This article describes the adaptation of a parent-focused evidence-based childhood obesity intervention program for implementation by county-based Extension educators in coordination with school district personnel in rural Pennsylvania. The Lifestyle Positive Parenting Program was designed and evaluated in Australia in clinical settings. Several minor and more serious adaptations, such as featured recipes and content of follow-up telephone calls, were made so that the program would be more appropriate for and appealing to target families. Conceptual issues regarding the adaptation of evidence-based programs are reviewed

DiNallo, Jennifer M.

Li, Jacinda C.

Nix, Robert L.

Welsh, Janet A.

English

Clemson University: TigerPrints

Journal of Extension Volume 58 Number 2 Article 10 April 2020 Cultural and Contextual Adaptation of a Childhood Obesity Preventive Intervention Program Jennifer M. DiNallo Pennsylvania State University Janet A. Welsh Pennsylvania State University Jacinda C. Li Pennsylvania State University Robert L. Nix University of Wisconsin This work is licensed under a Creative Commons Attribution-Noncommercial-Share Alike 4.0 License. Recommended Citation DiNallo, J. M., Welsh, J. A., Li, J. C., & Nix, R. L. (2021). Cultural and Contextual Adaptation of a Childhood Obesity Preventive Intervention Program. Journal of Extension, 58(2). Retrieved from https://tigerprints.clemson.edu/joe/vol58/iss2/10 This Ideas at Work is brought to you for free and open access by TigerPrints. It has been accepted for inclusion in Journal of Extension by an authorized editor of TigerPrints. For more information, please contact kokeefe@clemson.edu. April 2020Volume 58Number 2Article #v58-2iw2Ideas at WorkCultural and Contextual Adaptation of a Childhood ObesityPreventive Intervention ProgramAbstractThis article describes the adaptation of a parent-focused evidence-based childhood obesity interventionprogram for implementation by county-based Extension educators in coordination with school districtpersonnel in rural Pennsylvania. The Lifestyle Positive Parenting Program was designed and evaluated inAustralia in clinical settings. Several minor and more serious adaptations, such as featured recipes and contentof follow-up telephone calls, were made so that the program would be more appropriate for and appealing totarget families. Conceptual issues regarding the adaptation of evidence-based programs are reviewed.Keywords: adaptation, evidence-based intervention, child obesity   Much Extension work involves the dissemination of evidence-based intervention programs focused oncritical community needs. However, evidence-based intervention programs often require some adaptation tomaximize fit, acceptability, and impact in new settings (Barrera & Castro, 2006; Kumpfer, Alvarado, Smith,& Bellamy 2002). For many years, Extension has been involved in addressing the childhood obesityepidemic (Benke et al., 2013; Dart, Frable, & Bradley, 2008; Lanigan & Power, 2008). This article describesthe adaptation of an evidence-based childhood obesity program for use by Extension educators incoordination with local school district personnel.Principles of AdaptationAdaptation refers to modifications of evidence-based program content or delivery mode to accommodatecultural beliefs, attitudes, and behaviors in a new population (Castro, Barrera, & Martinez, 2004; Whaley &Davis, 2007). Adaptation at the surface structure level involves changes to observable "superficial"characteristics, such as matching photographs in program materials to participants' race/ethnicity.Adaptation at the deep structure level involves core components implicated in the program logic model(Resnicow, Soler, Braithwaite, Ahluwalia, & Butler, 2000).Jennifer M. DiNalloDirector of ResearchClearinghouse forMilitary FamilyReadinessPennsylvania StateUniversityUniversity Park,Pennsylvaniajmd422@psu.eduJanet A. WelshAssociate ResearchProfessorEdna Bennett PiercePrevention ResearchCenterPennsylvania StateUniversityUniversity Park,Pennsylvaniajaw900@psu.eduJacinda C. LiGraduate ResearchFellowDepartment of HumanDevelopment andFamily StudiesPennsylvania StateUniversityUniversity Park,Pennsylvaniajcl270@psu.eduRobert L. NixAssociate ProfessorDepartment of HumanDevelopment andFamily StudiesUniversity ofWisconsin–ExtensionMadison, Wisconsinrobert.nix@wisc.eduWhereas changes at the surface structure level are widely accepted, changes at the deep structure level areactively discouraged (Ferrer-Wreder, Sundell, & Mansoory, 2012; Kumpfer et al., 2002). Once deepstructure level changes are made, the evidence base for a program is compromised and may no longerapply.Adaptation of a Childhood Obesity ProgramStemming from prior successful collaborations, Extension educators, local school district personnel, and ourteam of university-based researchers comprised an ideal partnership for addressing childhood obesity