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Child Youth Serv Rev. Author manuscript; available in PMC 2016 June 01.
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Published in final edited form as:

Child Youth Serv Rev. 2015 June 1; 53: 113–120. doi:10.1016/[Link].2015.03.025.

Cultural Adaptation and Implementation of Evidence-Based

Parent-Training: A Systematic Review and Critique of Guiding
Evidence
Ana A. Baumann*,
Brown School, Washington University in St. Louis. 600 S. Euclid, CB 8217, St. Louis, Missouri
63110
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Byron J. Powell1,
Brown School, Washington University in St. Louis. One Brookings Drive, Campus Box 1196, St.
Louis, Missouri 63130

Patricia L. Kohl,
Brown School, Washington University in St. Louis. One Brookings Drive, Campus Box 1196, St.
Louis, Missouri 63130

Rachel G. Tabak,
Prevention Research Center, Washington University in St. Louis. 621 Skinker Boulevard, St.
Louis, Missouri 63130. United States

Valentina Penalba,
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Department of Counseling & Family Therapy, Saint Louis University. 3500 Lindell Blvd., St. Louis,
Missouri 63103

Enola E. Proctor,
Brown School, Washington University in St. Louis. One Brookings Drive, Campus Box 1196, St.
Louis, Missouri 63130

Melanie M. Domenech-Rodriguez, and

Utah State University. E. Eccles Jones, Education Building, Logan, Utah 84322

Leopoldo J. Cabassa
School of Social Work, Columbia University. 1255 Amsterdam Avenue, Mail Code 4600, New
York, New York 10027
Byron J. Powell: bjpowell@[Link]; Patricia L. Kohl: pkohl@[Link]; Rachel G. Tabak: rtabak@[Link]; Valentina
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Penalba: vpenalba@[Link]; Enola E. Proctor: ekp@[Link]; Melanie M. Domenech-Rodriguez:

[Link]@[Link]; Leopoldo J. Cabassa: ljc2139@[Link]

© 2015 Published by Elsevier Ltd.

*
Correspondence concerning this article should be addressed to Ana A. Baumann, Brown School, Washington University in St. Louis,
600 S. Euclid, CB 8217, St. Louis, Missouri 63110. abaumann@[Link]. Phone: 1-314-747-9109.
1BP is currently at Center for Mental Health Policy and Services Research, Department of Psychiatry, Perelman School of Medicine,
University of Pennsylvania. 3535 Market Street, 3rd Floor, # 3131, Philadelphia, PA 19104. byronp@[Link]
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our
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 Baumann et al. Page 2

Abstract
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With advances in knowledge regarding efficacious evidence-based interventions, there have been
significant attempts to culturally adapt, implement, and disseminate parent training interventions
broadly, especially across ethnic and cultural groups. We sought to examine the extent to which
researchers and developers of evidence-based parent training programs have used cultural
adaptation models, tested implementation strategies, and evaluated implementation outcomes
when integrating the interventions into routine care by conducting a systematic review of the
literature for four evidence-based parent training interventions: Parent-Child Interaction Therapy
(PCIT), The Incredible Years (IY), Parent Management Training-Oregon Model (PMTO™), and
the Positive Parenting Program (Triple P). A total of 610 articles across the four programs were
identified. Of those, only eight documented a rigorous cultural adaptation process, and only two
sought to test the effectiveness of implementation strategies by using rigorous research designs.
Our findings suggest that there is much work to be done to move parent-training intervention
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research towards a more rigorous examination of cultural adaptation and implementation

practices.

Keywords
parent training programs; implementation research; cultural adaptation; evidence-based practice

Child disruptive behavior is a public health concern and costly issue in the U.S. (Honeycutt,
Khavjou, Jones, Cuellar, & Forehand, 2013) and, if left untreated, can lead to delinquency
later in life (Fergusson, Horwood, & Ridder, 2004). With the assumption that parents'
behaviors mediate children behavior, parent training programs have been created to prevent
and/or intervene on child disruptive behavior (e.g., Hagen, Ogden, & Bjørnebekk, 2011;
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Honeycutt et al., 2013; Presnal, Webster-Stratton, & Constantino, 2014). Considering that
there are now a number of evidence-based parent training programs that could be readily
implemented in community settings (Substance Abuse and Mental Health Services
Administration, 2012; The California Evidence-Based Clearinghouse for Child Welfare,
2012), it should follow that parent training programs are disseminated and implemented in
usual care1 to prevent and intervene on child disruptive behavior. However, evidence-based
care is still the exception rather than the rule in usual care settings serving children, youth,
and families (Kohl, Schurer, & Bellamy, 2009; Raghavan, Inoue, Ettner, & Hamilton, 2010).
Indeed, an evaluation of parent-training programs in one midsized Midwestern city revealed
that only about 11% of agencies had adopted evidence-based programs (Kohl et al., 2009).
The low rates at which evidence-based parenting interventions are delivered suggests that
simply publishing reports on their availability and effectiveness, while necessary, is not
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sufficient given the myriad of barriers at the client, clinician, team, organizational, policy,
and funding-levels (e.g., Flottorp et al., 2013; Powell, Hausmann-Stablile, & McMillen,
2013). This signals a need to study the implementation of evidence-based parenting
interventions, and to evaluate strategies that can facilitate the uptake of such interventions in
usual care.

