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. Author manuscript; available in PMC: 2022 Jan 23.
Published in final edited form as: J Subst Abuse Treat. 2020 Mar;112 Suppl:28–33. doi: 10.1016/j.jsat.2020.02.006

One Size Does Not Fit All: A NIDA CTN Inspired Model for Community Engaged Cultural Adaptation

Ann Kathleen Burlew 1, Caravella McCuistian 1, Danni Lanaway 1, Mary Hatch-Maillette 2, Donna Shambley-Ebron 1
PMCID: PMC8784174  NIHMSID: NIHMS1568718  PMID: 32220407

Abstract

The NIDA National Drug Abuse Treatment Clinical Trials Network (NIDA CTN) is devoted to the development of effective interventions for people who use substances across a variety of populations. When positive outcomes of a particular intervention do not generalize to other groups, adaptation may improve effectiveness for a different target group. However, currently limited information is available for involving community participation in cultural adaptation. The current paper illustrates the evolution of our methodology for community engaged cultural adaptation by describing a series of sexual health and substance use interventions. We highlight the transition from minimal community involvement (the Delphi process), to moderate community involvement (theater testing), to full community engagement in cultural adaptation. Ultimately, the results of these three projects led to the development of Community Collaborative Cultural Adaptation, a novel and concrete approach to cultural adaptation. This approach emphasizes the advantage of establishing academic/community partnerships for cultural adaptation to increase the effectiveness and sustainability of interventions.

1.0. Introduction

The adage „One size does not fit all‟ is a relevant axiom for intervention development. The National Drug Abuse Treatment Clinical Trials Network (NIDA CTN), dedicated to the development of evidence-based interventions targeting individuals who use substances, has contributed substantially to the identification of multiple effective interventions. Although not always highlighted, another important contribution of the NIDA CTN findings is demonstrating that intervention outcomes from one group do not necessarily generalize to other groups (Burlew, Montgomery, Kosinski, & Forcehimes, 2013; Calsyn et al., 2012; Covey et al., 2010; Montgomery, Burlew, Haeny, & Ahuama-Jonas, 2019; Montgomery, Burlew, Kosinski, & Forcehimes, 2011; Winhusen et al., 2008). In such instances, cultural adaptation may enhance the effectiveness of an intervention for different target groups.

During the last decade, attention to cultural adaptation has increased. In a meta-analysis, Hall and colleagues (2016) concluded that evidence-based behavioral interventions culturally adapted for a specific target group are generally more effective for that target population than the generic versions of the same interventions. Lau (2006) suggests that factors such as ineffective clinical engagement, unique risk or resilience factors, unique symptoms, or evidence of ineffectiveness might warrant cultural adaptation. The Ecological Validity Model (EVF; Bernal & Saez-Santiago, 2006), Cultural Accommodation Model (CAM; Leong & Lee, 2006), Cultural Sensitivity Framework (CSF; Resnicow, Soler, Braithwaite, Ahluwalia, and Butler, 2000) and Cultural Adaptation Process Model (CAPM; Domenech-Rodriguez & Wieling, 2004) all provide guidelines for implementing adaptations to maximize the congruence between the intervention and the target group.

Several guidelines for cultural adaptation suggest collaborating with community stakeholders improves outcomes (CAPM, Domenech-Rodriguez & Wieling, 2004; Culturally Specific Prevention, Whitbeck, 2006; Heuristic Framework, Barrera & Castro, 2006; Formative Method for Adapting Psychotherapy, Hwang, 2006; and EVF, Bernal & Adames, 2017). Although community involvement leads to more effective interventions (Israel et al., 2010; Wallerstein & Duran, 2008), few models other than the one provided by Chen, Reid, Parker, and Pillemer (2012) outline concrete steps for culturally adapting interventions in partnership with the community. None to our knowledge highlight the steps for establishing and maintaining the community/academic partnership. This paper addresses this gap by describing the evolution of a model for community engaged cultural adaptation. Rooted in NIDA CTN interventions, we will describe a series of projects that illustrate the progression of our adaptation methods from relying solely on academic and clinical professionals to community engaged partnerships.

