Maria E. Fernandez, PhD
Associate Professor of Health Promotion and Behavioral Sciences
University of Texas Health Science Center at Houston
Who is responsible?
Researchers/ program developers, implementers, health service
providers, funders?
A barrier to translation of intervention research findings for
public health benefit is that both developers (often researchers)
and practitioners believe that the responsibility for dissemination
lies elsewhere.

Researchers: I don’t have the training or interest
in approaches to enhance dissemination of
research products; grant funding does not
support such activities.

Practitioners: The responsibility for
summarizing and making research products
useful lay elsewhere. But if they were easy to find
and use we would do it.
National Cancer Institute, Center for the Advancement of Health and Robert Wood
Johnson Foundation. Designing for dissemination: Conference summary report. 2002..
http://dccps.cancer.gov/d4d/d4d_conf_sum_report.pdf
Bridging the Gap: A Synergistic Model
Getting Evidence-Based Cancer Control Interventions Into Practice
GOAL: To increase the adoption, reach and impact of evidence -based cancer control
Science Push
Documenting,
improving,
and communicating
the intervention for
wide population use
Delivery Capacity
Building the capacity
of relevant systems to
deliver the
intervention
Market Pull/
Demand
Building a market
and demand for the
intervention
Increase the number of systems providing evidence-based cancer control
Increase the number of practitioners providing evidence-based cancer control
Increase the number of individuals receiving evidence-based cancer control
ULTIMATE GOAL:
Improve population health
and well being
Orleans, T. NCI Designing for Dissemination Conference, 2002; adapted by Jon Kerner
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Diffusion of Innovation Theory
(Rogers,1995)
Technology Transfer Model (Backer,
1995)
Reach, Efficacy or Effectiveness,
Adoption, Implementation and
Maintenance RE-AIM Model (Glasgow
et al., 2003; Glasgow et al., 2004;
Glasgow et al., 2006)
Model of Prevention Science (IOM,
1994)
Public Health Model (Mercy et al.,
1993)
Knowledge Management (Graham,
2006, adapted by Kerner, CPAC)
Source-based
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Patient-centered Medical Home
(Miller, 2010; Stange, 2010; Stewart,
2010)
Others have noted that communitycentered models are needed (Miller
and Shinn, 2005) or offered a
complex discussion of community
capacity (Goodman et al. 1998)
Combines Perspectives
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Interactive Systems Framework for
Dissemination & Implementation
(Wandersman, 2008)
User-based or
Community-centered
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Description of a planning
process derived from the
work of health promotion
interventionists
Seems to have stimulated
in the field
◦ enhanced attempts to
integrate theory and
evidence
◦ greater focus on both
behavior and environment
an ecological planning
approach
◦ greater attention to
planning for
implementation and
dissemination
1.
2.
3.
4.
5.
6.
Conduct a needs assessment
Create matrices of change objectives based on the
determinants of behavior and environmental
conditions
Select theory-based intervention methods and
practical applications
Translate methods and applications into an organized
program
Plan for adoption, implementation and sustainability of
the program
Generate an evaluation plan
1. Designing the health education program in ways that
enhance its potential for being adopted,
implemented, and sustained (IM Steps 1-4)
2. Designing interventions to influence adoption,
implementation and continuation (IM Step 5)
3. Using IM processes to adapt existing evidence-based
interventions
- Categorizing and identifying core elements of programs
Using Intervention Mapping
to Adapt
Evidence-Based Programs
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Some authors suggest that when developmental
issues and program targets are appropriate,
adaptation is seldom or never needed (Elliot
and Mihalic, 2004)
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Others point out that the formative work to
support adaptation is seldom done (Lau, 2006 )
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Nevertheless, in practice…
Adaptation Happens.