in tworural communities in Pennsylvania. Partnership members were especially interested in the Lifestyle PositiveParenting Program, also known as Lifestyle Triple P (LTP), because it is one of the few childhood obesityprograms with rigorous evidence of effectiveness. In a randomized controlled trial with a clinic-basedsample of families with overweight children, LTP improved parents' effectiveness in promoting children'shealthful behaviors and reduced children's body mass index over 1 year, compared to usual care (West,Sanders, Cleghorn, & Davies, 2010). LTP is manualized, consisting of 10 weekly parent group sessions andfour individual telephone calls. After reviewing curriculum content, we agreed that LTP was likely to befeasible and efficacious in rural Pennsylvania, with some modifications.Surface Structure AdaptationsIn close consultation with Matthew Sanders, PhD, the developer of LTP, we settled on two adaptations atthe surface structure level.First, the Australian-normed dietary guidelines for LTP did not conform to U.S. Department of AgricultureMyPlate guidelines. Furthermore, many of the recipes included in the recipe book included unfamiliar andpossibly unappealing ingredients. Therefore, we revised all dietary recommendations and featured recipes.Second, with extensive experience in implementing the Strengthening Families Program: 10–14 (Molgaard,Spoth, & Redmond, 2000), Extension educators and school district personnel believed that providingchildcare and meals would reduce a major barrier to family participation. They also believed that parentswould be more inclined to use LTP recipes if they could try them first. Thus, we provided meals from theprogram recipe book to families before each group session.More Serious AdaptationsIn close consultation with Dr. Sanders, we also decided to make three adaptations that existed in the grayarea between being clearly surface structure changes or being more serious deep structure changes.First, although the Australian trial of LTP relied on clinical psychologists to deliver the program, we werecommitted to implementing LTP in a community setting, using local facilitators with varied backgrounds.This decision was based on the understanding that in rural areas of the country, schools, not mental healthcenters, were the most stable existing community-based infrastructure for the dissemination of evidence-based programs for children.Second, Extension educators and school district personnel believed that content of some of the telephonecalls, such as questions about marital conflict and its effect on children's health, was too personal given theIdeas at Work Cultural and Contextual Adaptation of a Childhood Obesity Preventive Intervention Program JOE 58(2)©2020 Extension Journal Inc. 1new context in which LTP would be implemented. As a result, we eliminated two telephone calls. We left theremaining two telephone calls, which featured more general questions about positive parenting practices,unchanged.Third, because obesity is a highly stigmatizing issue, we believed that too much emphasis on obesity wouldbe off-putting to families. Instead, we chose to focus the program on health promotion, such as nutritiouseating and increased physical activity, during both recruitment and implementation.Testing Results and Concluding RemarksWhen adapting an evidence-based program, best practices involve maximizing program–context fit withoutcompromising program core components (Backer, 2001; Barrera & Castro, 2006). In this case, Extensioneducators and local school district personnel were experts in the local context and Dr. Sanders was theexpert in LTP core components. The contributions of all these experts increased the chances of programsuccess.Some changes to LTP, such as featured recipes, were relatively minor and clearly affected only surfacestructure features. Unfortunately, even with consultation with the program developer, it is sometimesdifficult to discern whether other changes, such as eliminating potentially uncomfortable telephone calls,might have a greater impact than intended. It was not clear how critical these features were to LTP's priorsuccess. Because of that uncertainty, we incorporated one additional best practice of adaptation: testing theeffectiveness of the revised program in the new context. The study we undertook relied on the fact thatmore families were interested in the program than could be accommodated. Rather than enroll families on afirst-come-first-served basis, we randomly assigned families to receive the program at two different timepoints, thus creating an ideal waiting list control condition that could be tested in a rigorous experimentalstudy design (Li, Welsh, DiNallo, & Nix, 2020).In sum, Extension educators should be aware that evidence-based intervention programs often requiresome adaptation for new contexts. In these cases, it is critically important to