1.1. Evolution of Cultural Adaptation Methods and Community Engagement in the NIDA CTN

CTN-0021 (Spanish Language Motivation Enhancement Therapy [MET]; Carroll et al., 2009), perhaps the earliest NIDA CTN attempt at cultural adaptation, exemplifies what Resnicow and colleagues (2000) refer to as surface adaptation. Surface adaptations retain the core curriculum of the intervention and only consider culture by altering the presentation (e.g., translating the language, utilizing staff similar in ethnicity to the target group) to be more acceptable or familiar to the target group. Aside from translating the materials and recruiting Spanish-speaking staff, the research team in CTN-0021 sought to maintain the curriculum of the original English version of MET conducted earlier within the NIDA CTN. To our knowledge, community members were not involved in the cultural adaptation.

Later, a study of substance use among American Indian and Alaska Native (AIAN) communities was one of the earliest efforts within the NIDA CTN to consider the role of culture in treatment and the need for community participation. Focus group participants in CTN-0033 argued that effective treatment must incorporate culture and tradition (Radin et al., 2015) and that community collaboration is essential to effective cultural adaptation (Thomas, Rosa, Forcehimes, & Donovan, 2011).

The projects described below in sections 2.0, 3.0, and 4.0 all illustrate our subsequent efforts at incorporating culture to improve the effectiveness of interventions initially conducted within the NIDA CTN when targeting specific racial/ethnic groups. Moreover, they all exemplify what Resnicow and colleagues (2000) refer to as deep structural adaptations. Deep structural adaptations revise core components and curriculum to incorporate the culture, social experiences, and values of a particular racial-ethnic group. The three projects that follow demonstrate our evolution in cultural adaptation from incorporating culture without community engagement ( Real Men Are Safe-Culturally Adapted, REMAS-CA; section 2.0) to moderate community engagement (Safer Sex Skills Building, SSSB, section 3.0) to the illustration of Community Collaborative Cultural Adaptation (CCCA), our model for full community engagement in section 4.0.

The methods for cultural adaptation employed in all three projects are outlined in Table 1. Before discussing the specific methodologies, we first provide background information on why sexual health and substance use are logical targets for community engaged cultural adaptation.

Table 1.

Models of Cultural Adaptation Procedures

Potential Strategy Strengths Limitations
Limited Community Engagement Delphi Process

Obtaining feedback from experts about the appropriateness of the intervention compared to other culturally-tailored interventions 		Independent feedback; comparison to other interventions Requires modification to attain feedback from community members not accustomed to providing written feedback
Moderate Community Engagement Theater testing

Mock demonstration of the generic intervention target group members serving as mock participants 		Useful for gaining feedback from target group Target group not involved in all stages
Full Community Engagement Community/Academic Partnerships

Partnering with members of the target group to collaboratively adapt the intervention for appropriateness within their culture 		Community involved in all stages Can be costly in terms of time and necessary financial support
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1.2. Sexual Health and Substance Use

Sexual health interventions for Black adults who use substances are ideal targets for cultural adaptation. Specifically, Black men and women who use substances are both members of groups with disproportionately high levels of HIV (CDC, 2018a; CDC, 2018b). Therefore, developing effective interventions for improving sexual health among Black adults who use substances should be a high priority.

When a local low-income Black community sought our help with addressing sexual health among their girls, we reviewed SSSB-CA and determined that it had the potential to benefit Black girls. However, further adaptation would be required (see section 4.0). In fact, Black girls were an ideal target group because of evidence suggesting substance use escalates the likelihood of risky sexual behaviors among Black girls in low income neighborhoods (Bachanas et al., 2002; Mandara, Murray, & Bangi, 2003).

2.0. Limited Community Involvement: The Delphi Process

The Delphi process (De Villiers, De Villiers & Kent, 2005), a structured method for obtaining expert feedback, was our primary tool for culturally adapting REMAS. The Delphi process utilizes “experts” to provide feedback by evaluating material presented to them. The procedures allow for multiple rounds of expert feedback. The empirically derived ratings in the Delphi process yield a collective opinion about the topic.

2.1. Application of the Delphi Process to Adapt REMAS

Don Calsyn, the principal investigator of REMAS CTN-0018, designed, implemented and evaluated whether the generic REMAS, a five-session ninety minute intervention, reduces HIV risk behaviors among men who use substances (Calsyn et al., 2009). In a randomized clinical trial, REMAS participants reported fewer unprotected sexual occasions than the comparison group at follow-up. However, the intervention is not specific to any one racial group and proved more effective for White than Black participants. For that reason, our first cultural adaptation project aimed to enhance the effectiveness of REMAS for Black men who use substances (Calsyn et al., 2012).