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Some researchers insist that adaptation is
essential and the challenge is to strike a
balance between program fidelity and
adaptation (Backer, 2001)

Even when higher fidelity was shown to be
associated with improved outcomes (Durlak &
DuPre, 2008) fidelity was not 100%; adaptation
may have added to effectiveness
During the adaptation process, planners often
choose pieces of programs that are the most
appealing or that seem the most feasible,
 Usually there is not much input from the
community
 Little or no process for
determining what in a program
needs to change and what must
stay the same
 This can lead to programs that are
incomplete with little chance of
maintaining impact
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Variously called core elements, active
ingredients, essential elements
Whatever we call them – we
◦ Often do not know what they are
◦ Program descriptions often do not include them
Botvin, 2004
Program Active Ingredients are:
1)Theoretical methods that are intended to
change determinants of behavior (of the atrisk group or environmental agents)
2)Practical applications of methods including
delivery channels
3)Characteristics of program materials and
messages
4)Characteristics of program implementation
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Several authors have described processes of
disseminating interventions including
approaches to adaptation (McKleroy, 2006;
Wandersman, 2008) that generally describe
the tasks involved.
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Planned adaptation models have been
proposed (Backer, 2001; Lee et al., 2008)
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Intervention Mapping provides a systematic
approach that adds detailed how tos to these
frameworks.
It can help planners identify and retain the
essential elements as programs are translated to
new communities and settings.
 “World
Starts With Me”
 Developed
to address the sexual and
reproductive health and rights needs of
secondary school students in Uganda
 Adapted
for adoption and implementation in
Indonesia

Adaptation of an existing EBP developed for
Mexican Americans for use in Puerto Rico
◦ Cultivando la Salud (CDC funded intervention
program- National Center for Farmworker
Health)
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Adaptation of a lay health worker delivered small
media intervention (Vivir sin Cancer) on HPV/HPV
vaccine originally developed for parents of girls
in the LRGV
◦ CPRIT funded intervention trial to increase HPV
vaccination among Hispanic girls in Houston
◦ Exploring possibility of adapting the
intervention for use in Puerto Rico
Adaptation Product: Description of discrepancy
between original program logic model of the
problem and the model in the new setting (including
priority population characteristics).
 Adaptation Questions:
1.
What is the logic model and priority population of
the problem from the original needs assessment?
2.
What is the logic model and priority population for
the adopting site?
3.
Do they match? How are they different?
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Phase 4
Personal and
External
Determinants
(Predisposing,
enabling,
reinforcing factors)
Phase 3
Behavioral
Factors
Environmental
Factors
Phase 2
Phase 1
Health
Problems
Quality
of Life
Indicators
Original Program- Cultivando la
Salud- Mexican Origin women
Low levels of
 Knowledge of breast and
cervical cancer and screening
guidelines
 Outcome Expectations
 Perceived Barriers and Benefits
 Attitude (fear of detection, fear
of procedure and belief that
cancer is incurable)
 Low Self-Efficacy
 Low Perceived Social Norms
 Availability and Accessibility
Puerto Rico
Low levels of
 Knowledge of breast and
cervical cancer and screening
guidelines (not as low)
 Knowledge of availability
 Perception of risk
 Perceived Barriers and Benefits
 Attitude (fear of detection, fear
of procedure)
 Low Self-Efficacy
Environmental Factors differ
considerably due to access to care
(Reforma – universal coverage in
PR vs indigent care in LRGV)
Outreach Program

Adaptation Product: Matrix of change objectives
that should be added to the original program to
improve validity the of the change model.
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1.
2.
Adaptation Questions:
What behavior and environmental conditions (and
their determinants) did the original program target
for change?
What should the adopting site seek to change in
behavior and environment (and their determinants)
that is different from the original program?
Determinant 1 Determinant 2
Performance
objective 1
Change objective Change objective
Performance
objective 2
Change objective Change objective
At Risk Group
Resources
Program
Activities &
Materials
Theoretic
Methods &
Practical
Strategies
Theoretic
Methods &
Practical
Strategies
Performance
Objectives
Determinants
Determinants
Performance
Objectives
Behavioral
Outcomes
Environmental
Outcomes
Environmental Agent
Program
Inputs
Program
Outputs
Logic of Change
Outcomes
Health
and
Quality
of Life
Designed to increase information seeking about HPV and HPV
vaccine among Hispanics along the TX-Mexico Border
Vivir Sin Cáncer
Young
Women
versions
Parent
versions
Live Without Cancer
Learn how to protect
yourself from cervical cancer
1-800-4-CANCER is confidential and they
can speak to you in Spanish if you prefer.
