Enhanced Milieu Teaching in resource-constrained settings: Stakeholder-informed adaptation guidelines

Background: Enhanced Milieu Teaching (EMT) is an evidence -based naturalistic developmental behavioural intervention (NDBI) for children with developmental disabilities. Little is known about the EMT's fit or what adaptations might be needed to improve its applicability within a resource -constrained setting. Objectives: To explore stakeholders' perceptions of the contextual fit of EMT for young children with developmental disabilities in a resource -constrained context and to identify adaptations to improve EMT's contextual fit. Method: We conducted a descriptive qualitative study using semi -structured interviews and focus groups. Participants included 5 speech and language therapists and 11 caregivers of children with developmental disabilities who speak English and Afrikaans or isiXhosa. Using thematic analysis, data were coded into 10 subthemes and grouped according to the Adaptome framework components. Results: Overall, stakeholders view EMT as an appropriate intervention in the South African context. They indicated that certain intervention components may need to be modified. Specifically, clinicians may need to adapt intervention materials and activities to be sensitive to families' available resources, preferred activity routines and priorities. From these data, we provide guidelines to improve the fit of EMT in South Africa. Conclusion: Enhanced Milieu Teaching is an appropriate intervention in the South African context, although some adaptations can enhance its fit. Contribution: This article highlights the importance of engaging with stakeholders to determine the fit of NDBIs, like EMT, as they are implemented in new contexts. Based on these insights, stakeholder -informed adaptation guidelines are provided for improving the contextual fit of EMT in resource -constrained settings.