1We use the term “usual care” to describe the care given by practitioners in a community without the judgment or normative
implications of the term “standard of care” (Dawson, Zarin, Emanuel, Friedman, Chaudhari, Goodman, 2009)

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The research-to-practice gap is even larger for racial and minority groups. Compared to non-
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Hispanic Whites, racial and ethnic minority groups in the U.S. tend to underutilize mental
health services, to discontinue treatment prematurely, and to receive poor care (Institute of
Medicine, 2003, 2009; United States Department of Health and Human Services, 2001).
Even with comparable insurance, needs, attitudes toward treatment, and beliefs about
treatments, African Americans and Latinos are less likely than their European counterparts
to use mental health services (Alegría et al, 2008; Chow, Jaffee, & Snowden, 2003). As
Kazdin and Blase (2013) articulate, the lack of services for most people in need has direct
implications for models of treatment delivery. The current methodology to provide mental
health services has not been successful in improving mental health in the U.S.; a shift and
expansion in intervention research and practice is needed to be able to prevent and treat
mental illness and decrease health and mental health disparities (Kazdin & Blase, 2013). A
powerful solution may be found in bringing together the fields of cultural adaptation
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research and implementation research. In the cultural adaptation, wherein program

modifications are intended to increase the fit of the intervention to the target population
while protecting scientific integrity (Castro, Barrera, & Martinez, 2004; Kumpfer et al.,
2002). In implementation research, methods aim to promote the systematic uptake of
research findings and evidence-based practices into routine practice (Eccles & Mitttman,
2006). In combination, these can be sources for thinking about designs and methodologies
that can accelerate the spreading of evidence-based prevention and intervention for those in
need. In fact, the Healthy People 2020 report challenges researchers and practitioners to
eliminate disparities and improve the health of all groups (United States Department of
Health and Human Services, & Office of Disease Prevention and Health Promotion, 2012).
To achieve such a goal, scholars tend to focus on adapting evidence-based interventions to
clients' culture with the premise that, to be effective, an intervention should be responsive to
the cultural practices and worldview of the target population (Domenech Rodríguez &
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Bernal, 2012). Similarly, implementation researchers aim to promote the systematic uptake
of evidence-based interventions to improve the quality and effectiveness of health services
(Eccles & Mittman, 2006).”

The Interventions
This review focuses on four parent training interventions that have been given the highest
possible rating as “well supported by research evidence” by the California Evidence-Based
Clearinghouse for Child Welfare ([Link] Parent-Child Interaction
Therapy (PCIT), The Incredible Years (IY), Parent Management Training-Oregon Model
(PMTOR), and the Positive Parenting Program (Triple P). Our sample was selected from the
list of 22 interventions indicated by SAMSHA's National Registry of Evidence-based
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Programs and Practices (NREPP) to have focused on mental health promotion and treatment
in early childhood, to have been funded by the National Institutes of Health, and have been
evaluated in comparative effectiveness research studies. From there, we selected our sample
based on the ratings from the California Evidence-Based Clearinghouse, as programs that
have (a) no case data suggesting a risk of harm; (b) a well-defined treatment manual and
strong empirical evidence demonstrating their ability to change parenting behaviors and
reduce child behavior problems; and (c) demonstrated efficacy across a variety of

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populations and in multiple settings. Triple P is a continuum of parent support and training
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(Sanders, Markie-Dadds, & Turner, 2003), so we focus here on Level 4 Triple P, which is
most comparable to the other interventions under consideration.

Cultural Adaptation of Evidence-Based Parenting Interventions

There are several types of intervention adaptation (e.g., adapting the training, the agency;
Stirman, Miller, Toder, & Calloway, 2013). We focus here on cultural adaptation, defined as
“the systematic modification of an evidence-based treatment (EBT) to consider language,
culture, and context in such a way that it is compatible with the client's cultural patterns
meanings and values” (Bernal, Jimenez-Chafey, & Domenech Rodríguez, 2009, p. 362).
Cultural adaptation is an important part of the implementation process (Cabassa &
Baumann, 2013), and considering the current diversity of the U.S. population, attention to
how cultural factors affect the implementation of parent trainings in usual care is crucial.
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Meta-analyses in the cultural adaptation field have indicated that adapting interventions to
clients' cultural backgrounds by explicitly integrating cultural factors such as language,
cultural beliefs, and explanatory models into the intervention improves the relevance,
acceptability, effectiveness, and sustainability of the intervention by the providers and target
populations (e.g., Benish, Quintana, & Wampold, 2011; Huey & Polo, 2008; Griner &
Smith, 2006; Smith, Domenech Rodríguez, & Bernal, 2011). Care should be taken, however,
as these meta-analyses reflect great variability in effect sizes, study designs, populations,
and interventions sampled (Cabassa & Baumann, 2013).