Thank you so much.
I’ll call when I get home.
Vivir Sin Cáncer
Live Without Cancer
Learn how to protect your daughter
from cervical cancer
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Goal is to adapt existing materials so that they fit
a new context (Houston urban Hispanics)
Differences in target behaviors:
◦ Original Project: HPV/HPV Vaccine information
seeking
◦ New/Adapted Intervention: HPV vaccination
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Differences in determinants?
Vivir sin Cancer – Mexican Origin
Women
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Knowledge/awareness of CIS “1800” number
Knowledge/awareness of CC, HPV
and HPV vaccine
Self-Efficacy for calling CIS
Skills for calling CIS
Perceived norms and social norms
about calling
Personal preferences about
information seeking
Common factors across parents
from LRGV and Houston
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Attitudes about HPV vaccination
Perceived risk of cervical cancer
and HPV (for daughter)
Perceived severity of cervical
cancer and HPV (for daughter)
Concerns about cost/Insurance
coverage
Concerns about sexual
disinhibition
Outcome expectation that their
questions would be answered
Media and mandate on HPV
vaccination
Outreach Program
Adaptation Product:
1. Description of theoretical methods or practical
applications that should be added to address new
change objectives or to make the original methods
apply to a different population/context.
2. Description of essential program elements that must
be retained.
 Adaptation Questions:
1.
What theoretical methods and practical applications
to promote change did the original program
include?
2.
What methods and practical applications must be
added to match new change objectives or modified
to fit the new population?
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1.
2.
3.
Adaptation Product: Description of recommended
changes in the program components and/or
delivery.
Adaptation Questions:
How well did the program components and delivery
implement the theoretical methods and practical
applications?
How well does the program delivery match
preferences the new population and context?
What changes in scope and sequence or materials
are necessary to deliver new methods and practical
applications?
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1.
2.
3.
4.
Adaptation Product:Description of how
program implementation should be changed
Adaptation Questions:
How well was the original program delivered
(completeness, fidelity, dose)?
How comprehensive and feasible is the
implementation protocol?
What are the implementation performance objectives
in the new setting?
Will implementation require additional elements in
the new setting?
Performance
Objectives
PO1 Clinic director adopts
Cultivando La Salud
Program
Personal Determinants
Knowledge/Awareness Perceived Social
Outcome
Norms
Expectations
K.1. Recognizes this program PSN.1. Describes other
as available
clinics as using this
program
K.1. Recognizes that the
program will provide
resources to the clinic
K.1. Describes the program as
promoting breast and Pap test
screening for farmworker
women 50+
OE.1. Expects that if they
use this program, rates of
screening will rise
Attitudes
A.1. Describes breast and cervical cancer
morbidity and mortality as a real problem
for farmworker women
A.1. Argues for increasing screening for
farmworker women
A.1. Describes the program as being
better than what they have now, fitting
with current services, triable, not too
complex
K.1. Describes program as
developed from extensive
work with the community
PO2 Clinic director
establishes and supports
promotora program
PO2.a. Clinic director
obtains staff buy-in
PO2.b. Clinic director
obtains community buy-in
K.2.a. Reflects that staff will
accept the program if given
the opportunity to talk about
promotoras, needs and
resources, program goals and
agency support
K.2.b.Reflects that involving
community leaders in
planning will help develop a
program that communities
will accept
PSN.2. Describes other
clinics in the LRGV as
using promotora
programs successfully
OE.2. Expects that
A.2. Describes promotora programs as
promotoras can effectively building ties to the community
engage women to
participate in clinic services A.2. Describes promotoras as a credible
