The document discusses adapting the Relationship Remix sexual violence prevention program, originally developed at the University of Michigan, for use at the University of Cape Coast in Ghana. It describes using the ADAPT-ITT model, an 8-step process for systematically adapting evidence-based interventions, to tailor Relationship Remix in a culturally-relevant way. Through assessments, pilot tests, and input from experts, the program was adapted over 2 years to better suit the Ghanaian context, resulting in a new intervention called Relationship Tidbits.

1. Do we have to start from scratch?
Using the ADAPT-ITT model to make culturally-relevant
adaptations to pre-existing sexual violence interventions

2. • Discuss the pros and cons of adapting pre-existing evidence-
based interventions
• Describe the ADAPT-ITT model
• Discuss a case study: Adapting Relationship Remix
• Summarize how this model may be useful in different campus
prevention contexts
Objectives

3. • Sarah Rominski
– University of Michigan Medical School, Department of OB/GYN
• Eugene Darteh
– University of Cape Coast, Department of Population Health
• Akua O. Britwum
– University of Cape Coast, Director of the Centre for Gender Research,
Advocacy, and Documentation
• University of Michigan Sexual Assault Prevention &
Awareness Center (SAPAC) & Sexperteam
• University of Cape Coast Research Assistants
• University of Michigan Students
Research Team & Partners

4. ADAPTATION
Why do we care about adaptation?

5. • The world is home to a diverse group
of individuals that all have
intersecting characteristics that make
them unique.
• There are also numerous
interventions that already exist
related to sexual violence and
primary prevention.
• Yet we know that these interventions
are not one size fits all!
Why should we consider adaptation?

6. Pros & Cons of Adapting an Intervention
Pros Cons
Saves time Miss out on community activism/support for the
intervention?
Saves money Will it be tailored to the needs of the
context/culture/population I am working with?
Consistency in interventions
across cultures and contexts
Consistency in interventions across cultures and
contexts
It already has an established
evidence base
Don’t know if it was the best option for your
context/culture/population.
Might be based on outdated evidence and
situations.

7. A Systematic Process for Adapting
Evidence-Based Interventions
• The ADAPT-ITT Model:
– Systematic framework for adapting evidence-based interventions
– Introduced in 2008 for HIV interventions
– Primary been used for HIV interventions
– Has been used to adapt interventions to:
• New locations
• New cultural contexts
• New populations
Wingood, G. M., & DiClemente, R. J. (2008). The ADAPT-ITT model: a novel method of adapting evidence-based HIV Interventions. JAIDS Journal of Acquired Immune
Deficiency Syndromes, 47, S40-S46.

8. The ADAPT-ITT Model
The ADAPT-ITT framework involves eights steps:
1) Assessment of the priorities of the new population
2) Decisions on whether or not to adapt the intervention and what content to adapt
3) Administration of the intervention
4) Production of an adapted version of the intervention
5) Topical experts assist in the adaptation process
6) Integration of feedback from the topical experts into the adapted intervention
7) Training students to implement the adapted intervention
8) Testing the adapted intervention.
Wingood, G. M., & DiClemente, R. J. (2008). The ADAPT-ITT model: a novel method of adapting evidence-based HIV Interventions. JAIDS Journal of Acquired Immune
Deficiency Syndromes, 47, S40-S46.

9. An Applied Example: Relationship Tidbits
Relationship Tidbits
ADAPT-ITT

10. RELATIONSHIP REMIX
University of Michigan’s Primary
Prevention Program

11. What is Relationship Remix?
• Primary prevention intervention developed at the University of
Michigan in 2011 by a group of students and staff from housing,
SAPAC, and Sexperteam.
• Delivered as an interactive in-person training (1.5 hours long) to
first year students by peers with a focus on healthy relationships
and consent, using a values-based framework.
Bonar, E., Rider-Milkovich, H., & Cunningham, R. (under review). Initial evaluation of a campus sexual assault prevention program for first-year college students. Journal of
American College Health.

12. Building Blocks Curriculum
• Curriculum is organized to be facilitated by two students
– One student is generally a volunteer with the Sexual Assault
Prevention and Awareness Center (SAPAC)
– The other student is generally a volunteer with the student sexual
health group, Sexperteam
• Work through the curriculum with each topic area building on the
previous content
• Delivered within resident halls as an interactive and required
program

13. • 10 Building blocks
1. Creating a safe and welcoming space
2. Thinking about our values
3. Decision-making from our own value system
4. Developing relationship skills
5. Communication
6. Gender equality
7. Consent
8. Making choices about sex
9. Sexual harassment
10. Campus resources
Building
Blocks
Title Main Activities
1 Creating a safe and
welcoming space
Participants identify ideas to create a safe space during the training (i.e.,
confidentiality, no judgment)
2 Thinking about our
values
Participants identify values important to them using a worksheet & then discuss why it
is important to think about our values
3 Decision-making from
our own value system
Participants think about their values and how they uphold them or what happens
when people do not act in accord with their values
4 Developing relationship
skills
Four quadrants exercise – participants use a worksheet to identify Essential, Tolerable,
Deal-Breaker, and Bonus characteristics in a relationship
5 Communication 20 questions game
6 Consent Discuss consent (focus on consent with alcohol use); Practice giving and receiving
consent
7 Making choices about
sex
Discussion about the health consequences of being in a sexual relationship (i.e.,
pregnancy, STIs)
8 Sexual harassment Review the definitions of sexual assault (terminology used at the University of Cape
Michigan) as well as coercion. Students are asked to create a case to discuss where
sexual harassment has occurred.
9 Campus resources Discuss resources available on campus

