Contributions to literature
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This study illustrates a participatory process for adapting a research-tested intervention with tribal partners. High quality adaptation processes conducted collaboratively with tribal partners are relatively rare.
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The process aligns with common adaptation steps identified in a recent scoping review on adaptation of evidence-based interventions.
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Given traditional uses of tobacco in American Indian communities, both surface and deep structure changes were required in this cultural adaptation of a research-tested intervention.
Background
Methods
Description of the original intervention
Overview of the adaptation process
Step Name | Step Description | Step Activities | |
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Formative Research Phase | 1. Assess Community | • Identify behavioral determinants and risk factors of the new target population using focus groups, interviews, needs assessments, and logic models • Assess organizational capacity to implement the program | Conducted ten focus groups with five tribal commununities- one smoking and one non-smoking each. Topics included barriers to EBI application and success, cultural differences impacting EBI, surface and deep changes to materials necessary |
2. Understand the Intervention | • Identify and review relevant EBIs and their program materials • Understand the theory behind the programs and their core elements | The majority of EBIs focused on smoking rules target multi-unit housing or public places, not single family homes; to our knowledge, no EBI focusing on smoke-free homes has been adapted to AI-AN populations. Most AI-AN adaptations seek to change smoking behavior itself, rather than smoke-free home rules. Additionally, adaptation team included original developers of the intervention at the Emory Prevention Research Center (EPRC) | |
3. Select the intervention | • Select the program that best matches the new population and context | SFH is an EBI with success in multiple contexts, and one of few interventions that seeks to change smoking rules in the home environment to reduce exposure to SHS and THS, and may be a pathway to quitting. Additional support for the intervention was given by focus group participants, regarding perceived acceptability and efficacy. | |
Adaptation Phase | 4. Consult with experts | • Consult with content experts, including original program developers, as needed • Incorporate expert advice into program | EPRC is home to experts on tobacco control research, smoke-free homes, and adaptation of EBIs. Additionally, it is both the source of the original intervention and this adaptation. Therefore, the members of the EPRC act as experts for this adaptation. Additionally, focus group participants are expects on their communities, as members, and as such were consulted regarding changes. |
5. Consult with Stakeholders | • Seek input from advisory boards and community planning groups where program implementation will take place • Identify stakeholder partners who can champion program adoption in new settings and ensure program fidelity | Establishment of AI-AN workgroup consisting of 16 members, including tribal partners from Michigan, Oklahoma, California, and Alaska. Tribal partners served to give input on adaptation materials and support future dissemination activities. | |
6. Decide what needs adaptation | • Decide whether to adapt or implement the original program • Determine how original and new target population/setting differ in terms of risk and protective factors • Identify areas where EPI needs to be adapted and include possible changes in program structure, content, provider or delivery method | Based on focus group results, previous literature, and consultation with the work group, decision was made to make surface-level changes to the materials, including most notably the adaptation of visuals and imagery to include primarily AI-AN individuals from diverse cultures, as well as images of nature, and AI-AN associated symbols, such as the medicine wheel. Additionally, some changes to language were made to emphasize family and community, as well as respect. Program structure, content, and delivery remained the same to ensure validity. | |
7. Adapt the original program | • Develop adaptation plan • Adapt the original program contents through collaborative efforts • Make culture adaptations continuously through pilot testing • Core components responsible for changes should not be modified | Materials were adapted in collaboration with an American Indian designer able to make changes that were culturally appropriate. Changes were reviewed by the adaptation team as well as the adaptation AI-AN work group, and revised as appropriate. |
Description of the focus groups
Recruitment of focus group participants
Focus group guide and participant survey
Analysis
Results
Key themes with implications for adapting the intervention
Gravity of tobacco messaging
Respect, familialism and intergenerationalism
“I like it because it’s respecting like -- it has like elders up here and it’s saying respect our past, and then of course everybody -- the reason why we all don’t allow smoking in our homes is for the benefit of our children’s health, I think everybody would agree that we want to protect our children, protect our children’s health, and that’s -- I think everybody would agree that we want to protect our children, protect our future, protect our health. ... Because without the children, there’s no future of the tribe.” (Michigan NS).
