as well as practitioner opinion, systematic reviews and meta-analyses provide the most reliable and rigorous tools presently available to address bias (Chalmers, 2005)
The evidence-based practice movement attaches too much importance to evidence generated from randomized controlled trials. Discuss this statement.
What is Evidence-Based Practice (EBP)?
o “…the conscientious [ethical, effective, honest], explicit [transparent, auditable], and judicious [considered, prudent] use of current best evidence [as rigorous as possible, subject to updating] in making decisions about the care of individual [people]…integrating individual clinical expertise with the best available external clinical evidence from systematic research” (Sackett et al., 1996, p. 71)
o “Without clinical expertise, practice risks becoming tyrannized by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual [person]. Without current best evidence, practice risks becoming rapidly out of date, to the detriment of [people]” (Sackett et al., 1996, p. 72)
Common objections to EBP:
o Ignores clinical expertise
o Ignores client values and preferences
o Is a cookbook approach
o Is simply a cost-cutting tool
o Is limited to clinical research
o Cannot be done; is an ivory-tower concept
o Results in ‘therapeutic nihilism’
- i.e., a contention that it is impossible to cure people or societies of their ills through treatment…In medicine, it was connected to the idea that many “cures” do more harm than good, and that one should instead encourage the body to heal itself (Michel de Montaigne; Jacob Stegenga)
o Assumes that professionals are rational agents
o Can always find evidence for a favored point of view
Cartwright and Munro introduce some concerns about how to interpret RCTs, arguing that they are by themselves typically “insufficient to meet the needs of policy or practice decision makers” (Cartwright and Munro, 2010, p. 265, as cited in Cowen et al., 2017)
“The primary result of an RCT is a judgment about the effectiveness of a treatment in producing an outcome in the study population, although the contribution of other factors to the outcome is unknown. The purpose of RCTs in the context of EBP is to help estimate the effectiveness of a treatment in a target population or populations different from the one on which the experiment was conducted, which raises questions about whether and when such inferences are warranted” (Cowen et al., 2017)
“It is widely acknowledged that we generally don’t know all the important causes for a factor, let alone knowing [their] distribution…in the study and the target populations” (Cartwright and Munro, 2010, p. 261)
There are two categories of causal factors, besides the intervention itself, that might affect the outcome (Cowen et al., 2017):
- First, there are factors that operate independently of the intervention. These will affect the overall size of the outcome but have no effect on what the intervention itself contributes to the outcome
- Second, there are factors that moderate how much effect the intervention can produce, factors that must be in place lest the intervention fail to produce its expected contribution. These are called support factors (sometimes also “interactive factors” or “moderator factors”)
- -> Support factors…bear on the central question of EBP: whether the intervention or policy will “work” in a targeted setting, i.e., whether it will produce some positive contribution to the desired outcome there
“Evidence based medicine is not restricted to randomised trials and meta-analyses. It involves tracking down the best external evidence with which to answer our clinical questions. To find out about the accuracy of a diagnostic test, we need to find proper cross sectional studies of patients clinically suspected of harbouring the relevant disorder, not a randomised trial. For a question about prognosis, we need proper follow up studies of patients assembled at a uniform, early point in the clinical course of their disease. And sometimes the evidence we need will come from the basic sciences such as genetics or immunology. It is when asking questions about therapy that we should try to avoid the non-experimental approaches, since these routinely lead to false positive conclusions about efficacy”
“Because the randomised trial, and especially the systematic review of several randomised trials, is so much more likely to inform us and so much less likely to mislead us, it has become the ‘gold standard’ for judging whether a treatment does more good than harm. However, some questions about therapy do not require randomised trials (successful interventions for otherwise fatal conditions) or cannot wait for the trials to be conducted. And if no randomised trial has been carried out for our patient’s predicament, we must follow the trail to the next best external evidence and work from there” (Sackett et al., 1996, p. 72)
What are the major challenges and solutions to taking evidence-based interventions to scale?
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Why is implementation fidelity important? What are the potential trade-offs when implementing social interventions with high fidelity?
Challenges: implementation fidelity and effectiveness
o Efficacy = whether an intervention can work
o Effectiveness = how well an intervention does work when applied in typical settings
o In this language, some interventions to reduce or prevent problem behavior have been shown to have efficacy, but almost no interventions have been shown to be generally effective
o If efficacious interventions are ineffective, it is likely that flawed implementation constitutes a large part of the reason
Balancing fidelity and fit:
o Fidelity vital, because it is assumed to drive effectiveness…
o Do adaptations change the implied theory of change?
o Did adaptation change the proposed core components and procedures so much that it became a different intervention?
o Above all, does the intervention (still) work…?
Do adapted interventions work better?
o What would be the best test? How much good data exists?
o Tension between adaptation and fidelity
o Look carefully at meta-analyses claiming culturally adapted interventions are/aren’t more effective – what did they actually test?
o Some SRs (Hall et al., 2016; Griner and Smith, 1995), lack counterfactual – make no comparison with non-adapted programs
- Huey et al., 2008, 2012 reached different conclusions
o Some interventions appear to ‘transport’ well across cultures, despite limited adaptation (in parenting field – Gardner et al., 2016; Reid et al., 2001; Leijten et al., 2016 compared home-grown and transported programs, finding no difference in effects)
o Culturally adapted family-based interventions for children can increase retention by up to 40%, but also reduce positive outcomes (Kumpfer et al., 2002) – suggests a possible trade-off between acceptability and effectiveness