14. Data on Relationship Remix
• Over the last 5 years, more than 18,000 students have received the
Relationship Remix training at the University of Michigan.
• A recent analysis of 2,305 students who had the training in 2015
noted that immediately after receiving Relationship Remix, students
had significant changes in:
–Values-based decision making
–Knowing how to ask for consent
–Relationship communication skills
Christensen, R. (2016, June). Relationship Remix in year five: An assessment of first-year students’ pre-workshop, post-workshop, and six-month follow-up questions. Ann
Arbor, MI: University of Michigan Community Matters.

15. RELATIONSHIP TIDBITS
University of Cape Coast’s Primary
Prevention Program

16. Project Background
• Sexual assault is a significant
challenge for universities
worldwide, affecting the health and
academic success of students
• Sexual violence prevention
programs are common at
universities in the United States
• These programs are non-existent in
Ghana

17. Cultural Context
• Ghana is located in West Africa and is
bordered by the Ivory Coast, Burkina Faso,
Togo, and the Gulf of Guinea.
• It was home to the British Gold Coast, where
a number of trading posts were established
for the trading of goods and eventually
people.
• The University of Cape Coast was established
in 1962.

18. The Beginning of the Project
• Study by Drs. Eugene Darteh & Sarah Rominski
- General survey of sexual and reproductive health of University of Cape
Coast students
- Data collected between January and March , 2015
- Residential students
- Self-administered, tablet computer-based

19. Results
• Sample: 556 males, 480 females
• Significantly more females than males report they were
“not at all willing” the first time they had sex (41.9% vs.
14.5%).
• Significantly more females than males report having ever
been forced into having sex (21% vs. 9.9%).
• 126 (26.3%) females and 91 (16.5%) males have had sex
either because they were forced or coerced, or when they
were “not at all willing”.

20. Conclusions
Further work is needed to investigate this phenomenon and to develop
interventions to prevent sexual coercion among this population.

21. Institutional Support for Sexual Violence
Response & Prevention
• In 2013 the University of Cape Coast established the Centre for Gender
Research, Advocacy, and Documentation (CEGRAD) in response to:
– Poor post-assault care from students
– Demands for sexual violence prevention
• They revised their Sexual Harassment policy in 2015; the term “sexual
harassment” encompasses all forms of unwanted sexual contact
(verbal or physical).

22. The Need
• There was a recognized need for primary prevention but the infrastructure did
not exist at the University of Cape Coast.
• After discussions between University of Michigan and University of Cape Coast
faculty, the decision was made to attempt to adapt Relationship Remix using a
systematic process to make it culturally and contextually applicable.
• The team decided to use the ADAPT-ITT framework to guide this process
Wingood, G. M., & DiClemente, R. J. (2008). The ADAPT-ITT model: a novel method of adapting evidence-based HIV Interventions. JAIDS Journal of Acquired
Immune Deficiency Syndromes, 47, S40-S46.

23. Date ADAPT-ITT Process
February 2016 Assessment 4 FGDs (2 with men, 2 with women; n=26) to discuss issues around sexual relationships & violence
February 2016 Assessment 20 cognitive interviews to validate the Illinois Rape Myth Acceptance Scale, the Gender Equity Men’s Scale,
and the Sexual Relationship Power Scale
March–April 2016 Decisions Based on information gathered from the FGDs, the first round of revisions to the intervention included:
•Addition of victim blaming scenarios
•Removal of much of the focus on alcohol
•Addition of “Consent as Tea” video
•Addition of a content area focused on gender equality
April 2016 Administration Beta testing conducted with 6 groups (2 with men, 2 with women, 2 with men and women combined; n=76)
to administer the revised program
June 2016 Production Production of draft #1 of the revised program
July 2016 Topical Experts Draft #1 reviewed with topical experts (Ghanaian and United States sexual assault centers)
July – August 2016 Decisions #2 Based on assessment, administration, and discussion with topical experts, a second round of revisions was
undertaken (Draft #2). Revisions included:
•Replaced two activities focused on communication and gender equality
•Added additional content on victim blaming
September 2016 Administration #2 Beta testing repeated with 6 groups (3 with men, 3 with women; n=57)
October 2016 Production #2 Production of Draft #2 of the revised curriculum
October–November 2016 Topical Experts #2 Reviewed content with topical experts (Ghanaian and United States sexual assault centers) for a second time
November 2016 Integration Results of beta testing sessions, meetings with topical experts, & readability test integrated
March 2017 Training Master trainers in Ghana participated in Facilitator’s Training Program to receive information about training
future peer facilitators and help create the manualized Facilitator’s Training Guide
August 2017 Testing In progress – testing of the final program as administered by trained peer facilitators

