Kaiser Bonnie N, Kaufman Julia, Wall Jonathan Taylor, Healy Elsa A Friis, Ayuku David, Aarons Gregory A, Puffer Eve S
Department of Anthropology; Global Health Program, University of California San Diego, La Jolla, CA, USA.
Duke Global Health Institute, Durham, NC, USA.
Implement Sci Commun. 2023 Aug 29;4(1):105. doi: 10.1186/s43058-023-00477-5.
A key question in implementation science is how to balance adaptation and fidelity in translating interventions to new settings. There is growing consensus regarding the importance of planned adaptations to deliver interventions in contextually sensitive ways. However, less research has examined ad-hoc adaptations, or those that occur spontaneously in the course of intervention delivery. A key question is whether ad-hoc adaptations ultimately contribute to or detract from intervention goals. This study aimed to (a) identify ad-hoc adaptations made during delivery of a family therapy intervention and (b) assess whether they promoted or interrupted intervention goals.
Tuko Pamoja (Swahili: "We are Together") is an evidence-informed family therapy intervention aiming to improve family dynamics and mental health in Kenya. Tuko Pamoja employs a task-shifting model, delivered by lay counselors who are afforded a degree of flexibility in presenting content and in practices they use in sessions. We used transcripts of therapy sessions with 14 families to examine ad-hoc adaptations used by counselors. We first identified and characterized ad-hoc adaptations through a team-based code development, coding, and code description process. Then, we evaluated to what extent ad-hoc adaptations promoted the principles and strategies of the intervention ("TP-promoting"), disrupted them ("TP-interrupting"), or neither ("TP-neutral"). To do this, we first established inter-coder agreement on application of these categories with verification by the intervention developer. Then, coders categorized ad-hoc adaptation text segments as TP-promoting, TP-interrupting, or TP-neutral.
Ad-hoc adaptations were frequent and included (in decreasing order): incorporation of religious content, exemplars/role models, community dynamics and resources, self-disclosure, and metaphors/proverbs. Ad-hoc adaptations were largely TP-promoting (49%) or neutral (39%), but practices were TP-interrupting 12% of the time. TP-interrupting practices most often occurred within religious content and exemplars/role models, which were also the most common practices overall.
Extra attention is needed during planned adaptation, training, and supervision to promote intervention-aligned use of common ad-hoc adaptation practices. Discussing them in trainings can provide guidance for lay providers on how best to incorporate ad-hoc adaptations during delivery. Future research should evaluate whether well-aligned ad-hoc adaptations improve therapeutic outcomes.
Pilot trial registered at clinicaltrials.gov (C0058).
实施科学中的一个关键问题是，在将干预措施应用于新环境时，如何平衡适应性和保真度。对于以因地制宜的方式实施干预措施时进行有计划的适应性调整的重要性，人们的共识日益增加。然而，较少有研究探讨临时适应性调整，即那些在干预实施过程中自发出现的调整。一个关键问题是，临时适应性调整最终是有助于还是有损于干预目标。本研究旨在：（a）识别在家庭治疗干预实施过程中所做的临时适应性调整；（b）评估这些调整是促进还是干扰了干预目标。
“团结在一起”（斯瓦希里语：“Tuko Pamoja”）是一项基于证据的家庭治疗干预措施，旨在改善肯尼亚家庭的家庭关系和心理健康。“团结在一起”采用任务转移模式，由非专业咨询师实施，他们在呈现内容和治疗过程中使用的方法上有一定的灵活性。我们使用了与14个家庭的治疗会话记录来研究咨询师所采用的临时适应性调整。我们首先通过基于团队的编码开发、编码和代码描述过程来识别和描述临时适应性调整。然后，我们评估临时适应性调整在多大程度上促进了干预的原则和策略（“促进Tuko Pamoja”）、破坏了这些原则和策略（“干扰Tuko Pamoja”），还是两者都没有（“Tuko Pamoja中性”）。为此，我们首先在这些类别的应用上建立了编码员间的一致性，并由干预开发者进行验证。然后，编码员将临时适应性调整的文本片段分类为促进Tuko Pamoja、干扰Tuko Pamoja或Tuko Pamoja中性。
临时适应性调整很常见，包括（按出现频率从高到低排列）：纳入宗教内容、榜样/模范、社区动态和资源、自我表露以及隐喻/谚语。临时适应性调整大多是促进Tuko Pamoja（49%）或中性（39%）情况，但有12%的情况是干扰Tuko Pamoja。干扰Tuko Pamoja的情况最常出现在宗教内容和榜样/模范中，而这两者也是总体上最常见的情况。
在有计划的适应性调整、培训和监督过程中，需要格外关注，以促进对常见临时适应性调整做法的干预一致性使用。在培训中讨论这些做法可以为非专业提供者提供指导，告诉他们在实施过程中如何最好地纳入临时适应性调整。未来的研究应该评估精心调整的临时适应性调整是否能改善治疗效果。
在clinicaltrials.gov上注册的试点试验（C0058）
