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Evidence-based social work practice calls for the use of research data to guide the development of social work interventions on the micro, mezzo and/or macro-levels. Kearney (2001) described ways qualitative research findings can inform practice. Qualitative findings can help social workers understand the clients’ experiences and “what it may feel like” (Kearney, 2001). Therefore, social workers can develop clinical interventions that take into account the experiences of their clients. Qualitative findings can also help social workers monitor their clients. For example, if after reading a qualitative study on how domestic violence survivors respond to stress, they can monitor for specific stress behaviors and symptoms (Kearney, 2001). In addition, they can educate their client what stress behaviors to look for and teach them specific interventions to reduce stress (Kearney, 2001) Given the increasing diversity that characterizes the landscape in the United States, social workers need to take into account culture when formulating interventions. Social workers can utilize qualitative findings to plan interventions in a culturally meaningful manner for the client. To prepare for this Discussion, read Knight et al.’s (2014) study from this week’s required resources. Carefully review the findings, the photographs, and how the researchers wrote up the findings. Finally, review the specific macro-, meso-, and micro-oriented recommendations. Then read Marsigilia and Booth’s article about how to adapt interventions so that they are culturally relevant and sensitive to the population the intervention is designed for. Finally, review the chapter written by Lee et al. on conducting research in racial and ethnic minority communities.Post the following:(Be very detailed in response and expound on the information being requested.)Using one of the direct quotes and/or photos from Knight et al.’s study, analyze it by drawing up a tentative meaning. Discuss how this would specifically inform one intervention recommendation you would make for social work practice with the homeless. This recommendation can be on the micro, meso, or macro level. Next, explain how you would adapt the above practice recommendation that you identified so that it is culturally sensitive and relevant for African Americans, Hispanics, or Asian immigrants. (Select only 1 group). Apply one of the cultural adaptations that Marsigilia and Booth reviewed (i.e., content adaption to include surface and/or deep culture, cognitive adaptations, affective-motivational adaptations, etc.)(pp. 424-426). Be as specific as you can, using citations to support your ideas. References Kearney, M. (2001). Levels and applications of qualitative research evidence. Research in Nursing and Health, 24, 145–153. Knight, K. R., Lopez, A. M., Comfort, M., Shumway, M., Cohen, J., & Riley, E. D. (2014). Single room occupancy (SRO) hotels as mental health risk environments among impoverished women: The intersection of policy, drug use, trauma, and urban space. International Journal of Drug Policy, 25(3), 556-561. Lee, M. Y, Wang, X., Cao, Y., Liu, C., & Zaharlick, A. (2016). Ceating a culturally competent research agenda. In A. Carten, A. Siskind, & M.P. Greene (Eds.), Strategies for deconstructing racism in the health and human services (pp.51-65). New York, NY: Oxford University Press. (PDF) Marsiglia, F.F. & Booth, J.M. (2015). Cultural adaptations of interventions in real practice settings. Research on Social Work Practice, 25(4), 423-432.


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Research Article
Cultural Adaptation of Interventions
in Real Practice Settings
Research on Social Work Practice
2015, Vol. 25(4) 423-432
ª The Author(s) 2014
Reprints and permission:
DOI: 10.1177/1049731514535989
Flavio F. Marsiglia1 and Jamie M. Booth2
This article provides an overview of some common challenges and opportunities related to cultural adaptation of behavioral
interventions. Cultural adaptation is presented as a necessary action to ponder when considering the adoption of an evidence-based
intervention with ethnic and other minority groups. It proposes a roadmap to choose existing interventions and a specific approach
to evaluate prevention and treatment interventions for cultural relevancy. An approach to conducting cultural adaptations is
proposed, followed by an outline of a cultural adaptation protocol. A case study is presented, and lessons learned are shared as
well as recommendations for culturally grounded social work practice.
evidence-based practice, literature
Culture influences the way in which individuals see themselves
and their environment at every level of the ecological system
(Greene & Lee, 2002). Cultural groups are living organisms
with members exhibiting different levels of identification with
their common culture and are impacted by other intersecting
identities. Because culture is fluid and ever changing, the process
of cultural adaptation is complex and dynamic. Social work and
other helping professions have attempted over time to integrate
culture of origin into the interventions applied with ethnic
minorities and other vulnerable communities in the United
States and globally (Sue, Arredondo, & McDavis, 1992). In
an ever-changing cultural landscape, there is a renewed need
to examine social work education and the interventions social
workers implement with cultural diverse communities.
Culturally competent social work practice is well established
in the profession and it is rooted in core social work practice
principles (i.e., client centered and strengths based). It strives
to work within a client’s cultural context to address risks and
protective factors. Cultural competency is a social work ethical
mandate and has the potential for increasing the effectiveness
of interventions by integrating the clients’ unique cultural assets
(Jani, Ortiz, & Aranda, 2008). Culturally competent or culturally
grounded social work incorporates culturally based values,
norms, and diverse ways of knowing (Kumpfer, Alvarado,
Smith, & Bellamy, 2002; Morano & Bravo, 2002).