Prior to recruiting the experts (i.e., researchers and substance abuse treatment counselors in our case) for our Delphi process, our research team identified four other culturally tailored HIV risk reduction interventions for men. Although these interventions included modules or topics similar to the generic REMAS, they did not target individuals who use substances. Next, the research team grouped each module from the generic REMAS with similar modules from other culturally tailored interventions. For example, we grouped a REMAS module on HIV information with modules on HIV information in other interventions designed for Black men. The team instructed the Delphi experts to rate each REMAS module and each of the corresponding modules on culturally appropriate language and content along with curriculum and activities consistent with the social context of the target group.

The process provided an evaluation of REMAS and the identification of modules requiring revisions. Cultural adaptation was unnecessary when experts rated a REMAS module high on the above criteria regardless of the ratings of the modules from other interventions. However, to generate ideas for adapting any REMAS modules with low ratings, we reviewed corresponding modules from other interventions with higher ratings. After adapting the modules, we sent only the adapted version of REMAS back to the experts for round two. This time, experts individually evaluated all REMAS modules in the adapted version on the same criteria as before. Since the experts rated the adapted versions of the REMAS modules as satisfactory on all criteria, we concluded that a third round of ratings was unnecessary. The procedures used to modify REMAS are described in more detail elsewhere (Calsyn et al., 2012).

Based on feedback from the Delphi Process, REMAS-CA differs from the generic REMAS in several distinct ways. REMAS-CA (1) is more interactive, (2) includes a new session on the relation of cultural factors and socialization to sexual behavior, (3) connects the material more closely to the lives of the target group through the use of video clips, and (4) includes discussions of culturally appropriate strategies for communicating about sex. Moreover, each session ends with an open conversation called a talking circle.

After culturally adapting the intervention, we piloted REMAS-CA in four NIDA CTN community treatment programs. The results indicated that the attendance rates for Black men in REMAS-CA (87.0%) exceeded the corresponding rates for generic REMAS (75.2%). Also, at the three month follow-up, REMAS-CA participants relative to generic REMAS participants reported fewer sexual occasions with casual partners (p < .04), and fewer unprotected sexual occasions with casual partners (p < .02) (Calsyn et al., 2013).

The fact that REMAS-CA yielded better outcomes for Black men who use substances than the generic version supports the utility of the Delphi process. Other advantages are that the independent process for rating the intervention components reduces social pressure, allows each expert’s opinion to be weighed equally, and provides more time for respondents to think through their responses before submitting their ratings. Despite the advantages, the Delphi process has several challenges. First, since the experts work independently, the methodology does not capitalize on the potential synergy emerging from a group discussion. Second, and most noteworthy, designing a Delphi procedure that enables both community stakeholders and target group members to provide their expertise is challenging. Some modification (e.g., developing creative ways for reviewing activities and providing feedback) may enable the procedure to incorporate the expertise of target community members such as the men in our study. Indeed, in our REMAS-CA adaptation, target group members provided only superficial oral feedback in small groups at the end of the last session of pilot testing, and we made minimal revisions based on that feedback. We sought to address that limitation in our next project, the cultural adaptation of Safer Sex Skills Building.

3.0. Moderate Community Engagement: Theater Testing

The limitation of solely relying on professional experts and the limited involvement of community members in the REMAS adaptation prompted our team to revise the methodology for our second project by adding theater testing (Wingood & DiClemente, 2008) to the Delphi process. Theater testing involves conducting a mock demonstration of the generic intervention in which members of the target population serve as participants while professional experts (similar to those used for the Delphi Process) observe each session as it is conducted. Following the mock demonstration of each session, participants and professionals provide feedback on the appropriateness of the activities. After an initial round of theater testing, the team adapts the intervention before theater testing a second time using the adapted version. This cycle may be repeated until the professional and target group members judge a final adapted version as acceptable.

3.1. Application of Theater Testing to Adapt SSSB

Susan Tross evaluated the effectiveness of Safer Sex Skills Building for reducing sexual risk behaviors among women who use substances in CTN 0019 (Tross et al., 2008). The original generic version was comprised of five 90-minute group sessions that focused on skill development and HIV risk awareness with rehearsals of correct condom use, and negotiating condom use with a partner (Tross et al., 2008). Despite the fact that the SSSB group reported 29% fewer unprotected sexual occasions than the control group after participating in the intervention, unprotected sexual occasions remained unacceptably high for all participants. Based on evidence of racial/ethnic differences in sexual risk factors (Ahuama-Jonas, Burlew, Campbell & Tross, 2017), we opted to attempt to further reduce sexual risk factors among Black women who use substances by culturally adapting the original SSSB intervention to include more culturally specific content.