distinguish between changesat surface structure and deep structure levels. When there are concerns that adaptations might broach thegray area between surface features and deep structure, it is important to retest the revised program. In thisway, educators are most likely to serve the mission of Extension in disseminating the best programspossible.AcknowledgmentsOur study was funded by the National Center for Advancing Translational Sciences, National Institutes ofHealth, grant UL Tr000127, to the Clinical and Translational Science Institute of Pennsylvania StateUniversity.ReferencesBacker, T. E. (2001). Finding the balance—Program fidelity and adaptation in substance abuse prevention:A State‐of‐the-art review. Rockville, MD: U.S. Department of Health and Human Services Substance Abuseand Mental Health Services Administration and Center for Substance Abuse Prevention.Barrera, M., & Castro, F. G. (2006). A heuristic framework for the cultural adaptation of interventions.Ideas at Work Cultural and Contextual Adaptation of a Childhood Obesity Preventive Intervention Program JOE 58(2)©2020 Extension Journal Inc. 2Clinical Psychology: Science and Practice, 13(4), 311–316. doi:10.1111/j.1468-2850.2006.00043.xBenke, C. J., Bailey, S. J., Martz, J., Paul, L., Lynch, W., & Eldridge, G. (2013). Developing a parent-centered obesity prevention program for 4-H families: Implications for Extension family programming.Journal of Extension, 51(3), Article v51-3a8. Available at: https://joe.org/joe/2013june/a8.phpCastro, F. G., Barrera, M., Jr., & Martinez, C. R. (2004). The cultural adaptation of preventive interventions:Resolving tensions between fidelity and fit. Prevention Science, 5, 41–45.Dart, L., Frable, P. J., & Bradley, P. J. (2008). Families and community partners learning together toprevent obesity. Journal of Extension, 46(1), Article 1IAW2. Available at:https://www.joe.org/joe/2008february/iw2.phpFerrer-Wreder, L., Sundell, K., & Mansoory, S. (2012). Tinkering with perfection: Theory development in theintervention cultural adaptation field. Child & Youth Care Forum, 41(2), 149–171. doi:10.1007/s10566-011-9162-6Kumpfer, K. L., Alvarado, R., Smith, P., & Bellamy, N. (2002). Cultural sensitivity and adaptation in family-based prevention interventions. Prevention Science, 3(3), 241–246.Lanigan, J., & Power, T. G. (2008). Obesity prevention and health promotion: How family life educatorsview their role. Journal of Extension, 46(6), Article 6FEA5. Available at:https://www.joe.org/joe/2008december/a5.phpLi, J. C., Welsh, J. A., DiNallo, J. M., & Nix, R. L. (2020). Parent-focused childhood obesity interventionimproves family functioning and children's well-being. Journal of Extension, 58(2), Article v58-2rb2.Available at: https://joe.org/joe/2020april/rb2.phpMolgaard, V. K., Spoth, R. L., & Redmond, C. (2000). Competency training: The Strengthening FamiliesProgram, for parents and youth 10–14. Washington, DC: U.S. Department of Justice, Office of JusticePrograms, Office of Juvenile Justice and Delinquency Prevention.Resnicow, K., Soler, R., Braithwaite, R. L., Ahluwalia, J. S., & Butler, J. (2000). Cultural sensitivity insubstance use prevention. Journal of Community Psychology, 28(3), 271–290. doi:10.1002/(SICI)1520-6629(200005)28:3<271::AID-JCOP4>3.0.CO;2-IWest, F., Sanders, M. R., Cleghorn, G. J., & Davies, P. S. (2010). Randomised clinical trial of a family-basedlifestyle intervention for childhood obesity involving parents as the exclusive agents of change. BehaviourResearch and Therapy, 48(12), 1170–1179. doi:10.1016/j.brat.2010.08.008Whaley, A. L., & Davis, K. E. (2007). Cultural competence and evidence-based practice in mental healthservices: A complementary perspective. American Psychologist, 62(6), 563–574. doi:10.1037/0003-066x.62.6.563Copyright © by Extension Journal, Inc. ISSN 1077-5315. Articles appearing in the Journal become theproperty of the Journal. Single copies of articles may be reproduced in electronic or print form for use inIdeas at Work Cultural and Contextual Adaptation of a Childhood Obesity Preventive Intervention Program JOE 58(2)©2020 Extension Journal Inc. 3educational or training activities. Inclusion of articles in other publications, electronic sources, or systematiclarge-scale distribution may be done only with prior electronic or written permission of the Journal EditorialOffice, joe-ed@joe.org.If you have difficulties viewing or printing this page, please contact JOE Technical SupportIdeas at Work Cultural and Contextual Adaptation of a Childhood Obesity Preventive Intervention Program JOE 58(2)©2020 Extension Journal Inc. 4

Cultural and Contextual Adaptation of a Childhood Obesity Preventive Intervention Program

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Cultural and Contextual Adaptation of a Childhood Obesity Preventive Intervention Program

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