Documenting two decades of longitudinal changes to a community-engaged obesity prevention intervention for Native American families to facilitate scale-up.

BACKGROUND: Community-based participatory research (CBPR) interventions frequently undergo adaptation as they move from efficacy studies to dissemination; yet long-term adaptations are rarely documented in ways that support replication or scale-up. PURPOSE: To demonstrate a structured approach for retrospectively documenting longitudinal adaptations to Healthy Children, Strong Families (HCSF)-a culturally grounded, evidence-based obesity prevention intervention for Native American families-as it evolved into Turtle Island Tales. METHODS: We conducted a retrospective review of permanent records generated between 2006 and 2026 spanning three major program iterations: HCSF1, HCSF2, and Turtle Island Tales. Guided by the Framework for Reporting Adaptations and Modifications to Evidence-based Interventions (FRAME), the implementation-strategy extension FRAME-IS, and the Adaptome, adaptations were categorized as changes to intervention governance, content, structure, or strategy. Data sources included intervention materials, study protocols, quantitative and qualitative trial data, meeting minutes, and emails. RESULTS: Adaptations were layered and interdependent and were documented as preserving core functions while supporting intended implementation outcomes (e.g. acceptability, feasibility, reach, adoption, sustainability). Governance adaptations reflected shifts from more centralized, CBPR-grounded adaptation and implementation processes to greater local decision-making by community implementers. Content adaptations included greater integration of traditional knowledge and new lessons addressing sleep, emotional regulation, and family traditions. Structural adaptations involved delivery changes aligned with community systems and development of culturally resonant branding and characters. Strategy adaptations included opt-out classroom-based recruitment, embedding implementation within existing community roles, and revised training materials. CONCLUSIONS: Organizing adaptations into governance, content, structure, and strategy provides a pragmatic approach for documenting flexibility across long-term CBPR partnerships and may offer considerations for documentation of intervention adaptations in similar settings. CLINICAL TRIAL INFORMATION: The Clinical Trials Registrations #NCT01776255, NCT06298149.