24. Date ADAPT-ITT Process
February 2016 Assessment 4 FGDs (2 with men, 2 with women; n=26) to discuss issues around sexual relationships & violence
February 2016 Assessment 20 cognitive interviews to validate the Illinois Rape Myth Acceptance Scale, the Gender Equity Men’s Scale,
and the Sexual Relationship Power Scale
March–April 2016 Decisions Based on information gathered from the FGDs, the first round of revisions to the intervention included:
•Addition of victim blaming scenarios
•Removal of much of the focus on alcohol
•Addition of “Consent as Tea” video
•Addition of a content area focused on gender equality
April 2016 Administration Beta testing conducted with 6 groups (2 with men, 2 with women, 2 with men and women combined; n=76)
to administer the revised program
June 2016 Production Production of draft #1 of the revised program
July 2016 Topical Experts Draft #1 reviewed with topical experts (Ghanaian and United States sexual assault centers)
July – August 2016 Decisions #2 Based on assessment, administration, and discussion with topical experts, a second round of revisions was
undertaken (Draft #2). Revisions included:
•Replaced two activities focused on communication and gender equality
•Added additional content on victim blaming
September 2016 Administration #2 Beta testing repeated with 6 groups (3 with men, 3 with women; n=57)
October 2016 Production #2 Production of Draft #2 of the revised curriculum
October–November 2016 Topical Experts #2 Reviewed content with topical experts (Ghanaian and United States sexual assault centers) for a second time
November 2016 Integration Results of beta testing sessions, meetings with topical experts, & readability test integrated
March 2017 Training Master trainers in Ghana participated in Facilitator’s Training Program to receive information about training
future peer facilitators and help create the manualized Facilitator’s Training Guide
August 2017 Testing In progress – testing of the final program as administered by trained peer facilitators

25. Assessment Goals
• Completed the assessment phase to “learn” about sexual violence at
University of Cape Coast in Ghana
• Went in with the idea that we might be able to adapt Relationship
Remix but that additional information was needed first
• Needed to identify measurement tools

26. Assessment Methods
• Conducted four semi-structured focus groups (gender separated) to
discuss:
– Sexual Relationships
– Sexual Violence
• Conducted 20 cognitive interviews to determine if the following
evaluation measures were contextually and culturally appropriate:
– Illinois Rape Myth Acceptance Scale – modified (McMahon & Farmer, 2011)
– Gender Equitable Men Scale (GEM) (Pulerwitz & Barker, 2008)
– Sexual Relationship Power Scale (SRPS) (Pulerwitz, Gortmaker, & DeJong, 2000)
McMahon, S., & Farmer, G. L. (2011). An updated measure for assessing subtle rape myths. Social Work Research, 35(2), 71-81.
Pulerwitz, J. & Barker, J. (2008). Measuring attitudes toward gender norms among young men in Brazil: Development and psychometric evaluation of the GEM scale. Men and
Masculinities, 10(3), 322-338. doi:10.1177/1097184X06298778
Pulerwitz, J., Gortmaker, S.L. & DeJong, W. (2000). Measuring sexual relationship power in HIV/STD research. Sex Roles, 42(7), 637-660. doi:10.1023/A:1007051506972

27. Assessment Results
Themes that emerged included:
1) Communication using body language and actions
2) Expectation of abstinence before marriage especially for women
3) Gendered power differentials in relationships
4) No means yes
5) Some degree of violence and control is accepted in marriages
6) Alcohol is not a precipitating factor in sexual violence.

28. Date ADAPT-ITT Process
February 2016 Assessment 4 FGDs (2 with men, 2 with women; n=26) to discuss issues around sexual relationships & violence
February 2016 Assessment 20 cognitive interviews to validate the Illinois Rape Myth Acceptance Scale, the Gender Equity Men’s Scale,
and the Sexual Relationship Power Scale
March–April 2016 Decisions Based on information gathered from the FGDs, the first round of revisions to the intervention included:
•Addition of victim blaming scenarios
•Removal of much of the focus on alcohol
•Addition of “Consent as Tea” video
•Addition of a content area focused on gender equality
April 2016 Administration Beta testing conducted with 6 groups (2 with men, 2 with women, 2 with men and women combined; n=76)
to administer the revised program
June 2016 Production Production of draft #1 of the revised program
July 2016 Topical Experts Draft #1 reviewed with topical experts (Ghanaian and United States sexual assault centers)
July – August 2016 Decisions #2 Based on assessment, administration, and discussion with topical experts, a second round of revisions was
undertaken (Draft #2). Revisions included:
•Replaced two activities focused on communication and gender equality
•Added additional content on victim blaming
September 2016 Administration #2 Beta testing repeated with 6 groups (3 with men, 3 with women; n=57)
October 2016 Production #2 Production of Draft #2 of the revised curriculum
October–November 2016 Topical Experts #2 Reviewed content with topical experts (Ghanaian and United States sexual assault centers) for a second time
November 2016 Integration Results of beta testing sessions, meetings with topical experts, & readability test integrated
March 2017 Training Master trainers in Ghana participated in Facilitator’s Training Program to receive information about training
future peer facilitators and help create the manualized Facilitator’s Training Guide
August 2017 Testing In progress – testing of the final program as administered by trained peer facilitators

29. Decisions Goals
• The second phase of the ADAPT-ITT process involves identifying
evidence-based interventions that may be suitable for adoption or
adaptation to the new cultural context.
• We entered the process with a potential intervention in mind,
Relationship Remix.