There is no single, correct way to culturally adapt interventions and there is no rule that
states that every EBT should be adapted (Domenech Rodríguez & Bernal, 2012). When
considering whether to culturally adapt an intervention, one should carefully consider what
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evidence about the intervention is available (e.g., what information does the literature
provide about the EBT?), the target population (e.g., who was the original target population?
To whom will the intervention be delivered?), and what is the target domain of the
intervention (e.g., changing parenting practices). Domenech Rodríguez and Bernal (2012)
provide guidelines to support the decision of whether to adapt an intervention, which
involve assessing whether (a) the EBT is accessible to the providers who will be delivering
the intervention, (b) the underlying mechanism of change of the intervention is a good fit for
the target population, and (c) the EBT is acceptable for the target population. If the decision
is to culturally adapt an intervention, the next step is to decide which framework will guide
the process.

There are two sets of cultural adaptation frameworks: those that inform modification to the
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content of the intervention and those that inform the process of adaptation (Ferrer-Wreder,
Snudell, & Mansoory, 2012). One model that informs what to adapt in the delivery and
content of the intervention is the Ecological Validity Model (EVM) by Bernal, Bonilla, and
Bellido (1995). The EVM specifies eight domains: language, persons, metaphors, content,
concepts, goals, methods, and context. Another content model is the cultural sensitivity
model, which distinguishes deep versus surface adaptations (Resnicow, Soler, Braithwaite,
Ahluwailia, & Butler, 2000).

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The second set of frameworks focus on the process of adaptation, where decisions about
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when to adapt, how to adapt, and which stakeholders should be involved in the process are
outlined. A number of frameworks fall into this category and vary in how prescriptive (i.e.,
have a set of a priori steps that guide the process) or specific (i.e., focused on the adaptation
of one specific EBT) they are (Ferrer-Wreder et al., 2012). Several of them have been
described elsewhere (Bernal & Domenech Rodríguez, 2012). Generally, these models
recommend adaptations to be informed by the expertise of stakeholders, use formative
research methods, and conduct formal evaluations of the adapted intervention (Cabassa &
Baumann, 2013; Domenech Rodríguez & Bernal, 2012). It is important to assess the extent
to which adaptations to parent training interventions have been guided by cultural adaptation
frameworks in order to document the types of adaptation that are being conducted and
examine how these adaptations impact intervention and implementation outcomes.

Implementation of Evidence-Based Parent Training Interventions

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Implementation refers to the process of integrating the intervention within a setting (Rabin
& Brownson, 2012). It extends efficacy and effectiveness research that focuses on
discovering what works to understanding how the implementation works in specific contexts
(Damschroder, Peikes, & Peterson, 2013). This paper focuses on empirical tests of strategies
used to implement the aforementioned evidence-based parent training programs. We define
an implementation strategy as a “systematic intervention process to adopt and integrate
evidence-based health innovations into usual care” (Powell et al., 2012, p. 124). The
literature reflects a wide range of different implementation strategies (Powell et al., 2012);
yet, the evidence to support the use of specific implementation strategies in mental health
and social service settings has lagged behind other fields such as nursing and medicine
(Powell, Proctor, & Glass, 2013). The recent prioritization of implementation research by
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the National Institutes of Health (2013) and the Institute of Medicine (2009) will
undoubtedly increase the number of empirical studies testing innovative approaches to
implementation. Developing a robust evidence-base for specific implementation strategies
and learning more about how they interact with contextual elements of the settings in which
they are deployed will give implementers the tools they need to improve the quality of care
in social service settings. In other words, the testing of implementation strategies will
attempt to answer the question set forth by Asgary-Eden and Lee (2011): “So now we've
picked an evidence-based program, what's next?” (p. 169).

Empirical tests of implementation strategies should be guided by available theories,

conceptual models, and/or frameworks, as they can ensure that essential contextual and
process elements related to implementation are not overlooked (Proctor, Powell, Baumann,
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Hamilton, & Santens, 2012; Tabak, Khoong, Chambers, & Brownson, 2012). Moreover,
frameworks provide a systematic way of evaluating the interventions and facilitating
replication of the implementation process in different settings. While there are over 60
dissemination and implementation frameworks and models (Tabak et al., 2012), evidence
from healthcare suggests that theory is drastically underutilized in implementation studies
(Colquhoun et al., 2013).