source of health information
Cultivando la Salud-Implementation Matrix
Personal Determinants
External Determinants
Performance
Knowledge
Objectives
PO1 Adopts the role K.1.a. Describes the role
of lay health worker of the lay health worker
K.1.b. Describes the
challenges involved with
being a lay health worker
PO2 Locates
farmworker women
50+
PO2.1.. Posts flyers
PO2.2. Identifies
community leaders
to help with
recruitment
PO2.3. Go door to
door in health
center
neighborhood
PO2.4.Contact and
work with
community centers,
churches, schools,
Migrant Headstart
and local migrant
councils
PO3 Conducts
home visits and
community group
visits
PO3.1. Develops a
safety plan for home
visits
PO3.2. Plans
community sessions
Skills and Selfefficacy
SSE.1.a. Feels
confident that she
can adopt and fulfill
the role of promotora
Attitudes
Perceived Social
Norms
A.1.a. Believes
PSN.1.a
that becoming a
Recognizes that
promotoras is an other women in
important
her community
contribution to the have become
community
promotoras
Social Support
K.2.a. Describes the
neighborhoods in which
farmworker women
reside
K.2.b. Compares the
needs of farmworker
women to other women
K.2.4.c. Identifies
community centers,
churches, and other
locations to conduct
education
SSE.2.a. Feels
confident in her
ability to locate
farmworker women
SSE.2.4.a. Feels
confident in her
ability to make
contact with
community centers,
churches, headstart
programs, and
migrant councils
A.2.a. Believes
that locating
farmworker
women is an
important part of
her job as a
promotora
Outcome
Expectations
OE.1.a. Expects
that if she adopts
the role of
promotoras she
will be successful
at providing
education to the
community
PSN.2.a.
OE.2.a. Expects
Recognizes that that locating and
successful
educating
promotoras
farmworker women
target at risk
will result
groups such as improvements in
farmworker
the health of the
women
community
OE.2.4.a. Expects
that collaborating
with churches,
community centers
and other
organizations will
help her locate
farmworker women
SS.2.a. Outreach
coordinators
provide
encouragement
and logistic
support to
promotoras in their
effort to locate
farmworkers.
SS.2.4.a. Other
promotoras will
provide contacts
and assistance in
locating
farmworker
women
K.3.a. Describes the
proper protocol for
conducting home visits
K.3.1.a. Describes safe
ways to conduct home
visits
K.3.2.a. Describes points
to discuss with manager
of community site
SSE.3.a.
Demonstrates the
approach to women
on home visits
SSE.3.b. Expresses
confidence in her
ability to conduct a
home visit
SSE.3.1.a.
A.3.a. Explains
that home visits
are an effective
way of reaching
farmworker
women
PSN.3.a.
Recognizes that
other respected
promotoras
conduct home
visits and
community
educational
sessions
SS.3.a. Other
promotoras
accompany new
promotoras on
home site visits.
SS.3.b. Family
members express
support and help
at home so that
OE.3.a. Expects
that if she follows
the protocol she
will be welcomed
into the homes of
farmworker women
OE.2.1.a Expects
that if she follows a
good safety plan
SS.1.a. Existing
promotoras
encourage new
promotoras and
express their
availability to help
them.
Breast & Cervical Cancer
Training Curriculum
◦ Introduction to the Training
◦ Role of the Lay Health
Worker
◦ Reaching Women from
Farmworker Families
◦ Finding Breast Cancer Early
◦ Breast Cancer Screening:
Barriers and Responses
◦ Pap Test: Barriers and
Responses
◦ Teaching Methods
◦ Practices Session Using
Program Materials
◦ Resources and Referrals
◦ Evaluation
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1.
2.
Adaptation Product: Evaluation questions
including effectiveness and acceptability of new
program elements
Adaptation Questions:
What program outcomes and change objectives was
the adapted program effective in meeting? And how
does effectiveness compare to the original program?
What was the reach, fidelity and completeness of the
adapted program? And how does the process
evaluation compare to the original program?

Systematic planning models such as Intervention
Mapping can guide planned adaptation that can
help ensure that
◦ important differences between the original program
population and setting are addressed with new
program objectives, methods, and practical
applications
◦ essential elements of programs are maintained
Thank You