30. Decisions Methods
• Utilize data collected during the assessment phase to make decisions
on the initial changes needed to adapt Relationship Remix.
• We also made decisions on whether or not our evaluation measures
were appropriate and how they needed to be modified.

31. Decisions Results
• We used information from the FGDs to begin to culturally adapt
Relationship Remix to the Ghanaian context by shifting the focus from
alcohol-facilitated sexual assault to recognizing and eventually reducing
gender inequality.
• Based on the cognitive interviews:
– Two questions were removed from the GEM
– One item was removed from the modified IRMA
– Terminology was changed in the modified IRMA to make them more
culturally appropriate (i.e. ‘slut’ changed to ‘flirt’).

32. Date ADAPT-ITT Process
February 2016 Assessment 4 FGDs (2 with men, 2 with women; n=26) to discuss issues around sexual relationships & violence
February 2016 Assessment 20 cognitive interviews to validate the Illinois Rape Myth Acceptance Scale, the Gender Equity Men’s Scale,
and the Sexual Relationship Power Scale
March–April 2016 Decisions Based on information gathered from the FGDs, the first round of revisions to the intervention included:
•Addition of victim blaming scenarios
•Removal of much of the focus on alcohol
•Addition of “Consent as Tea” video
•Addition of a content area focused on gender equality
April 2016 Administration Beta testing conducted with 6 groups (2 with men, 2 with women, 2 with men and women combined; n=76)
to administer the revised program
June 2016 Production Production of draft #1 of the revised program
July 2016 Topical Experts Draft #1 reviewed with topical experts (Ghanaian and United States sexual assault centers)
July – August 2016 Decisions #2 Based on assessment, administration, and discussion with topical experts, a second round of revisions was
undertaken (Draft #2). Revisions included:
•Replaced two activities focused on communication and gender equality
•Added additional content on victim blaming
September 2016 Administration #2 Beta testing repeated with 6 groups (3 with men, 3 with women; n=57)
October 2016 Production #2 Production of Draft #2 of the revised curriculum
October–November 2016 Topical Experts #2 Reviewed content with topical experts (Ghanaian and United States sexual assault centers) for a second time
November 2016 Integration Results of beta testing sessions, meetings with topical experts, & readability test integrated
March 2017 Training Master trainers in Ghana participated in Facilitator’s Training Program to receive information about training
future peer facilitators and help create the manualized Facilitator’s Training Guide
August 2017 Testing In progress – testing of the final program as administered by trained peer facilitators

33. Administration Goals
• The third phase involves administering, or pre-testing, the
intervention with the target audience in order to ascertain feedback
on the format, content, and attitudes about the intervention.
– This is often done with the original intervention, but can also be done
with some minor changes to the intervention.

34. Administration Methods
• Student participants were recruited for beta testing using
announcements and snowball sampling.
• Inclusion criteria included being:
1) Residential student at the participating University in Ghana
2) Able to speak and read English
3) > 18 years old.
• The Ghanaian research assistants delivered the adapted intervention in
group settings with observation by the Ghanaian and United States
researchers.

35. Administration Results
• The first administration of the beta-test lasted between 111 and 178
minutes.
• Participants had difficulty completing some of the activities included
in the intervention, and the facilitators felt the intervention was too
lengthy

36. Administration Results
• Male participants had significantly improved scores in the modified
IRMA (a higher score is associated with less rape myth acceptance).
– Each sub-scale of the modified IRMA (‘she asked for it’, ‘he didn’t
mean to’, ‘it wasn’t really rape’, ‘she lied’) also showed significant
improvement among the male participants.
• Both male and female participants demonstrated improvement in
endorsement of gender equality as measured by the GEM between
the pre- and post-intervention, although not all sub-scales changed.

37. Results from Administration
0
10
20
30
40
50
60
70
80
Pre Post Pre Post
RMA GEM
Female
Male66.5
(5.0)
76.2
(8.1)
p<.01

38. 20 Questions: What Happened in Ghana?
• They had never played 20 questions
• They were trying to think of the “best food” for a desert island.
What would last a long time? What would be filling?
• The concept of direct communication was completely lost….

39. Message Relay: What Happened in Ghana?
• They LOVED this activity!
• It was fun, interactive, and got everyone out of their seats.
• Most education in Ghana uses the British system so they are not
used to more interactive techniques.
• The concept of direct communication was easily observed.

