Addressing the Adherence-Adaptation Debate: Lessons from the Replication of an Evidence-Based Sexual Health Program in School Settings.

Whether high adherence to programs is necessary to achieve program outcomes is an area of great debate. The objectives of this study were to determine the frequency, type, and rationale of adaptations made in the implementation of an evidence-based program and to determine program outcomes for intervention program participants, as compared to comparison participants, by the level of adaptations. A total of 1608 participants in 45 classrooms participated. Percent adaptations was calculated by classroom. Thematic qualitative analysis was used to categorize types and rationales for adaptations. Program outcomes by level of adaptations were determined using logistic regression analyses and mean differences. Propensity score matching methods were used to create comparability between adaptation subgroup participants and comparison participants. Adaptations ranged from 2 to 97% across classrooms, with mean adaptations of 63%. Thematic analysis revealed that the adaptations made were related to delivery of content, rather than to the content itself and in response to participant needs and setting constraints. Program outcomes did not appear to be reduced for the high-adaptation subgroup. Understanding both rationale (intent) and type of adaptation made is crucial to understanding the complexity of adaptations. These finding support the argument for allowing facilitators some flexibility and autonomy to adapt the delivery of prescribed content to participant needs and setting constraints.