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It is also critical that implementation studies evaluate implementation outcomes. Proctor and
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colleagues (Proctor et al., 2011; Proctor & Brownson, 2012) have suggested a taxonomy of
implementation outcomes, including acceptability, adoption, appropriateness, cost,
feasibility, fidelity, penetration, and sustainability. Evaluation of implementation outcomes
can help investigators disentangle implementation effectiveness from treatment
effectiveness and to know, for example, if an intervention failed because it was ineffective
or it was implemented incorrectly (Proctor et al., 2011). Furthermore, assessing
implementation outcomes may improve our understanding of which implementation
strategies work best with given interventions, settings, and conditions.

Purpose
Cultural adaptation and implementation processes are inextricably linked and both processes
should be planned and documented to facilitate future replication (Cabassa & Baumann,
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2013). The purpose of this article is to review and assess the literature to determine the
extent to which studies of evidence-based parent training programs have (a) used cultural
adaptation models to guide the adaptation process, (b) tested implementation strategies, and
(c) evaluated implementation outcomes.

Methods
Inclusion and Exclusion Criteria
Cultural adaptation studies—Our review includes empirical studies of cultural
adaptation that explicitly accounted for clients' culture, ethnicity or race, and that used and
report data from experimental designs (e.g., RCTs). We excluded studies that simply
translated the materials into a different language and those that tested diagnosis-specific
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adaptations (e.g., adaptations for populations with autism).

Implementation studies—We included implementation studies that were empirical and

utilized comparative designs that tested the effectiveness of an implementation strategy or
set of strategies. To be included, studies also had to meet the standards of rigor set forth by
the Cochrane Effective Practice and Organisation of Care Group (2002), which specifies
four research designs: (a) randomized controlled trials, (b) controlled clinical trials, (c)
interrupted time series, and (d) controlled before and after studies. This inclusion criteria has
been used in other reviews of implementation studies in social service settings (e.g.,
Landsverk et al., 2011).

Search Strategy
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In order to locate empirical papers meeting our inclusion criteria we used a four-step process
that included (a) a database search, (b) a search of the authors' personal libraries, (c) an
examination of the website for each intervention, and (d) a query to treatment developers to
identify articles that we may have missed. For the database search, we took an inclusive
approach in generating search terms, using multiple variants of the four parent training
programs: (a) “Parent-Child Interaction Therapy” OR PCIT OR “Parent Child Interaction
Therapy”, (b) “Incredible Years”, (c) “PMTO” OR “Parent Management Training-Oregon

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Model” OR “Parent Management Training”, and (d) “Positive Parenting Program” OR

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“Triple P”.

We searched the following databases: PsycINFO, Medline/Pubmed, CINAHL, and

SocIndex in January of 2013. After articles from the first three phases of the search strategy
were coded, we emailed the treatment developers or spoke with members of their team to
ask whether we had identified all of the published articles that were potentially relevant to
our study objectives.

Selection of Studies
Five authors reviewed the articles; each was the primary coder for one intervention (two
authors reviewed Incredible Years). After potentially relevant articles were identified, full-
text review was completed by at least two authors. Any discrepancies were handled through
discussion until consensus was reached.
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Data Extraction and Coding Procedures

Coding for cultural adaptation—We coded two aspects of the adaptation process. To
evaluate what adaptations had been made to meet the needs of particular cultural groups, we
used the eight categories of the EVM framework: language, persons, metaphors, content,
concepts, goals, methods, and context (Bernal et al., 1995). To assess how the adaptation
was made, we extracted any descriptions of the process of adaptation from articles that fit
our criteria as well as from articles that solely described the process of adaptation.

Coding for implementation—For the implementation studies, we coded study designs,

implementation strategies, implementation outcomes, and whether or not a conceptual
model or framework was used to guide the study and/or implementation effort. For the
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implementation outcomes, we relied upon Proctor and colleagues' (2011) taxonomy that
includes: acceptability, adoption, appropriateness, cost, feasibility, fidelity, penetration, and
sustainability. To assess the implementation process, we extracted descriptions from articles
that fit our criteria as well as from articles that described the implementation process.

Data Synthesis
Given the small number of studies that met our inclusion criteria we relied primarily upon
tabulation and narrative summaries to describe our results.

Results
The database search yielded a total of 67 articles related to Triple P, 137 articles related to
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PCIT, 72 articles related to Incredible Years, and 62 articles related to PMTO. Additional
articles were added from the authors' personal libraries, intervention websites, and
intervention developer queries, yielding a total of 106 articles for Triple P, 192 articles for
PCIT, 209 articles for IY, and 103 articles for PMTO.