Imagery
“…it’d be nice to have things individually tailored to each area, but if I opened a thing and was just like oh my gosh, this is made for Natives, I mean, I’d just be so blown away, you know, because now my son watches TV and he’ll say there’s an Indian on -- I’ll be like well, that’s really a Mexican, but I’m glad that you’re excited … So I think yeah, it’d be good to have an individual component, but at the same time if you just got something that was like wow, they took the time to make this for a Native, you know, I think that that would kind of be like -- because we’re usually just -- not a race, but – [other].” (California NS).
Traditional tobacco
Cold weather as a barrier
“Well, if we’re sitting there in the middle of winter and we have people over, I’m like listen, if you want to go away from us from smoking, because they will, that is the norm. You don’t go outside. Just go in the living room or in the kitchen, and then my house is very large, and by now we just already know the problem.” (Michigan NS).
Adaptations made to the intervention materials
Surface Changes | Deep Structure Changes |
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1. No use of humor in messaging | 1. Theme change from “Some things are better outside” to “Respect Our Past, Protect Our Future” |
2. Images of AI/AN people | 2. Language change to emphasize familialism and intergenerationalism |
3. Imagery of nature, scenery familiar to specific tribes | 3. Respect-focused language |
4. Use medicine wheel imagery and colors | 4. Creation of traditional tobacco insert |
5. Addition of cold weather barrier |
Material | Description | Applicable Changes | |
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General Materials | Covers (n = 2) | Folders that double as envelopes for mailing 1. Depicting images of AI/AN individuals and families, with themes of nature and “Respect our Past, Protect Our Future,” respectively. | Theme change from “Some things are better outside” to “Respect our Past, Protect Our Future”; No use of humor in messaging; Images of AI/AN people, Language change to emphasize familialism and intergenerationalism; Imagery of nature, scenery familiar to specific tribes; Use medicine wheel imagery and colors; Respect-focused language. |
Envelopes (n = 5) | Envelopes used for mailings 2 and 3, which depict different nature scenes, including the plains, mountains, great lakes, pine forests, and deciduous forests, respectively. | Imagery of nature, scenery familiar to specific tribes. Removal of humor messaging. | |
Mailing 1 | 5-Step Guide | A guide that outlines the five steps to creating a smoke-free home. | No use of humor in messaging; Removal of dog images; Images of AI/AN people; Language change to emphasize familialism and intergenerationalism; Use medicine wheel imagery and colors. |
Stickers | No use of humor in messaging; Use medicine wheel imagery and colors. | ||
Window Cling | A window cling that states “This is a smoke-free home” | Use medicine wheel imagery and colors. | |
Traditional Tobacco Insert | An insert that addresses the difference between commercial tobacco and traditional tobacco. | Use medicine wheel imagery and colors; Creation of Traditional Tobacco insert. | |
Mailing 2 | Challenges & Solutions Factsheet | A factsheet that addresses multiple challenges individuals seeking to make their home smoke-free might face, as well as solutions to overcome those challenges. | Images of AI/AN people; Use medicine wheel imagery and colors; Addition of solutions for cold weather as a barrier. |
Photonovella | Comic-style story of a family who works to make their home smoke free to improve a child’s health. | Images of AI/AN people; inclusion of a father figure. | |
E-Cigarette Insert | An insert that addresses the health impacts of using e-cigarettes. | Use medicine wheel imagery and colors. | |
Mailing 3 | Smoke-Free Homes Newsletter | A newsletter containing stories of individuals, couples, and families who made their homes smoke-free, as well as why and how. | Images of AI/AN people; Language change to emphasize familialism and intergenerationalism; Respect-focused language. |
Stickers | No use of humor in messaging; Use medicine wheel imagery and colors. | ||
Window Cling | A window cling that states “This is a smoke-free home.” | Use medicine wheel imagery and colors. | |
Thirdhand Smoke Insert | An inset that addresses the health impacts of thirdhand smoke. | No changes. | |
Cigar Insert | An insert that addresses the health impacts of using cigar, little cigars, or cigarillos. | No changes. |