This adaptation process also began with the Delphi process. The team asked experts (i.e., academicians and clinicians) to evaluate SSSB modules along with modules on the same topic from other culturally tailored HIV risk reduction interventions for women. However, different from REMAS, we captured the group synergy by modifying the Delphi process to add a group discussion about the intervention with the experts after they submitted their written feedback. The remainder of the adaptation involved theater testing. Black women in substance use disorder treatment served as mock participants in the theater testing, while the professional experts observed each session. The team collected both written and oral feedback from everyone involved. We used the feedback from the Delphi process and the theater testing to create Safer Sex Skills Building-Culturally Adapted (SSSB-CA).

The final SSSB-CA (1) added activities on spirituality and sexual relationships (2) included an entire session on cultural influences on sex and relationships (3) included skill building and interactive activities on factors that influence Black women who use substances and (4) added more culturally appropriate and women affirming activities (e.g., adding a culturally specific affirmation). The intervention ended with a graduation ceremony that incorporated elements of Black culture.

We piloted the finalized version of SSSB-CA with five cohorts (48 Black women) enrolled in substance use disorder treatment. Participants received either the generic SSSB or SSSB-CA. We collected data at pre, post, and six week follow up. The findings for the 36 women who provided follow-up data revealed that SSSB-CA participants (52.4%) were more likely to report condom use the last time they had vaginal sex than generic SSSB participants (40%). Moreover, even among participants who reported at baseline that they had not used a male condom at the last vaginal sex encounter, 50% of the SSSB-CA participants compared to 33% of generic SSSB participants reporting using a male condom during last sexual encounter at follow up.

The addition of theater testing for the cultural adaptation of SSSB had noteworthy advantages over using the Delphi process alone. Theater testing expands beyond relying only on the feedback of professional experts, and involves target group members. Based on their personal experiences, members from the target group provided direct feedback about the content and delivery of the intervention. This allowed the adapted content to be more applicable to the identified target group. However, beyond providing feedback after participating in theater testing, the procedures did not allow for target group involvement in modifying and finalizing the intervention, a key component to further increase the relevance of adapted interventions (Jacquez, Vaughn, & Wagner, 2013). Our subsequent project, discussed in the next section, further expanded on the current methodology to address this limitation.

4.0. Full Community Engagement: Community/Academic Partnership

While the community provided limited feedback during the adaptation of REMAS and moderate feedback during the revisions to SSSB, previous literature also suggests that research conducted in full partnership with community members is more culturally appropriate and may result in quicker translation into use within the community (Jacquez et al., 2013). We therefore decided to increase community engagement by developing an academic/community partnership.

4.1. Application of Community Engagement to Further Adapt SSSB

The first step to developing community engaged interventions is creating and nurturing a partnership between the community and the academicians. In a previous study, residents in a local subsidized housing neighborhood expressed concern to our research team regarding the sexual health of young Black girls in their community (Shambley-Ebron, Dole, & Karikari, 2016). Based on our belief that a revised SSSB might benefit young Black girls and the demonstrated link between substance use and sexual risk taking for this population (Bachanas et al., 2002; Mandara et al., 2003), our team agreed to adapt SSSB a second time to be appropriate for Black girls.

Together, we established an academic/community research team. The community members of the research team consisted of the president of the residents‟ council, the program manager of a large social service agency based in the community, a social worker at the local school, and two older Black teens (ages 18–19). With the assistance of the community members, the academic research team members secured project funding through a local funding mechanism that encouraged academic/community partnerships.