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Cultural Adaptation Articles

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Only one article from Triple P, three articles from PCIT, and four articles from PMTO met
our criteria. No articles from IY fit our criteria. The results of our coding about cultural
adaptation are shown in Table 1. Two interventions were adapted to be delivered to Latinos
(Martinez & Eddy, 2005; Parra Cardona et al., 2012), including Puerto Rican families
(Matos, Bauermeister, & Bernal, 2009; Matos, Torres, Santiago, Jurado, & Rodriguez,
2006). Two articles reported adaptations for use with indigenous populations. Triple P was
adapted for use with Aboriginal and Torres Strait Islander families in Australia (Turner,
Richards & Sanders, 2007). Another article reported adaptation made to PMTO for use with
Somalis and Pakistanis in Norway (Bjørkness & Manger, 2013). McCabe and colleagues'
articles (McCabe & Yeh, 2009; McCabe, Yeh, Lau, & Argote, 2012) reported the
intervention of GANA, a PCIT intervention adapted for Mexican American families. The
adaptation of GANA was described in McCabe, Yeh, Garland, Lau, and Chavez (2005).
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All articles reported changes in language with the exception of Parra Cardona et al. (2012),
because the authors were adapting a manual that had already been translated to Spanish. All
but Parra Cardona and colleagues (2012) and McCabe et al. (2005) described changes in the
persons category, such as the inclusion professionals serving this population and parents
(Turner et al., 2007; Turner & Sanders, 2006) and the homogenization of gender in the
parenting groups (Bjørkness & Manger, 2013). Changes in metaphors included insertion of
idiomatic expressions, as well as changing the name of the program and pictures of the
manuals to fit the needs of the target population (Matos et al., 2006; McCabe et al., 2005;
Turner et al., 2007).

Changes in content were reported in all studies, including sessions with content about
biculturalism (Parra Cardona et al., 2012). Context and service delivery methods were also
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altered for Triple P in that group sessions were restructured to “allow time to discuss the
social and political context for parenting, develop trust, slow the pace of presentation, and
share personal stories” (Turner et al., 2007, p. 5).

One of the most common changes in concept was the expansion of family to include other
family members besides parents and children, and changes in goals to increase the fit of the
intervention for the target population (e.g., framing the intervention as an educational and
skill-building intervention; McCabe et al., 2005). All but Matos et al. (2006), Parra Cardona
et al. (2012) and Martinez and Eddy (2005) reported changes in method, including increases
in session time (McCabe et al., 2005). Finally, Matos et al. (2009), Matos et al. (2006), and
McCabe et al. (2005) reported changes such as giving additional time for parents to build
rapport with therapists, adapting the data collection process to include meals and child care,
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as well as explicitly mentioning issues regarding immigration aspects during the

intervention.

One of our questions was whether the articles identified a framework for informing the
adaptation, specifically to inform what about the intervention should be adapted and how
that adaptation should be made. Only Matos and colleagues (2006) explicitly mentioned a
framework that guided their process of content adaptation: Bernal and colleagues' (1995)
Ecological Validity Model.

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More authors reported frameworks that guided their process of adaptation. Turner et al.
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(2007) reported that the process of adaptation was made with extensive community
consultation, but the authors do not give specific details of the steps taken to establish
collaboration between researchers and community members. McCabe et al. (2005)
mentioned that they used a mixed method design to adapt the intervention, and Matos et al.
(2006) report that they based their adaptation process on Rounsaville, Carroll, and Onken
(2001) stage model of behavioral therapies. Domenech Rodríguez et al. (2011) used the
Cultural Adaptation Process model (Domenech-Rodríguez & Wieling, 2004) to inform their
adaptation process of PMTO. Parra-Cardona and colleagues (2011) adapted PMTO using
community-based participatory research principles, where the adaptation involved
translation and cultural adaptation of the materials, qualitative study of the community, and
a test of the adapted intervention. Finally, no framework was reported by Bjørkness &
Manger (2013) about the process of adaption of PMTO for Somalis and Pakistanis in
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Norway or by Matos et al. (2009), who adapted PCIT for Puerto Rican preschool children
with ADHD and behavior problems.

Some lessons can be learned about the cultural adaptation process from studies that did not
fit our criteria but that reported the adaptation process of the parent trainings. While the
emphasis on the following components varied, in general the adaptation of the parent
trainings involved: (a) review of the core components of the EBT; (b) survey of relevant
information from the clinical literature, from the empirical literature, expert opinion (cultural
adaptation experts), and qualitative data collected from target population and potential
providers to assess the fit of the EBT with target population; (c) preliminary adaptation of
EBT manual and training components; (d) feedback from consultants (cultural adaptation
experts), practitioners, community members, and treatment developer and his/her team; (e)
in-depth interviews with parents and providers and/or evaluation of data for further
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refinement of the intervention (e.g., Bigfoot & Funderbrook, 2001; Dionne, Davis, Sheeber,
& Madrigal, 2009; Domenech Rodríguez et al., 2011; Matos et al., 2006; McCabe et al.,
2005).

