Use of Culturally Focused Theoretical Frameworks for Adapting Diabetes Prevention Programs: A Qualitative Review

Introduction Diabetes disproportionately affects underserved racial/ethnic groups in the United States. Diabetes prevention interventions positively influence health; however, further evaluation is necessary to determine what role culture plays in effective programming. We report on the status of research that examines cultural adaptations of diabetes prevention programs. Methods We conducted database searches in March and April 2014. We included studies that were conducted in the United States and that focused on diabetes prevention among African Americans, American Indians/Alaska Natives, Asian Americans/Pacific Islanders, and Latinos. Results A total of 58 studies were identified for review; 29 were excluded from evaluation. Few adaptations referenced or followed recommendations for cultural adaptation nor did they justify the content modifications by providing a rationale or evidence. Cultural elements unique to racial/ethnic populations were not assessed. Conclusion Future cultural adaptations should use recommended processes to ensure that culture’s role in diabetes prevention–related behavioral changes contributes to research.


Introduction
Almost 29 million US adults have diabetes, and as many as 86 million have prediabetes (1). The high rate of diabetes among US minority populations is concerning because diabetes is a risk factor for cardiovascular disease, vision loss, end stage renal disease, disability, and mortality (2). From 2010 through 2012, African Americans (13.2%), American Indians/Alaska Natives (AI/ ANs) (15.9%), Asian Americans and other Pacific Islanders (9.0%), and Latinos (12.8%) were more often diagnosed with diabetes than were non-Hispanic whites (7.6%) (1). Diabetes is preventable through lifestyle changes that may also assist in diabetes control.
The Institute of Medicine (IOM) examined the impact of social and cultural environments on health outcomes and recommends that research advance in this area (3). According to the IOM report, health behaviors and other social variables occur in a cultural context that must be understood to determine which cultural variables influence adoption of health recommendations.
There is evidence that interventions (eg, for cancer care, mental health, health education) that emphasize integration of cultural knowledge (ie, ideas, rules of etiquette, and knowledge needed in social life) improve outcomes among adults (4)(5)(6). Emerging data suggest similar effects in diabetes interventions (7). Although data on cultural adaptations for youths are equivocal (5) and concerns have been raised about the impact and consequences of constituency involvement in assessments of cultural appropriateness for public health interventions (8), further evaluation is warranted to determine the key factors affecting outcomes.
The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Castro et al (9) suggest that the aim of cultural adaptations should be "to generate a culturally equivalent version of a model prevention program" when elements in the original intervention produce resistance to program activities or are in conflict with cultural attitudes. Castro et al (5) identified steps to guide decisions to culturally adapt evidence-based interventions, which involves justification of the effort. Justification for adaptation may be based on previous failure to engage members of priority populations or the presence of unique cultural risk factors and symptoms, or both. Once justified, an evidence-based intervention is selected and cultural adaptations of content and delivery are completed (5).
Frameworks for cultural adaptations have emerged in 2 forms. One form involves modification within content categories (10-12), with early discussions emphasizing "surface" and "deep structures" of modification (11). "Surface structure" modifications involve inclusion of photos, symbols, and recruitment and outreach strategies (11). Resnicow et al refer to "deep structure" as recognizing, reinforcing, and building on a group's values and behaviors to provide context and meaning to important intervention components (11). The framework proposed by Kreuter et al further specifies surface and deep cultural elements (10). Culturally sensitive programming requires changes to peripheral, evidential, linguistic, constituent-involving, and sociocultural categories (10). Peripheral approaches focus on colors, fonts, photographs, or declarative titles. Linguistic strategies assure that all intervention materials are in the preferred language of the group (12). Evidential approaches make use of testimonials, narratives, stories, and statistics specific to the group and raise awareness of perceived vulnerability to the health issue (10). Constituent-involving strategies include hiring or training group members or from the community or extensively engaging the community (10), which takes advantage of members' insider knowledge about the community's health perceptions and may increase acceptability and relevance (13). Sociocultural approaches discuss disease in the context of social or cultural characteristics (eg, including traditional foods and physical activities) (10).
The second form of cultural adaptation frameworks defines the steps of the intervention adaptation process (5,9,14) and offers the opportunity for a systematic process. The PEN-3 model completes cultural adaptions in 2 phases that support community input on the appropriate adaptation elements. The first phase, assessment, involves information gathering to learn about the community and its perspective (the resources that promote [ie, nurturers] or inhibit [ie, barriers] behavioral change and the roles that friends and family play in behavioral change). Once this information is gathered, the community and researchers use assessment data to critique current strategies and collaboratively develop culturally appropriate interventions (14).
Barrera et al (6) reviewed the past decade's literature to identify elements that are common to cultural adaptations of behavioral health interventions relevant for diabetes interventions. The authors report 5 stages of cultural adaptation that are a refinement of earlier recommendations: information gathering, preliminary design, preliminary testing, refinement, and final trials (3,6). The review suggests that interventions involving the inclusion of cultural elements in an adaptation are more effective than control or usual care conditions (6). The authors recommended that studies evaluate cultural adaptations completed in these stages.
In this article, we examine the cultural adaptation of diabetes prevention programs and the extent to which the call for research advances in this area is being met. We also examine content and characteristics of cultural adaptations and the extent to which the recommended "how" and "what" of adaptation have been adopted. Recommendations for next steps are provided.