Despite the awareness about the importance of implementing
culturally competent approaches, practitioners often struggle
with how to integrate the client’s worldview and the application
of evidence-based practices (EBPs). When selecting and
implementing social work interventions, practitioners often
continue to unconsciously place themselves at the center of
the provider–consumer relationship. Being unaware of their
power in the relationship and undervaluing the clients perspective in the selection of EBPs tends to result in a type
of social work practice that is culturally incompetent and
nonefficacious (Kirmayer, 2012). This ineffectiveness can
be experienced and interpreted by practitioners in several
ways. In instances when clients do not conform to the content
and format of existing interventions, they are easily labeled as
being resistant to treatment (Lee, 2010). In other cases, when
clients fail to adapt to a given intervention that does not feel
comfortable to them, the relationship is terminated or the
client simply does not return to services. Thus, terms such
as noncompliance and nonadherence may hide deeper issues
related to cultural mismatch or a lack of cultural competency
in the part of the practitioner.
Culturally grounded social work challenges practitioners to
see themselves as the other and to recognize that the responsibility of cultural adaptation resides not solely on the clients but
involves everyone in the relationship (Marsiglia & Kulis,
2009). In order to do this, practitioners need to have access
to interventions or tools that are consistent with the culturally
grounded approach. A culturally grounded approach starts with
assessing the appropriateness of existing evidence-based interventions and adapting when necessary, so that they are more
Southwest Interdisciplinary Research Center (SIRC), School of Social Work,
Arizona State University, Phoenix, AZ, USA
School of Social Work, University of Pittsburgh, Pittsburgh, PA, USA
Corresponding Author:
Jamie M. Booth, School of Social Work, University of Pittsburgh, 2117
Cathedral of Learning, 4200 Fifth Avenue, Pittsburgh, PA 15260, USA.
Email: [email protected]
relevant and engaging to clients from diverse cultural backgrounds, without compromising their effectiveness. This process
of assessment, refinement, and adaptation of interventions will
lead to a more equitable and productive helping relationship.
The ecological systems approach provides a structure for
understanding the importance of cultural adaptation in social
work practice. Situated on the outer level (macro level) of
the ecological system, culture frames the norms, values, and
behaviors that operate on every other level: individual beliefs
and behaviors (micro level), family customs and communication patterns (mezzo level), and how that individual perceives
and interacts with the larger structures (exo level), such as
the school system or local law enforcement (Szapocznik &
Coatsworth, 1999). In this approach, the relationships between
individuals, institutions, and the larger cultural context within
the ecological framework are bidirectional, creating a dynamic
and rapidly evolving system (Bronfenbrenner, 1977; Gitterman,
2009). The bidirectional nature of relationships is an important
concept to consider when discussing the cultural adaptation
of social work interventions for two reasons: (1) regardless
of the setting, in social work practice, the clients and the
social workers engage in work partnerships in which both parties must adapt to achieve a point of mutual understanding and
communication and (2) culture is in constant flux, as individuals interact with actors and institutions which either maintain
or shift cultural norms and values over time.
Although culturally tailoring prevention and treatment
approaches to fit every individual may not be feasible, culturally grounded social work may require the adaptation of
existing interventions when necessary while maintaining the
fidelity or scientific merit of the original evidence-based
intervention (Sanders, 2000). This article discusses the need
for cultural adaptation, presents a model of adaptation from
an ecological perspective, and reviews the adaptations conducted by the Southwest Interdisciplinary Research Center
(SICR) as a case study. The recommendations section connects the premises of this article with the existing literature
on cultural adaptation and identifies some specific unresolved
challenges that need to be addressed in future research.
Empirically Supported Interventions (ESIs) in
Social Work Practice
EBP has become the gold standard in social work practice and
involve the ‘‘conscientious’’ and ‘‘judicious’’ application of
the best research available in practice (Sackett, 1997, p. 2).
It is commonly believed that utilizing EBP simply requires the
practitioner to locate interventions that have been rigorously
tested using scientific methods, implement them, and evaluate
their effect; however, EBP acknowledges the role of individuals and relationships in this process. EBP requires the integration of evidence and scientific methods with practice
wisdom, the worldview of the practitioner, and the client’s
perspectives and values (Howard, McMillen, & Pollio, 2003;
Regehr, Stern, & Shlonsky, 2007). The clinician’s judgment and
the client’s perspective are not only utilized in the selection of
Research on Social Work Practice 25(4)
the EBP intervention; they are also influential in how the intervention is applied within the context of the clinical interaction
(Straus & McAlister, 2000). Achieving a balance between both
the client and the practitioner’s perspective in the application of
ESIs is essential for bridging the gap between research and practice (Howard et al., 2003). However, the inclusion of the clinician’s judgment and the client’s history potentially muddles
the scientific merit of the intervention being implemented. This
is the fundamental tension and challenge when implementing
EBP and a key reason why the gap between research and practice exists (Regehr et al., 2007).