Table 2 shows the target population, the design and comparison groups and the main results
of these studies. Overall, adapted interventions are associated with great retention and
satisfaction. Data also indicate the feasibility and effectiveness of the adapted interventions
as compared to control groups or waiting list.

Implementation
Out of the 610, only two (0.32%) studies from PCIT met our criteria. Chaffin et al. (2009)
manipulated the presence of motivational interviewing aimed at improving parenting
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retention in one of the PCIT studies implemented in child welfare with parents of children
between 2.5 and 12 years of age. A double-randomized design was employed in which
participants were first randomized to either the standard orientation or to the self-motivation
orientation, and then were again randomized to either PCIT or to a standard didactic group.
Their results showed that motivational interviewing improved retention only when
combined with PCIT, but only for low to moderately motivated child welfare clients.
Herschell and colleagues (2009) evaluated whether simply giving the manual to therapists

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would be sufficient to master PCIT knowledge and skills. They also tested whether either
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didactic or experiential training was more effective in improving a number of outcomes,

including therapists' attitudes toward treatment manuals, skill acquisition, knowledge gain,
and satisfaction with the intervention. Their results show that reading a treatment manual
increased both knowledge and skills related to PCIT; however, was not sufficient for
clinicians to obtain mastery. Both the experiential and didactic (control) group improved
clinicians' attitudes toward manualized treatments, PCIT knowledge and skill, and
satisfaction with the training; however, few clinicians reached mastery after the two-day
training.

Several articles that did not fit our criteria described the experiences of implementing parent
trainings. Some interventions did follow a framework (e.g., Bekkema, Wiefferink, &
Mikolajczak, 2008; Ogden, Hagen, Askeland, & Christensen, 2009), but the majority of the
authors simply described the steps taken to implement the interventions: (a) standardization
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of treatment delivery via manuals; (c) standardization of training for providers delivering the
intervention; and (d) ongoing fidelity monitoring. All authors highlighted the importance of
peer support amongst providers during training, certification of providers, and constant
supervision for fidelity checking. Fidelity was assessed during training and up to
certification, and at different times after certification to ensure maintenance and quality of
intervention delivery. Moreover, authors unanimously mentioned that sustainability and
success of the intervention involved agency support, which includes acceptance of the EBT,
integrating EBT with caseloads, and procuring ongoing funding (e.g., Webster-Stratton,
2009; Ogden et al., 2009; Turner & Sanders, 2006).

Discussion
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The goals of this review were to determine the extent to which researchers and developers of
evidence-based parent training programs (a) used cultural adaptation models, (b) tested
implementation strategies, and (c) evaluated implementation outcomes. Our results were
discouraging. Out of 610 published reports, only eight studies fit our criteria for cultural
adaptation studies and two fit our criteria for implementation studies.

We used the Ecological Validity Model (EVM; Bernal et al., 1995) as a framework to code
the cultural adaptation of content of the parent trainings as it provides researchers a
comprehensive list of potential targets of cultural adaptation and identifies critical areas
where cultural factors can play a role in psychosocial interventions. Another advantage of
EVM is that it helps identify surface and deep level adaptations (Resnicow et al., 2000).
Surface modifications, such as translation of the materials, increase the feasibility of the
program. Deep modifications, such as changes in methods and content, enhance the program
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impact (Resnicow et al., 2000). Oftentimes the translation of the materials (surface
modifications) could be sufficient to produce impact of the culturally adapted program but
we advocate for these to be carefully thought and planned (Cabassa & Baumann, 2013).

There is, however, debate regarding deep adaptations. Some scholars advocate for a
rationale for cultural adaptations prior to adapting EBTs given concerns regarding an
absence of data that confirms that such adaptations are needed, as well as concerns regarding

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feasibility, cost, and other resources needed to properly test the effectiveness of adapted
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treatments (Domenech Rodríguez & Bernal, 2012). Others also advocate that making
adaptations: (1) delays implementation/delivery of the intervention unnecessarily (while
adaptations are made); (2) is based on a potentially false assumption that people will not
benefit from an intervention; (2) results in delivering an untested form of an intervention
(National Advisory Mental Health Council's Workgroup, 2010).

However, arguments have also been advanced on the need to assume that culture must be
taken into account on the basis of ethical and professional standards on the premise that
adaptations are not needed when they, in fact, could require researchers to conduct research
that harms vulnerable (e.g., marginalized) individuals (Domenech Rodríguez & Bernal,
2012). Moreover, as expressed in the Surgeon's General report ([USDHHS], 2001), ‘culture
counts’ in mental health care, as it shapes how people seek help and engage in health
behaviors and shapes how providers communicate with clients and deliver services.
Author Manuscript

Considering that the population of ethnic minorities in the U.S. is projected to be 50% of the
U.S. population by 2060 (Colby & Ortman, 2015), and that service delivery in its current
form has not been efficient in reaching those in need, a careful assessment of the
methodologies currently being used to provide service delivery may be important so as to
“shift” current thinking and promote greater reach to those in need (Kazdin & Blasé, 2011).
Implementation science, with methodology that aims to promote the spread of EBTs can be
a powerful resource for helping accelerate the uptake of evidence-based parent interventions
in usual care.