Throughout the project, the community and academic collaborators worked together to adhere to foundational principles of community-based research (Israel, Schulz, Parker, & Becker, 1998). Our collaboration utilized the strengths of the community and allowed for co-learning between partners. Both academic and community team members assumed leadership roles on various tasks, further increasing collaboration and shared decision-making power. For example, community members described cultural norms, discussed perceptions about sexual relationships held by the target group, and identified effective strategies for recruitment. The academic members were responsible for introducing the SSSB-CA intervention originally developed for adult women, sharing the cultural adaptation framework, providing training on human subjects research, and maintaining the study budget. The two groups employed various techniques to maintain a collaborative partnership throughout all phases of the project such as frequent group meetings within the community, encouragement of equal participation in conversation, and majority vote on all decisions. Building upon the techniques utilized earlier in adapting SSSB, the collaborators began by first conducting theater testing of the adult SSSB-CA. Twelve Black teen girls between the ages of 13–17 served as participants in a mock demonstration of SSSB-CA while community and academic collaborators observed. After each activity, research team members and the teen participants provided written and oral feedback. After the theater test of SSSB-CA, academic and community collaborators participated in over six hours of team meetings reviewing the feedback. The partnership then used the feedback from the target group as well as the expertise of the community members to modify the intervention to be more compatible with the norms, values, and beliefs within the community.

The feedback suggested the need for two versions of the SSSB intervention; one targeting Black teen girls (SSSB-CA: Teen Version) and another that jointly targets both Black teen girls and their mothers (SSSB-CA: Mother/Daughter Version). Community research team members and participants in the mock demonstration suggested the adapted versions include activities targeting cultural values that impact sexual decision making, abstinence, spirituality, consideration of future life goals, and cultural affirmations. The intervention ends with a ceremony to encourage the development of cultural and self-pride. More detail on the adaptation is provided in Burlew and colleagues (2018).

Following the modification of the manual, 41 young Black girls participated in pilot testing of either the SSSB-CA: Teen Version or the SSSB-CA: Mother/Daughter Version. The two groups completed assessments on HIV knowledge and correct condom use (factors known to contribute to a reduction in HIV risk behavior; Donovan & Ross, 2000) at the beginning and end of the intervention. Among participants receiving either version of the intervention, examination of effect size differences from pre to post indicated increased knowledge of correct condom use and increased HIV knowledge.

While this iterative process of community engaged cultural adaptation borne out of adapting NIDA CTN interventions includes several strengths, we encountered several obstacles. For example, while community inclusion was vital, it was also difficult at times. Specifically, the older teen members of the research team were not consistently engaged, suggesting a need for more creative efforts to engage older teens from the target group when using this method. System-level barriers also prevented fully shared decision-making power and control (e.g., requirement that academic staff correspond with the IRB and manage the budget within the university).

Despite the obstacles, the process has several advantages. This method represents the highest level of community involvement throughout the multiple adaptation techniques. Due to their equal participation in all aspects of the project, the community team members also gained skills to facilitate intervention activities, which could further promote sustainability. Ultimately, along with community members as co-authors, we published a comprehensive description of this process (Burlew et al., 2018).

5.0. Discussion

The NIDA CTN, since its inception, has been dedicated to developing and assessing the effectiveness of substance use interventions. While studies within the NIDA CTN have demonstrated the effectiveness of multiple interventions, evidence of group differences in intervention outcomes in several studies supports the need for cultural adaptation (Burlew, Montgomery et al., 2013; Calsyn et al., 2012; Covey et al., 2010; Montgomery, Burlew, Haeny, & Ahuama-Jonas, 2019; Montgomery, Burlew, Kosinski, & Forcehimes, 2011; Winhusen et al., 2008). This paper describes the evolution of our cultural adaptation procedures from limited community involvement to partnership with the community to adapt interventions.

The differential effectiveness of the generic REMAS intervention revealed the need for cultural adaptation to increase effectiveness specifically for Black men. While the initial technique of using the Delphi process included professional experts, the original version of the Delphi allowed only limited target group input. While culturally adapting SSSB, we increased community involvement by including both professional experts as well as members of the target group in theater testing. Although the mock demonstrations created an opportunity for community members to provide feedback, community involvement in adapting the intervention was limited. In order to address this issue, we increased the community involvement once more to include community members on the research team during the adaptation of SSSB for teens. From REMAS-CA to SSSB-CA and finally to both SSSB-CA: Teen Version and SSSB-CA: Mother/Daughter Version, the community involvement in the cultural adaptation process greatly increased.

In Burlew et al. (2018), we introduced a new model of cultural adaptation called CCCA which provides concrete steps to researchers on involving community members in cultural adaptation. CCCA is outlined in Table 2. Originating from the cultural adaptation of NIDA CTN interventions, the CCCA model relies on community/academic partnerships throughout with community members sharing in all aspects of the process. The CCCA model occurs in three stages, each of which includes community involvement. These stages are presented sequentially, but the CCCA model is iterative and dynamic, with phases potentially occurring more than once.

