Adaptation of a digital health intervention for rural adults: application of the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME)

Maura Kepper ^1* Callie Walsh-Bailey ^2* Loni Parrish ¹ Ainsley Mackenzie ^1* Lisa Klesges ¹ Peg Allen ¹ Kia Davis ¹ Randi Foraker ^1* Ross Brownson ¹

• ¹ Washington University in St. Louis, St. Louis, United States
• ² Northwestern Medicine, Chicago, Illinois, United States

Adaptation is a key aspect of implementation science; interventions frequently need adaptation to better fit their delivery contexts and intended users and recipients. As digital health interventions are rapidly developed and expanded, it is important to understand how such interventions are modified. This paper details the process of engaging end-users in adapting the PREVENT digital health intervention, originally designed to improve health behavior counseling for adolescents in urban clinical care settings. We systematically report adaptation for rural adults and the integration of social needs resources using the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME). PREVENT's adaptations were informed by two pilot feasibility trials and a planning grant which included advisory boards, direct clinic observations, and qualitative interviews with patients, caregivers, and healthcare team members. Adaptations were catalogued in an Excel tracker, including a brief description of the change. The secondary objective was to tailor FRAME for digital health interventions and to document potential implications for equity. Pilot coding was conducted on a subset of adaptations to revise the FRAME codebook and generate consensus. We used a directed content analysis approach, and conducted a secondary data analysis to apply the revised FRAME to all adaptations made to PREVENT (n=20). All but one adaptation was planned, most were reactive (versus proactive), and all adaptations preserved fidelity to PREVENT. Adaptations were made to content and features of the PREVENT tool and may have positive implications for equity that will be tested in future trials. Engaging rural partners to adapt our digital health tool prior to implementation with rural adults was critical to meet the unique needs of rural, low-income adult patients, fit the rural clinical care settings, and increase the likelihood of generating the intended impact among this patient population. The digital health expansion of FRAME can be applied prospectively or retrospectively by researchers and practitioners to plan, understand, and characterize digital health adaptations. This can aid intervention design, scale up, and evaluation in the rapidly expanding area of digital health.