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Red, Yellow, and Green Light Changes: Adaptations to Extension Health Promotion Programs

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Abstract

Extension professionals have high autonomy to adapt the programs they deliver. However, fidelity is typically not reported, so it is unknown what adaptations are made. It is also unknown whether agents have the necessary training to adapt programs while maintaining fidelity to the core components. The purpose of this study was to determine (1) adaptations that Extension agents and specialists are making to programs they deliver, (2) the reasons for making these adaptations, (3) timing of adaptations, and (4) Extension agents' and specialists’ understanding of the adaptation process. Extension agents and specialists nationwide were invited to complete a survey which queried about adaptations based on the traffic light model, adaptome, and adaptation taxonomy. Specifically, the traffic light model assigns a color for adaptations: tailoring language or pictures (green), adding/substituting activities or session sequence (yellow), or deleting lessons and decreasing timeline or session length (red). Responses were received from 98 agents and 24 specialists. Most agents and specialists reported making green (85% and 79%, respectively), yellow (89% and 75%), and red light changes (81% and 58%). Agents were significantly more likely than specialists to change the age appropriateness of lessons or activities, respond to individual client needs, substitute activities, delete lessons or activities, decrease the length and/or number of sessions, and shorten the program timeline. Within green light changes, each of those that could increase cultural appropriateness (tailoring language, scenarios, and pictures) were reported by less than 50% of agents and specialists. Of the most common adaptations reported, the primary reasons for these decisions were difficulty retaining or engaging participants and lack of time/competing demands on time. Most adaptations were made before the program was delivered. Agents rated their confidence level in the program adaptation process as somewhat confident to confident. Dissemination and implementation strategies to improve program adaptation within Extension are needed, including participatory approaches, training on the adaptation process, bi-directional evidence-based program repositories, and organizational-level changes.

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References

  • Ackermann, R., & O’Brien, M. (2020). Evidence and challenges for translation and population impact of the iabetes Prevention Program. Current Diabetes Reports, 20, 1–10.

    Article  Google Scholar 

  • Balis, L., & Harden, S. (2019). Scaling out a 4-H healthy meeting initiative: Challenges in implementation and comprehensive evaluation. Journal of Nutrition Education and Behavior, 51, 1020–1024.

    Article  Google Scholar 

  • Balis, L., Houghtaling, B., & Buck, J. (n.d.) Evaluating fidelity to the national Extension Dining with Diabetes program: Challenges and opportunities. Evaluation and Program Planning: under review.

  • Balis, L., John, D., & Harden, S. (2019). Beyond evaluation: Using the RE-AIM framework for program planning in Extension. Journal of Extension, 57.

  • Balis, L., Strayer, T., Ramalingam, N., Wilson, M., & Harden, S. (2018). Open-access physical activity programs for older adults: A pragmatic and systematic Review. The Gerontologist, 59(4), e268–e278.

  • Balis, L., Strayer, T. E., III., Ramalingam, N., & Harden, S. M. (2019). Beginning with the end in mind: Contextual considerations for scaling-out a community-based intervention. Frontiers in Public Health, 6, 1–14. https://doi.org/10.3389/fpubh.2018.00357

    Article  Google Scholar 

  • Braithwaite, J., Glasziou, P., & Westbrook, J. (2020). The three numbers you need to know about healthcare: The 60-30-10 challenge. BMC Medicine, 18. https://doi.org/10.1186/s12916-020-01563-4

  • Braun, B., Bruns, K., Cronk, L., Kirk Fox, L., Koukel, S., Le Menestrel, S., et al. (2014). Cooperative Extension’s National Framework for Health and Wellness. https://nifa.usda.gov/sites/default/files/resource/Cooperative_extensionNationalFrameworkHealth.pdf. Accessed 6 October 2020.

  • Cancer Prevention and Control Research Network. (2017). Putting Public Health Evidence in Action Training Workshop. http://cpcrn.org/pub/evidence-in-action/. Accessed 6 October 2020.

  • Carvalho, M., Honeycutt, S., Escoffery, C., Glanz, K., Sabbs, D., & Kegler, M. (2013). Balancing fidelity and adaptation: Implementing evidence-based chronic disease prevention programs. Journal of Public Health Management and Practice, 19, 348–356. https://doi.org/10.1097/PHH.0b013e31826d80eb

    Article  PubMed  Google Scholar 

  • Castro, F., Barrera, M., Jr., & Holleran Steiker, L. (2010). Issues and challenges in the design of culturally adapted evidence-based interventions. Annual Review of Clinical Psychology, 6, 213–239. https://doi.org/10.1146/annurev-clinpsy-033109-132032

    Article  PubMed  PubMed Central  Google Scholar 

  • Centers for Disease Control and Prevention. (2019). High Obesity Program. https://www.cdc.gov/nccdphp/dnpao/state-local-programs/hop-1809/high-obesity-program-1809.html/. Accessed 6 October 2020.

