Issues and Challenges in the Design of Culturally Adapted Evidence-Based Interventions

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  • ANRV407-CP06-09 ARI 22 February 2010 15:15

    Issues and Challenges in theDesign of Culturally AdaptedEvidence-Based InterventionsFelipe Gonzalez Castro,1,2 Manuel Barrera Jr.,1

    and Lori K. Holleran Steiker31Department of Psychology, Arizona State University, Tempe, Arizona 85287-1104;email: felipe.castro@asu.edu2Southwest Interdisciplinary Research Center, Arizona State University, Phoenix,Arizona 850043School of Social Work, University of Texas at Austin, Austin, Texas 78712

    Annu. Rev. Clin. Psychol. 2010. 6:21339

    First published online as a Review in Advance onJanuary 6, 2010

    The Annual Review of Clinical Psychology is onlineat clinpsy.annualreviews.org

    This articles doi:10.1146/annurev-clinpsy-033109-132032

    Copyright c 2010 by Annual Reviews.All rights reserved

    1548-5943/10/0427-0213$20.00

    Key Words

    cultural adaptation, adaptation models

    AbstractThis article examines issues and challenges in the design of culturaladaptations that are developed from an original evidence-based inter-vention (EBI). Recently emerging multistep frameworks or stage mod-els are examined, as these can systematically guide the developmentof culturally adapted EBIs. Critical issues are also presented regardingwhether and how such adaptations may be conducted, and empiricalevidence is presented regarding the effectiveness of such cultural adap-tations. Recent evidence suggests that these cultural adaptations areeffective when applied with certain subcultural groups, although theyare less effective when applied with other subcultural groups. Generally,current evidence regarding the effectiveness of cultural adaptations ispromising but mixed. Further research is needed to obtain more deni-tive conclusions regarding the efcacy and effectiveness of culturallyadapted EBIs. Directions for future research and recommendations arepresented to guide the development of a new generation of culturallyadapted EBIs.

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    Contents

    OVERVIEW OF CULTURE ANDINTERVENTIONADAPTATIONS . . . . . . . . . . . . . . . . . . 214

    PURPOSE AND SCOPE. . . . . . . . . . . . . 215PERSPECTIVES AND

    CHALLENGES IN THEDESIGN OF CULTURALADAPTATIONS . . . . . . . . . . . . . . . . . . 216Concepts of Culture and

    Cultural Frameworks . . . . . . . . . . . 216Population Segmentation. . . . . . . . . . . 217Subcultural Groups . . . . . . . . . . . . . . . . 217The Structure of Culture as a

    Collection of CulturalElements . . . . . . . . . . . . . . . . . . . . . . . 217

    Systemic-Ecological Modelsof Culture . . . . . . . . . . . . . . . . . . . . . . 217

    Cultural Change andAcculturative Adaptation . . . . . . . . 218

    Cultural Relevance andCultural Adaptation . . . . . . . . . . . . . 218

    Terminology for ApproachingCultural Adaptation . . . . . . . . . . . . . 219

    PROFESSIONAL CONTEXTSAFFECTING THE DESIGN OFCULTURAL ADAPTATIONS . . . . 220Distinctions Regarding Types of

    Evidence-Based Interventions . . . 220FOUR MAJOR ISSUES IN

    CULTURAL ADAPTATION. . . . . . 221The Fidelity-Adaptation Dilemma . . 221

    CONCERNS OVER EROSIONOF INTERVENTIONEFFECTIVENESS. . . . . . . . . . . . . . . . 221Issue #1: Are Cultural Adaptations of

    Evidence-Based TreatmentsJustiable? . . . . . . . . . . . . . . . . . . . . . . 222

    Issue #2: What Procedures ShouldIntervention Developers FollowWhen Conducting a CulturalAdaptation?. . . . . . . . . . . . . . . . . . . . . 225

    Issue #3: Is There Evidence thatCultural Adaptations areEffective? . . . . . . . . . . . . . . . . . . . . . . . 228

    Issue #4: How Can WideWithin-Group Cultural VariationBe Accommodated in a CulturalAdaptation?. . . . . . . . . . . . . . . . . . . . . 229

    APPLYING CULTURALADAPTATION APPROACHES . . . 230Exemplars of Culturally Grounded

    Cognitive-BehavioralTreatments . . . . . . . . . . . . . . . . . . . . . 230

    Exemplar of a Culturally GroundedSubstance Abuse PreventionIntervention . . . . . . . . . . . . . . . . . . . . 231