One problem when deciding whether or not to adapt a parent training is that few clinical
trials have included a sufficient number of ethnic minority families to permit generalization
across cultures (McCabe et al., 2005), and the gap in utilization of EBTs by minority
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populations still exists (Institute of Medicine, 2009). Moreover, the field of cultural
adaptation still needs to address questions such as “what (if any) are the adaptations
necessary to achieve cultural relevance and treatment efficacy?” (italics added) and “What
are the most relevant procedures that should be undertaken in any process of cultural
adaptation?” (Parra Cardona et al., 2012, p.3). While the answers to these questions are not
straightforward, one methodology to answer these questions is to use differential research
designs. This would entail testing two differentially culturally adapted versions of an
existing EBT to examine their efficacy, feasibility and cultural acceptability (Martinez &
Eddy, 2005; Parra Cardona et al., 2012). An alternative way to address whether or not to
adapt an intervention is to bridge the fields of cultural adaptation and implementation
whereby the evaluation of whether, when, and how to adapt a parent training would be part
of the implementation process (Cabassa & Baumann, 2013; Chambers, Glasgow, & Stange,
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2013). To do so, one should carefully choose the frameworks that would guide the process.

Our review revealed that few scholars were using cultural adaptation frameworks. Cultural
adaptation frameworks are important to promote effective implementation research as it
helps maintain high fidelity and avoid decrements in intervention impact (Allen et al., 2012).
We advocate for the explicit description of what has been adapted, why it was adapted, and
how it was adapted. The documentation of the process is important to inform stakeholders
on how to (a) identify the diversity of adaptations being made; (b) examine the impact of the

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 Baumann et al. Page 12

intervention on different populations; (c) help provide technical assistance to community

Author Manuscript

providers, and (d) scale up programs (Stirman et al., 2013).

While no IY study fit our criteria, we note that there is a large amount of work by Webster-
Stratton and her team to implement IY with minority groups (Webster-Stratton, 2009; Reid,
Webster-Stratton, & Beauchaine, 2001). Cultural adaptation efforts for multicultural groups
may be difficult to implement as the very pluralism of the group creates challenges for
specific tailoring efforts. Future research could provide clarity on what kinds of adaptations
may be made in multicultural contexts to address the diversity within groups.

The surprisingly low number of studies (n = 2) that fit our criteria of implementation
indicates that the field of parent training, to date, has focused primarily on determining the
effectiveness of the interventions. That is not to say that investigators are not assessing
implementation outcomes. For example, other types of articles described findings on fidelity
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(e.g., Sigmarsdóttir & Gudmundsdóttir, 2013) or cost effectiveness (e.g., Foster, Olchowski,
& Webster-Stratton, 2004). It seems, however, that the field is poised to engage in more
rigorous research involving comparative tests of implementation strategies and evaluating
implementation outcomes.

Our review has several limitations. First, there was a discrepancy between the numbers or
articles from database search and from our personal libraries and inquiries to treatment
developers and their team. Some of the articles that were captured from our personal
libraries and/or from indications from the treatment developers did not contain the names of
the interventions in the titles, and one intervention had several articles on their website that
were also indexed by database. This poses a challenge for database searches; thus, we call
for scholars to carefully consider titles, key words, and abstracts when publishing study
Author Manuscript

results.

Second, our criteria could have been too stringent considering current state of research on
parenting intervention. For example, articles such as those using observational or case study
designs were excluded. An analysis of the excluded articles may provide an interesting
picture of the adaptation and implementation work being done in the field. For example,
while Domenech Rodríguez et al. (2011) provide a detailed description of how they used the
EVM model to adapt the PMTO intervention,; their study was excluded from our analyses
because they did not include data from the randomized controlled trial. Third, we were also
stringent on our selection of parent trainings. Future studies could assess whether other
interventions would provide a different picture of the cultural adaptation and the
implementation process. Finally, while our team reached consensus about articles to include
in this review, others may have a different perspective about our selection criteria. In terms
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of treatment adaptations, we focused on cultural adaptation. However, we recognize that

other types of adaptations may be necessary during implementation in order to fit the
intervention to the setting, such as adaptions in context, training, and modifications at the
agency level and system level (Stirman et al., 2013).