40. Date ADAPT-ITT Process
February 2016 Assessment 4 FGDs (2 with men, 2 with women; n=26) to discuss issues around sexual relationships & violence
February 2016 Assessment 20 cognitive interviews to validate the Illinois Rape Myth Acceptance Scale, the Gender Equity Men’s Scale,
and the Sexual Relationship Power Scale
March–April 2016 Decisions Based on information gathered from the FGDs, the first round of revisions to the intervention included:
•Addition of victim blaming scenarios
•Removal of much of the focus on alcohol
•Addition of “Consent as Tea” video
•Addition of a content area focused on gender equality
April 2016 Administration Beta testing conducted with 6 groups (2 with men, 2 with women, 2 with men and women combined; n=76)
to administer the revised program
June 2016 Production Production of draft #1 of the revised program
July 2016 Topical Experts Draft #1 reviewed with topical experts (Ghanaian and United States sexual assault centers)
July – August 2016 Decisions #2 Based on assessment, administration, and discussion with topical experts, a second round of revisions was
undertaken (Draft #2). Revisions included:
•Replaced two activities focused on communication and gender equality
•Added additional content on victim blaming
September 2016 Administration #2 Beta testing repeated with 6 groups (3 with men, 3 with women; n=57)
October 2016 Production #2 Production of Draft #2 of the revised curriculum
October–November 2016 Topical Experts #2 Reviewed content with topical experts (Ghanaian and United States sexual assault centers) for a second time
November 2016 Integration Results of beta testing sessions, meetings with topical experts, & readability test integrated
March 2017 Training Master trainers in Ghana participated in Facilitator’s Training Program to receive information about training
future peer facilitators and help create the manualized Facilitator’s Training Guide
August 2017 Testing In progress – testing of the final program as administered by trained peer facilitators

41. Production
• The production phase involves creating
the materials needed for the intervention.
• In this particular study, materials included
a Facilitator’s Manual to maintain fidelity
as well as a Facilitator’s Training Guide.
• These materials were developed based on
the original content from Relationship
Remix as well as the results from the first
three phases.

42. Date ADAPT-ITT Process
February 2016 Assessment 4 FGDs (2 with men, 2 with women; n=26) to discuss issues around sexual relationships & violence
February 2016 Assessment 20 cognitive interviews to validate the Illinois Rape Myth Acceptance Scale, the Gender Equity Men’s Scale,
and the Sexual Relationship Power Scale
March–April 2016 Decisions Based on information gathered from the FGDs, the first round of revisions to the intervention included:
•Addition of victim blaming scenarios
•Removal of much of the focus on alcohol
•Addition of “Consent as Tea” video
•Addition of a content area focused on gender equality
April 2016 Administration Beta testing conducted with 6 groups (2 with men, 2 with women, 2 with men and women combined; n=76)
to administer the revised program
June 2016 Production Production of draft #1 of the revised program
July 2016 Topical Experts Draft #1 reviewed with topical experts (Ghanaian and United States sexual assault centers)
July – August 2016 Decisions #2 Based on assessment, administration, and discussion with topical experts, a second round of revisions was
undertaken (Draft #2). Revisions included:
•Replaced two activities focused on communication and gender equality
•Added additional content on victim blaming
September 2016 Administration #2 Beta testing repeated with 6 groups (3 with men, 3 with women; n=57)
October 2016 Production #2 Production of Draft #2 of the revised curriculum
October–November 2016 Topical Experts #2 Reviewed content with topical experts (Ghanaian and United States sexual assault centers) for a second time
November 2016 Integration Results of beta testing sessions, meetings with topical experts, & readability test integrated
March 2017 Training Master trainers in Ghana participated in Facilitator’s Training Program to receive information about training
future peer facilitators and help create the manualized Facilitator’s Training Guide
August 2017 Testing In progress – testing of the final program as administered by trained peer facilitators

43. Topical Experts
• Working with topical experts comprises the fifth phase.
• Topical experts are identified based on the type of intervention, who
developed the intervention, and the context to which the
intervention is being adapting.
• Should be able to give feedback on the format, content, & types of
materials developed during the ADAPT-ITT process.

44. Topical Experts
• Our topical experts included:
– Staff members of the sexual assault center and wellness center at
the University of Michigan which originally developed the
intervention for consistency of main messages (i.e., values,
healthy relationships)
– CEGRAD at the University of Cape Coast for cultural & contextual
applicability.

