Commentary on “Integrating Community-Engagement And A Multiphase Optimization Strategy Framework: Adapting Substance Use Prevention For American Indian Families

“Integrating Community-Engagement and a Multiphase Optimization Strategy Framework: Adapting Substance Use Preventionfor American Indian Families” by Whitesell and colleagues[1] is an excellent example of a scientific approach to addressing the tension between fidelity and fit. As described by Castro,[2]this tension arises because there is the need to implement programs that “deliver the best science while also addressing the practical concerns of a local community.” This paper demonstrates how to do this in a systematic and rigorous way. The authors adapt an evidence-based early substance abuse prevention program (Iowa Strengthening Families Program for Parents and Youth 10-14, referenced as SFP `0-14) for American Indian families. The intervention is delivered to youth and their families across seven weekly meetings.

The adaptation was done through a community-engaged process that paid careful attention to fit. They involved a set of foundational changes that were included throughout the curriculum to align the content with the community’s cultural values, as well as three discrete changes: (a) using tribal language to describe kinship relationships; (b) using social media to reinforce program messages and (c) replacing the substance abuse specific content with an alternative session on healthy eating and exercise.

Fidelity to the program was measured in several ways. First, design fidelity was ensured by continually consulting the developers of the original program to ensure adaptations maintained fidelity. Second, a fractional factorial design was used to test the effectiveness of combinations of adapted components against the core intervention. Effectiveness was measured by reported substance use, as well as by a variety of mediators drawn from the SFP theory. Instruments were designed or adapted in consultation with the communities. Implementation fidelity to both the core and adapted interventions was measured using fidelity checklists.

The results from the factorial experiment indicated that none of the adaptations resulted in a difference in effectiveness. The authors used process and program evaluation data to evaluate the adaptations on four criteria other than effectiveness: efficiency, economy, scalability, and acceptability. Given the lack of differentiation across the adaptation components based on effectiveness, these criteria were used to select the final adaptations. Substance abuse content and traditional kinship language were included as adaptations but not the use of social media.

This paper demonstrates a systematic approach to the adaptation process that intensively engages the community, but uses a scientifically mixed rigorous process to assess the relationship between fidelity and fit. It is particularly telling that the final adaptations were not just based on effectiveness, but on other implementation and acceptability criteria. In his paper describing this tension, Castro quotes a community leader who asks “What good is science if it doesn’t help us?” This paper is a thoughtful demonstration of how it is possible to do both.

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[1] Whitesell, N. R., Mousseau, A. C., Keane, E. M., Asdigian, N. L., Tuitt, N., Morse, B., . . . Kaufman, C. E. (2019). Integrating Community-Engagement and a Multiphase Optimization Strategy Framework: Adapting Substance Use Prevention for American Indian Families. Prev Sci.

[2] Castro, F. G., Barrera, Jr., M., & Martinez, Jr., C. R. (2004). The Cultural Adaptation of Prevention Interventions: Resolving Tensions Between Fidelity and Fit. Prevention Science, 5(1), 41-45