The attraction of EBP is clear; locating and potentially
utilizing empirically tested treatment and prevention interventions allow social workers to feel more confident that they
will achieve the desired outcomes and provide clients with
the best possible treatment, thereby fulfilling their ethical
responsibility (Gilgun, 2005). Despite this clear rationale, the
utilization of EBP is limited (Mullen & Bacon, 2006) and
when it is applied, research-supported interventions may not
be implemented in the manner the authors of the intervention
This lack of treatment fidelity when implementing EBP
may be due to practitioner’s awareness that the evidence
generated by randomized control trials (RCTs) may not be
applicable to the diverse needs of their clients or adequately
address the complexity of the clients’ life (Webb, 2001;
Witkin, 1998). Practitioners have natural tendency to adapt
interventions to better fit their clients (Kumpfer et al.,
2002). Some adaptations are made consciously, but others are
made quickly during the course of implementation and based
on clinical judgment (Bridge, Massie, & Mills, 2008; Castro,
Barrera, & Martinez, 2004). ESIs, however, can only be
expected to achieve the same results as those observed when
originally tested, if they are implemented with fidelity or
strict adherence to the program structure, content, and dosage
(Dumas, Lynch, Laughlin, Phillips Smith, & Prinz, 2001;
Solomon, Card, & Malow, 2006). Although adaptations are
typically made in response to a perceived need, when they
are not done systematically, based on evidence and with the
core elements of the intervention preserved, the efficacy that
was previously achieved in the more controlled environment
may not be replicated (Kumpfer et al., 2002). Informal adaptation has the potential for compromising the integrity of
the original intervention, thus negating the value of the accumulated evidence that supports the intervention’s effectiveness. This tension between fidelity and fit has generated a
need for strategies to create fit while insuring fidelity.
Cultural Adaptation
The primacy of scientific rigor over cultural congruence may
be a limitation in applying ESIs and a standard that should not
be maintained in culturally competent social work practice.
When working with real communities, both must be satisfied
to the highest degree possible (Regehr et al., 2007). One solution to tension between using culturally relevant practices and
Marsiglia and Booth
ESIs is locating interventions that have been designed for and
tested with a given cultural group. However, the limited availability of culturally specific interventions with strong empirical support may create barriers to this approach. Despite the
progress that has been made to date, most ESIs are developed
for and tested with middle-class White Americans, with the
assumption that evidence of efficacy with this group can be
transferred to nonmajority cultures, which may or may not
be the case (Kumpfer et al., 2002).
For example, a prevention intervention with Latino parents
found that assimilated, highly educated Latino parents were
responsive to the prevention interventions presented to them,
while immigrant parents with less education were less likely
to benefit (Dumka, Lopez, & Jacobs-Carter, 2002). This highlights the differential effects of an intervention based on culture
as well as a clear need for a more culturally relevant intervention for immigrant parents. Despite a clear need for adaptation
in some circumstances, there is a strong risk of compromising
the effectiveness of the ESI when unstructured cultural adaptations are implemented in response to perceived cultural incongruence (Kirk & Reid, 2002; Kumpfer & Kaftarian, 2000;
Miller, Wilbourne, & Hettema, 2003; Solomon et al., 2006).
For that reason, when culturally and contextually specific interventions exist with strong evidence, it is certainly preferable to
select that intervention; however, in the absence of an ESI
designed and tested for the population being served, adaptation
may be a more viable and cost-effective option for scientifically merging a client’s cultural perspectives/values and the
ESI (Howard et al., 2003; Steiker et al., 2008). Systematically
adapting an intervention may increase the odds that the treatment will achieve similar results than those found in more
controlled environments by minimizing the amount of spontaneous adaptations that the practitioner feels that they must
make to communicate within the client cultural frame
(Ferrer-Wreder, Sundell, & Mansoory, 2012).
Cultural adaptation may not only preserve the ESI’s efficacy but also enhance the results attained in clinical trials
(Kelly et al., 2000). Culturally adapted interventions have the
potential to improve both client engagement in treatment and
outcomes and might be indicated when either rates fall below
what could be expected based on previous evidence (Lau,
2006). In an evaluation of a culturally adapted version of
the Strengthening Families intervention, there was a 40%
increase in program retention in the culturally adapted version
of the intervention (Kumpfer et al., 2002). Although outcomes
were not found to be significantly better in the adapted version
of the intervention, the increase in retention is a significant
improvement. Improving retention expands the intervention’s
potential to reach and impact individuals who would not
typically remain in treatment. Despite the lack of difference
in outcomes in the Strengthening Families intervention, some
evidence has emerged that culturally adapted interventions
not only increase retention but are also more effective. In a
recent meta-analysis, culturally adapted treatments had a
greater impact than standard treatments, produced better outcomes, and were most successful when they were culturally
tailored to a single ethnic minority group (Smith, Domenech
Rodrı́guez, & Bernal, 2010).