45. Date ADAPT-ITT Process
February 2016 Assessment 4 FGDs (2 with men, 2 with women; n=26) to discuss issues around sexual relationships & violence
February 2016 Assessment 20 cognitive interviews to validate the Illinois Rape Myth Acceptance Scale, the Gender Equity Men’s Scale,
and the Sexual Relationship Power Scale
March–April 2016 Decisions Based on information gathered from the FGDs, the first round of revisions to the intervention included:
•Addition of victim blaming scenarios
•Removal of much of the focus on alcohol
•Addition of “Consent as Tea” video
•Addition of a content area focused on gender equality
April 2016 Administration Beta testing conducted with 6 groups (2 with men, 2 with women, 2 with men and women combined; n=76)
to administer the revised program
June 2016 Production Production of draft #1 of the revised program
July 2016 Topical Experts Draft #1 reviewed with topical experts (Ghanaian and United States sexual assault centers)
July – August 2016 Decisions #2 Based on assessment, administration, and discussion with topical experts, a second round of revisions was
undertaken (Draft #2). Revisions included:
•Replaced two activities focused on communication and gender equality
•Added additional content on victim blaming
September 2016 Administration #2 Beta testing repeated with 6 groups (3 with men, 3 with women; n=57)
October 2016 Production #2 Production of Draft #2 of the revised curriculum
October–November 2016 Topical Experts #2 Reviewed content with topical experts (Ghanaian and United States sexual assault centers) for a second time
November 2016 Integration Results of beta testing sessions, meetings with topical experts, & readability test integrated
March 2017 Training Master trainers in Ghana participated in Facilitator’s Training Program to receive information about training
future peer facilitators and help create the manualized Facilitator’s Training Guide
August 2017 Testing In progress – testing of the final program as administered by trained peer facilitators

46. Round Two: Decisions, Administration,
Production, & Topical Experts
Since we were adapting to new location, culture, and a context that had never
had a primary prevention intervention we found a need to repeat certain
portions of the ADAPT-ITT process

47. Round Two Results
• Changes to the program based on round two activities included:
1) Replacing two activities that did not work in the Ghanaian cultural
context focused on communication and gender equality
2) Adding additional content on victim blaming (e.g., a causes of
rape activity).

48. Round Two Administration
• Small number of participants (n=57)
• 56% (14/25) of females reported being the victim of at least one form
of sexual assault
• Significant improvement in overall GEM (and two subscales) and
modified IRMA (all subscales)
• Significant differences in modified IRMA between genders (males have
higher levels of RMA than females, as in other locations)
• Significantly different levels of change between genders (females had a
bigger change in the GEM and RMA)

49. Results from Round Two Administration
0
10
20
30
40
50
60
70
80
90
100
Pre Post Pre Post
RMA GEM
Female
Male
71.9
(15.7)
85.8
(14.9)
59.9
(5.6)
62.0
(5.8)
p<.001
p<.001
66.5
(5.0)
76.2
(8.1)
p<.01

50. Integration Goals & Methods
• The integration phase involves incorporating changes based on the
first five phases that result in an adapted intervention suitable for
pilot testing.
• The integration phase took into consideration the results of the
assessment, both administrations (beta-testing), and consultation
with topical experts to create the final Facilitator Manual for the
Ghanaian context.
• At this time, readability testing was also performed using the Flesch-
Kincaid readability test.

51. Integration Results
• Integration resulted in a fully manualized version of Relationship
Tidbits, which was ready for the next steps of facilitator training and
pilot testing.
• Since Relationships Tidbits is an interactive, peer-delivered
intervention, our team believes there may be future changes to the
manual.
• The current intervention has undergone a rigorous adaptation
process and current readability test results indicate a Flesch-Kincaid
Grade Level of 8.4, which would be appropriate for an incoming
group of university students.

52. Date ADAPT-ITT Process
February 2016 Assessment 4 FGDs (2 with men, 2 with women; n=26) to discuss issues around sexual relationships & violence
February 2016 Assessment 20 cognitive interviews to validate the Illinois Rape Myth Acceptance Scale, the Gender Equity Men’s Scale,
and the Sexual Relationship Power Scale
March–April 2016 Decisions Based on information gathered from the FGDs, the first round of revisions to the intervention included:
•Addition of victim blaming scenarios
•Removal of much of the focus on alcohol
•Addition of “Consent as Tea” video
•Addition of a content area focused on gender equality
April 2016 Administration Beta testing conducted with 6 groups (2 with men, 2 with women, 2 with men and women combined; n=76)
to administer the revised program
June 2016 Production Production of draft #1 of the revised program
July 2016 Topical Experts Draft #1 reviewed with topical experts (Ghanaian and United States sexual assault centers)
July – August 2016 Decisions #2 Based on assessment, administration, and discussion with topical experts, a second round of revisions was
undertaken (Draft #2). Revisions included:
•Replaced two activities focused on communication and gender equality
•Added additional content on victim blaming
September 2016 Administration #2 Beta testing repeated with 6 groups (3 with men, 3 with women; n=57)
October 2016 Production #2 Production of Draft #2 of the revised curriculum
October–November 2016 Topical Experts #2 Reviewed content with topical experts (Ghanaian and United States sexual assault centers) for a second time
November 2016 Integration Results of beta testing sessions, meetings with topical experts, & readability test integrated
March 2017 Training Master trainers in Ghana participated in Facilitator’s Training Program to receive information about training
future peer facilitators and help create the manualized Facilitator’s Training Guide
August 2017 Testing In progress – testing of the final program as administered by trained peer facilitators