Methods
The studies included in this review were compiled from a search of computerized databases conducted in March and April of 2014. The search performed was Academic Search Complete, and the following databases were selected: Academic Search Complete, CINAHL (Cumulative Index to Nursing and Allied Health Literature), CINAHL Plus, Family and Society Studies Worldwide, Global Health, Global Health Archive, Medline, PsycINFO, and Social Work Abstracts. Research published from 2004 through 2014 was included to capture systematic research of cultural adaptations of diabetes prevention programs among ethnic minorities (3,6,10-12). Key words were used to search titles, abstracts, and subject headings in all databases. The Boolean search used key words, including "Diabetes Prevention Program" or "DPP" or "diabetes prevention" and "translation" or "translating" and "African American" or "African-American" or black or "American Indian" or "Native American" or "Latino" or "Latina" or "Hispanic" or "Asian" or "Asian American"; "Diabetes Prevention Program" or "DPP" or "diabetes prevention" and "translation" or "translating" and "sociocultural" or "cultural adaptation" or "sociocultural adaptation." A supplemental search used the terms "PEN-3" and "deep culture" to identify additional articles.
Each study identified had to meet the following criteria for inclusion: 1) was a quantitative or qualitative research study completed in the United States; 2) had diabetes prevention as the primary focus, research question, or hypothesis of the study; 3) had diabetes education and interventions aimed at prevention activities, such as diet, exercise or physical activity, or health communication; and 4) included group-specific analyses on African Americans, AI/AN, Asian Americans/Pacific Islanders, or Latinos (although these pri-ority populations did not have to be the only group studied). The reference lists of these articles were reviewed to identify other studies that met the inclusion criteria. Review articles, meta-analyses, dissertation abstracts, and articles in languages other than English were excluded from this evaluation. Journal articles reporting data from a single study were reported separately but evaluated as a single study.
Included studies were evaluated for 1) study population included; 2) diabetes prevention activity and program studied; 3) cultural adaptation process used; 4) formative research completed and analytic method (quantitative or qualitative) used; 5) cultural components and attributes (ie, peripheral, linguistic, evidential, sociocultural, constituent-involving) included to address values, attitudes, and behaviors; 6) inclusion of community strengths and resources in program or intervention; 7) channel or media selected or used in intervention; and 8) unique cultural elements assessed (eg, inclusion of spiritual factors, identity, rituals). Studies were coded by a graduate research assistant trained by the first author (V.L.S.). The first author then reviewed all studies and coding to resolve questions identified by the graduate research assistant or the author.
The Diabetes Prevention Program (DPP) was the dominant evidence-based program subject to adaptation (84.6%). Of the 7 non-DPP adaptations, 1 was based on a program (Group Lifestyle Balance Program) (19) that was an earlier adaptation of DPP. DPP was adapted for each of the racial/ethnic categories.
Approximately 55.6% of studies conducted some form of information gathering or formative research in preparation for the cultural modification of an evidence-based program (15-17,23,24,28,31,36-43). Most studies collected qualitative data or used mixed methods. The primary data collection methods included focus groups for qualitative studies (n = 11) and surveys for quantitative studies (n = 4).

Discussion
This analysis suggests an increasing number of diabetes prevention cultural adaptations across racial/ethnic populations, reporting positive outcomes, primarily weight loss. The lack of comparisons to evidence-based interventions (no control or reliance on usual care controls) made it difficult to ascertain superior cultural adaptations. However, study data combined with the results of a recent diabetes treatment cultural adaptation (7) support the importance of continued research.
Few studies referenced recommendations for cultural adaptation processes or content. Given the recent emergence of some process recommendations, this is understandable (5,6); however, the PEN3 model (14) and content recommendations are older (10,11). Although the use of CBPR and various theoretical frameworks resulted in community input into cultural adaptations, a culturally focused approach may increase understanding of how specific cultural health beliefs vary across multiple populations and subpopulations (8) and aid in identification of key mechanisms for change (7). Also of concern was the limited documentation of the rationale for modifications, as illustrated by Osuna et al (15) and the fact that only 52% of studies involved information gathering or a formative research phase to support the cultural modifications made to the original evidence-based diabetes prevention program. These data may have been reported as subpopulation research studies and may have been missed in our search, or authors omitted this information from study reports. However, a deliberative process should occur to avoid modifications informed by stereotypical or monolithic views of racial/ethnic communities. For example, it should not be assumed that all members of a Latino community speak Spanish as their primary language. Issues related to socioeconomics, religion, and sexual orientation should also be included.

PREVENTING CHRONIC DISEASE
That studies varied in their use of peripheral, linguistic, evidential, sociocultural and constituent-involving strategies is not surprising. As Osuna et al note (15), cultural adaptations should be restricted to issues and elements dictated by current research evidence and data emerging from the information-gathering phase. Although the types of modifications reported in studies seemed effective, the failure to measure participants' responses to cultural elements is a lost opportunity to understand program acceptance and behavioral change.
Future diabetes prevention cultural adaptations should use recommended processes for cultural adaptation, including justification for the adaptation, the processes of formative research and information gathering and modification, modifications in response to data, reports of refinements based on preliminary studies, and the results of final testing (6). Detailed reporting of adaptations helps researchers develop information on common cultural program modifications and makes replication of the adapted intervention easier (45). To build evidence that diabetes prevention interventions that focus on integration of culture positively influence outcomes, studies should compare cultural adaptations to the original evidence-based intervention. Researchers should also evaluate unique cultural elements included in adaptations to determine their utility. Racial/ethnic groups are not monolithic and the cultural issues that affect their responses to health programs should be examined, with the process recommended by Castro et al (5)