Currently, community-based agencies are expected to deliver EB programs with fidelity (Castro et al. 2004
). Typically, fidelity
means adherence to the same activities, scripts, and instructions that the researchers used in the original study that documented an EB program’s efficacy. Given this study’s results demonstrating that there were variable ways in which the same principles were demonstrated in different interventions, it may be possible to define fidelity
in terms of construct fidelity
or fidelity to the principle
, rather than to specific, sequenced routines or scripts. If researchers and providers have greater awareness of the robust
components and principles that are common to all EB programs, there might be greater flexibility in adapting or developing EB programs. It may be that the local providers can identify different strategies to deliver HIV prevention more applicable to their population, while still having fidelity to the common principles, processes, and structures of the original EB programs. Implementation is far more likely when community providers can exercise flexibility, use their knowledge of their target population, and experience ownership of the programs they deliver (Dworkin et al. 2008
). An argument against an approach to adapting EB program based on common elements would be that community interventionists are not competent to deliver EB program without being trained to replicate specific, sequenced activities and scripts. This argument does not give credit to the professional level of education and experience of community interventionists. Future research should test the comparative effectiveness of EB program replicated using a common elements approach.
To date, the approach to translating research to practice is to maintain the original package, but to overcome barriers to replication and tolerate minor adaptations from community members. Interventionists at the community level are thus faced with the choice between selecting a single EB program and replicating it in its entirety, with fidelity to variously defined core elements, or constructing an original program that is not evidence-based. When the core elements are defined on an abstract level of common elements, including common principles identified in this study, then the professional interventionists can replicate elements from a variety of EB programs and incorporate their original ideas, often stemming from long experience with their target population, all the while assuring that all core principles are incorporated.
One feature of an EB program is its delivery format. Each of the adolescent programs analyzed in this article was delivered in small groups. To date, no prevention program has identified the core elements of the delivery format, separate from the content or theory of the intervention. A science of delivery format is sorely needed for all prevention research, not just HIV prevention. It may be that some principles are more easily transmitted and acquired in small group formats in contrast to one-on-one sessions, community-level interventions, or technological innovations incorporating internet and/or mobile phone delivery. An empirical literature is absent in this area.
The use of qualitative methods to identify principles in EB programs is a useful methodological contribution to the strategies of translating research to community practice. The methodology we used involves the rating and concept development by people who are not invested in the researcher’s theory and specific program design, but who bring a commitment to stay close to the data and allow new, unforeseen concepts to emerge. Theoretical foundations may not be sufficient for identifying core elements, since programs from differing theoretical orientations are equally effective and incorporate very similar components (see Albarracin et al. 2005
). Our content analysis of these EB programs demonstrated the gap between how scientists describe their programs and what is actually done in the programs. Qualitative research is a useful tool for finding cross-theoretical commonalities as well as elements that the designers did not recognize as efficacious and essential. This may be a useful strategy to apply to analyze robust components of other EB programs for physical and mental health challenges.
The usefulness and acceptability of our model of 10 core principles requires further research. Here is a working list of questions to guide our inquiries:
- Are these principles indeed robust and efficacious components of EB programs, as identified by deductive, quantitative research studies such as meta-analyses or component analyses?
- If the same research method were applied to videotaped recordings of group interventions, rather than the instructions in the program manual, would the same list of principles be recognized?
- Would examination of a different set of 5EB programs by a different research team following the same method yield the same list of principles?
- Do the researchers who designed, empirically tested, and disseminated packages of these programs agree that the 10 core principles are indeed present and essential?
- Do facilitators of effective community prevention programs find these principles to be core elements?
- Do adolescents who successfully maintain self-protective health behaviors, even in the face of temptations and peer pressure, recognize these 10 principles as ones they believe in?
- Does the list of principles make a contribution to research on “protective factors”, i.e., would adolescents whose behavior is guided by these principles, whether or not they articulate them verbally, be less likely to contract HIV, and more likely to benefit from HIV prevention programs?
- Will these principles be applicable to design of interventions for adolescents with chronic diseases, such as diabetes?
- Would these principles reflect health in a non-US population?
The more we can accurately and comprehensively specify the robust components in our EB programs for adolescents and others, the more easily we can broadly diffuse these programs. HIV prevention efforts must focus on the distinction between core elements and elements that can be modified, tailored, or eliminated without threat to successful outcomes, in order to make an empirically validated knowledge base more accessible to community interventionists. Current approaches to identifying core element are varied and have not yet led to clear guidelines that would enable community providers to assure that their programs carry the essential elements. Furthermore, the core principles identified in the present study hold promise for designing interventions in areas other than HIV prevention, such as drug abuse, anger management, and management of chronic illnesses.
The literature on translation from research studies to community settings often conveys a bias in favor of the researchers and quantitative empirical data over professional interventionists and their clinical and community experience. In a common elements approach to translation and adaptation, interventionists would be trusted to integrate research and practice, bringing their cultural competence, creativity, and professional experience to bear in program development. The CDC’s REP and DEBI programs have succeeded in meeting the essential need to diffuse EB programs to community providers and their clients with fidelity to the original program to ensure effectiveness in scale-up. A common elements approach meets another pressing need and addresses one of the major barriers to diffusion, the lack of buy-in by staff members to programs for which they have no sense of ownership. The lack of a clear vision for community-provider partnering and input in adapting and disseminating EB programs has been noted in the REP and DEBI program agenda (Dworkin et al. 2008
). It is our hope and intention with this paper and others (Ingram et al. 2008
; Rotheram-Borus et al. 2008
) to stimulate discussion in the field around new methods for EB program development and dissemination in order to reach communities in need with effective and engaging prevention programs with the capacity for population-specific tailoring and community and provider ownership.