Table 2.

Steps of Community Collaborative Cultural Adaptation (CCCA)

Stage 1: Prepare to Culturally Adapt
   - Step 1: Community Engagement
   - Step 2: Recruitment and Selection of Research Team
   - Step 3: Orientation and Training of University and Community Collaborators
Stage 2: Complete Cultural Adaptation
   - Step 4: Recruitment of Participants for Theater Testing
   - Step 5: Conduct Theater Testing of Original Version of Intervention
   - Step 6: Modifications to the Intervention
   - Step 7: Training of Community Collaborators to Deliver Culturally Adapted Intervention
   - Step 8: Theater Testing of the Culturally Adapted Version
Stage 3: Make Final Revisions, Pilot Test, and Take Steps Towards Sustainability
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Although the CCCA process represents a high level of community collaboration, there are several challenges. First, the level of community collaboration demonstrated within CCCA often does not occur without expending significant time building a strong community/academic partnership. Second, since considerable heterogeneity exists even within a racial/ethnic group, clinicians must be continually aware that an intervention adapted to better fit a specific cultural group may not meet the needs of all members of that target group.

The Fidelity-Adaptation dilemma is another challenge not only relevant to CCCA but to all culturally adapted intervention (Burlew, Copeland, Ahuama-Jonas, & Calsyn, 2013). Castro and Yasui (2017) raise the concern that an adapted intervention, while eliminating cultural mismatches, may become a new intervention if it does not adhere to the core components or the original theory of change within the generic intervention. Consequently, Meija, Leijten, Lachman and Parra-Cardona (2017) challenge interventionists, rather than adhering to a strict fidelity or a complete adaptation orientation, to pursue a ‘both-and’ approach.

We encourage researchers to consider ways to creatively modify the Delphi process of the CCCA model to include community representatives (stakeholders and target group members). For example, instead of relying solely on reviews of written materials, the intervention might be presented in video clips to obtain community feedback.

Despite the limitations, the CCCA model for cultural adaptation has several strengths. First, the CCCA model provides concrete steps for including community members in the cultural adaptation process, which has received little focus in the scientific literature. While we suspect the CCCA model may result in improved intervention outcomes and increased sustainability, the CCCA model has yet to be compared empirically to other intervention development techniques. We encourage further testing in controlled trials to further validate the model.

The NIDA CTN has inspired projects that have potentially improved intervention effectiveness across different target groups by increasing community engagement in cultural adaptation. We offer the CCCA method as a roadmap for including community involvement in cultural adaptation. During the first preparatory stage, the goal is to establish a joint research team and to solidify the bond between the academic and community research team members. The community and academic research team members also train each other on their unique expertise. The second stage focuses on cultural adaptation. During this phase, the partnership theater tests the original and, later, the adapted version with community and academic research team members observing and providing feedback. The final stage of the CCCA process involves final revision, pilot testing, and activities to promote sustainability. We encourage researchers to evaluate the effectiveness of their interventions for various groups (e.g., racial-ethnic minorities, sexual minorities, etc.) or investigate if unique factors (e.g., risk/resilience, symptoms, etc.) for a specific group have implications for intervention curriculum (Burlew, Montgomery, Kosinski, & Forcehimes, 2013). If so, cultural adaptation through community engagement may be an important step for improving intervention effectiveness.

Highlights.

  • Intervention outcomes from one group do not necessarily generalize to other groups.

  • Cultural adaptation especially when the adaptation incorporates cultural norms and values can improve outcomes. Evidence suggests that engaging with community members during intervention development is a useful way for incorporating the norms and values of a culture. Despite this, few examples are available of concrete steps for increasing community participation in cultural adaptation.

  • The Delphi process, one form of cultural adaptation, requires modification in order to facilitate community participation.

  • Theater testing is a methodology for cultural adaptation by gaining feedback from the target group but does not necessarily involve the target group in the re-design of the intervention.

  • Academic/community partnerships are useful for full community engagement in cultural adaptation.

Acknowledgments

This work was supported by the National Institute on Drug Abuse (grant RC1 DA028245) and University of Cincinnati Research Office of Research, Comparative Effectiveness and Patient Centered Outcome Research. Pilot Grants.

Footnotes

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