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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.
Related protocols: CTN-0018A fidelity measure was developed for use with Real Men Are Safe-Culturally Adapted (REMAS-CA), an HIV prevention intervention for ethnically diverse men in substance abuse treatment developed as an outgrowth of National Drug Abuse Treatment Clinical Trials Network protocol CTN-0018 (Reducing HIV/STD Risk Behaviors: A Research Study for Men in Drug Abuse Treatment). The aims of this ancillary investigation of data from that project were to: 1) assess the reliability of the Fidelity Rating and Skill Evaluation (FRASE); 2) measure improvement in therapist competence and adherence over time while delivering REMAS-CA; and 3) identify which modules of REMAS-CA were most difficult to deliver.
Conclusions: Results showed that the FRASE was a reliable instrument for measuring the fidelity of REMAS-CA delivery, and therapists achieved adequate adherence and competence after training, demonstrating significant improvement over time. Sessions 4 and 5 of REMAS-CA were found to contain the most challenging modules for therapists to deliver. These findings offer some guidelines for increasing counselor competence in implementing REMAS-CA for research or clinical practice. Specifically, more effort should be spent on training the counselors to implement the emotionally charged discussion and the specific skill building present in Sessions 4 and 5.
Related protocols: CTN-0018
The changing ethnic composition of the nation and increasing requirements to use evidence-based treatments (EBTs) challenge mental health professionals to adapt treatments and interventions to be appropriate for their clients. This article applies the available information on cultural adaptation to substance abuse. The most common approaches for adapting substance use interventions include some combination of either community involvement in the adaptation, existing research and literature, and/or consultation from experts to adapt EBTs. As an example of the process used to develop a culturally-adapted intervention, research stemming from National Drug Abuse Treatment Clinical Trials Network protocol CTN-0018 (Reducing HIV/STD Risk Behaviors: A Research Study for Men in Drug Abuse Treatment) is described.
This project found that the Real Men Are Safe (REMAS) protocol was less effective for black male substance users than for whites, leading the research team to develop a culturally adapted version of the intervention. After addressing the sociocultural factors associated with HIV risk behaviors among ethnic minority males abusing substances, the resulting REMAS-CA intervention (Real Men Are Safe – Culturally Adapted) was found to be more effective than the original in reducing HIV risk behaviors in black and Hispanic men. The challenges facing the development of culturally adapted interventions include the need for additional research to determine which specific EBTs warrant adaptation, the responsibility of maintaining the balance between fidelity and adaptation, and the challenge of intragroup diversity.
Related protocols: CTN-0018
The National Drug Abuse Treatment Clinical Trials Network (CTN) recently completed a randomized clinical trial evaluating the utility of Real Men Are Safe (REMAS), an HIV prevention intervention for men in substance abuse treatment (protocol CTN-0018). Analysis of the data with a focus on racial/ethnicity-related differences found a differential effect for white versus minority men. This study aimed to determine the acceptability, participants’ receptivity, and effectiveness of a culturally adapted version of Real Men Are Safe (REMAS-CA). In 2010 and 2011, the authors compared participants who attended at least 1 (of 5) REMAS-CA session (n=66) with participants in the original REMAS study (n=136). Participants completed an assessment battery at baseline and at 3-month follow-up with measures of substance abuse, HIV risk behaviors, perceived condom barriers, and demographics. Post-intervention focus groups were conducted at each clinic. Results found that minority REMAS-CA participants were more likely to have attended 3 or more sessions (87%), meeting the study definition of “intervention completion,” than were minority participants in the REMAS study (75.1%; odds ratio: 2.1). For REMAS-CA participants with casual partners (n=25), the number of unprotected sexual occasions in the past 90 days declined (6.2 vs. 1.6). Among minority men in the REMAS study (n=36), the number of unprotected sexual occasions with casual partners changed little (9.4 vs. 8.4).
Conclusions: REMAS-CA was effective across ethnic groups and appears to be more appealing to minorities than the original REMAS intervention. The finding that REMAS-CA was appealing across ethnic groups is especially important because many HIV risk reduction programs serve a diverse clientele and lack the resources to target an intervention solely to one ethnic group.