Adapting interventions in partnership with communities also
enhances the community’s commitment to the implementation
and the chances that the program will be sustained overtime
(Castro et al., 2004). For example, efforts to adapt HIV prevention programs by modifying the messages and protocols
in order for them to sound and feel natural or familiar intellectually and emotionally to individuals, families, groups, and
communities have improved the communities’ receptiveness,
retention, outcomes, and overall satisfaction, in addition to
retaining high levels of fidelity (Kirby, 2002; Raj, Amaro,
& Reed, 2001; Wilson & Miller, 2003).
Finally, cultural adaptation is advantageous because it
allows the social worker to address culturally specific risk
factors and build on identified protective factors. In the case
of Latino families, differential rates of acculturation between
parents and youth appear to be a risk factor for substance use
and delinquency among youth, indicating that family-based
interventions may be the most culturally relevant intervention
(Martinez, 2006). In addition to a source of risk, cultural
norms that place a high value on family loyalty are protective
factors against a variety of negative outcomes (German,
Gonzales, & Dumka, 2009; Marsiglia, Nagoshi, Parsai, &
Castro, 2012). Identifying risk and protective factors unique
to a community and addressing these within an intervention
have the potential to increase the efficacy of the intervention.
The importance of EBP and culturally competent practice
has created tension in the field of social work. Evidence
has landed support to both claims: (1) interventions are more
effective when implemented with fidelity (Durlak & DuPre,
2008) and (2) interventions are more effective when they are
culturally adapted because they ensure a good fit (Jani et al.,
2008). These different perspectives highlight the tension in
the field between implementing manualized interventions
exactly as they were written versus to adjusting them to fit the
targeted population or community (Norcross, Beutler, &
Levant, 2006). Although this debate is far from resolved, theories of adaptation have been developed that allow the
researcher/practitioner to adjust the fit without compromising
the integrity of the intervention (Ferrer-Wreder et al., 2012).
If the cultural adaptation is done systematically, it has the
potential for maximizing the benefit of the fit, as well as the
benefit of the ESI, thus providing a strategy that addresses
many of the concerns surrounding EBP’s applicability in
social work practice (Castro et al., 2004).
An Emerging Roadmap for Cultural Adaptation
Cultural adaptation is an emerging science that aims at
addressing these challenges and opportunities to enhance the
effectiveness of interventions by grounding them in the lived
experience of the participants. Strategies and processes to systematically adapt interventions while insuring a more optimal
cultural fit without compromising the integrity of scientific
merit have been proposed and are beginning to be tested
(La Roche & Christopher, 2009). The first step in all adaptation
models is determining that the cultural adaptation of an intervention should be perused. Adaptation of an ESI is indicated when
(1) a client’s engagement in services falls below what is
expected, (2) expected outcomes are not achieved, and (3) identified culturally specific risks and/or protective factors need to
be incorporated into the intervention (Barrera & Castro, 2006).
Once the determination is made to conduct an adaptation,
there are a variety of models that one could follow all of which
fall into two categories: content and process (Ferrer-Wreder
et al., 2012). Although most current adaptation models have
merged the discussions regarding the content that should be
modified and process by which this modification takes place,
it is useful to consider them separately.
Content models identify an array of domains that may be
crucial to address when conducting an adaptation. The ecological validity model, for example, focuses on eight dimensions
of culture: language, persons, metaphors, content, concepts,
goals, methods, and social context (Bernal, Jiménez-Chafey,
& Domenech Rodrı́guez, 2009). The cultural sensitivity model,
also a content model, identifies two distinct content areas: deep
culture, which includes aspects of culture such as thought patterns, value systems, and norms, and surface culture, which refers
to elements, such as language, food, and customs (Resnicow,
Soler, Braithwaite, Ahluwailia, & Butler, 2000). Proponents of
the cultural sensitivity model argue that both aspects of culture
should be assessed and potentially addressed if areas of conflict
or incongruence between the culture and the intervention are
identified (Resnicow et al., 2000). Surface adaptations allow the
participants to identify with the messages, potentially enhancing
engagement; while, deep culture adaptations ensure that the
outcomes are impacted (Resnicow et al., 2000).
Castro, Barrera, and Martinez (2004) and Castro, Barrera,
and Steiker, 2010 have proposed a content model that identifies
a set of specific dimensions—at the surface and deep le …
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