53. • 10 Building blocks
1. Creating a safe and welcoming space
2. Thinking about our values
3. Decision-making from our own value system
4. Developing relationship skills
5. Communication
6. Gender equality
7. Consent
8. Making choices about sex
9. Sexual harassment
10. Campus resources
Building
Blocks
Title Main Activities
1 Creating a safe and
welcoming space
Participants identify ideas to create a safe space during the training (i.e.,
confidentiality, no judgment)
2 Thinking about our
values
Participants identify values important to them using a worksheet & then discuss why it
is important to think about our values
3 Decision-making from
our own value system
Participants think about their values and how they uphold them or what happens
when people do not act in accord with their values
4 Developing relationship
skills
Four quadrants exercise – participants use a worksheet to identify Essential, Tolerable,
Deal-Breaker, and Bonus characteristics in a relationship
5 Communication Telephone game to illustrate the need for open and honest communication
6 Gender equality Read a handout on gender equality and share a story in groups about how they have
personally noticed their gender impact their life
7 Consent Consent as Tea video, case studies where students determine whether or not consent
has been garnered, practice giving and receiving consent
8 Making choices about
sex
Discussion about the health consequences of being in a sexual relationship (i.e.,
pregnancy, STIs)
9 Sexual harassment Review the definitions of sexual harassment (terminology used at the University of
Cape Coast) as well as coercion. Students are asked to create a case to discuss where
sexual harassment has occurred.
10 Campus resources Discuss resources available on campus

54. Date ADAPT-ITT Process
February 2016 Assessment 4 FGDs (2 with men, 2 with women; n=26) to discuss issues around sexual relationships & violence
February 2016 Assessment 20 cognitive interviews to validate the Illinois Rape Myth Acceptance Scale, the Gender Equity Men’s Scale,
and the Sexual Relationship Power Scale
March–April 2016 Decisions Based on information gathered from the FGDs, the first round of revisions to the intervention included:
•Addition of victim blaming scenarios
•Removal of much of the focus on alcohol
•Addition of “Consent as Tea” video
•Addition of a content area focused on gender equality
April 2016 Administration Beta testing conducted with 6 groups (2 with men, 2 with women, 2 with men and women combined; n=76)
to administer the revised program
June 2016 Production Production of draft #1 of the revised program
July 2016 Topical Experts Draft #1 reviewed with topical experts (Ghanaian and United States sexual assault centers)
July – August 2016 Decisions #2 Based on assessment, administration, and discussion with topical experts, a second round of revisions was
undertaken (Draft #2). Revisions included:
•Replaced two activities focused on communication and gender equality
•Added additional content on victim blaming
September 2016 Administration #2 Beta testing repeated with 6 groups (3 with men, 3 with women; n=57)
October 2016 Production #2 Production of Draft #2 of the revised curriculum
October–November 2016 Topical Experts #2 Reviewed content with topical experts (Ghanaian and United States sexual assault centers) for a second time
November 2016 Integration Results of beta testing sessions, meetings with topical experts, & readability test integrated
March 2017 Training Master trainers in Ghana participated in Facilitator’s Training Program to receive information about training
future peer facilitators and help create the manualized Facilitator’s Training Guide
August 2017 Testing In progress – testing of the final program as administered by trained peer facilitators

55. Training Goals
• Step seven involves training those who will be involved with
administering the intervention or maintaining fidelity.
• In our project, this involved training a group of “Master Trainers” that
could administer the program and train future peer facilitators.
• Additionally, because this is a peer-delivered intervention it was
important for us to have students involved in the training process.

56. Training Methods
• Training Manual was developed for all “Master Trainers”
• A group of six students traveled to Ghana with us to conduct the
training
• Workshops
– Each workshop was developed by one UM or UCC student
– They were designed to be 1-1.5 hours long
– They were all interactive and fun!

57. Training Topics
• Background on Sexual Violence in the US
• Background on Sexual Violence in Ghana
• Sexual Health & Techniques to Educate
Others
• Self-Reflection & Identification of Biases
• Facilitation Skills for Master Trainers
• Redirection & Handling Difficult Questions
• Self-Care

58. Feedback on Training
• Ghanaian Students said:
“It was so nice to get the training from students our own age instead of
having an adult tell you what you are supposed to do.”
• University of Michigan students said:
“It was the warmest and most fulfilling trip of my college career. I gained so
much from being in a place so vastly different from America. I learned a lot
about myself and the lens through which I view the world. It was the kind of
influential trip that will shape the public health and community education
work I do in the future.” – Briana Sanders

59. Date ADAPT-ITT Process
February 2016 Assessment 4 FGDs (2 with men, 2 with women; n=26) to discuss issues around sexual relationships & violence
February 2016 Assessment 20 cognitive interviews to validate the Illinois Rape Myth Acceptance Scale, the Gender Equity Men’s Scale,
and the Sexual Relationship Power Scale
March–April 2016 Decisions Based on information gathered from the FGDs, the first round of revisions to the intervention included:
•Addition of victim blaming scenarios
•Removal of much of the focus on alcohol
•Addition of “Consent as Tea” video
•Addition of a content area focused on gender equality
April 2016 Administration Beta testing conducted with 6 groups (2 with men, 2 with women, 2 with men and women combined; n=76)
to administer the revised program
June 2016 Production Production of draft #1 of the revised program
July 2016 Topical Experts Draft #1 reviewed with topical experts (Ghanaian and United States sexual assault centers)
July – August 2016 Decisions #2 Based on assessment, administration, and discussion with topical experts, a second round of revisions was
undertaken (Draft #2). Revisions included:
•Replaced two activities focused on communication and gender equality
•Added additional content on victim blaming
September 2016 Administration #2 Beta testing repeated with 6 groups (3 with men, 3 with women; n=57)
October 2016 Production #2 Production of Draft #2 of the revised curriculum
October–November 2016 Topical Experts #2 Reviewed content with topical experts (Ghanaian and United States sexual assault centers) for a second time
November 2016 Integration Results of beta testing sessions, meetings with topical experts, & readability test integrated
March 2017 Training Master trainers in Ghana participated in Facilitator’s Training Program to receive information about training
future peer facilitators and help create the manualized Facilitator’s Training Guide
August 2017 Testing In progress – testing of the final program as administered by trained peer facilitators