  • Chambers, D., & Azrin, S. (2013). Partnership: A fundamental component of dissemination and implementation research. Psychiatric Services, 64.

  • Chambers, D., & Norton, W. (2016). The adaptome: Advancing the science of intervention adaptation. American Journal of Preventive Medicine, 51, S124–S131.

    Article  Google Scholar 

  • Chapman-Novakofski, K., & Karduck, J. (2005). Improvement in knowledge, social cognitive theory variables, and movement through stages of change after a community-based diabetes education program. Journal of the American Dietetic Association, 105, 1613–1616.

    Article  Google Scholar 

  • Diabetes Prevention Program Research Group. (2009). 10-year follow up of diabetes incidence and weight loss in the Diabetes Prevention Program outcomes study. Lancet, 374, 1677–1686. https://doi.org/10.1016/S0140-6736(09)61457-4

    Article  PubMed Central  Google Scholar 

  • Dill, S., & Rhodes, J. (2012). Adapting Annie’s Project in Maryland: Findings and results. Journal of Extension, 50.

  • Domenech Rodríguez, M., Baumann, A., & Schwartz, A. (2011). Cultural adaptation of an evidence based intervention: From theory to practice in a Latino/a community context. American Journal of Community Psychology, 47, 170–186. https://doi.org/10.1007/s10464-010-9371-4

    Article  PubMed  Google Scholar 

  • Downey, L. H., Peterson, D. J., Donaldson, J., & Hardman, A. (2017). An Extension application of the RE-AIM evaluation framework. Journal of Extension, 55(3).

  • Dunifon, R., Duttweiler, M., Pillemer, K., Tobias, D., & Trochim, W. M. K. (2004). Evidence-based Extension. Journal of Extension, 42.

  • Economos, C. D., Anzman-Frasca, S., Koomas, A. H., Bakun, P. J., Brown, C. M., Brown, D., et al. (2019). Dissemination of healthy kids out of school principles for obesity prevention: A RE-AIM analysis. Preventive Medicine, 119, 37–43. https://doi.org/10.1016/j.ypmed.2018.12.007

    Article  PubMed  Google Scholar 

  • Estabrooks, P., Fox, E., Doerksen, S., Bradshaw, M., & King, A. (2005). Participatory research to promote physical activity at congregate-meal sites. Journal of Aging and Physical Activity, 13, 121–144.

    Article  Google Scholar 

  • Estabrooks, P., & Glasgow, R. (2006). Translating effective clinic-based physical activity interventions into practice. American Journal of Preventive Medicine, 31, S45–S56. https://doi.org/10.1016/j.amepre.2006.06.019

    Article  PubMed  Google Scholar 

  • Estabrooks, P., Harden, S., Almeida, F., Hill, J., Johnson, S., Porter, G. C., & Greenawald, M. (2019). Using integrated research-practice partnerships to move evidence-based principles into practice. Exercise and Sport Sciences Review, 47, 176–187. https://doi.org/10.1249/JES.0000000000000194

    Article  Google Scholar 

  • Estabrooks, P. A., Bradshaw, M., Dzewaltowski, D. A., & Smith-Ray, R. L. (2008). Determining the impact of Walk Kansas: Applying a team-building approach to community physical activity promotion. Annals of Behavioral Medicine, 36, 1–12. https://doi.org/10.1007/s12160-008-9040-0

    Article  PubMed  Google Scholar 

  • Fetsch, R. J., MacPhee, D., & Boyer, L. K. (2012). Evidence-based programming: What is a process an Extension agent can use to evaluate a program’s effectiveness? Journal of Extension, 50.

  • Folta, S., Koomas, A., Metayer, N., Fullerton, K., Hubbard, K., Anzman-Frasca, S., et al. (2015). Engaging stakeholders from volunteer-led out-of-school time programs in the dissemination of guiding principles for healthy snacking and physical activity. Preventing Chronic Disease, 12. https://doi.org/10.5888/pcd12.150270

  • Glasgow, R., Klesges, L., Dzewaltowski, D., Bull, S., & Estabrooks, P. (2004). The future of health behavior change research: What is needed to improve translation of research into health promotion practice? Annals of Behavioral Medicine, 27, 3–12.