The “Real Men Are Safe-Culturally Adapted” (REMAS-CA) study was an outgrowth of the National Drug Abuse Treatment Clinical Trials Network protocol CTN-0018, which developed and evaluated Real Men Are Safe (REMAS), a safer sex skills training intervention for men in substance abuse treatment. The study aimed to develop an adherence scale for REMAS-CA, a modified version of the original REMAS intervention tailored for African Americans and Hispanics, measure improvement in counselors’ intervention delivery skills over time, and identify which modules of the new adapted intervention were hardest to deliver. REMAS-CA was piloted in four addiction treatment programs, with two counselors per site running 3 or 4 rounds of REMAS-CA groups over about 9 months. Group recordings were reviewed by a team of four (lead- and co-investigator plus two undergraduates) for 1) manual adherence, 2) avoidance of proscribed behaviors, 3) global empathy and co-therapy. Inter-rater reliability was calculated for all raters, and adherence and skill scores were compared for counselors’ first and last cohorts using paired t-tests.
Results found that counselors did not improve delivery of REMAS-CA over time, except in global empathy, which showed significant improvement from first cohort to last. Discussions of current and past relationships, and role plays of communication skills with partners, were most difficult for counselors.
Conclusions: A highly reliable system for rating counselor skill and adherence to REMAS-CA was developed for this study. Counselors’ lack of significant improvement in skill, co-therapy, global empathy, and avoidance of proscribed behaviors may have been because they scored relatively high even in their first round of intervention delivery. Results suggest that the 2-day training and subsequent certification process, manual structure, and early supervision may have solidified counselors’ skills, leaving little “room for improvement.”
Related protocols: CTN-0018
The presentation reports on a study designed to revise the CDC recognized, evidence-based HIV prevention intervention, “Real Men Are Safe” (REMAS) to be more culturally relevant to African American and Hispanic men, and then conduct a pilot feasibility trial of the revised REMAS (REMAS-CA) in four CTN community treatment providers that have a high percentage of minority clients. Comparisons between the original REMAS manual and four culturally tailored interventions (Nia, d-up, Many Men Many Voice, and Cuidate) were made, focusing in particular on language/expressions of the target group; activities that enhance ethnic identity, consistency with the norms, knowledge, and cultural values of the target group; and understanding of the social context and living situations of the target group. Resultant changes to the original intervention are described, along with data and feedback from focus groups following pilot testing of the REMAS-CA.
Related protocols: CTN-0018
The National Drug Abuse Treatment Clinical Trials Network (CTN) recently completed a randomized clinical trial (CTN-0018) evaluating an HIV prevention intervention targeting men in substance abuse treatment called “Real Men Are Safe (REMAS).” REMAS was found to be effective at reducing the number of unprotected sexual occasions for men in substance abuse treatment compared to an HIV education control intervention. This CTN ancillary study used a modified Delphi process to compare modules from REMAS to similar-content modules from other CDC-approved, culturally tailored HIV prevention interventions. Utilizing ratings and recommendations obtained from an independent expert panel, REMAS was subsequently revised to be more culturally adapted for an ethnically diverse group of men. Ratings suggested REMAS was culturally fair, but that in certain areas the culturally tailored interventions were more in tune with African Americans and Hispanic men. Revisions to REMAS included an added focus on how culture, social norms, and upbringing affect a man’s sexual behavior and relationships.
Related protocols: CTN-0018
This poster reports on a study designed to revise the CDC recognized, evidence-based HIV prevention intervention, “Real Men Are Safe” (REMAS) to be more culturally relevant to African American and Hispanic men, and then conduct a pilot feasibility trial of the revised REMAS in four CTN community treatment providers that have a high percentage of minority clients. The Delphi Process was used to modify the intervention, with expert panel members reviewing and rating all the modules from REMAS and four other HIV prevention interventions tailored to minority men. Panel members also provided specific suggestions of ways to revise REMAS to make it more culturally sensitive. After round 1, the manual was revised and then rated again by the expert panel in round 2. Following round 2, the final version, REMAS-CA (“culturally adapted”) was completed and readied for pilot testing.
The Delphi Process was found to be a successful technique for the revision process, and though the quantitative ratings and qualitative suggestions were, for the most part, consistent with each other, the qualitative feedback was utilized more extensively in making revisions to REMAS (specific revisions are noted in the poster). The effectiveness of the REMAS-CA at decreasing high risk sexual behavior of African American and Hispanic men in substance abuse treatment is currently undergoing pilot testing.