    ISSUES, ANSWERS, ANDABIDING CHALLENGES. . . . . . . . 232Directions for Future

    Development . . . . . . . . . . . . . . . . . . . 233Some Recommendations . . . . . . . . . . . 234

    OVERVIEW OF CULTURE ANDINTERVENTION ADAPTATIONS

    Clinical psychologists have a deep respectfor scientic principles that have contributedto the development of interventions and thesubstantiation of their effectiveness in relievinghuman suffering and remediating problems inliving. This research tradition has promoteddisciplinary standards of evidence for deter-mining that an intervention is efcacious inproducing one or more targeted outcomes

    (Flay et al. 2005). Subsequently, tested-and-effective treatment procedures have beenincorporated into treatment manuals and othermedia to facilitate consistency in treatmentdelivery (Chambless & Hollon 1998).

    From the perspective of clinical practice,clinical psychologists have equal respect for anin-depth understanding of the person and ofhuman variation (Sue & Sue 1999). The essenceof the clinical method involves the applicationof nomothetic principles ltered through an

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  • ANRV407-CP06-09 ARI 22 February 2010 15:15

    individual case conceptualization and informedby clinical judgment for effectively treatingeach person. Within this duality, a dynamictension has emerged between the standardizednomothetic scientic top-down approach thatdemands delity in its implementation and theidiographic casewise bottom-up approach thatdemands sensitivity and responsiveness to eachpersons unique needs.

    This dynamic tension can foment con-troversy, raise contentious issues, and launcha search for common ground. The culturaladaptation of evidence-based interventionsis a specic topic where these two equallyimportant professional values have clashed,particularly as embodied by the delity-adaptation dilemma (Castro et al. 2004, Elliott& Mihalic 2004). Within this context, weexamine the literature on treatment andprevention interventions; thus, we use the termevidence-based interventions (EBIs) to refer tointerventions of two types: (a) those developedto treat existing disorders, usually within clin-ical settings, i.e., evidence-based treatments(EBTs) and (b) interventions developed forpreventing disorders within various at-riskpopulations, i.e., evidence-based preventioninterventions (EBPIs).

    The cultural adaptation of EBIs has emergedas an intervention strategy and will likely growin prominence as a result of two trends (LaRoche & Christopher 2008, Lau 2006): (a) thegrowing demand for EBIs and (b) the growingdiversication of the American population. Thegrowing demand for EBIs has emerged despiteclinicians concerns that it may be prematureand may impose unrealistic constraints on clin-ical practice (Bernal & Scharron-del-Ro 2001,Norcross et al. 2006).

    Division 12 of the American Psychologi-cal Association (APA) has taken a leadershiprole in establishing criteria for determining thata psychological intervention is evidence basedand in maintaining a catalog of interventionsthat meet these criteria (Am. Psychol. Assoc.1995, 2006). Other groups, including the Na-tional Registry of Evidence-Based PreventionPrograms (NREPP) (Schinke et al. 2002), have

    created such lists (Subst. Abuse Mental HealthServ. Admin. 2009). This demand has also beendriven by several professional groups, includingclinical researchers and scientist-practitionerswho feel a professional responsibility to developand deliver interventions supported by researchevidence. Other advocates include agencies thatpay for psychological services and civic, com-munity, and governmental organizations thatdemand evidence that limited funds will bespent appropriately on interventions that work(Whaley & Davis 2007).

    The second trend involves the growing cul-tural diversity within the United States andthe globalization of intervention disseminations(Iwamasa 1997, Weisman et al. 2006). Unfor-tunately, the infusion of cultural factors intoEBIs and tests of their efcacy with subculturalgroups have not kept pace with these diver-sication trends. In this regard, La Roche &Christopher (2008) note that racial/ethnic mi-nority participants have rarely been includedin samples used for validating the efcacy ofEBIs, including many of those recognized byAPAs Division 12 in 1995 (Am. Psychol. Assoc.1995). This limitation has changed only mod-erately over the past decade.

    PURPOSE AND SCOPE

    The purpose of this review is to provide an anal-ysis of issues and challenges involved in the de-sign of cultural adaptations that are developedfrom original EBIs. We do so by pursuing twoaims. First, we review fundamental approachesand frameworks for a deep structure analysis ofculture, as tools for designing cultural adapta-tions of EBIs. Second, we identify and discusscritical issues and challenges in the design ofthese cultural adaptations. The analy