    Article  Google Scholar 

  • Griffie, D., James, L., Goetz, S., Balotti, B., Shr, Y., Corbin, M., & Kelsey, T. (2018). Outcomes and economic benefits of Penn State Extension’s Dining With Diabetes program. Preventing Chronic Disease, 15, 170407. https://doi.org/10.5888/pcd15.170407

    Article  Google Scholar 

  • Harden, S., Johnson, S. B., Almeida, F., & Estabrooks, P. (2017). Improving physical activity program adoption using integrated research-practice partnerships: An effectiveness-implementation trial. Translational Behavioral Medicine, 7, 28–38. https://doi.org/10.1007/s13142-015-0380-6

    Article  PubMed  Google Scholar 

  • Harden, S., Steketee, A., Glasgow, T., Glasgow, R., & Estabrooks, P. (2020). Suggestions for advancing pragmatic solutions for dissemination: Potential updates to evidence-based repositories. American Journal of Health Promotion. https://doi.org/10.1177/0890117120934619

    Article  PubMed  Google Scholar 

  • Harden, S., Washburn, L., Berg, A., Pena-Purcell, N., Norman-Burgdolf, H., & Franz, N. (2020). A brief report on a facilitated approach to connect Cooperative Extension Southern Region state-level health specialists. Journal of Human Sciences and Extension, 8, 191–205.

    Google Scholar 

  • Harden, S. M., Ramalingam, N., Breig, S., & Estabrooks, P. (2019). Walk this way: Our perspectives on challenges and opportunities for Extension statewide walking promotion programs. Journal of Nutrition Education and Behavior, 51, 636–643. https://doi.org/10.1016/j.jneb.2018.12.010

    Article  PubMed  Google Scholar 

  • Holston, D., Stroope, J., Cater, M., Kendall, M., & Broyles, S. (2020). Implementing policy, systems, and environmental change through community coalitions and Extension partnerships to address obesity in rural Louisiana. Preventing Chronic Disease, 17. https://doi.org/10.5888/pcd17.190284

  • IBM Corp. (Released 2019). IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp

  • Israel, B., Eng, E., Schulz, A., & Parker, E. (2005). Methods in community-based participatory research for health. Jossey-Bass.

    Google Scholar 

  • Kennedy, L., Strayer III, T., & Balis, L. Addressing health inequities: An exploratory assessment of Extension educators' perceptions of program demand for diverse communities. Family & Community Health: under review.

  • Klesges, L., Estabrooks, P., Dzewaltowski, D., Bull, S., & Glasgow, R. (2005). Beginning with the application in mind: Designing and planning health behavior change interventions to enhance dissemination. Annals of Behavioral Medicine, 29, 66–75.

    Article  Google Scholar 

  • Kline, T., Kneen, H., Barrett, E., Kleinschmidt, A., & Doohan, D. (2012). Adapting Extension food safety programming for vegetable growers to accommodate differences in ethnicity, farming scale, and other individual factors. Journal of Extension, 50.

  • Lau, A. (2006). Making the case for selective and directed cultural adaptations of evidence-based treatments: Examples from parent training. American Psychological Association, 13, 295–310.

    Google Scholar 

  • Lee, H., Fitzpatrick, J., & Baik, S. (2013). Why isn’t evidence based practice improving health care for minorities in the United States? Applied Nursing Research, 26.

  • Moore, J. E., Bumbarger, B. K., & Rhoades Cooper, B. (2013). Examining adaptations of evidence-based programs in natural contexts. Journal of Primary Prevention, 34, 147–161. https://doi.org/10.1007/s10935-013-0303-6

    Article  Google Scholar 

  • National 4-H Council. (2018). What is 4-H? https://4-h.org/about/what-is-4-h/ Accessed 6 October 2020.

  • National Cancer Institute. (n.d.). Implementation Science at a Glance: A Guide for Cancer Control Practitioners. https://cancercontrol.cancer.gov/IS/docs/NCI-ISaaG-Workbook.pdf Accessed 6 October 2020

  • National Extension Association of Family & Consumer Sciences. (2018). National Extension Association of Family & Consumer Sciences. https://www.neafcs.org/ Accessed 6 October 2020.

  • Norton, W., & Chambers, D. (2020). Unpacking the complexities of de-implementing inappropriate health interventions. Implementation Science, 15. https://doi.org/10.1186/s13012-019-0960-9

  • Norton, W., Chambers, D., & Kramer, B. (2019). Conceptualizing de-implementation in cancer care delivery. Journal of Clinical Oncology, 37, 93–96. https://doi.org/10.1200/JCO.18.00589

    Article  PubMed  Google Scholar 

  • Powell, B. J., Waltz, T. J., Chinman, M. J., Damschroder, L. J., Smith, J. L., Matthieu, M. M., et al. (2015). A refined compilation of implementation strategies: Results from the Expert Recommendations for Implementing Change (ERIC) project. Implementation Science, 10.

  • Prusaczyk, B., Swindle, T., & Curran, G. (2020). Defining and conceptualizing outcomes for de-implementation: Key distinctions from implementation outcomes. Implementation Science Communications, 1. https://doi.org/10.1186/s43058-020-00035-3

  • Rasmussen, W. D. (2002). Taking the University to the People: Seventy-Five Years of Cooperative Extension: Purdue University Press.

