Table 1 Adaptation Process based on Adaptation Guidance

Formative Research Phase

1. Assess Community

• Identify behavioral determinants and risk factors of the new target population using focus groups, interviews, needs assessments, and logic models

• Assess organizational capacity to implement the program

Conducted ten focus groups with five tribal commununities- one smoking and one non-smoking each. Topics included barriers to EBI application and success, cultural differences impacting EBI, surface and deep changes to materials necessary

2. Understand the Intervention

• Identify and review relevant EBIs and their program materials

• Understand the theory behind the programs and their core elements

The majority of EBIs focused on smoking rules target multi-unit housing or public places, not single family homes; to our knowledge, no EBI focusing on smoke-free homes has been adapted to AI-AN populations. Most AI-AN adaptations seek to change smoking behavior itself, rather than smoke-free home rules. Additionally, adaptation team included original developers of the intervention at the Emory Prevention Research Center (EPRC)

3. Select the intervention

• Select the program that best matches the new population and context

SFH is an EBI with success in multiple contexts, and one of few interventions that seeks to change smoking rules in the home environment to reduce exposure to SHS and THS, and may be a pathway to quitting. Additional support for the intervention was given by focus group participants, regarding perceived acceptability and efficacy.

Adaptation Phase

4. Consult with experts

• Consult with content experts, including original program developers, as needed

• Incorporate expert advice into program

EPRC is home to experts on tobacco control research, smoke-free homes, and adaptation of EBIs. Additionally, it is both the source of the original intervention and this adaptation. Therefore, the members of the EPRC act as experts for this adaptation. Additionally, focus group participants are expects on their communities, as members, and as such were consulted regarding changes.

5. Consult with Stakeholders

• Seek input from advisory boards and community planning groups where program implementation will take place

• Identify stakeholder partners who can champion program adoption in new settings and ensure program fidelity

Establishment of AI-AN workgroup consisting of 16 members, including tribal partners from Michigan, Oklahoma, California, and Alaska. Tribal partners served to give input on adaptation materials and support future dissemination activities.

6. Decide what needs adaptation

• Decide whether to adapt or implement the original program

• Determine how original and new target population/setting differ in terms of risk and protective factors

• Identify areas where EPI needs to be adapted and include possible changes in program structure, content, provider or delivery method

Based on focus group results, previous literature, and consultation with the work group, decision was made to make surface-level changes to the materials, including most notably the adaptation of visuals and imagery to include primarily AI-AN individuals from diverse cultures, as well as images of nature, and AI-AN associated symbols, such as the medicine wheel. Additionally, some changes to language were made to emphasize family and community, as well as respect. Program structure, content, and delivery remained the same to ensure validity.

7. Adapt the original program

• Develop adaptation plan

• Adapt the original program contents through collaborative efforts

• Make culture adaptations continuously through pilot testing

• Core components responsible for changes should not be modified

Materials were adapted in collaboration with an American Indian designer able to make changes that were culturally appropriate. Changes were reviewed by the adaptation team as well as the adaptation AI-AN work group, and revised as appropriate.