In summary, our data indicate that the field of prevention science is ripe for more studies
documenting the content and process of cultural adaptations and empirically testing different

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 Baumann et al. Page 13

approaches to implementation. As the Institute of Medicine report (2009) points out: much
Author Manuscript

research is needed to identify essential aspects of implementation, especially when

implementing interventions whose evidence may be “significantly affected or impeded by
aspects of the ethnic, linguistic, and cultural environment in which they are implemented”
(p.4). In short, efforts to implement evidence-based parent training programs must be
complemented with evidence-based approaches to cultural adaptation if they are to be
adopted, implemented, sustained, and scaled-up in community settings (Cabassa &
Baumann, 2013).

Acknowledgments
AAB, LJC, PLK and EKP received support from NIMH R25 MH080916. AB and EKP also received support from
UL1 TR0000448. PLK received support from NICHD 1R01HD061454 and CDC 1 U01/CE001627. BJP was
supported by a Doris Duke Charitable Foundation Fellowship for the Promotion of Child Well-Being, the Fahs-
Beck Fund for Research and Experimentation, NIMH T32 MH019960, and NIMH F31 MH098478. RGT is
Author Manuscript

supported in part by Cooperative Agreement Number U48/DP001903 from the Centers for Disease Control and
Prevention (the Prevention Research Centers Program). LJC received support from K01 MH091108 and
R01MH104574-01. The content of this article is solely the responsibility of the authors and does not represent the
official views of the National Institutes of Health.

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Highlights
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• We examined the extent to which researchers and developers of evidence-based

parent training programs have used cultural adaptation models, tested
implementation strategies, and evaluated implementation outcomes

• Four evidence-based parent interventions

• Much work to be done to move parent-training intervention research towards a

more rigorous examination of cultural adaptation and implementation practices
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Table 1
Results of the Coding for Cultural Adaptation Studies

Triple P PCIT IY PMTO Total

Total # 106 192 209 103 610
Baumann et al.

Cultural adaptation articles 1 3 0 3 8

EVM categories
Language 1 3 2 8
Content 2 2 6
Persons 1 2 5
Metaphors 1 2 5
Methods 1 3 1 7
Concepts 1 1 4
Goals 1 1 3
Context

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Table 2

Main Results of the Cultural Adaptation Studies.

Study Intervention Target population Design and comparison Results

groups
Baumann et al.

Turner, Richards & Triple P Indigenous families living in Repeated measures randomized Good retention rate of families in intervention and high satisfaction by families;
Sanders, 2007 Australia group; culturally sensitive small drop out of families in waiting list prior to engaging them in intervention.
Triple P with waiting list Decrease in child problem behavior; improvement parenting practices (decrease
on parent verbosity).
Matos, Bauermeister, & PCIT Puerto Ricans families living in Repeated measures randomized Significant reduction on mother's depression and child outcome (hyperactivity,
Bernal, 2009 Puerto Rico group; adapted PCIT with inattention, aggression and oppositional behaviors), and increase in the use of
waiting list adequate parenting practices on the intervention group.
Matos, Torres, PCIT Puerto Ricans famlies living in Pre-post assessment; single High retention rates and satisfaction level from parents. Significant reduction in
Santiago, Jurado, & Puerto Rico group children‘s’ externalizing problems, reduction of parenting stress, and
Rodriguez, 2006 improvement in parenting practices.
McCabe & Yeh (2009) PCIT Mexican American families living GANA (PCIT adapted), Both GANA and PCIT produced significant decrease in child externalizing
in the US standard PCIT or treatment as behavior, increase in parent practices, and decrease in parent distress TAU.
usual GANA was not superior to PCIT.
Martinez & Eddy, 2005 PMTO Latino families in the U.S. (50% RCT; PMTO vs. No High retention rates; high satisfaction from parents and strong support for group
target children were U.S.-born, 50% intervention intervention. Significant improvement in parenting practices (general parenting,
were foreign born) skill encouragement, overall effective parenting), as well as significant decrease in
youth aggression, externalizing behaviors, likelihood of smoking and use of
alcohol, marijuana and other drugs.
Parra Cardona et al., PMTO Latino families living in the US RCT; CAPAS-Enhanced (with High engagement, retention and parent satisfaction in both arms. Participants from
2012 two extra sessions about CAPAS-Enhanced emphasized the importance of devoting time to reflect about
bicultural experience) vs. cultural themes.
CAPAS-Original (PMTO
translated to Spanish)
Bjørkness & Manger, PMTO Muslim families from Somalia and RCT; adapted PMTO and Moderate retention rate; high satisfaction. Improvement in parenting practices
2013 Pakistan living in Norway waiting list (decrease in hash discipline and increase in positive parenting), and reduction on
child behavior problem as reported by mothers. No difference in child behavior as
reported by teachers.

Child Youth Serv Rev. Author manuscript; available in PMC 2016 June 01.
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