  • Rolleri, L. A., Fuller, T. R., Firpo-Triplett, R., Lesesne, C. A., Moore, C., & Leeks, K. (2014). Adaptation guidance for evidence-based teen pregnancy and STI/HIV prevention curricula: From development to practice. American Journal of Sexuality Education, 9, 135–154. https://doi.org/10.1080/15546128.2014.900467

    Article  PubMed  PubMed Central  Google Scholar 

  • Solomon, J., Card, J. J., & Malow, R. M. (2006). Adapting efficacious interventions: Advancing translational research in HIV prevention. Evaluation & The Health Professions, 29, 162–194. https://doi.org/10.1177/0163278706287344

    Article  Google Scholar 

  • Spear, M., Rowland, B., Vincent, J., Brown, T., Wilson, A., Palenske, C., et al. Results of a rural community’s traffic calming event to promote physical activity. Journal of Extension: under review.

  • Steele, C. B., Rose, J. M., Chovnick, G., Townsend, J. S., Stockmyer, C. K., et al. (2016). Use of evidence-based practices and resources among comprehensive cancer control programs. Journal of Public Health Management and Practice, 21, 441–448. https://doi.org/10.1097/PHH.0000000000000053

    Article  Google Scholar 

  • Strayer, T., III., Kennedy, L., Balis, L., Ramalingam, N., Wilson, M., & Harden, S. (2020). Cooperative Extension gets moving, but how? Exploration of Extension health educators’ sources and channels for information-seeking practices. American Journal of Health Promotion, 34, 198–205. https://doi.org/10.1177/0890117119879606

    Article  PubMed  Google Scholar 

  • Strayer, T., III., Balis, L., & Harden, S. (2020). Partnering for successful dissemination: How to improve public health with the National Cooperative Extension System. Journal of Public Health Management & Practice, 26, 184–186. https://doi.org/10.1097/PHH.0000000000001025

    Article  Google Scholar 

  • U.S. Department of Agriculture. (n.d.). Extension. https://nifa.usda.gov/extension. Accessed 6 October, 2020.

  • U.S. Department of Agriculture. (2019). SNAP-Ed Toolkit: Obesity Prevention Interventions and Evaluation Framework. https://snapedtoolkit.org/. Accessed 6 October, 2020.

  • Wells, S., Merritt, L., & Briggs, H. (2009). Bias, racism and evidence-based practice: The case for more focused development of the child welfare evidence base. Child and Youth Services Review, 31, 1160–1171.

    Article  Google Scholar 

  • Wendler, D., Kington, R., Madans, J., Van Wye, G., Christ-Schmidt, H., Pratt, L., et al. (2005). Are racial and ethnic minorities less willing to participate in health research? PLoS Medicine, 3, e19. https://doi.org/10.1371/journal.pmed.0030019

    Article  PubMed  PubMed Central  Google Scholar 

  • Wilson, M. L., & Strayer, & III, T., Davis, R., & Harden, S.M. . (2018). Use of an integrated research-practice partnership to improve outcomes of a community-based strength-training intervention for older adults: Reach and effect of Lifelong Improvements through Fitness Together (LIFT). International Journal of Environmental Research and Public Health, 15, 237. https://doi.org/10.3390/ijerph15020237

    Article  PubMed Central  Google Scholar 

  • Wilson, M. L., Strayer, T., Davis, R., & Harden, S. M. (2018). Informed adaptations of a strength-training program through a research-practice partnership. Frontiers in Public Health, 6. https://doi.org/10.3389/fpubh.2018.00058

  • Wiltsey Stirman, S., Baumann, A., Miller, C. (2019). The FRAME: an expanded framework for reporting adaptations and modifications to evidence-based interventions. Implementation Science, 14.

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Authors and Affiliations

  1. Balis Consulting Group, LLC, WY, Lander, USA

    Laura E. Balis

  2. Michigan State University, East Lansing, MI, USA

    Lauren E. Kennedy

  3. Louisiana State University AgCenter, Baton Rouge, LA, USA

    Bailey Houghtaling

  4. Virginia Polytechnic Institute and State University, VA, Blacksburg, USA

    Samantha M. Harden

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  1. Laura E. Balis
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  2. Lauren E. Kennedy
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  4. Samantha M. Harden
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Correspondence to Laura E. Balis.

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Balis, L.E., Kennedy, L.E., Houghtaling, B. et al. Red, Yellow, and Green Light Changes: Adaptations to Extension Health Promotion Programs. Prev Sci 22, 903–912 (2021). https://doi.org/10.1007/s11121-021-01222-x

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