The Challenges of Adaptation

Like many other project directors, Melissa Streppa, a Prevention/Early Intervention grantee in Burke County, North Carolina, knew that successful implementation of an evidence-based program would be enhanced through careful adaptation based on the needs of her target population. While one of the project's adaptations was planned from the beginning, the need for the two other adaptations only became apparent once the program was underway.

Adaptation One - Format Change

Nurturing Parententing Program, an evidence-based program, was selected because of its heavy emphasis on creating impact through prevention and early intervention among parents of school-aged children. Lack of appropriate parenting information and skills can lead to emotional and physical abuse and neglect, which can in turn lead to behavioral problems in children, which show up in the classroom. The program's framework includes four pillars of learning - appropriate expectations, empathy, non-violent behavioral management and appropriate familial roles. It was developed to be used with groups of parents, not individual families. Burke County's grant application, however, was written for a home-based, one-on-one program, thought to be more effective with a high-risk population. In addition, since Burke County covers a large rural geographic area with little public transportation, "we could get to them; they couldn't get to us" says Sonia Heflin, a family mentor.

Program staff and family mentors worked with Dr. Stephen Bavolek, the developer of Nurturing Parenting Program, to adapt the program to a one-on-one, home-based program. Although Dr. Bavelok expressed reservations about the loss of group interaction in an individualized program, he had a home based version for the 0-5 age group. Working together, they found that the program's core messages could be delivered intact. The curriculum is structured and easy to follow, allowing the shift from a group to an individual setting.

Adaptation Two - Service Before Instruction

The realities of life in this rural, high poverty area of Western North Carolina dictated the next adaptation. As anticipated, families referred to the program were in dire need of medical attention, medication for mental illness, heat/air, food and clothing - starting the Nurturing Parenting Program without addressing these core problems would have been fruitless. Thus, they adapted the program by delaying the onset of the directed learning modules and focused more of their initial energies on case management. This served two important purposes - one, they made sure basic living needs were met and two, they built rapport with the families that would enable them to better deliver the NPP. "It's hard to concentrate on learning skills when you have unmet mental health needs," Melissa explains. Agreeing with Melissa, Sonia adds, "We need to be case managers first - to advocate for the families and connect them with needed services." The stability of the family is crucial to the curriculum delivery. While family mentors never shortened the curriculum's 23 lessons, they often delayed the onset of the program by an average of one to two months to insure that basic needs were addressed first.

Adaptation Three - Comprehension Level adjustments

Dr. Bavelok coached the family mentors in the third major adaptation. During the administration of the key measurement instrument, the Adult/Adolescent Parenting Inventory (AAPI), the mentors found that parents were struggling to answer parts of the questionnaire. Mentors realized that the program was designed for parents with higher levels of comprehension than existed among their families. This was of particular concern to program staff because of the impact it could have on outcome data. Dr. Bavelok coached parent mentors as they adapted the questionnaire and encouraged them to assist the families in completing the questionnaires, if needed.

Although this means mentors interject explanations of questions when needed, Melissa and the family mentors work very hard as a group to keep to a high level of consistency in the way they explain terms. They make sure that though there may be variation in assistance offered to complete the AAPI, all parent mentors deliver the program's curriculum in the same way, in the same order and with the same expectations for outcomes.

As the only bilingual parent mentor, Sonia conducted the Spanish version/translation of the AAPI. She found that the Spanish-speaking families scored very low. This ran counter to her knowledge of their skills. A conversation with Dr. Bavelok gave her a more accurate way of scoring these inventories based on Spanish norms. Having access to the program's developer helped prevent a measurement error.

Sonia and Melissa offer the following insights and advice for adaptation:

• The home-based, one-on-one nature of their adaptation permits a good understanding of family functioning. The intensive nature of the interaction helps make fundamental changes in belief systems. On the other hand, the ideal program would also incorporate opportunities for parents to meet as a group to exchange ideas and experiences. In a rural area, parents can feel very isolated.
• Hire implementers who are flexible and comfortable with adaptation. Although you're adapting a program, the philosophy and theoretical underpinnings of the evidence-program stay intact. Find staff who are comfortable adapting programs and believe in the material and the process.
• Have access to the program developer. Nurturing Parenting Program was chosen in part because of the proximity of its developer. This made learning and collaborating much easier. It also meant they could commit to working in a cost-effective manner and could tailor his assistance to meet their needs. Collaborating with a program's developer helps you maintain higher levels of fidelity.
• Attending the facilitators' training with some program experience under your belt helps to strengthen the training activities and exercises and helps tailor the training to specific needs. Melissa comments, "We didn't attend the facilitator's training early on because we didn't have the experience to be able to pick and choose the pieces that were most pertinent. Timing is everything."