60. Testing
• Currently in progress
• Will evaluate the final version of the adapted program as
administered by the trained peer facilitators
• Will prepare the program for scale-up to the entire University of
Cape Coast student population

61. Long Term Goal
Decrease sexual violence perpetration at UCC and enable all students
to engage in healthy, satisfying relationships based on their values

62. How will we do that?
• Have a manualized version of Relationship Tidbits that includes a:
– Facilitator Manual
– Facilitator’s Training Guide
• Relationship Tidbits will be delivered to all incoming students at the
University of Cape Coast
• Begin to use the adaptation process to adapt Relationship Remix to
other universities in Ghana and throughout sub-Saharan Africa

63. Lessons Learned
• Adapting content to new locations and/or
populations requires engaging in an ongoing,
iterative process
• Working with the target population is essential.
We can not make assumptions. The target
population knows best.
• You are never done. You are always learning from
the population, the delivery of the content, and
new individuals. It is important to incorporate this
new learning into your facilitation skills.

64. An Alternative Example:
MKit

65. Adapting a WebApp to a New Population

66. Date ADAPT-ITT Process
August 2016 Community
Engagement
Met with Technical Expertise Group to introduce the WebApp, get buy in, and discuss ADAPT-ITT
process. They provided feedback on the focus group and interview process.
November 2016 –
February 2017
Assessment Students: 7 FGDs to discuss issues around healthy relationships and sexual violence. Total number of
participants: 43
Faculty & Staff: 3 FGDs & 1 individual interview to discuss issues around healthy relationships and
sexual violence. Total number of participants: 16
March 2017 Decisions Based on the information gathered in the focus group discussion, made decisions on:
1)Editing pre-existing tiles
2)Replacing tiles
April 2017 Administration Theater testing using cognitive interviews done in small groups (2-3 people) with campus organizations
(n=44)
May 2017 Community
Engagement
Members of the Technical Expertise Group revised some of the key “tiles”
June-August 2017 Production Production of the revised WebApp by my tech partners
August-September
2017
Topical Experts Revised WebApp is currently being reviewed by four topical experts (who were not involved in the
WebApp development) including a sexual violence expert, primary prevention expert, student expert,
and technology expert
August-September
2017
Community
Engagement
The Technical Expertise Group has an opportunity to review the beta version of the WebApp
September 2017 Integration Results of beta testing will be integrated into beta version of WebApp
September 2017 Training Relationship Remix facilitators are trained to advertise the WebApp
September 2017 –
April 2018
Testing Pilot test with 300 students

67. Comparing Relationship Tidbits & MKit
• Used the ADAPT-ITT process
• Adapted to a new culture and
context
• Intended to be a primary prevention
intervention
• Script-based intervention delivered
by peer facilitators
• Used the ADAPT-ITT process
• Adapted to a new population with a
new focus
• Intended to be a reinforcement to
already existing primary prevention
interventions
• WebApp technology based
intervention

68. Putting it Together:
What will the ADAPT-ITT process look like
in your contexts?

69. Where might the ADAPT-ITT process be useful?
• Community or Commuter Colleges
• Technical Schools
• International Student Programs
• Colleges or Universities with multiple campuses that serve different
students populations
• Non-traditional Students

70. Keys to a Successful Adaptation
• Know your population
– We spent the majority of our time getting to know Ghanaian students
and how they understand and view sexual violence.
• Engage your community
– Student, Organization, or Community Advisory Board
• Think about your timeline
– When are students on campus and available?
– What is realistic given your workload?

71. Keys to a Successful Adaptation
• Build a team
– Do you need campus administrators to help promote the program?
– Do you need researchers to help evaluate data?
– Do you need to involve facilities or campus housing to logistically
enable the program?
– Do you need a technology partner?
• Identify financial support
– Do you have human resources?
– Do you have support for program resources?
– Will this program require finances for sustainability?

72. Making it your own!
• The ADAPT-ITT process creates a unique program based on your
population/location/context and needs
• Using a pre-existing program serves only as a base, this allows you
to include the information, naming, and branding that is most
appropriate for your institution

73. Questions?

74. Thank you for participating!
Michelle Munro-Kramer
Assistant Professor
University of Michigan
School of Nursing
mlmunro@umich.edu